PATIENT EVALUATION 3 OBJECTIVES (history and physical examination) 1.Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. 2.Reveal identifiable causes of high BP (Secondary hypertension). 3.Assess the presence or absence of target organ damage and CVD.
Risk Factors for Primary Hypertension Age/Heredity Sex Race Obesity Stimulants Sodium Alcohol Stress Hyperlipidemia Diabetes Socioeconomic Status
JNC 7 - Major cardiovascular risk factors Hypertension: component of metabolic syndrome Tobacco use, particularly cigarettes, including chewing tobacco Elevated LDL cholesterol (or total cholesterol ≥240 mg/dL) or low HDL cholesterol: component of metabolic syndrome Diabetes mellitus: component of metabolic syndrome Obesity (BMI ≥30 kg/m2): component of metabolic syndrome
JNC 7 - Major cardiovascular risk factors Age greater than 55 years for men or greater than 65 years for women: increased risk begins at the respective ages; the Adult Treatment Panel III used earlier age cut points to suggest the need for earlier action Estimated glomerular filtration rate < 60 mL/min Micro albuminuria Family history of premature cardiovascular disease (men < 55 years; women < 65 years) Lack of exercise
INTERHEART: Impact of multiple risk factors on CV risk Yusuf S et al. Lancet. 2004;364:937-52. Odds ratio for 1st MI (99% CI) 64 512 16 1 2 256 128 32 8 4 Smk (1) DM (2) HTN (3) ApoB- ApoA1 (4) 1+2+3All 4All 4 + Obes All 4 + Ps All risk factors 220.127.116.11.313.042.368.5182.9333.7 Smk = smoking DM = diabetes HTN = hypertension Obes = obesity Ps = psychosocial factors Note: odds ratio plotted on a doubling scale
What is the specific symptom of Hypertension? NONE!
Symptoms suggesting secondary hypertension Family history of renal disease(Polycystic kidney) Renal disease, UTI, hematuria, analgesic abuse (Parenchymal renal disease) Oral contraceptives (hypertension due to drugs) Episodes of sweating,headache, anxiety (Phaeochromocytoma)
Symptoms suggesting secondary hypertension Episodes of muscle weakness and tetany (hyperaldosteronism) A history of cold or heat tolerance, sweating, lack of energy, and bradycardia or tachycardia may indicate hypothyroidism or hyperthyroidism A history of obstructive sleep apnea may be noted.
Drugs and hypertension Search for exogenous potentially modifiable factors that can induce/aggravate hypertension Prescription Drugs: –NSAIDs, including Coxibs –Corticosteroids and anabolic steroids –Oral contraceptive and sex hormones –Vasoconstricting/sympathomimetic decongestants –Calcineurin inhibitors (cyclosporin, tacrolimus) –Erythropoietin and analogues –Monoamine oxidase inhibitors (MAOIs) –Midodrine
Drugs and hypertension Search for exogenous potentially modifiable factors that can induce/aggravate hypertension Other: –Licorice root –Stimulants including cocaine –Salt –Excessive alcohol use –Sleep apnea
Symptoms of organ damage Brain and eyes: Headache, vertigo, impaired vision, transient ischaemic attacks, sensory or motor deficit Heart: Palpitations, chest pain, shortness of breath, ankle oedema Kidney: Thirst, polyuria, nocturia, haematuria Peripheral arteries: Cold extremities
Focused Clinical Examination General: Obesity, Waist measurement, endocrine manifestations Anemia: Renal and other causes Odema: Fluid overload, renal and cardiac failure All pulses: Coarctation and pvd Bruits: Carotid and abdomen
An accurate measurement of Blood Pressure is the key to Diagnosis (see next chapter)
Height,weight and waist Measuring waist circumference: a practical guide from the NIDDK/NIH Place a tape measure around the bare abdomen, just above the hip bone. Be sure the tape is snug, but does not compress the skin. The tape should be parallel to the floor, midway between the top of the iliac crest and the lower rib margin on each side. The patient should relax and exhale while the measurement is made. Measurement
Signs of Target Organ damage Brain: Murmurs over neck arteries, motor or sensory defect Retina: Fundoscopic examination Heart: Location & characteristics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales, dependent oedema Peripheral arteries : Absence, reduction or asymmetry of pulses, cold extremities, ischemic skin lesions.
There is a link between the presence of certain signs of hypertensive retinopathy (eg, retinal hemorrhages, microaneurysms, cotton-wool spots) and an increased cardiovascular risk (eg, stroke, stroke mortality). Therefore, a funduscopic evaluation of the eyes should be performed to detect any evidence of early or late, chronic or acute hypertensive retinopathy, including arteriovenous nicking or changes in the vessel wall (eg, copper wiring, silver wiring, SOT, hard exudates, flame-shaped hemorrhages, papilledema).
Fundus examination Indeed, ocular changes can be the initial finding in an asymptomatic patient necessitating a primary care referral; acute and chronic changes may manifest in the eyes. Alternatively, a symptomatic patient may be referred to the ophthalmologist for visual changes due to hypertensive changes.
Suspect secondary hypertension Severe or resistant hypertension An acute rise in blood pressure over a previously stable value Proven age of onset before puberty Age less than 30 years with no family history of hypertension and no obesity
Clinical Examination Signs suggesting secondary hypertension Features of Cushing’s syndrome Skin stigmata of neurofibromatosis(Phaeochromocytoma) Palpation of enlarged kidneys (Polycystic kidney) Auscultation of abdominal murmurs(Renovascular hypertension) Auscultation of precordial or chest murmurs(Aortic coarctation) Diminished and delayed femoral pulses and reduced leg blood pressure (Aortic coarctation)