Chronic hypertension resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Classification

Classification	Blood pressure (mmHg)
Normal	< 120/80
Prehypertension	120-139/80-89
Stage 1 hypertension	140-159/90-99
Stage 2 hypertension	≥ 160/110
Isolated systolic hypertension
Isolated diastolic hypertension

Diagnosis

Shown below is an algorithm summarizing the diagnosis of

General Approach to Suspected Hypertension

Suspected hypertension BP > 140/90 mmHg

Blood pressure measurement Before taking the BP ❑ Sit patient quietly in a chair for 5 mins ❑ Avoid caffeine, exercise, smoking at least 30 mins ❑ Ensure appropriate cuff size ❑ Take 2 readings and find the average ❑ Take repeated measurements in patients with arrhythmia ❑ Measure BP at both arms at first visit to detect possible differences ❑ Out-of-office BP Click here for more information regarding blood pressure measurement

Confirmed hypertension

Normotensive

Classify the patient based on the BP reading

White-coat hypertension

SBP 120-139 mmHg DBP - 80-89 mmHg

SBP 149-159 mmHg DBP 90-99 mmHg

SBP >160 mmHg DBP >110 mmHg

Prehypertension

Stage 1 hypertension Proceed to complete diagnostic approach

Stage 2 hypertension Proceed to hypertensive crisis resident survival guide

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Treatment Lifestyle modification ❑ Weight reduction ❑ Maintain a waist circumference of <40 inches (102cm) for men <35 inches (88cm) for women BMI of ≤25 kg/m2 ❑ Adopt healthy diet ❑ DASH diet (rich in fruits, vegetables, whole grains, low sodium, low-fat proteins) ❑ Dietary sodium intake of ≤ 100 mmol/day (2.4g Na or 6g NaCl) ❑ Limit alcohol consumption ❑ ≤ 2 drinks/day for men (24oz beer or 10oz wine or 3oz 40% whisky ❑ ≤ 1 drink/day for women ❑ Regular aerobic physical activity (brisk walking, jogging, cycling, swimming) for at least 30 mins per day ❑ Patient education ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑

Complete Diagnostic Approach

Obtain a detailed history: History of present hypertension ❑ Time of first diagnosis ❑ Current and past BP measurements ❑ Current and past antihypertensive medications Identify secondary causes of hypertension: Family history ❑ Chronic kidney disease (suggestive of polycystic kidney disease) ❑ Premature CVD or HTN History of renal disease: ❑ Hematuria ❑ UTI ❑ Analgesic abuse (suggestive of renal parenchymal disease) ❑ Flank pain Medication/substance abuse ❑ Amphetamines ❑ Cocaine ❑ Cyclosporine ❑ Erythropoietin ❑ Liquorice ❑ NSAIDs ❑ Oral contraceptive pills ❑ Steroids History suggestive of pheochromocytoma ❑ Recurrent episodes of sweating, palpitation and hypertension History suggestive of hyperaldosteronism ❑ Muscle weakness and tetany History suggestive of thyroid disease History to assess risk factors ❑ Personal and family history of: ❑ HTN and CVD ❑ Dyslipidemia ❑ Diabetes mellitus ❑ Excessive sodium intake >2.4g per day ❑ Tobacco usage ❑ Obesity ❑ Alcoholism >1.5 drinks/day ❑ Metabolic syndrome ❑ Physical inactivity ❑ Sleep apnea History to assess presence of organ damage/complications ❑ CNS: ❑ Headache ❑ Vertigo ❑ Transient ischemic attack ❑ Stroke ❑ Eyes: ❑ Loss or blurring of vision ❑ Cardiovascular: ❑ History of MI or syncope ❑ Chest pain ❑ Shortness of breath ❑ Pedal edema ❑ Palpitation ❑ Arrhythmia ❑ Pedal edema ❑ Sexual function ❑ Kidneys: ❑ Polyuria ❑ Hematuria ❑ Proteinuria

Examine the patient: General examination: ❑ Calculate BMI ❑ Moon face, truncal obesity, striae (suggestive of cushing disease) ❑ Goitre, exophthalmus, pretibial myxedema (suggestive of graves disease) ❑ Dry skin (suggestive of hypothyroidism) Eyes ❑ Fundoscopy to diagnose retinopathy ❑ Hemorrrhage ❑ Papilledema ❑ Cotton wool spots ❑ Narrow pulse pressure (<25 mmHg) Neck ❑ Carotid bruits (suggestive of ) ❑ Thyroid gland enlargement (suggestive of hyperthyroidism) Cardiovascular examination ❑ Evidence of long-standing hypertension: ❑ Cardiomegaly ❑ Displaced apex beat (suggestive of enlarged left ventricle) Respiratory examination ❑ Crackles/crepitations/rales Abdominal examination ❑ Bruits over abdominal aorta (suggestive of aortic aneurysm) ❑ Bruits over renal artery (suggestive of renal artery stenosis)Hepatomegaly ❑ Extremity examination ❑ Absent or diminished femoral pulsation (suggestive of coarctation of aorta) ❑ Bruits over renal artery (suggestive of renal artery stenosis)Hepatomegaly ❑ Pedal edema (suggestive of congestive heart failure) ❑ Delayed return of deep tendon reflexes (suggestive of hypothyroidism) Neurological examination ❑ Findings suggestive of hypertensive encephalopathy ❑ Confusion ❑ Coma ❑ Altered mental status

Order tests: Routine ❑ CBC (rule out anemia) ❑ ❑ ❑ ❑ Electrolytes ❑ ❑ Serum calcium ❑ Serum magnesium ❑ BUN, creatinine ❑ Urinalysis ❑ Fasting blood sugar ❑ Fasting lipid profile ❑ Liver function tests ❑ TSH ❑ Chest X-ray ❑ Cardiomegaly (cardiothoracic ratio >50%) ❑ EKG ❑ 2-D echocardiography with Doppler Additional tests to diagnose specific etiologies: ❑ ANA, rheumatoid factor (for rheumatologic diseases) ❑ Diagnostic tests for hemochromatosis, pheochromocytoma ❑

Does this patient have an identifiable secondary etiology?

Yes

No

Primary hypertension

Secondary hypertension

Proceed to treatment

Treatment

Shown below is an algorithm summarizing the treatment of

References

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