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 Click here for more information regarding blood pressure measurement

Office BP >140/90 mmHg on 2-3 visits

Does the patient have any evidence of target organ damage, DM, or CKD?

Yes

No

Proceed to hypertensive crisis resident survival guide

Perform home BP/out-of-office monitoring

Is the average home BP measurement <140/90?

Yes

Inconclusive

No

Perform 24-hour ABPM

Is the 24-hour ABPM ≤135/85?

White-coat hypertension confirmed

Yes

No

Hypertension confirmed

❑ Continue BP monitoring ❑ Follow-up appointment in ....

Classify the patient based on the BP reading

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

Determine who to treat based on the following:

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 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) ❑ 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 ❑ 12-lead EKG (for evidence of LVH or old infarct) ❑ CBC ❑ Anemia (associated with chronic renal failure) ❑ Polycythemia (may be seen in pheochromocytoma) ❑ Urinalysis ❑ Proteinuria (suggestive of end organ damage) ❑ Serum potassium ❑ Hypokalemia (suggestive of hyperaldosteronism) ❑ Serum calcium ❑ Serum magnesium ❑ Serum creatinine with estimated glomerular filtration rate (eGFR) ❑ Serum uric acid ❑ Fasting blood sugar ❑ Hyperglycemia (suggestive of diabetes mellitus) ❑ Fasting lipid profile Additional tests based on results of the routine tests above: ❑ Echocardiography (may reveal LVH or left ventricular mass) ❑ 24-hour urinary metanephrine and normetanephrine (elevated in pheochromocytoma) ❑ Plasma renin activity (PRA) (low renin suggests hyperaldosteronism) ❑ Plasma aldosterone (elevated in hyperaldosteronism) ❑ TSH ❑ Serum parathyroid hormone (PTH) (To evaluate parathyroid disease) ❑ Dexamethasone suppression test ❑ Unchanged levels of cortisol to high dose dexamethasone suggests Cushing's syndrome ❑ 24-hour urine free cortisol (elevated in Cushing's syndrome) ❑ TSH ❑ Renal duplex ultrasound and magnetic resonance angiography (MRA) of renal arteries ❑ To evaluate renal artery stenosis ❑ Chest CT angiography (To evaluate aortic coarctation) ❑ Sleep study with O2 saturation (To evaluate sleep apnea) ❑

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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