Hypertension evaluation 1

HYPERTENSION

Evaluation of Hypertension

Mohammad Ilyas, M.D.

Assistant Clinical Professor

University of Florida / Health Sciences Center

Jacksonville, Florida USA 1

Outline

1. Definition, Regulation and Pathophysiology

2. Measurement of Blood Pressure, Staging of Hypertension and Ambulatory Blood Pressure Monitoring

3. Evaluation of Primary Versus Secondary

4. Sequel of Hypertension and Hypertension Emergencies

5. Management of Hypertension (Non-Pharmacology versus Drug Therapy)

6. The Relation Between Hypertension: Obesity, Drugs, Stress and Sleep Disorders.

7. Hypertension in Renal diseases and Pregnancies

8. Pediatric, Neonatal and Genetic Hypertension

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INTRODUCTION

• Most hypertensive patients have no clinical cardiovascular disease or signs of

hypertension-related target organ damage.

• The diagnosis of hypertension is made in this setting only after an elevated

and properly measured blood pressure has been confirmed on at least three

separate occasions. (e.g. in office, at home or via ABPM)

• The assessment of overall cardiovascular risk is important, particularly in the

large number of patients with prehypertension, in order to establish

appropriate management

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Ambulatory monitoring

• White coat hypertension — Approximately 20 to 25 percent of patients

with stage 1 office hypertension have "white coat" or isolated office

hypertension in that their blood pressure is repeatedly normal when

measured at home, at work, or by ambulatory blood pressure monitoring

• Masked hypertension — Twenty-four-hour monitoring of larger

populations has revealed a significant number of patients with elevated out-

of-office readings despite normal office readings

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EVALUATION

1. To rule out identifiable and often curable causes of hypertension

2. To determine the extent of target organ damage.

3. To assess the patient's overall cardiovascular risk status.

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Basic Workup

• History

• Physical examination

• Laboratory testing

• Hematocrit, urinalysis, routine blood chemistries (glucose, creatinine, electrolytes), and estimated

glomerular filtration rate

• Lipid profile (total and HDL-cholesterol, triglycerides)

• Electrocardiogram

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Additional tests

• May be indicated in certain settings:

• Microalbuminuria

• Echocardiography

• Testing for renovascular hypertension

• Testing for endocrine causes of HTN

• Genetic and other causes

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History

• Search for those facts that help determine the presence of precipitating or

aggravating factors, the natural course of the blood pressure, the extent of

target organ damage, and the presence of other risk factors for cardiovascular

disease

• The patient should also be asked about the signs and symptoms that suggest

an identifiable cause of hypertension

• Another important consideration, particularly in the patient with very high

blood pressures (≥180/120 mmHg), is the history of prior treatment for

hypertension and non-adherence to antihypertensive medications.

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History

History

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History

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Signs and Symptoms

(Silent killer) If BP is very high, patient may experience:

• Fatigue

• Decreased activity tolerance

• Dizziness

• Palpitations

• Angina

• Dyspnea 13

Physical Exam

• Measurement of your weight, height, and BMI.

• Eye exam of the retina.

• CVS exam for murmur, rub, rate and rhythm.

• An exam of extremities for edema, and the pulse.

• Abdominal exam to listen to the blood vessels (abdominal bruits).

• Neck exam an enlarged thyroid, distended neck veins, and bruits in the

carotid arteries. 14

Routine Laboratory Tests

1. Urinalysis

2. Complete blood count

3. Blood chemistry (potassium, sodium and creatinine)

4. Fasting glucose

5. Fasting lipid profile

6. Standard 12-leads ECG

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Types of Hypertension

• Primary HTN:

• >95% cases of HTN in adult

• Cause Unknown.

• Multiple risk factors: including age,

family history, genetics, race,

environment etc…

• Secondary HTN:

• < 5% HTN in adult are secondary

• Secondary to other potentially

rectifiable causes.

• Often overlooked & under screen

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Causes of Secondary HTN

• Common

• Intrinsic renal disease

• Renovascular disease

• Mineralocorticoid excess

• Sleep Breathing disorder

• Uncommon

• Pheochromocytoma

• Glucocorticoid excess

• Coarctation of Aorta

• Hyper/hypothyroidism

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Secondary HTN

Overview

• Testing for secondary HTN can be expensive and requires high

index of clinical suspicion.

• General principles:

• New onset HTN if <30 or >50 years of age

• HTN refractory to medical Rx (>3-4 meds)

• Specific clinical/lab features typical for dz :

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Secondary HTN

Clues in Medical History

• Onset: at age < 30 yrs. ( Fibro muscular dysplasia) or > 55 years (atherosclerotic renal artery stenosis), sudden onset (thrombus or cholesterol embolism).

• Severity: Stage II or unresponsive to treatment.

• Episodic, headache and chest pain/palpitation (pheochromocytoma, thyroid dysfunction).

• Morbid obesity with history of snoring and daytime sleepiness (sleep disorders)

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Secondary HTN

Clues on Physical Exam

• Pallor, edema, other signs of renal disease.

• Abdominal bruit especially with a diastolic component

(renovascular)

• Truncal obesity, purple striae, buffalo hump (hypercortisolism)

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Secondary HTN

Clues on Routine Laboratory

• Increased creatinine, abnormal urinalysis (renovascular and renal parenchymal disease)

• Unexplained hypokalemia (hyperaldosteronism)

• Impaired blood glucose (hypercortisolism)

• Impaired Thyroid function test (Hypo/hyperthyroidism)

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Secondary HTN-Screening Tests

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www.nhlbi.nih.gov

Renal causes

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Endocrine

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Sings for 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.

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Time for quiz !!

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Quiz 1. All of the following statements are FALSE

except?

A. Most hypertensive patients have mild clinical sign and symptoms.

B. Most of the hypertensive patients will developed signs of hypertension-

related target organ damage.

C. Secondary HTN is the most common cause of hypertension in adolescent.

D. The diagnosis of HTN is made only after an elevated and properly

measured blood pressure and confirmed on at least three separate

occasions.

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Quiz 1. All of the following statements are FALSE

except?

A. Most hypertensive patients have mild clinical sign and symptoms.

B. Most of the hypertensive patients will developed signs of hypertension-

related target organ damage.

C. Secondary HTN is the most common cause of hypertension in adolescent

D. The diagnosis of HTN is made only after an elevated and properly

measured blood pressure and confirmed on at least three separate

occasions.

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Quiz 2. Which of the following Statement is false

about White Coat Hypertension?

A. Approximately 20 to 25 percent of patients with stage 1 office hypertension

have "white coat" HTN

B. Ambulatory BP monitor is the only method to detect White coat HTN

C. The isolated office hypertension could be due to anxiety and stress associated

with physician office setting

D. Blood pressure when repeatedly normal at home, at work, or by ambulatory

blood pressure monitoring ruled out HTN.

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Quiz 2. Which of the following Statement is false

about White Coat Hypertension?

A. Approximately 20 to 25 percent of patients with stage 1 office hypertension

have "white coat" HTN

B. Ambulatory BP monitor is the only method to detect White coat HTN

C. The isolated office hypertension could be due to anxiety and stress associated

with physician office setting

D. Blood pressure when repeatedly normal at home, at work, or by ambulatory

blood pressure monitoring ruled out HTN.

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Quiz 3. Which of the following is the most important

component of hypertension evaluation

A. History

B. Accurate BP measurement

C. Physical examination

D. Laboratory testing

E. Electrocardiogram

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Quiz 3. Which of the following is the most important

component of hypertension evaluation

A. History

B. Accurate BP measurement

C. Physical examination

D. Laboratory testing

E. Electrocardiogram

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Quiz 4. Following Routine Laboratory Tests are required

for initial evaluation of HTN EXCEPT?

A. Urinalysis

B. Complete blood count

C. Blood chemistry (potassium, sodium and creatinine)

D. Micro albuminuria

E. Fasting lipid profile

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Quiz 4. Following Routine Laboratory Tests are required

for initial evaluation of HTN EXCEPT?

A. Urinalysis

B. Complete blood count

C. Blood chemistry (potassium, sodium and creatinine)

D. Micro albuminuria

E. Fasting lipid profile

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Quiz 5. Following are the most common Complications of

Prolonged Uncontrolled HTN, EXCEPT

A. Changes in the vessel wall leading to vessel trauma and arteriosclerosis

B. Liver dysfunction and ultimately failure.

C. Damage to the eye blood vessels (retinopathy)

D. Stroke

E. Heart failure

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Quiz 5. Following are the most common Complications of

Prolonged Uncontrolled HTN, EXCEPT

A. Changes in the vessel wall leading to vessel trauma and arteriosclerosis

B. Liver dysfunction and ultimately failure.

C. Damage to the eye blood vessels (retinopathy)

D. Stroke

E. Heart failure

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