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Hypertension
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Hypertension- Patient AssessmentExaminationMeasure weight, hip-waist ratio, calculate BMI.Assess for features of Cushing’s Syndrome (Moon faces, trunchal obesity, stretch marks). Radio-femoral delay A difficult clinical sign to detect but may be found in rare adult patient with unrecognised coarctation of the aorta. This condition is associated with upper body hypertension. A systolic murmur is present over the precordium and the murmur is usually also heard posteriorly. High pulse-pressure Commonly seen in elderly patients with long-standing hypertension with reduced aortic compliance. Can also be seen in patients with high cardiac stroke volume such as patients with severe aortic regurgitation, thyrotoxicosis and also seen in some rare conditions such as in acromegaly, or those with AV fistulae. Fundoscopy Advanced changes from severe untreated hypertension are now seen rarely. Precordium A displaced and sustained apex beat is present in those with significant left ventricular hypertrophy. Abdominal bruit Might indicate presence of underlying renal artery stenosis. Palpable kidneys Enlarged kidneys may be palpable in patients with polycystic kidney disease. Other signs of end-organ damage Carotid or femoral bruits, reduced peripheral pulses, enlarged abdominal aorta. Laboratory TestsLow serum potassium not due to diuretic therapyCan be seen in Conn’s syndrome or primary hyperaldosteronism (excessive aldosternone levels) or in Cushing’s syndrome (excessive glucocorticoid levels) Aldosterone/renin ratio This ratio has been promoted for the diagnosis of primary hyperaldosteronism. Conclusions should not be based upon an elevated ratio alone, but significant elevation of plasma aldosterone levels should also be present, since use of the ratio in isolation will increase false positive rates due to presence of very low renin levels. In instances of a possible positive test, repeating the test after intravenous fluid administration is said to be helpful to demonstrate non-suppression of elevated aldosterone levels. Elevated serum creatinine Elevation of serum creatinine is a late feature in renal artery stenosis. Renal disease may be the cause of hypertension or be secondary to severe hypertension Thyrotoxicosis Significant thyrotoxicosis will result in increased cardiac output and in some patients may cause hypertension with a high pulse pressure Abnormal urinalysis Can indicate presence of underlying renal disease which may be cause of hypertension. Microalbuminuria not due to diabetes or other renal disease can be an indicator of early renal damage secondary to hypertension. Urinary catecholamines An easy screening test for phaechromocytoma. ECGA simple test to examine for left ventricular hypertrophy, although not as sensitive as echo assessment for left ventricular hypertrophy. Presence of left ventricular hypertrophy indicates a worse prognosis.EchocardiographyEchocardiography is not recommended as a routine examination for all patients. However, if left ventricular mass is calculated at echocardiography, the sensitivity of detecting hypertrophy is increased, compared to ECG diagnosis of LVH. Echocardiographically determined hypertrophy has been correlated with a worse prognosis.Chest XRPresence of cardiomegaly on CXR may be due to hypertrophy or due to cardiac chamber enlargement. However, beware of “apparent” cardiomegaly- on CXR the heart may falsely appear enlarged in obese patients with high diaphragms where the heart is placed more horizontally in the chest; some obese patients also have significant pericardial fat which will also contribute to “apparent” cardiomegaly.Ambulatory blood pressure monitoringThis can be useful to identify white-coat hypertension; or to confirm good control of hypertension in high- risk patients such as those with left ventricular hypertrophy or those with significant microalbuminuria, or in those with other end-organ damage.Renal tract ultrasound and renal artery doppler studiesMay be useful to investigate patients for secondary causes of hypertension.
Hitesh Patel, Cardiologist Users should read this document on "copyright" and "conditions of use". |