blood pressure measurements taken over at least a 3 month period are higher than 140/90 mmHg. If the blood pressure is found to be very high, however, three such measurements may not be required to make the diagnosis. Different diagnosis Systemic hypertension may be classified as : • Primary ( essential ) hypertension, for which there is no identified cause. This accounts for 95% of cases • Secondary hypertension, for which there is a clear cause History to focus on the differential diagnosis of high blood pressure Presenting Complaint Hypertensive patients are often asymptomatic. Occasionally they complain of headaches, tinnitus, recurrent epistaxis or dizziness. In this situation a detailed systems review may reveal clues as to a possible cause of hypertension : weight loss or gain : tremor, hair loss, heat intolerance or feeling cold may suggest the presence of thyroid disease. paroxymal palpitations, sweating, headaches or collapse may indicate the possibility of a phaeochromocytoma Ask the patient about symtoms that may indicate the presence complications of hypertension such as : Dyspnoea, orthopnoea or ankle oedema suggesting cardiac failure Chest pain indicating ischaemic heart disease Unilateral weakness or visual disturbance (either persistent or transient) suggesting cerebrovascular disease Past medical history To gain information about a condition that has so many varied causes it is crucial to ask about all previous illneses and operations. Example include : Recurrent urinary tract infections, especially in childhood, may lead to chronic pyelonephiritis, a common cause renal failure A history of asthma may reveal chronic corticosteroid intake, leading to Cushing’s syndrome • Thyroid surgery in the past • Evidence of peripheral vascular disease (leg claudication or previous vascular surgery may suggest the possibility of underlying renovascular disease ) Drug history
A careful history of all drugs being taken
regularly is needed, including the use proprietary analgesics ( aspirin, the possibility of underlying renovascular disease ) Family history Essential hypertension is a multifactorial disease requiring both genetic and evironmental inputs. A family history of hypertension is therefore not an uncommon finding in these patients. Some secondary causes of hypertension have a genetic component : • Adult polycystic kidney disease is an autosomal dominant condition associated with hypertension, renal failure and cerebral artery aneurysms • Phaechromocytoma may occur as part of a multiple endocrine neoplasia syndrome ( MEN 2, autosomal dominant ) associated with medullary carcinoma of the thyroid and hyperparathyroidism Social history
Smoking, like hypertension, is a risk factor for
ischaemic heart disease. Execessive alcohol intake can cause hypertension. Causes of secondary hypertension System invoved Pathology
glucocorticoids Psychogenic Stress Examination of patients who have high blood pressure When performing the examination, look for :
Signs of end-organ damage ( cardiac
failure ischaemic heart disease, peripheral artery disease, cerebrovascular disease and renal impairment ) Signs of an underlying cause hypertension Blood pressure Important points to note are : Patient should be seated comfortably preferably for 5 mm before masurement of blood pressure in a quiet warm setting Correct cuff size should be used if too small a spuriously high reding will result The manometer should be correctly calibrated The bladder should be inflated to 20 mmHg above systolic blood pressure • Systolic blood pressure is recorded as the point during bladder deflation where regular sounds can be heard. Systolic blood pressure can also be measured as the pressure at which th epalpated distal pulse disappears • Diastolic blood pressure is recorded as the point at which the sounds disappear ( korotkoff phase V ). To childern and pregnant women muffling of the sounds is used as the diastolic blood pressure ( korotkoff phase IV ) Cardiovascular examination Examine the pulse, considering following : Rate tachycardia or bradycardia may indicate underlying thyroid disease Rhythm atrial fibrillation may occur as a result of hypertensive heart disease Symmetry compare the pulses ; radioradial delay is a sign of coarctation as is the finding of abnormally weak foot pulses Bear in mind that : • Weak or absent peripheral pulses along with cold extremities suggest peripheral vascular disease • Jugular venous pressure may be elevated in congestive cardiac failure, a complication of hypertension • A displacaed apex is seen in left ventricular due to dilatation of the left ventricular • Mitral regurgitation may occur secondary to dilatation of the valve ring that occur during left ventricular dilatation • In patients who have coarctation, bruits may be heard over the scapulas and a systolic murmur may be heard below the left clavicle Respiratory system Bilateral basal crepitations of pulmonary oedema may be heard on examination of the respiratory system Gastrointestinal system Hepatomegaly and ascites may be seen in patients with congestive cardiac failure. Abdominal aortic aneurysm must be looked for because it is a manifestation of generalized atherosclerosis. Palpable kidneys may be evident in individuals who have polycystic kidney disease. A renal artery bruit may be heard in patients with renal artery stenosis. Limbs
Peripheral oedema is a sign congestive
cardiac failure or underlying renal disease Eyes Hypertensive retinopathy A detailed examination of the fundi is crucial in all patients who have hypertension because it provides valuable information about severity of the hypertension. Patients exhibiting grade III or IV hypertensive retinopathy have accelerated or malignant hypertension and need urgent treatment. Other findings on examination
When examining a patient who has a
disorder that has many possible causes, a through examination of all systems is vital. Remember to look out for signs of thyroid disease, Cushing’s disease, acromegaly, renal impairment, etc. Investigation of patients who have high blood pressure Algorithms for the investigation of high blood pressure are given. Look for evidence of end-organ damage and possible underlying causes. Features of hypertensive retinopathy on opthalmoscopy
Grade Features
I Narrowing of the arteriolar lumen occurs giving the classical
”silver wings” effect
II Sclerosis of the adventitia and thickening of the muscular wall
of the arteries leads to compression of underlying veins and arteriovenous ripping III Rupture of small vessels leading to haemorrhages and exudates IV Papiloedema ( plus signs of grades I-IV ) OD Blood tests The following blood tests may help in the diagnosis : Electrolytes and renal function many patients who have hypertension may be treated with diuretics and therefore may have hypocalaemia or hyponatraemia as a result. Renal impairment as a result of hypertension or its treatment must be exlcluded Full blood count polycythaemia may be present. Macrocytosis may be seen in hypothyroidism, anaemia may be a result of chronic renal failure • Blood glucose elevated blood glucose may be seen in diabetes mellitus or in Cushing’s disease • Thyroid function • Blood lipid profile like hypertension, an important risk factor for ischemic heart disease Urinalysis
Look for protein casts or red blood cells
asign underlying renal disease Electrocardiography There may be evidence of left ventricular hypertrophy. Features of left ventricular hypertrophy are : Tall R waves in lead V6 ( > 25 mm ) R wave in V5 plus S wave in V2 > 35 mm Deep S wave in lead V2 Inverted T waves in lateral leads ( I, AVL, V5 & V6 ) There may be evidence of an old myocardial Infarction or of rhythm disturbance especially Atrial fibrillation. Chest radiography Look for : • An enlarge left ventricle seen on the chest radiograph as an enlarged cardiac shadow. The normal ratio of cardiac width to thoracic widthis 1:2 • Evidence of coarctation of the aorta this is seen as poststenotic dilatation of the aorta with an identation above producing the reversed figure three, along with rib nothing due to dilatation of the posterior intercostal arteries Echocardiography
This investigation is used to :
• Reveal left ventricular hypertrophy • Reveal poor left ventricular function • Show any areas of left ventricular hypokinesia suggestive of old MI. Investigations to exclude secondary hypertension The above investigations may point to possible underlying causes of secondary hypertension, but they are not exhaustive. It would not, however, be cost effective to investigate all hypertensive patients for these disorders because over 95% of cases of hypertension are primary. Careful selection of patients who are more likely to have secondary hypertension is therefore needed before embarking on more detailed an invasive investigations. Secondary hypertension is more likely in patients who are under 35 years of age and also in patients who have : • Symptoms to malignat hypertension ( severe headaches, nausea and vomiting, blood pressure > 180/100 mmHg, papiloedema ) • Evidence of end organ damage ( grade III & IV retinopathy, raised serum creatinine, cardiac failure ) • Signs of secondary causes ( hypokalaemia in the absence of diuretics, signs of coarctation, abdominal bruit, symptoms of phaechromocytoma, famly history of renal disease or stroke at a young age ) • Poorly controlled blood pressure despite medical therapy Investigation of secondary hypertension Underlying causes investigation Notes result
Renal parenchymal 24 hour creatinine clerence
disease 24 hour protein excretion Renal ultrasound Bilateral small kidneys Renal biopsy In some cases
Renal artery stenosis Renal ultrasound Often asymmetrical kidneys
Radionucleotide studies using Decreased upteke on affected DTPA side ; this control is Highlighted by administration of an ACE inhibitor Renal angiography or MRI angiography
rarely used CTscan of abdomen Tumour is often large MIBG scan To identify extraadrenal tumours (seen in 10% cases) Cushing’s disease 24 hour urinary free cortisol Dexamethasone suppresion test Low dose 48 hour test initially high dose test to rule out ectopic source of ACTN 09.00 & 24.00 blood control Reveals loss of cirdacian rhythm in Cushing’s disease Adrenal CTscan May show adrenal tumour Pituitary MRI scan May show enlarged pituitary chestX-ray May show oat cell carcinoma of bronchus ( ectopic ACTH )