One high reading does not mean you have high blood pressure. It is necessary to measure your blood pressure at different times, while you are resting comfortably for at least five minutes. To make the diagnosis of hypertension, at least three readings that are elevated are usually required

1. DIAGNOSIS OF HYPERTENSION

2. WHY
HYPERTENSI
ON IS SO
IMPORTANT
?
• CHRONIC DISEASE
• NONCOMMUNICABLE DISEASE
• HIGH BP REMAINS THE LEADING CAUSE OF DEATH
WORLDWIDE
• ONE OF THE WORLD'S GREAT PUBLIC HEALTH
PROBLEMS
• MOST OF THE PEOPLE HAVE IT [90% BY AGE OF 78]
• MOST OF THE PEOPLE FEAR IT
• TREATMENT IS LIFELONG
• BP IS NOT CONTOLLED -85%
• 40% OF STROKE DEATH AND 16% OF CVD DEATH
• WOMEN AFTER MENOPAUSE WORSE THAN MEN TO
OWN THIS

3. WHO WILL GOING TO HAVE IT ?

5. DEFINE
•SBP <120 mmHg
•DBP <80 mmHg
Normal blood
pressure
•SBP: 120 to 129 mmHg
•Diastolic <80 mmHg
Elevated blood
pressure
•Stage 1 :SBP 130 to 139 & DBP: 80 to 89
mmHg
•Stage 2 : SBP:≥140 mmHg & ≥ 90 mmHg
Hypertension:

6. OUT PATIENT CLINIC HTN
• HYPERTENSION IS DEFINED AS A USUAL OFFICE BP OF 140/90 MM HG OR HIGHER
• BUT SHOULD BE CONFIRMED BY HOME AND AMBULATORY BLOOD PRESSURE
MEASUREMENT IF THERE IS ANY SUSPICION OF WHITE COAT

7. DIFFERENT GUIDELINES HAVE DIFFERENT CUT
OFF
• EPIDEMIOLOGIC DATA SHOW CONTINUOUS POSITIVE RELATIONSHIPS BETWEEN
THE RISK OF CORONARY ARTERY DISEASE (CAD) AND STROKE DEATHS WITH
SYSTOLIC OR DIASTOLIC BP DOWN TO VALUES AS LOW AS 115 OR 75 MM HG

8. STAGING OF HTN

9. DIFFERENT METHOD –DIFFERENT CUT OFF

10. • MODIFIED FROM GABB GM, MANGONI A, ANDERSON CS, ET AL. GUIDELINE FOR
THE DIAGNOSIS AND MANAGEMENT OF HYPERTENSION IN ADULTS—2016. MED J
AUST 2016;205:85.

12. MEASUREMENT OF BP
• OFFICE [PRONE FOR WHITE COAT]
• HOME[MOST CORRECT ]
• AMBULATORY [24HOURS ]

13. INDICATION FOR AMBULATORY BP
MEASUREMENT
• OFFICE BP OF 140/90 MM HG OR
HIGHER ON AT LEAST THREE
SEPARATE OFFICE VISITS, WITH TWO
MEASUREMENTS MADE AT EACH VISIT
• AT LEAST TWO OUT-OF-OFFICE BP
READINGS LOWER THAN 140/90 MM
HG
• NO EVIDENCE OF TARGET-ORGAN
DAMAGE

14. TOOLS TO MEAUSRE
• SPIMGOMANOMETRE USING MERCURY COLUMN :OFFICE ,HOME,ICU
• ANEROID METER [OPD/HOUSE/AMBULATORY]
• OSCILLOMETER METHOD [ICU]

15. S
CUFF SIZE AND PLACEMENT
1. THE CUFF SIZE SHOULD HAVE A BLADDER WIDTH THAT IS
APPROXIMATELY 40 PERCENT OF THE CIRCUMFERENCE OF
THE UPPER ARM, MEASURED MIDWAY BETWEEN THE
OLECRANON AND THE ACROMION
2. THE LENGTH OF THE CUFF BLADDER SHOULD ENCIRCLE
80 TO 100 PERCENT OF THE CIRCUMFERENCE OF THE
UPPER ARM MIDWAY BETWEEN THE OLECRANON AND THE
ACROMION
3. THE BLADDER WIDTH-TO-LENGTH SHOULD BE AT LEAST
1:2

16. WHERE TO TIE BP CUFF
• AVOID STIMULANT DRINKING
• QUIET ROOM
• 2CM ABOVE ANTECUBETAL FOSSA
• 3-5 MINUTES REST
• RIGHT ARM SEATING POSITION
• PALPATE
• ARM IS AT THE LEVEL OF HEART
• MERCURY MANOMETER AT THE LEVEL OF
HEART
• USE THE BELL OF THE STETHOSCOPE

17. • ALLOWING THE ARM TO HANG BELOW THE HEART WILL ELEVATE BP LEVELS BY
THE ADDED HYDROSTATIC PRESSURE INDUCED BY GRAVITY (AS MUCH AS 10 TO
12 MMHG IN ADULTS)

18. WALK ONE STEP AT A TIME
• THE CUFF SHOULD BE INFLATED TO 20 TO 30 MMHG ABOVE THE ANTICIPATED
SYSTOLIC BP (SBP)
• DEFLATED SLOWLY AT A RATE OF 2 TO 3 MMHG PER HEARTBEAT
• THE SYSTOLIC BP IS EQUAL TO THE PRESSURE AT WHICH THE BRACHIAL PULSE
CAN FIRST BE HEARD BY AUSCULTATION (KOROTKOFF PHASE I)
• MUFFLING (KOROTKOFF PHASE IV) IS DIASTOLIC BP FOR ADULT
• PHASE V IS RECOMMENDED FOR DBP DETERMINATION IN CHILDREN
•

19. NUMBER OF MEASUREMENTS
• THE BP SHOULD BE TAKEN AT LEAST TWICE ON EACH VISIT
• THE MEASUREMENTS SEPARATED BY ONE TO TWO MINUTES TO ALLOW THE
RELEASE OF TRAPPED BLOOD
• IF THE SECOND VALUE IS MORE THAN 5 MMHG DIFFERENT FROM THE FIRST,
CONTINUED MEASUREMENTS SHOULD BE MADE UNTIL A STABLE VALUE IS
ATTAINED
• THE RECORDED VALUE ON THE PATIENT'S CHART SHOULD BE THE AVERAGE OF
THE LAST TWO MEASUREMENTS

20. OSCILLOMETER DEVICES
• AUTOMATED OSCILLOMETRIC DEVICES MEASURE MEAN ARTERIAL BP BASED
UPON PRESSURE OSCILLATIONS OF THE BRACHIAL ARTERY WALL AS THE CUFF IS
DEFLATED
• SBP AND DBP MEASUREMENTS ARE CALCULATED BASED ON THE MEAN BP
• EASY TO USE
• DECREASE IN OBSERVER BIAS
• HIGHER COMPARED WITH READINGS OBTAINED BY AUSCULTATION
• A HIGH BP SHOULD BE CONFIRMED BY SPHYGMOMANOMETER

21. MUST MENTION END ORGAN DAMGE
• MI
• STROKE
• RENAL FAILURE
• AORTIC DISSECTION
• HEART FAILURE
• LOSS OF VISION

22. ISOLATED SYSTOLIC HTN
• SYSTOLIC >140 AND DIASTOLIC <90 MMHG
• REPRESENT AN EXAGGERATION OF THIS AGE-DEPENDENT STIFFENING PROCESS
• ISH IS MORE COMMON IN WOMEN
• ASSOCIATED PROMINENTLY WITH HEART FAILURE WITH PRESERVED SYSTOLIC
FUNCTION
• THOSE WITH BP IN THE HIGH-NORMAL RANGE (PREHYPERTENSION) WILL MORE
LIKELY DEVELOP ISH AFTER 55 YEARS OF AGE

23. HYPERTENSIVE EMERGENCY
• SEVERE HYPERTENSION (USUALLY A DIASTOLIC BLOOD PRESSURE ABOVE 120
MMHG)
• EVIDENCE OF ACUTE END-ORGAN DAMAGE IS DEFINED
• HYPERTENSIVE EMERGENCIES CAN BE LIFE-THREATENING
• REQUIRE IMMEDIATE TREATMENT
• USUALLY WITH PARENTERAL MEDICATIONS IN A MONITORED SETTING

24. HYPERTENSIVE URGENCY
• SEVERE HYPERTENSION (USUALLY A DIASTOLIC BLOOD PRESSURE ABOVE 120
MMHG) IN ASYMPTOMATIC
• NOT EXPERIENCING ACUTE END-ORGAN DAMAGE
• MOST CASES OF ASYMPTOMATIC
• BLOOD PRESSURE ELEVATIONS CAN BE ADDRESSED IN THE OFFICE SETTING
WITHOUT REFERRAL TO A HIGHER LEVEL OF CARE

25. RESISTANT HYPERTENSION
BLOOD PRESSURE THAT IS NOT CONTROLLED TO GOAL DESPITE ADHERENCE TO
AN APPROPRIATE REGIMEN OF THREE ANTIHYPERTENSIVE DRUGS OF DIFFERENT
CLASSES (INCLUDING A DIURETIC) IN WHICH ALL DRUGS ARE PRESCRIBED AT
SUITABLE ANTIHYPERTENSIVE DOSES
BLOOD PRESSURE THAT REQUIRES AT LEAST FOUR MEDICATIONS TO ACHIEVE
CONTROL IS CONSIDERED CONTROLLED RESISTANT HYPERTENSION.

26. REFRACTORY HYPERTENSION
• BP IS NOT CONTROLLED EVEN USING UP TO 5 DRUGS ,ONE OF WHICH IS
DIURETIC

27. ACCLERATED HTN
• ACCELERATED HYPERTENSION IS
DEFINED AS A RECENT SIGNIFICANT
INCREASE OVER BASELINE BP THAT
IS ASSOCIATED WITH TARGET
ORGAN DAMAGE. THIS IS USUALLY
SEEN AS VASCULAR DAMAGE ON
FUNDUSCOPIC EXAMINATION, SUCH
AS FLAME-SHAPED HEMORRHAGES
OR SOFT EXUDATES, BUT WITHOUT
PAPILLEDEMA

28. MALIGNANT HTN
• DEFINED AS A RECENT SIGNIFICANT
INCREASE OVER BASELINE BP THAT
IS ASSOCIATED WITH TARGET
ORGAN DAMAGE. THIS IS USUALLY
SEEN AS VASCULAR DAMAGE ON
FUNDUSCOPIC EXAMINATION, SUCH
AS FLAME-SHAPED HEMORRHAGES
OR SOFT EXUDATES, BUT WITH
PAPILLEDEMA

29. RENOVASCULAR HTN
• DUE TO RENAL ARTERY STENSOSIS

30. PREGNANCY INDUCED HTN
• BEYOND 20 WEEK OF PREGNANCY

34. INVESTIGATION

39. FEATURES SUGGESTIVE OF
PHEOCHROMOCYTOMA
Hypertension, Persistent or Paroxysmal
•Markedly variable blood pressures (± orthostatic hypotension)
•Sudden paroxysms (± subsequent hypertension) in relation to:
• Stress: anesthesia, angiography, parturition
• Pharmacologic provocation: histamine, nicotine, caffeine, beta blockers,
glucocorticoids, tricyclic antidepressants
• Manipulation of tumors: abdominal palpation, urination
•Rare patients persistently normotensive
•Unusual settings
•Childhood, pregnancy, familial
•Multiple endocrine adenomas: medullary carcinoma of the thyroid (MEN-2), mucosal
neuromas (MEN-2B)
•Von Hippel–Lindau syndrome

40. •Neurocutaneous lesions: neurofibromatosis
Associated Symptoms
•Sudden spells with headache, sweating, palpitations, nervousness, nausea, vomiting
•Pain in chest or abdomen
Associated Signs
Sweating, tachycardia, arrhythmia, pallor, weight loss

41. WHICH PATIENT MAY HAVE HTN
• WOMEN >65 YEARS
• SMOKING
• DYSLIPIDEMIA (LDL-C >115 MG/DL)
• IMPAIRED FASTING GLUCOSE (102-125 MG/DL) OR ABNORMAL GLUCOSE TOLERANCE
TEST RESULT
• FAMILY HISTORY OF PREMATURE CARDIOVASCULAR DISEASE
• ABDOMINAL OBESITY
• DIABETES MELLITUS

42. FROM SUBCLINICAL END ORGAN DAMAGE
• LEFT VENTRICULAR HYPERTROPHY
• CAROTID WALL THICKENING OR PLAQUE
• LOW ESTIMATED GLOMERULAR FILTRATION RATE ≤60 ML/MIN/1.73 M 2
• MICROALBUMINURIA
• ANKLE-BRACHIAL BP INDEX <0.9

43. ESTABLISHED TARGET ORGAN DAMAGE
• CEREBROVASCULAR DISEASE: ISCHEMIC STROKE, CEREBRAL HEMORRHAGE,
TRANSIENT ISCHEMIC ATTACK
• HEART DISEASE: MYOCARDIAL INFARCTION, ANGINA, CORONARY
REVASCULARIZATION, HEART FAILURE
• RENAL DISEASE: DIABETIC NEPHROPATHY, RENAL IMPAIRMENT
• PERIPHERAL ARTERIAL DISEASE
• ADVANCED RETINOPATHY: HEMORRHAGES OR EXUDATES, PAPILLEDEMA

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