EVALUATING

HYPERTENSION Dr A.Swalay FEDALLY.

. Nephrologist.
SSRN Hospital
25 June 2022
 Hypertension in adults (>18 years) is defined as
systolic blood pressure (SBP) of 140 mm of Hg or
greater and/or diastolic blood pressure (DBP) of 90
mm of Hg or greater, based on the average of two or
more properly measured, seated BP readings on
EVALUATING each of two or more visits.

HYPERTENSION For 90 percent of people with high blood pressure,

the cause of their hypertension is unknown — this is
. called essential, or primary, hypertension.
When a cause can be found, the condition is
called secondary hypertension.
 EVALUATING
HYPERTENSION
 History Taking.
Blood Pressure Measurement

EVALUATING The patient should record their blood pressure

recording for at least four days but ideally for seven
HYPERTENSION days.

. After 7-14 days discard the measurements taken on

the first day and use the average value of all the
remaining measurements to confirm a diagnosis of
HTN.
  Essential hypertension. 
This type of hypertension is diagnosed after a
doctor notices that your blood pressure is high on
three or more visits and eliminates all other causes

EVALUATING of hypertension.
Usually people with essential hypertension
HYPERTENSION have no symptoms, but you may experience

. frequent headaches, tiredness, dizziness, or nose

bleeds.
Although the cause is unknown, we do know
that obesity, smoking, alcohol, diet and heredity all
play a role in essential hypertension.
  Secondary hypertension. 
The most common cause of secondary
hypertension is an abnormality in the arteries
supplying blood to the kidneys.
Other causes include airway obstruction during

EVALUATING
sleep, diseases and tumors of the adrenal glands,
hormone abnormalities, thyroid disease, and too
HYPERTENSION much salt in the diet or alcohol.

. Drugs can cause secondary hypertension,

including over-the-counter medications such as
NSAIDs and pseudoephedrine.
The good news is that if the cause is found,
hypertension can often be controlled.
  Additional Hypertension Types: Isolated Systolic,
Malignant, and Resistant

EVALUATING Isolated systolic hypertension, malignant

HYPERTENSION hypertension, and resistant hypertension are all

recognized hypertension types with specific
. diagnostic criteria.
  Isolated systolic hypertension. 
Blood pressure is recorded in two numbers: The
upper, or first, number is the systolic pressure, which is
the pressure exerted during the heartbeat; the lower, or
second, number is the diastolic pressure, which is the
pressure as the heart is resting between beats. Normal
blood pressure is considered under 120/80.
EVALUATING With isolated systolic hypertension, the systolic
HYPERTENSION pressure rises above 140, while the lower number stays
near the normal range, below 90. This type of
hypertension is most common in people over the age of
65 and is caused by the loss of elasticity in the arteries.
The systolic pressure is much more important than
the diastolic pressure when it comes to the risk of
cardiovascular disease for an older person.
  Malignant hypertension. 
This hypertension type occurs in only about 1
percent of people with hypertension. It is more
common in younger adults, African-American men,
and women who have pregnancy toxemia.
Malignant hypertension occurs when your blood
EVALUATING pressure rises extremely quickly. If your diastolic
pressure goes over 130, you may have malignant
HYPERTENSION hypertension.
This is a medical emergency and should be
treated in a hospital.
Symptoms include numbness in the arms and
legs, blurred vision, confusion, chest pain, and
headache.
  Resistant hypertension. 
If your doctor has prescribed three different
types of antihypertensive medications and your
blood pressure is still too high, you may have
resistant hypertension.
Resistant hypertension may occur in 20 to 30
EVALUATING percent of high blood pressure cases.

HYPERTENSION Resistant hypertension may have a genetic

component and is more common in people who are
older, obese, female, African American, or have an
underlying illness, such as diabetes or kidney
disease.
  Descriptive Hypertension Terms
White coat hypertension and labile hypertension are terms that
have been used interchangeably to describe hypertension types that
come and go. These forms could indicate a higher risk for developing
hypertension, or they could just be a normal response. The term
"labile" means blood pressure that changes over time — a pretty
common occurrence for almost everyone.
The term "white coat hypertension" comes from the well-
studied phenomena that patients may have high blood pressure

EVALUATING when taken at their doctor's office or a clinic but have normal blood
pressure when taken at home.

HYPERTENSION Studies show this type of high blood pressure may affect as
many as 30 percent of the population. Because blood pressure can
vary, the recommendations are the need to have your blood pressure
documented at least three different times to accurately diagnose
hypertension. Another suggestion is to repeat high blood pressure
readings after 5 to 10 minutes.
 Evaluating
Hypertension.
 Evaluating  PHYSICAL EXAMINATION
Hypertension. IN HYPERTENSION
 Evaluating  Often there are no physical signs.

Hypertension.  However, a full examination for any signs of an

underlying condition or hypertension-mediated
organ damage is recommended. 
  This should include :
height,
weight,

Evaluating waist circumference,

Hypertension. palpation and auscultation of the heart and

carotid arteries,
palpation of peripheral pulses,
neurological examination, and

fundoscopy.
  A thorough physical examination should be
performed in the hypertensive patient to identify
Evaluating signs of end organ damage as well findings that

Hypertension. might suggest that the hypertension is secondary

to another disorder ( secondary hypertension)
such as renal artery stenosis.
 The physical examination should include:
 The physical examination should include:
 Vital Signs
Measurement of vital signs (temperature, pulse, respiratory rate, blood
pressure). Blood pressure should be measured according to appropriate technique.

Measurement of height, weight, waist and abdominal circumferences.

Calculation of BMI is required.

Evaluating  Head
Moon facies  suggests Cushing's syndrome

Hypertension.  Eyes
Examination of optic fundi to identify evidence of end organ damage such
as papilledema
 Neck
Auscultation of the suprasternal notch to ascertain if a bruit  suggestive
of coarctation  is present
 Palpation of thyroid gland to assess for hyperthyroidism
 Cardiac
Assess for end organ damage such as left ventricular hypertrophy and heart
failure.
  Abdomen
Auscultate for presence of an abdominal bruit they may suggest renal artery stenosis
Abdominal examination for enlarged kidneys, masses, distended urinary bladder, and
abnormal aortic pulsations that suggest an abdominal aortic aneurysm
 Pulses
The presence of coarctation is suggested by a radial femoral delay, a difference in the
strength of the pulse in the upper extremities (right stronger than left) and the following detailed
findings:

Evaluating Left subclavian proximal to coarctation: hypertension and normal pulses  in both arms

and hypotension  and diminished pulses in lower extremities (differential hypertension).

Hypertension.
Synchronous radial pulses, but radial-femoral delay will be present under palpation in either arm.
This may be appreciated best by simultaneous arm and leg pulse palpation.
Left subclavian distal to coarctation: hypotension and diminished pulses in left arm and
lower extremities. Asynchronous radial pulses will be detected in the right and left arms. A
brachial-femoral delay between the right arm and the femoral artery may be apparent, while no
such delay may be observed with left arm brachial-femoral palpation.
Both right and left subclavian artery originate below coarctation: blood pressure
and pulses decreased in all four extremities.
In mild cases though the pulses are palpable in all for extremities a brachial-femoral delay
can be appreciated.
Femoral pulses are often diminished in strength. Exercise exacerbates this gradient.
 Neurological assessment
Focal neurologic deficits suggestive of end organ damage should be noted
 Evaluating
Hypertension.  CardioVascular Risk Factors.
   Hypertension is a major risk factor for
cardiovascular disease (CVD) and typically
Evaluating coexists with other CVD risk factors and
Hypertension. unhealthy lifestyle behaviors, such
as smoking, diabetes, dyslipidemia,
overweight, physical inactivity, and
unhealthy diet.
 What are cardiovascular disease risk factors ?
 Family history
 Age
 Ethnicity
 Sex
Evaluating  Socioeconomic status

Hypertension.  Cholesterol
 High blood pressure
 Diabetes
 Smoking
 Physical inactivity
 Obesity
 Diet
  HMOD ( Hypertension-Mediated Organ
Evaluating Damage)

Hypertension. ----> End Organ Damage

  Hypertension mediated organ damage (HMOD)
Evaluating refers to structural or functional changes in

Hypertension. arteries or target organs that can be present in

long-standing hypertension, but it can be also
found in naïve never treated patients.
  The presence of hypertensive mediated organ

Evaluating damage is related to increased vascular risk and

mortality and its prevention should be a
Hypertension. therapeutic target and a surrogate marker of
in/adequate blood pressure control.
   In old adult hypertensive patients the therapeutic
target should be to prevent major cardiovascular

Evaluating events,

Hypertension.  but in young hypertensive subjects the focus

should be pointed on preventing the development
of hypertensive mediated organ damage, since
most of the hard events are preceded by
functional and structural tissues injury.
   Hypertension Guidelines of the International
Society of Hypertension recognizes that some
Evaluating variables like electrocardiographic or

Hypertension. echocardiographic left ventricle hypertrophy,

chronic kidney disease or advance retinopathy, all
considered as hypertensive mediated organ
damage,
 Evaluating
Hypertension.

ISH 2020
Risk Factors: Age (>65 y), sex (m>f), heart rate (>80 b/m), overweight, DM, high LDL-C/trig., family history of CVD,
family history of HBP, early-onset menopause, smoking, psychosocial or socioeconomic factors.

HMOD: LVH (LVH with ECG), (CKD; eGFR <60 ml/min/1.73m2), any other available measure of organ damage.

Disease: CHD, HF, stroke, peripheral vascular disease, AF, CKD Stage 3+
  Hypertension can lead to damage to numerous
Evaluating internal organs.

Hypertension.  The most susceptible, however, seem to be the

heart, central and peripheral arteries, kidneys,
central nervous system, and eyes.
 Evaluating  5 MAJOR ORGANS AFFECTED BY HIGH BLOOD

Hypertension. PRESSURE
  #1 THE EYES.
Hypertension over long periods of time
can result in constriction of the small arteries in the
eye.
This can cause damage to the retina in
the form of small hemorrhages. There also may be
Evaluating swelling of the optic nerve due to reduced blood

Hypertension. supply.
If high blood pressure continues for an
extended period of time, patients can develop
complete loss of visual acuity and eventually
blindness.
Hypertensive
Retinopathy
Hypertensive
Retinopathy.
  #2 THE BRAIN
The brain is full of blood vessels, so high blood
pressure can certainly lead to adverse effects on this
crucial organ.
Evaluating Hypertension can lead to small mini-strokes
Hypertension. and cognitive impairment disorders.
If left untreated, severe hypertension can
create ruptures in the tiny blood vessels in your
brain. Over time this may culminate into
a hemorrhagic stroke.
  #3 THE HEART
The heart is a muscle that must constantly
work to pump blood throughout your body.
Evaluating When the heart has to compensate for
Hypertension. irregular health problems with high blood pressure, it
can cause the heart to enlarge. An enlarged heart
may eventually lead to heart failure.
Severe high blood pressure can also lead to
a heart attack.
  #4 THE KIDNEYS
High blood pressure is a very common
Evaluating cause of kidney disease in the world.

Hypertension It can result in chronic kidney disease and

eventually progress into end stage kidney disease,
especially in the African-American population.
  #5 BLOOD VESSELS
Long-standing high blood pressure can lead
to enlargement of the large blood vessels, including
Evaluating the aorta.

Hypertension Those at higher risk include diabetics,

patients with high cholesterol, and patients with
vascular disease.
 Evaluating  SECONDARY HYPERTENSION
Hypertension
  Secondary hypertension is a type
of hypertension which by definition is caused by
an identifiable underlying primary cause.
 It is much less common than the other type,
Evaluating called essential hypertension, affecting only 5-10%

Hypertension of hypertensive patients.

 It has many different causes including endocrine
diseases, kidney diseases, and tumors.
 It also can be a side effect of many medications.
 Evaluating  TYPES OF SECONDARY
Hypertension HYPERTENSION.
  KIDNEY
1.--- Renovascular hypertension.
Renovascular hypertension is a condition in

Evaluating which high blood pressure is caused by the kidneys

hormonal response to narrowing of the arteries
Hypertension. supplying the kidneys.
It has two main causes : fibromuscular dysplasia
and atherosclerosis of the renal artery resulting in
stenosis.
 2. ----Diseases of the kidney.
 polycystic kidney disease

Evaluating   glomerulonephritis

Hypertension.  renal tumors

 Chronic kidney disease.
 Renal segmental hypoplasia.
  Hypertension secondary to endocrine
disorders.
1. ----Neurogenic hypertension.

Evaluating -- excessive secretion of norepinephrine and

epinephrine which
Hypertension. promotes vasoconstriction resulting from chronic
high activity of the sympathoadrenal system,
the sympathetic nervous system and the adrenal
gland.
 2. ----Pheochromocytoma
– a tumor which results in an excessive secretion
of norepinephrine and epinephrine which promotes
vasoconstriction.
Evaluating 3. ----Hyperaldosteronism (Conn's syndrome)
Hypertension. – idiopathic hyperaldosteronism, liddle's
syndrome (also called pseudoaldosteronism),
glucocorticoid remediable aldosteronism.
 4. ---- Cushing's syndrome
 – an excessive secretion of glucocorticoids
causes the hypertension

Evaluating 5. ---- Hyperparathyroidism

6. ---- Acromegaly
Hypertension. 7. ---- Hyperthyroidism
8. ---- Hypothyroidism
  Adrenal
A variety of adrenal cortical abnormalities can
cause hypertension, In primary aldosteronism, there
is a clear relationship between the aldosterone-
induced sodium retention and the hypertension.
1. ---- Congenital adrenal hyperplasia, a group of

Evaluating autosomal recessive disorders of the enzymes

responsible for steroid hormone production, can lead
Hypertension. to secondary hypertension by creating atypically
high levels of mineralocorticoid steroid hormones.
These mineralocorticoids cross-react with the
aldosterone receptor, activating it and raising blood
pressure.
2. ----  Cushing's syndrome.
 Other secondary hypertension
 Hormonal contraceptives
 Neurologic disorders
 Obstructive sleep apnea
 Liquorice (when consumed in excessive amounts)

Evaluating  Scleroderma

Hypertension.  Neurofibromatosis
 Pregnancy: unclear cause.
 Cancers: tumours in the kidney can operate in the
same way as kidney disease. More commonly,
however, tumors cause inessential hypertension by
ectopic secretion of hormones involved in normal
physiological control of blood pressure.
  Drugs: In particular, alcohol, nasal decongestants
with adrenergic effects, NSAIDs, MAOIs,
adrenoceptor stimulants, and combined methods

Evaluating of hormonal contraception (those containing

ethinylestradiol) can cause hypertension while in
Hypertension. use.
 Heavy alcohol use
 Steroid use
 Nicotine use.
  Malformed aorta, slow pulse, ischemia: these
cause reduced blood flow to the renal arteries,
with physiological responses.
 Coarctation of the aorta
 Atherosclerosis
Evaluating  Anemia: unclear cause.
Hypertension.  Fever: unclear cause.
 White coat hypertension, that is, elevated blood
pressure in a clinical setting but not in other
settings, probably due to the anxiety some people
experience during a clinic visit.
  Perioperative Hypertension is development of

Evaluating
hypertension just before, during or after surgery. It
may occur before surgery during the induction
Hypertension. of anesthesia; intraoperatively e.g. by pain-
induced sympathetic nervous system stimulation.
 Perioperative Hypertension
 In the early post-anesthesia period, e.g. by pain-
induced sympathetic
stimulation, hypothermia, hypoxia,

Evaluating or hypervolemia from excessive intraoperative

fluid therapy; and in the 24 to 48 hours after the
Hypertension. postoperative period as fluid is mobilized from the
extravascular space. In addition, hypertension
may develop perioperatively because of
discontinuation of long-term antihypertensive
medication.
  Medication side effects.
 NSAIDs and steroids can cause hypertension.
Other medications include estrogens (such as
Evaluating those found in oral contraceptives with high
estrogenic activity)
Hypertension. Certain antidepressants such as venlafaxine,
carbamazepine, bromocriptine, and cyclosporine.
 Medications side effects

HBP that is associated with the

sudden withdrawal of
various antihypertensive medications is called
Evaluating rebound hypertension.

Hypertension. Rebound hypertension may result in

a hypertensive emergency.
Rebound hypertension is avoided by gradually
reducing the dose (also known as "dose tapering")
  Pregnancy
Few women of childbearing age have high blood
pressure, up to 11% develop hypertension of
pregnancy. While generally benign, it may herald
three complications of pregnancy: pre-
eclampsia, HELLP syndrome and eclampsia.
Evaluating Follow-up and control with medication is therefore

Hypertension. often necessary

 Sleep disturbances.
Another common and under-recognized cause of
hypertension is sleep apnea, which is often best
treated with nocturnal nasal continuous positive
airway pressure (CPAP).
  Arsenic exposure.
Because of the ubiquity of arsenic in ground
water supplies and its effect on cardiovascular
health, low dose arsenic poisoning should be
Evaluating inferred as a part of the pathogenesis of idiopathic
hypertension.
Hypertension. Arsenic exposure has also many of the same
signs of primary hypertension such as headache,
somnolence, confusion, proteinuria, visual
disturbances, and nausea and vomiting.
  Potassium deficiency

Evaluating Due to the role of intracellular potassium in

regulation of cellular pressures related to sodium,
Hypertension. establishing potassium balance has been shown to
reverse hypertension.
 Evaluating
Hypertension.