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

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HYPERTENSION CLINICAL PRESENTATION & INVESTIGATIONS

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Dr zahoor ali shaikh

Dr. Zahoor Ali Shaikh

HYPERTENSION CLINICAL PRESENTATION & INVESTIGATIONS


Hypertension

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.


Hypertension1

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.


Hypertension2

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.


Hypertension3

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.


Hypertension4

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.


Hypertension5

HYPERTENSION

Presentation

  • Patient with mild hypertension is usually asymptomatic.

  • BP maybe detected on routine examination.

  • Patient may present with headache, Epistaxis.


Hypertension6

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.


Hypertension7

HYPERTENSION

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


Hypertension8

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


Hypertension9

HYPERTENSION

Examination of patient to look for cause and effects of increase BP on organs

  • Increased BP maybe only abnormal sign.

    Look for underlying cause

  • Cardiac examination may reveal left ventricular hypertrophy.

  • Signs of cardiac failure maybe there.


Hypertension10

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.


Hypertension11

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


Hypertension clinical presentation investigations

NORMAL FUNDUS


Fundus of hypertensive patient

Fundus of Hypertensive Patient


Hypertension12

HYPERTENSION

Investigations in Hypertension

  • Chest X-ray

  • ECG

  • Echocardiogram

  • Urinalysis

  • Fasting blood glucose and lipids

  • Serum urea, creatinine and electrolytes


Hypertension13

HYPERTENSION

Further investigations

  • If urea or creatinine are increased then creatinine clearance should be done.

  • Renal angiography if renal artery stenosis is suspected.


Hypertension14

HYPERTENSION

Investigations [cont]

  • If serum potassium is low and Hyperaldosteronism is suspected or Glucocorticoids excess then do

    - Aldosterone level

    - Cortisol level

    - Renin level


Hypertension15

HYPERTENSION

Investigations [cont]

  • If phaeochromocytoma is suspected then do

    - urinary metanephrins

    - plasma or urinary catecholamines


Hypertension16

HYPERTENSION

Investigations [cont]

  • ECG may show evidence of coronary artery disease e.g. IHD or left ventricular hypertrophy.


Hypertension clinical presentation investigations

NORMAL ECG


Hypertension clinical presentation investigations

ISCHEMIC HEART DISEASE


Hypertension17

HYPERTENSION

Investigations [cont]

  • X-ray chest may show cardiomegly.


Hypertension18

HYPERTENSION

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


Hypertension clinical presentation investigations

NORMAL X-RAY CHEST


Hypertension clinical presentation investigations

X-RAY CHEST IN HEART FAILURE


Hypertension clinical presentation investigations

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


Hypertension19

HYPERTENSION

Assessment and Treatment of Hypertension

  • There are three stages

    1. Assessment

    2. Non-pharmacological treatment

    3. Drug treatment


Hypertension20

HYPERTENSION

  • Assessment

  • Excludes secondary causes of hypertension.

  • Evaluate target organ damage e.g. heart, kidney, retina.

  • Look for diabetes mellitus, hypercholestermia.


Hypertension21

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


Hypertension22

HYPERTENSION

3.Drug treatment

  • Diuretics

  • Beta blockers

  • ACEI (angiotensin converting enzyme inhibitors)

  • Angiotensin II receptor blocker (ARB)

  • Calcium blockers


Hypertension23

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


Thank you

THANK YOU


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