Hypertension is the blood pressure is higher than 140 over 90 in 3 consecutive visits 24 hours apart. A diagnosis of hypertension may be made when one or both readings are high: systolic

Essential hypertension is the presence of sustained hypertension in the absence of underlying, potentially correctable renal, adrenal or other factors.Malignant hypertension is that with a diastolic pressure > 120 mmHg and exudative vasculopathy in the retinal and renal circulations. Refractory hypertension is a BP > 140/90 mmHg despite maximum dosage of two durgs for 3 – 4 months. Secondary hypertension is hypertension due to secondary cause such as renal endocrine or cardiac.

hypertension or increased arterial blood pressure increases risk of  stroke, coronary heart disease, renal disease, heart failure and atrial fibrillation. Treatment may be lifelong, hence the need for careful work-up.

< 120 < 80 Recheck in 2 years.
120 – 139 80 – 89 Recheck in 1 year – lifestyle advice.
140 – 159 90 – 99 Confirm within 2 months – lifestyle advice.
160 – 179 100 – 109 Evaluate or refer within 1 month – lifestyle advice.
≥ 180 ≥ 110 * Further evaluate and refer within 1 week

 

Clinical features Likely cause
Abdominal systolic bruit Kidney artery stenosis
Proteinuria, haematuria, casts Glomerulonephritis
Bilateral kidney masses with or without haematuria Polycystic disease
History of claudication and delayed femoral pulse Coarctation of the aorta
Progressive nocturia, weakness Primary aldosteronism (check serum potassium)
Paroxysmal hypertension with headache, pallor, sweating, palpitations Phaeochromocytoma
truncal obesity with pigmented striae Cushing’s syndrome

Conn’s syndrome: Weakness due to hypokalaemia. polyuria and polydypsia, Na ↑, K ↓, alkalosis,  Aldosterone ↑ (serum and urine)

Phaeochromocytoma: Paroxysms or spells of: hypertension, headache (throbbing), sweating, palpitations, pallor/skin blanching, rising sensation of tightness in upper chest and throat (angina can occur), Investigation: 24 hour urinary free catecholamines ↑ (VMA)

Management of hypertension

History of hypertension

  • Method and date of initial diagnosis
  • duration and levels of elevated BP
  • Symptoms that may indicate the effects of high BP on target organ damage, such as headache, dyspnoea, chest pain, claudication, ankle oedema and haematuria
  • Symptoms suggesting secondary hypertension
  • The results and side-effects of all previous antihypertensive treatment

Presence of other diseases and risk factors

  • A history of cardiovascular, cerebrovascular or peripheral vascular disease, renal disease, diabetes mellitus or recent weight gain
  • Other cardiovascular risk factors, including obesity, hyperlipidaemia, carbohydrate intolerance, smoking, salt intake, alcohol consumption, exercise levels and analgesic intake
  • Other relevant conditions, such as asthma or psychiatric illness (particularly depressive illness)

Management principles

  • The goal –  improve the long-term survival and quality of life.
  • Doctor patient relationship.
  • Aim to reduce the levels to 140/90 mmHg or less (ideal).
  • Undertake a thorough assessment of all cardiovascular risk factors.
  • Non-drug treatment strategies and their potential benefits.
  • In patients with mild-to-moderate hypertension and no target organ damage, consider ambulatory or home BP monitoring.
  • Drug therapy should be given to those with:
    • sustained high initial readings (e.g. DBP 95 mmHg)
    • target organ damage
    • failed non-drug measures
  • Make a careful selection of an antihypertensive drug and an appraisal of the side-effects against the benefits of treatment.
  • Avoid drug-related problems such as postural hypotension.
  • Avoid excessive lowering of BP-aim for steady and graduated control.
  • Aim to counter the problem of patient non-compliance.
  • Be aware of factors that may contribute to drug resistance.

extracted from Murthag’s clinical medicine ….

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