DIAGNOSIS & ASSESSMENT

OF HYPERTENSION

Stella Palar
Aim for evaluation
Diagnose Hypertension
Detect the risk & contributing factors
Baseline for laboratory value that can be
affected by anti hypertensive medicine
Detect any organ damage
Evaluate the cause of secondary
hypertension
DIAGNOSIS
 Diagnosis of Hypertension

Hypertension is defined as:

- BP 140/90 mm Hg
- during 1-5 visits
- with an average of 2 readings per visit
 Data Supported Diagnosis

Anamnesis
Family History
Age
Others:
Related to risk factor of hypertension
High sodium intake
Data of current medicine
In women: history of hypertension on
pregnancy, contraceptive pills
Other previous medical history
 Symptoms

Headache
Dizziness
Fatigue
Pounding of the heart
Symptoms are not specific and no more
frequent than in patients with normotension.
Symptoms of complications : heart failure,
chest pain, claudication, vision
The physical examination
An appropriate measurement of BP, with verification in the
contralateral arm
Examination of the optic fundi
Calculation of body mass index (BMI)
Auscultation for carotid, abdominal, and femoral bruits
Palpation of the thyroid gland
Examination of the heart and lungs
Examination of the abdomen for enlarged kidneys, masses,
and abnormal aortic pulsation
Palpation of the lower extremities for edema and pulses
Neurological assessment.
Laboratory Tests and
Other Diagnostic Procedures
Routine tests
Electrocardiogram
Urinalysis
blood glucose and hematocrit
serum potassium, creatinine (or the corresponding estimated
glomerular filtration rate [GFR]), Calcium
lipid profile, after 9- to 12-hour fast, that includes high
density lipoprotein cholesterol and low-density lipoprotein
cholesterol, and triglycerides.
Optional tests
measurement of urinary albumin excretion or
albumin/creatinine ratio.
More extensive testing for identifiable causes is not indicated
generally unless BP control is not achieved.
CLINICAL ASSESSMENT
 Assessment of Hypertensive
Patients

Contributing & risk factors

Causes of secondary hypertension

Complications of hypertension / target organ

damage

Cardiovascular risk
 Assessment of Hypertension
CONTRIBUTING FACTORS :
Dislipidemia
Disglycemia (e.g. impaired fasting glucose, diabetes)
Obesity
Unhealthy eating
Physical inactivity

2009 Canadian Hypertension Education Program

Recommendations
 RISK FACTORS OF HYPERTENSION :
1. Age: Blood pressure increase equal to the age
starting at age 40
2. Race: black race has higher prevalence
compared to white race, there also variation
between the culture in Indonesia; the lowest in
Lembah Bailem Jaya, Papua (0,6%), and the
highest in Sukabumi, West Java (28,6%)
3. Urban/rural: more in the urban area
4. Geographic: beach > mountain
5. Sex : female > male
6. Obesity : Fat > lean
7. Stress
8. Personality type A : type A > type B
9. Diet : high salt diet
10. Diabetes Mellitus
11. Water composition :
- Sodium (natrium): inconsistent
- Cadmium : evidence in some study
- Lead (Plumbum) : probably has relationship
12. Alcohol:
- high prevalence if > 3x/day
- moderate drinker was thought to have
protective effect
13. Smoking: related but not significant
14. Caffeine: not clear
15. Contraceptive Pills: risk increase with
the duration of pills consumption.
16. Family history of hypertension
 Activity and Blood Pressure
SBP DBP
Activity
(mmHg) (mmHg)
Relaxing 0.0 0.0
Sleeping -10.0 -7.6
Television + 0.3 + 1.1
Reading + 1.9 + 2.3
Talking + 6.7 + 6.7
Eating + 8.8 + 9.6
Walking + 12.0 + 5.5
Meetings + 20.2 + 15
 Search for exogenous potentially modifiable factors that can
induce/aggravate hypertension
Prescription Drugs:
NSAIDs, including COXIBS (e.g. celecoxib)
Corticosteroids and anabolic steroids
Oral contraceptive and sex hormones
Vasoconstricting/sympathomimetic decongestants
Calcineurin inhibitors (cyclosporin, tacrolimus)
Erythropoietin and analogues
Monoamine oxidase inhibitors (MAOIs)
Other sympathomemetics e.g. Midodrine

Other:
Licorice root
Stimulants including cocaine
Salt
Excessive alcohol use
Sleep apnea

2009 Canadian Hypertension Education Program Recommendations

 Preliminary Investigation
1. Blood glucose
2. Lipid profile (total cholesterol, HDL, LDL,
TG)
3. Uric acid
4. Creatinine clearance
5. Serum creatinine
6. Potassium
7. EKG
8. Urinalysis
 Follow up investigations
During the maintenance phase of hypertension
managements, test (including electrolytes,
creatinine, glucose, and fasting lipids) should be
repeated with a frequency reflecting the clinical
situation.
 Complications of Hypertension:
End-Organ Damage

Hypertension

Hemorrhage, LVH, CHD, CHF

Stroke

Peripheral
Vascular
Disease Renal Failure,
Retinopathy
Proteinuria
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy Slide Source
Hypertension Online
Chobanian AV, et al. JAMA. 2003;289:2560-2572. www.hypertensiononline.org
 Hypertension complication

Eyes Brain Target Organ damage!!

retinopathy stroke

Damages depend on:

Heart
ischaemic heart disease How high of the blood
Kidneys left ventricular hypertrophy pressures
renal failure heart failure
How long the
uncontrolled and
untreated high blood
presure
Peripheral arterial disease
Assessment of Hypertension
Search for target organ damage

Cerebrovascular disease
- transient ischemic attacks
- ischemic or hemorrhagic stroke
- vascular dementia
Hypertensive retinopathy
Left ventricular dysfunction
Left ventricular hypertrophy
Coronary artery disease
- myocardial infarction
- angina pectoris
- congestive heart failure
Chronic kidney disease
- hypertensive nephropathy (GFR < 60
ml/min/1.73 m2)
- albuminuria
Peripheral artery disease
- intermittent claudication
- ankle brachial index < 0.9

2009 Canadian Hypertension Education Program Recommendations

Hypertensive Retinopathy:
Grade I Thickening of
arterioles.
Grade II Focal
Arteriolar spasms. Vein
constriction.
Grade III Hemorrhages
(Flame shape), dot-blot
and Cotton wool and
hard waxy exudates.
Grade IV - Papilloedema
Prognostic factors associated with the heart

LVH>2cm

1. Left ventricular hypertrophy

2. Aortic Sclerosis
 1. Serum creatinine
2. Dipstick for proteinuria evaluation

Spot urine protein/creatinine ratio,

24h urine test --------------------------- optional

The US National Kidney Foundation recommends screening for micro-albuminuria

Decreased vascular compliance

Acutely elevated blood pressure

Changes the elastic behaviour of

both large and small arteries
Generally, few other blood or urine tests are
necessary.
In spesific circumstances, plasma renin activity,
24h urine collections, and some serum insulin
levels can be useful

Some newly appreciated markers of

cardiovascular risk,
C-reactive protein and Homocystein
 Age < 30 years old & family history of hypertension (-)
Severe hypertension & > 50 years old
Refractory hypertension
Sudden increase of BP of previously
controlled hypertensive patient
Malignant hypertension
Immediate increase of Cr serum after ACEI/ARB
The symptoms of these forms of secondary hypertension
that may help the clinician are related to hypokalemia.

Usually prominent are muscle weakness, cramps, polyuria,

and even nocturia.

The majority of patients (50-60%) with these syndrome

have a benign adrenal adenoma that secretes aldosterone autonomously

Some (30-50%) have bilateral (idiopathic) adrenal hyperplasia

Rarer causes include adrenal carcinomas, glucocorticoid-suppresible

Hyperaldosteronism.
Symptoms characteristic of sleep apnea, thyroid disorders,
Hyperparathyroidism, and Cushings syndrome

Should be noted, as these disorders may indicated

Hypertension that responds to therapy directed at the primary disease
 Investigation in Specific
population
Rennin, aldosterone, corticosteroid,
catecholamine to evaluate hypertension
caused by Cushing syndrome, aldosteronism,
phaeochromocitoma, parenchyma kidney
disease
Arteriography, USG, adrenal ultrasound, CT-
Scan, MRI to evaluate hypertension caused
by renovasculer
 CVD Risk Factors
Hypertension*
Cigarette smoking
Obesity* (BMI >30 kg/m2)
Physical inactivity
Dyslipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR <60 ml/min
Age (older than 55 for men, 65 for women)
Family history of premature CVD
(men under age 55 or women under age 65)
* Components of the metabolic syndrome.