High Blood Pressure

A person is hypertensive if three sets of

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

Renal Renal parenchymal disease 9 chronic atropic pyelonepheritis,

chronic glomerulonepheritis, renal artery stenosis, renin producing
tumours, primary sodium retention

Endocrin Acromegaly, hypo and hyperthyroidism, hypercalcaemia, adrenal

cortex disorders ( Cushing’s disease, Conn’s syndrome, congetinal
adrenal hyperplasia ), adrenal medulla disorders
( phaeochromocytoma )
Vascular disease Coarctation of the aorta

Other Hypertension of pregnacy

Increased Polycythaemia ( primary of secondary )
Intravascular
volume

Drugs Alcohol, oral contraceptives, monoamine oxidase inhibitors,

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
Renal parenchymal 24 hour creatinine clerence
disease 24 hour protein excretion
Renal ultrasound
Renal biopsy
Renal artery stenosis Renal ultrasound
Radionucleotide studies using
DTPA
Renal angiography or MRI
angiography
paheochromocytoma 24 hour urone cathecolamines
CTscan of abdomen
MIBG scan
Notes result


Bilateral small kidneys
In some cases
Often asymmetrical kidneys
Decreased upteke on affected
side ; this control is
Highlighted by administration
of an ACE inhibitor
, VMA measurement noq
rarely used
Tumour is often large
To identify extraadrenal
tumours (seen in 10% cases)
Cushing’s disease 24 hour urinary free cortisol
Dexamethasone suppresion test
09.00 & 24.00 blood control
Adrenal CTscan
Pituitary MRI scan
chestX-ray

Low dose 48 hour test initially
high dose test to rule out
ectopic source of ACTN
Reveals loss of cirdacian
rhythm in Cushing’s disease
May show adrenal tumour
May show enlarged pituitary
May show oat cell carcinoma of
bronchus ( ectopic ACTH )