Patient explanation

Gold standard case presentation

Hypertension

Hypertension is one of the world’s biggest silent killers and is defined as a systolic blood pressure above 140 mmHg or a diastolic blood pressure above 90 mmHg. Nearly 66% of adults over the age of 60-years of age are affected to some degree and the WHO estimates at least 7.5 million deaths are due to undiagnosed / untreated hypertension.

The true measurement of the blood pressure could occur in a calm, quiet environment, with an empty bladder, rested and arm resting on a firm table. Two readings need to be taken at least 5-minutes apart

Symptoms and signs

• Asymptomatic for most
• Dizziness
• Headaches

Risk factors

• Aged over 55-years for men and over 65-years for women
• Obesity
• Diabetes mellitus
• Excess caffeine intake
• Smoking
• Alcohol use
• Positive family history
• Dyslipidaemia
• Renal dysfunction
• Poor physical activity

Investigations

• Urine dipstick (for haematuria and proteinuria in renal damage)
• ECG
  • Left ventricular hypertrophy
  • Ischaemic changes
  • Bundle branch block
• Bloods
  • Full blood count (anaemia)
  • Renal function
  • Calcium and phosphate levels
  • Thyroid function tests (hyperthyroidism)
  • Liver function tests
  • Erythrocyte sedimentation rate
  • Autoimmune serology
  • Cholesterol and lipid levels
  • Renin and angiotensin levels
• 24-hour ambulatory blood pressure monitoring if concerned about white coat hypertension
• Imaging
  • Chest X-ray if concerned about heart failure
  • Renal ultrasound and screening if concerned about renal artery stenosis
  • Echocardiogram
  • Myocardial perfusion scan if further cardiac disease evaluation needed

Management

• Lifestyle factors:
  • Weight loss
  • Smoking cessation
  • Alcohol intake reduction
  • Caffeine intake reduction
• Medications
  • Calcium channel blockers (e.g. amlodipine)
  • Angiotensin receptor inhibitors (e.g. ramipril) – with renal checks soon after commencing
  • Beta-blockers (e.g. bisoprolol)
  • Alpha-channel blockers (e.g. doxazosin)
  • Compliance is a big problem due to the asymptomatic nature of hypertension and prior to adding new drugs, compliance issues should be assessed
  • Diuretics if heart failure present