- Treatment of hypertension is the most common reason for physician office visits in the US. The number of hypertensive individuals is increasing due to an aging population and rising obesity rates. - Up to 5% of hypertension cases are secondary, meaning a specific cause can be identified like renal artery stenosis or pheochromocytoma. However, routine screening for secondary causes is not usually recommended due to low prevalence. - Complications of uncontrolled hypertension include heart failure, stroke, kidney disease, and heart attacks. Proper treatment and control of blood pressure can significantly reduce risks of these complications.

1. D . B A S E M E L S A I D E N A N Y
L E C T U R E R O F C A R D I O L O G Y
A I N S H A M S U N I V E R S I T Y
Hypertension: Diagnosis

2. --Treatment of hypertension is the most common reason
for office visits to physicians in the United States.
-- Number of patients with hypertension is likely to grow as
the population ages.
-- The rising incidence of obesity will also increase the
number of hypertensive individuals.
-- Control of the disease is far from adequate:
Poor access to health care and medications
Lack of adherence with long-term therapy for a condition
that is usually asymptomatic

3. DEFINITIONS
--The seventh report of the Joint National Committee (JNC 7):
Based upon the average of two or more properly measured
readings at each of two or more visits after an initial screen:
*Normal blood pressure: systolic <120 mmHg and diastolic <80
mmHg
*Prehypertension: systolic 120-139 mmHg or diastolic 80-89
mmHg
*Hypertension:
Stage 1: systolic 140-159 mmHg or diastolic 90-99 mmHg
Stage 2: systolic ≥160 or diastolic ≥100 mmHg
*Isolated systolic hypertension  ≥140/<90 mmHg
*Isolated diastolic hypertension  <140/≥90 mmHg.

4. European guidelines 2007

5. Definitions based upon ambulatory and home readings
*A 24-hour average above 135/85 mmHg
*Daytime (awake) average above 140/90 mmHg
*Nighttime (asleep) average above 125/75 mmHg
-- Home readings correlate more closely with the results of
daytime ambulatory measurements than with blood pressure
taken in the physician's office. Thus, the definition of
hypertension based upon an average of multiple home readings
is the same as for daytime ambulatory blood pressure.
=The current ACC/AHA guidelines for exercise stress testing
suggest a hypertensive response to exercise is one in which
systolic blood pressure rises to more than 250 mm Hg or
diastolic blood pressure rises to more than 115 mm Hg.

7. ESSENTIAL (PRIMARY) HYPERTENSION
--Pathogenesis:
Poorly understood. A variety of factors have been implicated,
including:
*Increased sympathetic neural activity, with enhanced beta-adrenergic
responsiveness.
*Increased angiotensin II activity and mineralocorticoid excess.
*Hypertension is about twice as common in subjects who have one or
two hypertensive parents and multiple epidemiologic studies suggest
that genetic factors account for approximately 30 % of the variation in
blood pressure in various populations.
*Reduced adult nephron mass may predispose to hypertension, which
may be related to genetic factors, intrauterine developmental
disturbance (eg, hypoxia, drugs, nutritional deficiency), and post-natal
environment (eg, malnutrition, infections).

8. Risk factors
--A variety of risk factors have been associated with essential hypertension:
*Hypertension tends to be both more common and more severe in blacks.
*Excess sodium intake increases the risk for hypertension, and sodium
restriction lowers blood pressure.
*Excess alcohol intake is associated with the development of hypertension.
*Obesity and weight gain are major risk factors for hypertension and are also
determinants of the rise in blood pressure that is commonly observed with
aging.
*Physical inactivity increases the risk for hypertension, and exercise is an
effective means of lowering blood pressure.
*Dyslipidemia, independent of obesity is associated with hypertension.
*Data are conflicting as to whether a high intake of fructose from sugar-
sweetened beverages is or is not associated with an increased risk of
developing hypertension.
*Hypertension may be more common among those with certain
personality traits, such as hostile attitudes and time urgency/impatience.
*Vitamin D deficiency is associated with an increased risk of hypertension

9. SECONDARY OR IDENTIFIABLE HYPERTENSION
*Primary renal disease:
Both acute and chronic kidney disease, particularly with glomerular or vascular disorders.
Polycystic kidney (Bilateral abdominal palpable masses commonly are due to polycystic kidney
disease. Typically the history reveals the presence of hypertension with renal failure in other family
members), (transient episode of periorbital swelling and dark-colored urine that went untreated
may point to a chronic glomerulonephritis), (Multiple episodes of cystitis or urinary infection left
untreated or with incomplete treatment will lead to and suggest chronic pyelonephritis)
*Oral contraceptives:
Oral contraceptives often raise the blood pressure within the normal range but can also induce
overt hypertension.
*Drug-induced:
Chronic nonsteroidal antiinflammatory agents and many antidepressants can induce hypertension.
Chronic alcohol intake and alcohol abuse can also raise blood pressure.
*Pheochromocytoma:
About one-half of patients with pheochromocytoma have paroxysmal hypertension, most of the
rest have what appears to be primary hypertension.
The preferred treatment is laparoscopic adrenalectomy
The best screening test is plasma free metanephrines (normetanephrine and metanephrine).
*Primary aldosteronism:
The presence of primary mineralocorticoid excess, primarily aldosterone, should be suspected in
any patient with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis.
However, some patients have a normal plasma potassium concentration. The prevalence of
primary aldosteronism should also be considered in patients with resistant hypertension.
Aldosterone/renin level >20 (morning level)

10. *Renovascular disease:
Common disorder, occurring primarily in patients with generalized atherosclerosis.
=Onset at young age (<35 years) in female patient Renal artery medial fibromuscular dysplasia
=Onset at a late age (>55 years), especially in a patient with atherosclerosis,
Exaggerated drop in blood pressure and/or kidney function with initiation of ACEI,
Abdominal bruit Renal artery stenosis
*Cushing's syndrome:
Hypertension is a major cause of morbidity and death in patients with Cushing's syndrome=excess
cortisol (pituitary tumor=Cushing’s disease or adrenal tumor or ectopic ACTH). HTN, DM, central
obesity, osteoporosis, hypokalemia, abdominal stria
*Other endocrine disorders:
Hypothyroidism, hyperthyroidism, and hyperparathyroidism may also induce hypertension.
*Obstructive sleep apnea:
Independent risk factor for systemic hypertension.
*Coarctation of the aorta:
One of the major causes of secondary hypertension in young children
*Hyperparathyroidism: Renal calculi, elevated calcium level

11. -Many patients with pheochromocytoma have a normal baseline blood pressure,
with high blood pressure values only on occasion. Postural hypotension is a classical feature.
High serum catecholamine levels explain the sweating and palpitations and the low fever, elevation
of serum glucose, and leukocytosis. Gentle palpation of the abdomen during physical examination
may sometimes trigger a crisis. Because of the general and metabolic manifestations of the disease,
it may mimic a large variety of conditions (e.g., vasculitis, diabetes), and a high level of suspicion is
always necessary.
Some patients present with a high blood pressure that is constant rather than paroxysmal. A rule
of 10 may be applied: 10% of all cases are familial, 10% are bilateral, 10% are due to a malignant
adrenal tumor, 10% recur, 10% are extra-adrenal, 10% occur in children, 10% are associated with
a multiple endocrine neoplasia (MEN) syndrome, and 10% present with a stroke as the inaugural
symptom.
Diagnosis of a pheochromocytoma is rewarding because this very sick patient who is prone to
life-threatening complications can be virtually cured. The current recommendation for biochemical
diagnosis of pheochromocytoma is urine testing for metanephrines and fractionated
catecholamines.
These tests only certify the presence of a catecholamine-secreting tumor; therefore, the next step is
to localize it (90% are in the adrenal medulla; the other 10% are scattered where chromaffin tissue
is
found). The preferred treatment is laparoscopic adrenalectomy.

12. Up to 5% of all hypertension cases are secondary,
meaning that a specific cause can be identified.
Most of these causes are treatable (e.g., surgery for an
adrenal tumor, stenting of a renal artery
stenosis, or correction of an aortic coarctation).
-Given the low prevalence of secondary hypertension,
routine screening for secondary hypertension is not
usually recommended

13. COMPLICATIONS
*Hypertension is quantitatively the major risk factor for premature cardiovascular
disease, being more common than cigarette smoking, dyslipidemia, or diabetes,
the other major risk factors. In older patients, systolic pressure and pulse pressure
are more powerful determinants of risk than diastolic pressure.
*The risk of heart failure increases with the degree of blood pressure elevation.
*Left ventricular hypertrophy is a common finding in patients with hypertension,
and is associated with an enhanced incidence of heart failure, ventricular
arrhythmias, death following myocardial infarction, and sudden cardiac death.
*Hypertension is the most common and most important risk factor for ischemic
stroke, the incidence of which can be markedly reduced by effective
antihypertensive therapy.
*Hypertension is the most important risk factor for the development of
intracerebral hemorrhage.
*Hypertension is a risk factor for chronic kidney disease and end-stage renal
disease. It can both directly cause kidney disease, called hypertensive
nephrosclerosis, and accelerate the progression of a variety of underlying renal
diseases.
*Marked elevations in blood pressure can cause an acute, life-threatening
emergency

14. Screening
--The 2007 United States Preventive Services Task
Force (USPSTF) guidelines on screening for high blood
pressure recommend screening every two years for
persons with systolic and diastolic pressures below 120
mmHg and 80 mmHg, respectively (normal BP in JNC
7), and yearly for persons with a systolic pressure of
120 to 139 mmHg or a diastolic pressure of 80 to 89
mmHg (prehypertension in JNC 7).

15. Measurement
--In the absence of end-organ damage, the diagnosis of
mild hypertension should not be made until the blood
pressure has been measured on at least three to six visits,
spaced over a period of weeks to months.
-- Sequential studies have shown that the blood pressure
drops by an average of 10 to 15 mmHg between visits one
and three, thus, many patients considered to be
hypertensive at the initial visit are in fact normotensive.
-- The presence of postural hypotension, defined as a 20
mmHg or greater fall in systolic pressure upon rising from
supine to an unassisted upright position, should be
pursued in patients over age 65, those experiencing
dizziness or weakness upon standing, or those with
diabetes.

18. White coat hypertension and ambulatory
monitoring
--Approximately 20 to 25% of patients with stage 1 office
hypertension have "white-coat" or isolated office hypertension
in that their blood pressure is repeatedly normal when
measured at home, at work, or by ambulatory blood pressure
monitoring.
--More common in the elderly, but is infrequent (less than 5 %)
in patients with office diastolic pressures ≥105 mmHg.
--Ambulatory blood pressure monitoring (ABPM), which
records the blood pressure at preset intervals (usually every 15
to 20 minutes during the day and every 30 to 60 minutes during
sleep), can be used to confirm or exclude the presence of white
coat hypertension in patients with persistent office hypertension
but normal blood pressure readings out of the office.
--Masked hypertension: 24-hour monitoring of larger
populations has revealed a significant number of patients with
elevated out-of-office readings despite normal office readings.

19. Indications for ABPM:
--Suspected white coat hypertension
--Suspected episodic hypertension (eg, pheochromocytoma)
--Hypertension resistant to increasing medication
--Hypotensive symptoms while taking antihypertensive
medications
--Autonomic dysfunction
--Non dippers=Failure of the BP to fall by at least 10 % during
sleep {risk factor for the development of left ventricular
hypertrophy (LVH), heart failure and other cardiovascular
complications, associated with microalbuminuria and faster
progression of nephropathy in patients with diabetes mellitus}.

20. EVALUATION
--To determine the extent of target organ damage.
--To assess the patient's overall cardiovascular risk
status.
--To rule out identifiable and often curable causes of
hypertension.

21. History, examination
--For:
Precipitating or aggravating factors (including
prescription medications, non-prescription
nonsteroidal antiinflammatory agents, and alcohol
consumption)
The natural course of the blood pressure
The extent of target organ damage
Presence of other risk factors for cardiovascular
disease

29. Laboratory testing
--The only tests that should be routinely performed
include:
*Hematocrit, urinalysis, routine blood chemistries
(glucose, creatinine, electrolytes), and estimated
glomerular filtration rate
*Lipid profile (total and HDL-cholesterol, triglycerides)
*Electrocardiogram
--Additional tests may be indicated in certain settings:
*Echocardiography is indicated to detect possible end-
organ damage (LVH).

30. *Microalbuminuria{persistent albumin excretion between 30 and 300
mg/day}:
-Appears to be a signal that the vasculature, particularly the endothelium, is
not functioning normally.
-Relation to renal disease, important risk factor for cardiovascular disease and
early cardiovascular mortality.
- K/DOQI guidelines {Kidney Disease Outcome Quality Initiative }suggest
that microalbuminuria alone that persists for more than three months falls
within the definition of chronic kidney disease.
-Measurement of the urine albumin-to-creatinine ratio in an untimed urinary
sample is the preferred screening strategyit does not require early morning
or timed collections, it gives a quantitative result that correlates with the 24-
hour urine values over a wide range of protein excretion, it is simple to
perform and inexpensive, and repeat values can be easily obtained to
ascertain that microalbuminuria, if present, is persistent.
-ACE inhibitor or angiotensin II receptor blocker (ARB) greater ability of
these drugs to reduce albuminuria compared to other antihypertensive drugs.

31. *Testing for renovascular hypertension:
--Indicated only in patients in whom there are suggestive clinical clues
and only if a corrective procedure will be recommended if significant
renal artery stenosis is detected.
--At present, there is no sufficiently accurate, noninvasive radiologic
or serologic screening test that, if negative, will completely exclude the
presence of renal artery stenosis.
--Medical therapy for control of hypertension is indicated in all
patients with unilateral renal artery stenosis.
--Revascularization, usually by percutaneous angioplasty with
stenting, is reasonable in patients with a hemodynamically significant
lesion who have resistant hypertension, malignant hypertension, an
inability to tolerate antihypertensive medications, or recurrent
episodes of flash pulmonary edema.
--Surgery is primarily warranted for correction of complex lesions.

32. *Serum Uric Acid:
Hyperuricemia has been found to be a precursor and
possible pathogenetic factor for hypertension. It is not
known whether the presence of hyperuricemia or its
treatment will influence the management of hypertension.
*Ambulatory blood pressure monitoring
*Plasma renin activity:
Although the PRA may provide prognostic information, the
test is usually performed only in patients with possible low-
renin forms of hypertension, such as primary
mineralocorticoid excess. The PRA may provide guidance
in the evaluation of resistant hypertension.

33. Thank you