Definition
Persistent rise of arterial BP above the arbitrarily normal range. If systolic blood pressure > 140 mm Hg, diastolic BP > 90 mm Hg, the patient is diagnosed as hypertensive.
Causes
1. Primary or essential hypertension (95%)—cause unknown.
2. Secondary (5%)—
a. Renal (most common secondary cause)—
— Chronic glomerulonephritis.
— Chronic pyelonephritis.
— Diabetic nephropathy.
— Adult polycystic kidney disease.
— Renal artery stenosis.
b. Endocrine—
— Cushing’s syndrome.
— Conn’s syndrome (primary aldosteronism).
— Phaeochromocytoma.
— Congenital adrenal hyperplasia.
— Hyperparathyroidism.
— Primary hypothyroidism.
— Hyperthyroidism.
— Acromegaly.
c. Drugs—
— Alcohol.
— Oral contraceptive pill.
— Steroid.
— Erythropoietin.
3. Others—
–– Preeclampsia and eclampsia (toxaemia of pregnancy).
–– Pregnancy-induced hypertension.
–– Coarctation of aorta.
–– Cerebral tumour.
Clinical Features
Symptoms
• May be asymptomatic, detected during a routine examination.
• Headache, dizziness, giddiness, insomnia, blurring of vision.
• Features of complications—heart failure, CVD, renal failure etc.
Complications of Hypertension
1. Cardiovascular—
–– Ischaemic heart disease.
–– Acute left ventricular failure.
–– Dissecting aneurysm.
2. Renal—
–– Renal failure.
3. Ocular—
–– Retinopathy.
4. Neurological—
–– CVD (intracerebral haemorrhage)
–– Subarachnoid haemorrhage.
–– Hypertensive encephalopathy.
Investigations in Hypertension
History
1. Age: If young, likely to be secondary cause. If elderly, likely to be primary.
2. Family history: Family history of hypertension, hyperlipidaemia, diabetes mellitus, obesity,
etc. may be present in primary hypertension. In some secondary hypertension, there may
be positive family history, e.g. polycystic kidney disease.
3. Past medical history: Previous history of renal disease (haematuria, UTI, renal trauma, pain,
pyelonephritis), toxaemia of pregnancy (in females).
4. Drug history: Prolong use of NSAIDs, steroids, oral contraceptive pill, etc.
5. Smoking and alcohol.
6. Symptoms to find out the secondary cause:
–– Symptoms of renal disease like polyuria, frequency, haematuria, loin pain.
–– Paroxysmal attack of headache, palpitation, flushing and sweating (phaeochromocytoma).
–– Polyuria, polydipsia, extreme muscular weakness, tingling (Conn’s syndrome).
–– Weight gain, hirsutism, striae, menstrual abnormality in female (Cushing’s syndrome).
–– Claudication and cramp in lower limbs in young patient (coarctation of aorta).
–– Frequent attacks of headache, vomiting, visual disturbance, neurological features (intracranial tumour).
Physical findings which indicate specific cause—
• Puffy face—renal failure.
• Central obesity with plethoric moon face, hirsutism, striae—Cushing’s syndrome.
• Pulse—bradycardia suggests raised intracranial pressure, feeble pulse in lower limbs with
radiofemoral delay found in coarctation of aorta.
• BP—high BP in upper limbs but low in lower limbs suggest coarctation of aorta.
• Anaemia—suggests chronic renal failure.
• Oedema—may be present in renal failure.
• Cardiovascular system—apex beat may be heaving and shifted (left ventricular hypertrophy),
murmur may be present in coarctation of aorta.
• Abdomen—bilateral renal mass in polycystic kidney disease, renal bruit in renal artery
stenosis.
• Fundoscopy.
• Other finding according to suspicion of cause like intracranial mass.
• Bed side urine examination for haematuria and proteinuria.
Laboratory Investigations
1. Routine—
–– Urine R/M/E—to see protein, RBC cast, pus cell.
–– Blood urea, creatinine.
–– Serum electrolytes.
–– Fasting blood sugar.
–– Serum lipid profile (total serum cholesterol, VLDL, LDL, HDL, triglyceride).
–– X-ray chest PA view.
–– ECG.
–– Echocardiogram.
2. Other investigations according to suspicion of cause—
–– If renal cause—ultrasonogram of kidney, IVU, CT scan of renal system, isotope renogram.
–– Cushing’s syndrome—serum cortisol level, 24-hour urinary cortisol, ACTH, dexamethasone
suppression test, etc.
–– Phaeochromocytoma—24 hours urinary VMA, serum catecholamines, USG, CT/MRI of suprarenal gland.
–– Conn’s syndrome—plasma aldosterone and renin.
–– Coarctation of aorta—CT scan, aortogram.
Treatment of Hypertension
1. General measures (nondrug treatment):
–– Salt restriction (<6 g/day).
–– Smoking should be stopped.
–– Weight reduction in obese patient.
–– Dietary modification—low fat, consumption of more fruits and vegetables.
–– Regular exercise (at least 30 minutes daily).
–– Avoid anxiety and tension.
–– Control of diabetes mellitus.
–– Restriction of tea and coffee.
–– Restriction of alcohol intake (<21 units/week for men and <14 units/week for women).
–– Control of other modifiable risk factors.
2. Drug treatment:
–– Diuretic—thiazide (bendroflumethiazide).
–– ACE inhibitor- enalapril, lisinopril, ramipril.
–– ARB—losartan, valsartan, irbesartan.
–– Calcium channel blocker—amlodipine, nifedipine, diltiazem, verapamil.
–– Beta-blocker—atenolol, metoprolol, bisoprolol.
–– Combined alpha- and beta-blocker—labetalol, carvedilol.
–– Alpha-blocker—prazosin.
–– Others—Methyldopa (used in pregnancy).
3. Management of primary cause, if any.