Hypertension: Diagnosis and Management

Hypertensive Disorders

• Hypertension diagnosis is made when systolic and diastolic values rise above a specific threshold, corresponding to the level of BP at which the risk of cardiovascular complications and benefits of treatment outweigh the treatment costs and potential side effects of therapy.

Objectives

• Diagnosis of hypertension
• Stages of hypertension
• Investigations
• Threshold of treatment
• Monitoring blood pressure control
• Pharmacological and non-pharmacological treatment
• Target blood pressure
• Investigations for secondary causes

Pathogenesis and Etiology

• In more than 95% of cases, no specific underlying cause of hypertension can be found (essential hypertension)
• In about 5% of cases, hypertension is secondary to a specific disease

Causes of Secondary Hypertension

• Not specified in the provided text

Risk Factors

• Non-modifiable risk factors:
  • Positive family history
  • Ethnicity
  • Advanced age
• Modifiable risk factors:
  • Obesity
  • Diabetes
  • Smoking, excessive alcohol or caffeine intake
  • Diet high in sodium, low in potassium
  • Physical inactivity
  • Psychological stress

Clinical Features

• Hypertension is usually asymptomatic until the diagnosis is made or a complication arises
• Physical Examination signs in hypertensive patients:
  • Signs of left ventricular hypertrophy
  • Accentuation of the aortic component of the second heart sound
  • A fourth heart sound
  • Afib is common

Diagnosis of Hypertension

• If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM)
• Confirm diagnosis of hypertension in people with a clinic blood pressure of 140/90 mmHg or higher and ABPM daytime average or HBPM average of 135/85 mmHg or higher

White Coat Hypertension

• Definition: arterial hypertension detected only in clinical settings or during blood pressure measurement at a physician's practice
• Etiology: anxiety experienced by the patient
• Clinical features: consistently normal blood pressure measurements and normalization of elevated blood pressure outside of a clinical setting
• Diagnostics:
  • Take different blood pressure measurements several minutes apart (after the patient had time to relax)
  • Take blood pressure measurements on several visits (at least 2)

Stages of Hypertension

• NICE guidelines, August 2020
• ACC/AHA classification of hypertension 2017

Investigations

• Aims to:
  • Assess cardiovascular risk
  • Determine the presence of target organ damage

Target Organ Damage

• Damage to organs such as the heart, brain, kidneys, and eyes
• Examples: left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy, or increased urine albumin:creatinine ratio

Red Flags for Hypertensive Crisis

• Dyspnea
• Chest pain
• Altered mental status
• Focal neurologic symptoms

Diagnostics

• Evaluate for signs of end-organ damage
• Laboratory studies:
  • CBC: signs of microangiopathic hemolytic anemia
  • BMP: altered electrolytes and/or elevated creatinine and urea, suggesting kidney failure
  • BNP: elevated in heart failure
  • Troponin: elevated in myocardial ischemia
  • Urinalysis: signs of glomerular injury (e.g., proteinuria, hematuria)
• ECG: left ventricular hypertrophy, signs of cardiac ischemia
• Chest x-ray: cardiomegaly, pulmonary edema

Management

• Hypertensive urgency:
  • Outpatient treatment is recommended
  • Move patient to a quiet room for 30 minutes