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 ❑ 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

References

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