HYPERTENSION

Detection, Evaluation
and Non-pharmacologic Intervention
Misbah Keen, MD, FAAFP
Act. Asst. Professor Family Medicine
University of Washington School of Medicine
Seattle WA

Problem Magnitude

Hypertension( HTN) is the most common

primary diagnosis in America.
35 million office visits are as the primary
diagnosis of HTN.
50 million or more Americans have high BP.
Worldwide prevalence estimates for HTN may be
as much as 1 billion.
7.1 million deaths per year may be attributable to
hypertension.

Definition
A systolic blood pressure ( SBP) >139
mmHg and/or
A diastolic (DBP) >89 mmHg.
Based on the average of two or more
properly
measured, seated BP
readings.
On each of two or more office visits.

Accurate Blood Pressure Measurement

The equipment should be regularly inspected and

validated.
The operator should be trained and regularly retrained.
The patient must be properly prepared and positioned
and seated quietly for at least 5 minutes in a chair.
The auscultatory method should be used.
Caffeine, exercise, and smoking should be avoided
for at least 30 minutes before BP measurement.
An appropriately sized cuff should be used.

BP Measurement
At least two measurements should be
made and the average recorded.
Clinicians should provide to patients
their specific BP numbers and the BP
goal of their treatment.

Follow-up based on initial BP

measurements for adults*

www.nhlbi.nih.gov

*Without acute end-organ

Classification

www.nhlbi.nih
.gov

Prehypertension

SBP >120 mmHg and <139mmHg and/or

DBP >80 mmHg and <89 mmHg.

Prehypertension is not a disease category

rather a designation for individuals at high risk
of developing HTN.

Pre-HTN

Individuals who are prehypertensive are not

candidates for drug therapy but
Should be firmly and unambiguously advised to
practice lifestyle modification
Those with pre-HTN, who also have diabetes or
kidney disease, drug therapy is indicated if a
trial of lifestyle modification fails to reduce their
BP to 130/80 mmHg or less.

Isolated Systolic Hypertension

Not distinguished as a separate entity as
far as management is concerned.
SBP should be primarily considered
during treatment and not just diastolic BP.
Systolic BP is more important
cardiovascular risk factor after age 50.
Diastolic BP is more important before age
50.

Frequency Distribution of Untreated HTN by Age

Isolated
Systolic
HTN

Systolic Diastolic
HTN

Isolated
Diastolic
HTN

Hypertensive Crises

Hypertensive Urgencies: No progressive

target-organ dysfunction. (Accelerated
Hypertension)
Hypertensive Emergencies: Progressive
end-organ dysfunction. (Malignant
Hypertension)

Hypertensive Urgencies
Severe elevated BP in the upper range of
stage II hypertension.
Without progressive end-organ
dysfunction.
Examples: Highly elevated BP without
severe headache, shortness of breath or
chest pain.
Usually due to under-controlled HTN.

Hypertensive Emergencies

Severely elevated BP (>180/120mmHg).

With progressive target organ dysfunction.
Require emergent lowering of BP.
Examples: Severely elevated BP with:
Hypertensive encephalopathy
Acute left ventricular failure with pulmonary
edema
Acute MI or unstable angina pectoris
Dissecting aortic aneurysm

Types of Hypertension

Primary HTN:
also known as
essential HTN.
accounts for 95%
cases of HTN.
no universally
established cause
known.

Secondary HTN:
less common cause
of HTN ( 5%).
secondary to other
potentially rectifiable
causes.

Causes of Secondary HTN

Common

Intrinsic renal disease

Renovascular disease
Mineralocorticoid
excess
Sleep Breathing
disorder

Uncommon

Pheochromocytoma
Glucocorticoid excess
Coarctation of Aorta
Hyper/hypothyroidism

Secondary HTN-Clues in Medical

History

Onset: at age < 30 yrs ( Fibromuscular dysplasi)

or > 55 (athelosclerotic renal artery stenosis),
sudden onset (thrombus or cholesterol
embolism).
Severity: Grade II, unresponsive to treatment.
Episodic, headache and chest pain/palpitation
(pheochromocytoma, thyroid dysfunction).
Morbid obesity with history of snoring and
daytime sleepiness (sleep disorders)

Secondary HTN-clues on Exam

Pallor, edema, other signs of renal
disease.
Abdominal bruit especially with a diastolic
component (renovascular)
Truncal obesity, purple striae, buffalo
hump (hypercortisolism)

Secondary HTN-Clues on Routine

Labs
Increased creatinine, abnormal urinalysis
( renovascular and renal
parenchymal disease)
Unexplained hypokalemia
(hyperaldosteronism)
Impaired blood glucose
( hypercortisolism)
Impaired TFT (Hypo-/hyper- thyroidism)

Secondary HTN-Screening
Tests

www.nhlbi.nih.gov

Renal Parenchymal Disease

Common cause of secondary HTN (2-5%)
HTN is both cause and consequence of
renal disease
Multifactorial cause for HTN including
disturbances in Na/water balance,
vasodepressors/ prostaglandins
imbalance
Renal disease from multiple etiologies.

Renovascular HTN

Atherosclerosis 75-90% ( more common in

older patients)
Fibromuscular dysplasia 10-25% (more
common in young patients, especially females)
Other

Aortic/renal dissection
Takayasus arteritis
Thrombotic/cholesterol emboli
CVD
Post transplantation stenosis
Post radiation

Complications of Prolonged
Uncontrolled HTN
Changes in the vessel wall leading to
vessel trauma and arteriosclerosis
throughout the vasculature
Complications arise due to the target
organ dysfunction and ultimately failure.
Damage to the blood vessels can be seen
on fundoscopy.

Target Organs
CVS (Heart and Blood Vessels)
The kidneys
Nervous system
The Eyes

Effects On CVS
Ventricular hypertrophy, dysfunction and
failure.
Arrhithymias
Coronary artery disease, Acute MI
Arterial aneurysm, dissection, and
rupture.

Effects on The Kidneys

Glomerular sclerosis leading to impaired
kidney function and finally end stage
kidney disease.
Ischemic kidney disease especially when
renal artery stenosis is the cause of HTN

Nervous System
Stroke, intracerebral and subaracnoid
hemorrhage.
Cerebral atrophy and dementia

The Eyes
Retinopathy, retinal hemorrhages and
impaired vision.
Vitreous hemorrhage, retinal detachment
Neuropathy of the nerves leading to
extraoccular muscle paralysis and
dysfunction

Retina Normal and Hypertensive

Retinopathy
A
B

Normal Retina

Hypertensive
Retinopathy

A: Hemorrhages
B: Exudates (Fatty
Deposits)
C: Cotton Wool Spots
(Micro Strokes)

Stage I- Arteriolar Narrowing

Arteriolar
Narrowing

Stage II- AV Nicking

AV
AVNicking
Nicking
AV Nicking

AV Nicking

Stage III- Hemorrhages (H), Cotton

Wool Spots and Exudats (E)
H

Stage IV- Stage III+Papilledema

Patient Evaluation Objectives

(1) To assess lifestyle and identify other

cardiovascular risk factors or concomitant
disorders that may affect prognosis and guide
treatment
(2) To reveal identifiable causes of high BP
(3) To assess the presence or absence of
target organ damage and CVD

(1) Cardiovascular Risk factors

Hypertension
Cigarette smoking
Obesity (body mass index 30 kg/m2)
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimated GFR <60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men
under age 55 or women under age 65)

(2) Identifiable Causes of HTN

Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushings syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease

(3) Target Organ Damage

Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy

History

Angina/MI Stroke: Complications of HTN,

Angina may improve with b-blokers
Asthma, COPD: Preclude the use of b-blockers
Heart failure: ACE inhibitors indication
DM: ACE preferred
Polyuria and nocturia: Suggest renal
impairment

History-contd.

Claudication: May be aggravated by bblockers, atheromatous RAS may be present

Gout: May be aggravated by diuretics
Use of NSAIDs: May cause or aggravate HTN
Family history of HTN: Important risk factor
Family history of premature death: May have
been due to HTN

History-contd.
Family history of DM : Patient may also
be Diabetic
Cigarette smoker: Aggravate HTN,
independently a risk factor for CAD and
stroke
High alcohol: A cause of HTN
High salt intake: Advice low salt intake

Examination

Appropriate measurement of BP in both arms

Optic fundi
Calculation of BMI ( waist circumference also
may be useful)
Auscultation for carotid, abdominal, and femoral
bruits
Palpation of the thyroid gland.

Examination-contd.
Thorough examination of the heart and
lungs
Abdomen for enlarged kidneys, masses,
and abnormal aortic pulsation
Lower extremities for edema and pulses
Neurological assessment

Routine Labs

EKG.
Urinalysis.
Blood glucose and hematocrit; serum potassium,
creatinine ( or estimated GFR), and calcium.
HDL cholesterol, LDL cholesterol, and
triglycerides.
Optional tests
urinary albumin excretion.
albumin/creatinine ratio.

Goals of Treatment

Treating SBP and DBP to targets that are

<140/90 mmHg
Patients with diabetes or renal disease, the BP
goal is <130/80 mmHg
The primary focus should be on attaining the
SBP goal.
To reduce cardiovascular and renal morbidity
and mortality

Benefits of Treatment
Reductions in stroke incidence,
averaging 3540 percent
Reductions in MI, averaging 2025
percent
Reductions in HF, averaging >50 percent.

Lifestyle modifications

www.nhlbi.nih.gov

Lifestyle Changes Beneficial in Reducing Weight

Decrease time in sedentary behaviors such

as watching television, playing video games, or
spending time online.
Increase physical activity such as walking,
biking, aerobic dancing, tennis, soccer,
basketball, etc.
Decrease portion sizes for meals and snacks.
Reduce portion sizes or frequency of
consumption of calorie containing beverages.

DASH Diet
Dietary approaches to Stop Hypertension
As effective as one medication

JNC 7 Summary
Joint National Commission 7th Report
PDF File on website
50 page document

Other JNC 7 Resources

Software for use with Palm and Pocket

PC

JNC 7 Reference Card

Other Resources

Chronic Kidney Disease Information

GFR Calculator
www.nephron.com

Hyperlipedemia Information

Adult Treatment Panel 3 Guidelines

www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

Questions

mkeen@fammed.washington.edu