HYPERTENSION CLINICAL PRESENTATION & INVESTIGATIONS

1. Dr. Zahoor Ali Shaikh HYPERTENSION CLINICAL PRESENTATION & INVESTIGATIONS

2. HYPERTENSION DEFINITION • Hypertension is said to be present when blood pressure is greater than expected for a person of particular age, sex and race on at least three separate occasions under resting condition whether symptoms are present or not.

3. HYPERTENSION IMPORTANT INFORMATION • Elevated arterial BP is major cause of pre-mature vascular disease leading to cerebrovascular events, ischemic heart disease and peripheral vascular disease. • BP is characteristic of each person. • BP varies with age and ethnic background. • BP increases with age.

4. HYPERTENSION • Hypertension is one of the commonest chronic condition in the developed countries. • It may be present up to 20-30% of adult population. • In black Africans – hypertension may affect 40-50% of adult population. • Hypertension is affecting one billion people world wide.

5. HYPERTENSION • Most common cause for an outpatient visit to the physician. • High BP is associated with high mortality and morbidity. • All adults should have BP measured routinely every 2 years.

6. HYPERTENSION • Seated BP should be measured after 5 mins of rest. • In diabetes mellitus, old age – standing BP should be measured to exclude postural hypotension.

7. HYPERTENSION Presentation • Patient with mild hypertension is usually asymptomatic. • BP maybe detected on routine examination. • Patient may present with headache, Epistaxis.

8. HYPERTENSION Presentation may be due to complications of hypertension • Patient may present with breathlessness due to left ventricular failure or cardiac failure. • Patient may present with renal failure. • Patient may present stroke.

9. HYPERTENSION • Presentation maybe headache, palpitation, sweating – they occur in paroxysmal attacks, which may point to diagnosis of phaeochromocytoma.

10. HYPERTENSION • Malignant hypertension may present with severe headache, visual disturbance, fits, transient loss of consciousness or symptoms of heart failure. IMPORTANT NOTE • Malignant Hypertension if not controlled, survival less than ONE –TWO YEARS due to CVA, Heart Failure, Chronic Renal Failure

11. HYPERTENSION Examination of patient to look for cause and effects of increase BP on organs • Increased BP maybe only abnormal sign. Look for underlying effect • Cardiac examination may reveal left ventricular hypertrophy. • Signs of cardiac failure maybe there.

12. HYPERTENSION Look for underlying cause • Renal artery bruits maybe present due to renal artery stenosis. • Radio femoral delay is present in Coarctation of aorta. • Look at the fundus.

13. HYPERTENSION • Fundascopy is essential part of examination in hypertensive patient. • There are four grades of abnormality according to the Keith-Wagener classification. Grade 1 – Tortuosity of retinal artery (silver wiring) Grade 2 – Grade 1 + A:V nipping (arteriovenous nipping) Grade 3 – Grade 2 + flame shaped hemorrhage and soft (cotton wool) exudates Grade 4 – Grade 3 + papilloedema

14. NORMAL FUNDUS

15. Fundus of Hypertensive Patient

17. HYPERTENSION Investigations in Hypertension • Chest X-ray • ECG • Echocardiogram • Urinalysis • Serum urea, creatinine and electrolytes • Fasting blood glucose and lipids

18. HYPERTENSION Further investigations • If urea or creatinine are increased then creatinine clearance should be done. • Renal angiography if renal artery stenosis is suspected.

19. HYPERTENSION Investigations [cont] • If serum potassium is low and Hyperaldosteronism is suspected or Glucocorticoids excess then do - Aldosterone level - Cortisol level - Renin level

20. HYPERTENSION Investigations [cont] • If phaeochromocytoma is suspected then do - urinary metanephrins - plasma or urinary catecholamines

21. HYPERTENSION Investigations [cont] • ECG may show evidence of coronary artery disease e.g. IHD or left ventricular hypertrophy.

22. NORMAL ECG

23. ISCHEMIC HEART DISEASE

24. HYPERTENSION Investigations [cont] • X-ray chest may show cardiomegly.

25. HYPERTENSION • X-ray chest may show Rib notching – which is sign of Coarctation of aorta, if so, do MRI.

26. NORMAL X-RAY CHEST

27. X-RAY CHEST IN HEART FAILURE

28. In Coarctation of the aorta, the dilated LSCA, indentation of coarct and post-stenotic aortic dilation form “3”

29. HYPERTENSION Assessment and Treatment of Hypertension • There are three stages 1. Assessment 2. Non-pharmacological treatment 3. Drug treatment

30. HYPERTENSION • Assessment • Excludes secondary causes of hypertension. • Evaluate target organ damage e.g. heart, kidney, retina. • Look for diabetes mellitus, hypercholestermia.

31. HYPERTENSION 2.Non-pharmacological treatment • Reduce weight if over-weight or obesity • Decrease sodium intake in diet • Use low-fat diet • Exercise • Increase fruit and vegetable

32. HYPERTENSION 3.Drug treatment • Diuretics • Beta blockers • ACEI (angiotensin converting enzyme inhibitors) • Angiotensin II receptor blocker (ARB) • Calcium blockers

33. HYPERTENSION 3.Drug treatment (cont) • Alpha blockers(cause vasodilatation) • Vasodilators(act on smooth muscle of blood vessel) • Sodium nitroprusside – potent arterial and venous dilator (used intravenously in hypertensive crises) • Centrally acting drugse.g. methyl dopa – acts on central α2 receptors

35. THANK YOU