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HYPERTENSION. Presented BY :. Objectives. Identify differential diagnosis of a case presented with the symptoms of lower limb oedema . Differentiate between different etiologies of hypertension. Discuss briefly between stages of hypertension.

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Presented BY :


  • Identify differential diagnosis of a case presented with the symptoms of lower limb oedema.

  • Differentiate between different etiologies of hypertension.

  • Discuss briefly between stages of hypertension.

  • Enumerate and discuss the importance signs& symptoms in patients with hypertension.

  • Investigate appropriately apatient with hypertension.

  • Advice initial management plan for a patient with hypertension according to recent guidelines (NICE 127).

  • Discuss non-drug management of hypertension.

  • Identify long term complications of hypertension.


A 50-year-old woman presents to your clinic for routine follow-up. She has a history of diabetes mellitus and hypertension for ~ 20 years. She mentions that she has noted fatigue and increased

swelling in her lower extremities during the past several weeks.


- Lisinopril 10 mg p.o. q.i.d.

- NPH insulin 20 units s.c. Q. a.m. and 10 units s.c. q. p.m.

- Regular insulin 5 units s.c. Q. a.m..


On exam she appears to be in no apparent distress. Her height is153 cm and weight is 100kg.

Blood pressure is 165/98 mmHg, pulse 85/minute and respirations 20/minute.

Fundoscopic exam reveals diabetic retinopathy. There were no visible hemorrhages or papilledema.

Cardiac exam was remarkable for an S1, S2 and S4.

Lungs were clear to auscultation and percussion.

Abdomen was obese, non-tender and without masses or bruits. Lower extremities had good pulses with 3+ pitting edema. Neurological exam is remarkable for decreased sensation in a stocking-glove distribution, otherwise intact.


Significant morbidity and mortality

- CAD including MI and CHF

- Stroke

- Chronic kidney disease

Why Do We Care?

Heart disease is still leading cause of death


Why Do We Care?

comprehensive investiga­tions for blood pressure assessment in 35 areas of Saudi Arabia.

Applying the criteria of W.H.O. of blood pressure > 160/95 mmHg as hypertension

measured systolic and diastolic blood pressure in 14,660 adult Saudis (6,162 males and 8,498 females)

they found prevalence Among the adults (> 18 years), 5.3% had systolic hypertension, while 7.9% had diastolic hypertension.

The majority (>75%) of those with hypertension were 40 years of age or older.

In the age group 40-75 years, they found that a higher prevalence of :

- systolic hypertension : Females > Males (15.7%)

- diastolic hypertension: Males > Females (8.2%)


Out of 65% of people over age 60 diagnosed with hypertension :

Only 1 in 4 of these individuals are taking adequate medication

Framingham data suggests that individuals who are normotensive at age 55 have a 90% lifetime risk of developing HTN

  • HTN is VERY prevalent


Common Causes of Leg Edem




Less Common Causes of Leg Edem




What is Hypertension?

A term used to describe high blood pressure.

Blood pressure is a measurement of the force against the walls of the arteries as the heart pumps

blood through the body.

The risk of morbidity and mortality increases progressively with increasing systolic and diastolic

blood pressure..


Risk factors

Non- modifiable factors


Advanced age

Fetal factor & family history

Gender-related risk patterns

Black people.

especially those 60 years and older

Men and postmenopausal women

Babies born with low birth weight get high BP

Family history of hypertension and CVS diseases


Risk factors

Modifiable factors




Increase alcohol consumption

Increase salt intake

increase sympathetic activity

lepton hormone derived from adipose tissue, causes increase sympathetic activity via hypothalamus

systolic BP is affected more.

causes increase blood volume, increase cardiac output, increase peripheral resistance





hypertensive crisis :

(BP >180/120 mm Hg) may be categorized as either -hypertensive emergency (extreme BP elevation with acute or progressing target organ damage)

-hypertensive urgency (severe BP elevation without acute or progressing target organ injury).

- Malignant hypertensionwhen diastolic BP more than 130mmHg. Unless treated, it may lead to death due to renal failure, heart failure or stroke.



- BP must be measured correctly

- Feet on floor

- Both arms if elevated

- Cuff bladder must circle at least 80% of the arm

- Arm supported at level of heart

- Back supported

-Measure blood pressure in both arms

To Make The Diagnosis


To Make The Diagnosis

In clinic: -IF blood pressure ( 140/90 mmHg ) or higher confirm by . ambulatory blood pressure monitoring (ABPM)

> least 2 measurements/ hr during person’s waking hours

> average value of at least 14 measurements taken to confirm HTN

:At home

Use home blood pressure monitoring (HBPM) to confirm a diagnosis of hypertension

> blood pressure is recorded twice daily ( morning/evening )

> blood pressure recording continues for at least 4 days, ideally for 7 days

Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension.





To Make The Diagnosis

Postural hypotension

● In people with symptoms of postural hypotension (falls or postural dizziness):

− measure blood pressure with the person either supine or seated

− measure blood pressure again with the person standing for at least 1 minute prior to measurement.

● If the systolic blood pressure falls by 20 mmHg or more when the person is standing:

− review medication

− measure subsequent blood pressures with the person standing

− consider referral to specialist care if symptoms of postural hypotension persist.


1) Primary (essential) Hypertension:

Has no known cause (idiopathic)

Multi-factorial etiology :

1.Genetic Factors

- Positive Family History

2. Environmental Factors


-Increased Sodium Intake


- Increased Alcohol Intake

-95% of hypertensive patient fall into this category.


2) Secondary Hypertension:

Due to an underlying medical condition

Chronic alcohol abuse






2) Secondary Hypertension:


- Polycystic disease

- Renal artery stenosis

- Renin-producing tumors

- Chronic renal disease

- Renal vasculitis


2) Secondary Hypertension:


-Adrenocorticalhyperfunction (Cushing syndrome, primary aldosteronism,congenital adrenal hyperplasia)

-Exogenous hormones (glucocorticoids, estrogen)






2) Secondary Hypertension:


-Coarctationof aorta


- Increased intravascular volume


2) Secondary Hypertension:


- Steroids

- Oral contraceptives

- Amphetamines and cocaine


- Psychiatric: carbamazepine, lithium and tricyclic antidepressants


1) Severe headache

2) Fatigue or confusion

3) Vision problems

4) Chest pain

5) Difficulty breathing

6) Irregular heartbeat

7) Hematuria

8) Lower limb edema


Note :

Patients with pheochromocytoma may have a history of paroxysmal headaches, sweating, tachycardia, palpitations, and orthostatic hypotension.


  • HTN Investigations


  • HTN Investigations

Optional laboratory tests:

Aortic Coarctation

- Arm to leg systolic Blood Pressure difference (abnormal if >20 mmHg)

- Chest X-Ray (notching of the lower rib borders)

- Echocardiogram (Children)

- MRI Chest (Adults)

Cushing's Disease

-24 hour Urine Cortisol

- Late night Salivary cortisol

- Low dose Dexamethasone Suppression Test


-24h Urine Metanephrine

- Plasma free metanephrines


  • HTN Investigations

X-rays :

-May show cardiomegaly



  • HTN Investigations

Specialist investigations

● Refer people to specialist care the same day if they have:

− accelerated hypertension (BP > 180/110 mmHg ) with signs of papilloedema and/or retinal haemorrhage)

− suspected phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor and diaphoresis).

● If nedded more investigations for secondary cause of hypertension.



  • 1st Life Style Modifications

1) Weight reduction (BMI, 18.5 to 24.9 kg/m2)

2) Adoption of the Dietary Approaches to Stop

Hypertension (DASH) eating plan :

- Low content of saturated fat, cholesterol, and total fat

- Focuses on fruits, vegetables, and fat-free or low-fat dairy products

- Rich in whole grains, fish, poultry, beans, seeds, and nuts

- Contains fewer sweets, added sugars and sugary beverages, and red meats

- Dietary sodium restriction ideally to 1.5 g/day


  • 1st Life Style Modifications

4) Regular aerobic physical activity.

5) Moderate alcohol consumption (2 or fewer drinks/day).

6) Smoking cessation

7) Do not offer calcium, magnesium or potassium supplements as a method of reducing blood pressure


  • How Much Will This Help?


  • 2nd Pharmacological Treatment

HNT Drugs

ACE inhibitors

β-blockers (BB).

thiazide diuretics

calcium antagonists (CA)

angiotensin receptor antagonists (ARB)

*Will lower BP and reduce the complications of HTN


  • 2nd Pharmacological Treatment

I) Thiazide diuretics:

  • ● Where to start?

    • - Hydrochlorothiazide 12.5 mg

    • - Chlorthalidone 12.5 mg

  • ● How much ?

    • - Up to 25 mg, unclear benefit beyond that

  • ● Cost? Cheap!

  • ● Side effects -- hypokalemia, glucose intolerance


Where to start?

- Lisinopril10 mg QD

- Benazapril10 mg QD

- Enalapril5 mg QD

● How much?

- Up to 80 mg (only 40 mg for enalapril)

● Cost -- cheap!

● Side effects -- cough

  • 2nd Pharmacological Treatment

2) ACE Inhibitors


Where to start?

- Amlodipine5 mg QD

- DiltiazemER 120 mg QD

- NifedipineER 30 mg QD

● How much ?

- Amlodipine10 mg QD

- DiltiazemER 540 mg QD

- NifedipineER 120 mg QD

● Cost ?

- Amlodipineis generic

- Diltiazem=cheap!

- Nifedipine-less cheap

● Side effects ?

- edema

- constipation

  • 2nd Pharmacological Treatment

3) CCBs


Where to start?

- Not with beta blockers

● Why not?

- Possible increase in stroke risk, particularly in

elderly patients

- first-line alternatives in patients who are 60 years and older, especially for stroke prevention.

  • 2nd Pharmacological Treatment

3) Beta Blockers


Where to start?

- Metoprolol25 mg BID

- Atenolol25 mg QD

● How much ?

- Up to 100 mg

● Cost -- cheap!

● Side effects -- bradycardia, fatigue, depression

  • 2nd Pharmacological Treatment

3) Beta Blockers


ARBs (losartan is generic but still pricey)

● Alpha blockers

● Aldosteroneantagonists

  • 2nd Pharmacological Treatment

Even More Meds

ACE inhibitors and ARBs not as effective in African-Americans


indications and contraindicationsof medications


indications and contraindicationsof medications


Labs: Potassium and Creatinine, maybe sodium

● at initiation of treatment

● 2-4 weeks after starting

● Again after every dose adjustment

● Annually


long term complications


End organ Damage with HTN



formation of fibro fatty lesions in the intimal lining of the large and medium sized arteries such as aorta and its branches, coronary arteries and cerebral arteries

2)Stroke or Heart Attack:

If an atherosclerotic plaque breaks off inside the artery, or the blood vessel ruptures, a blood clot can form within the artery. If this blocks blood flow to the brain it can lead to a stroke. If it blocks blood flow to the heart it can result in a heart attack.



This is when the blood vessels have been weakened to such an extent that part of the blood vessel wall ‘balloons’ or bulges. The most common locations for an aneurysm include the main artery that carries blood from the heart, arteries in the

brain, legs, intestines, and the arteries leading to the spleen

4)Vascular dementia:

High blood pressure can cause the blood vessels that supply your brain with blood to narrow or become damaged. If the brain is not supplied with enough oxygen due to stroke, cells in the brain may be damaged causing adverse effects on a person’s memory, thinking, or language skills. This condition is called vascular dementia


5) Hypertensive retinopathy :


- Kumar & Clark's Clinical Medicine (Saunders, 2009)

- Davidson's Principles and Practice of Medicine 21st Edition

- Pharmacotherapy 7th edition McGraw Hill Dipiro

- NICE quick reference HTN



Have a Nice Day ^_^