Chronic hypertension resident survival guide

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

Overview

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

Causes

Life Threatening Causes

Common Causes

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

Hemorrhage
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 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 (may be high or low in hypo- and hyperthyroidism, respectively)
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 free urinary 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

Do's

Don'ts

References


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