Definition

Chronic condition, characterized by elevation of the systolic and or diastolic measurement of blood pressure (> 140/90 or marked at > 170/110).

Symptoms

Essential: Usually none however, the patient may complain of headaches and epistaxis with severe hypertension.

Secondary: Depending on the etiology, patients may have one of many symptoms. Renovascular hypertension should be suspected in patients who have symptoms suggestive of chronic glomerulonephritis and pyelonephritis such as recurrent hematuria. Patients suffering from aortic coarctation would have no symptoms until the hypertension produces left ventricular hypertrophy. Symptoms such as tremor, sweating, and pallor (suggestive of pheochromocytoma) must also be considered when establishing a diagnosis of secondary hypertension. Patients presenting with truncal obesity and purple striae may suggest Cushing syndrome.

Malignant: An acute presentation, with symptoms of progressive renal failure, left ventricular failure, and stroke.

General: Usually, patients are unaware of the condition. Risk factors associated with cardiovascular disease (e.g., smoking, obesity, high fat diet, etc.) are most often also present. Patients may have a history or symptoms of cerebrovascular or renal disease, diabetes mellitus, hyperlipidemia, or gout. Oftentimes, patients may have been treated for hypertension in the past and discontinued medication due to cost or side effects. A family history is of critical importance as is a dietary assessment. Psychosocial and environmental factors, especially employment, family support and education, must also be determined. A drug history (both prescription and over the counter) is useful if the patiental drug interactions to consider. Drug history for contraceptive use is also important to establish, as this may cause mild elevations in blood pressure.

Age: Usually detected in the fourth to fifth decades of life. Men, particularly in middle age, are most commonly affected by essential hypertension. Women have a greater prevalence in advancing age groups. Head, Eyes, Ears, Nose, and Throat (HEENT): Examination should focus on the presence of carotid bruits, distended veins, or any enlargement of the thyroid.

Neurologic: Global assessment, with particular attention to cerebellar function. Onset: Usually gradual.

Duration: Essential hypertension is a lifelong condition.

Intensity: If treated and the patient’s compliance is good, evidenc has shown that the patient’s risk for cardiovascular morbidity and mortality decreases. If left untreated or the patient’s compliance is poor, then the risk of target organ damage and cardiovascular morbidity increases.

Aggravating Factors: Noncompliance with medication or life style modifications strategies, caffeine, smoking, adrenergic stimulants (e.g., nasal decongestants or eye drops for pupillary dilitation).

Alleviating Factors: Weight loss, sodium restriction, alcohol, and tobacco avoidance have all been shown to lower a patient’s blood pressure. For secondary hypertension, treatment of the underlying etiology will generally restore the patient to a normotensive state.

Associated Factors: African Americans are more at risk to develop essential hypertension, as are elderly individuals.

Physical Examination

General: An elevation in the systolic and / or diastolic blood pressure measurement on 2 or more readings separated by 2 minutes. Verification in the contralateral arm and with the patient sitting, lying, or standing. Arm should be supported at the level of the heart. Cuff size should be appropriate for the patient. Home readings can be taken to avoid “white coat hypertension.” Height and weight measurements should also be documented.

Cardiovascular: Signs of left ventricular hypertrophy or dysfunction such as increased rate, displacement of the apical impulse, precordial heave, clicks, murmurs, arrhythmias, and the presence of S3 or S4 heart sounds.

Extremities: Any sign of diminished or absent peripheral arterial pulsations, bruits, and edema.

Gastrointestinal: Check for the presence of bruits, enlarged kidneys, masses, and abnormal aortic pulsation.

Age: Usually detected in the fourth to fifth decades of life. Men, particularly in middle age, are most commonly affected by essential hypertension. Women have a greater prevalence in advancing age groups. Head, Eyes, Ears, Nose, and Throat (HEENT): Examination should focus on the presence of carotid bruits, distended veins, or any enlargement of the thyroid.

Neurologic: Global assessment, with particular attention to cerebellar function.

Onset: Usually gradual.

Duration: Essential hypertension is a life long condition.

Intensity: If treated and the patient’s compliance is good, evidence has shown that the patient’s risk for cardiovascular morbidity and mortality decreases. If left untreated or the patient’s compliance is poor, then the risk of target organ damage and cardiovascular morbidity Increases.

Ophthalmologic: Check for arteriolar narrowing, AV nicking, hemorrhages, exudates, or papilledema on fundoscopic examination.

Pathophysiology

Essential hypertension is primarily due to increased peripheral arteriolar resistance of unknown mechanism. Secondary hypertension mayor may not differ in the pathophysiology of the disease. For instance, in pheochromocytoma, hypertension is due to both increased cardiac output and peripheral resistance caused by epinephrine and norepinephrine respectively.

Diagnostic Studies

Laboratory: Should be performed before instituting therapy. The physician assistant (PA) should always be aware of laboratory findings consistent with target organ disease.

Urinalysis: To rule out renal dysfunction or glycosuria.

Complete blood count: To rule out anemia before instituting therapy. Serum chemistry values: To evaluate potassium, calcium, creatinine, uric acid, fasting blood glucose, cholesterol (both high density and low density liproproteins), and triglycerides. Some of these tests are needed to determine cardiac risk, while others can rule out secondary causes of hypertension. plasma renin /urine sodium determinations: To evaluate for renovascular hypertension.

Radiology

CXR: May show cardiomegaly with long standing hypertension, evidence of left ventricular failure or aortic calcification.

Other

ECG: Identify rhythm or cardiac function abnormalities.

Echocardiogram: To assess left ventricular size and function.

Differential Diagnosis

While the differential diagnosis for hypertension can be quite lengthy, in 90 to 95 percent of the cases, the diagnosis is that of essential hypertension. However, the PA should always consider causes of secondary hypertension such as renovascular, endocrine, and aortic coarctation.

Traumatic

Renal trauma: Distant or acute may cause renovascular hypertension.

Infectious

Repeated urinary tract infections: May cause renal parenchymal disease.

Metabolic

Aldosteronism: Must be considered in patients with muscle weakness, polyuria, nocturia, and polydipsia.

Neoplastic

Pheochromocytoma: Suspected in patients with continuous hypertension associated with head pain, perspiration, or tremors. Elevated serum norepinephrine levels.

Vascular

Renal artery stenosis/thrombosis/arteritis: Seen on renal angiogram.

Congenital

Coarctation of the aorta: Upper extremity hypertension associated with concommitant lower extremity hypotension.

Acquired

Drug induced: Especially with recreational drugs (e.g., cocaine, amphetamines), tricyclic antidepressants, ephedrine, phencyclidine, methylphenidate and monoamine oxidase inhibitors. Estrogen preparations have also been shown to increase blood pressure.

Treatment

Life-style modifications, essentially the hallmark of nonpharmacologic therapy, should be instituted for all patients, whether or not they are treated concomitantly with pharmacologic therapy. These life-style changes include weight loss, limited alcohol intake, smoking cessation, and reduced dietary fat and cholesterol. Pharmacologic therapy is indicated in patients with sustained (>3 visits) elevations in the diastolic or systolic blood pressure and/or target organ damage. Initial drug therapy for patients with mild to moderate hypertension consists of a thiazide diuretic (25 mg of hydrochlorothiazide or chorthalidone) or a beta blocker. A calcium channel blocker (diltiazem 30 to 60 mg three times a day or nifedipine SR 30 to 60 mg) may also be used. Patients with target organ damage may benefit from a beta blocker or angiotensin converting enzyme inhibitor (captopril or enalapril). Many of these agents have synergistic effects and can be used concomitantly. Long-term clinical trials using diuretics and beta blockers have shown them to be useful and effective in controlling hypertension as well as demonstrating long-term reductions in cardiovascular morbitity and mortality.

Pediatric Considerations

The clinical maxim “the higher the blood pressure and younger the child” should alert every PA to suspect the diagnosis of secondary hypertension. Children with periodic elevations of blood pressure should be monitored closely, especially if they have a hypertensive parent. Primary prevention strategies are especially important in children with a strong family history of essential hypertension.

In children, it is critical that the examiner use proper techniques for obtaining the blood pressure and that the obtained values be compared to a well-established age and gender specific standards table. Before diagnosing essential hypertension, extreme care must be taken to rule out common causes of secondary hypertension such as renal parenchymal disease, renal artery disease, and coarctation of the aorta. Management should focus on nonpharmacologic therapies such as weight reduction, reduced sodium intake, regular exercise, etc.

Drug therapy should be considered if these modalities fail to lower blood pressure. Pharmacologic management is conducted in the same fashion as with adults. Special consideration should be given to medication side effects and the potential impact on the growing child.

Obstetrical Considerations

In pregnancy, the diagnosis of chronic hypertension (nonpregnancy­induced hypertension) can be made if the blood pressure greater than 140/90 is recorded prior to the 20th gestational week. These patients with chronic essential hypertension can also develop superimposed pregnancy”induced hypertension, and should be monitored closely for undue weight gain, edema, and proteinuria. The effects of hypertension on the pregnant patient include decreased blood flow to the uterus, an increased risk of intrauterine growth retardation, and the possibility of early delivery.

Therefore, the pregnancy should be carefully monitored by the use of ultrasound to accurately determine the exact gestational age of the fetus. Monitoring should also include the use of nonstress test, contraction stress test, or biophysical profile beginning at the 30th gestational week to ensure that the fetus is tolerating the intrauterine environment. When the pregnant hypertensive patient rests, it should be only in the left lateral recumbent position to maintain maximum uterine blood flow.

Management considerations should involve self-monitoring of the patient’s blood pressure at home, use of a low-salt diet, and strict abstinence from smoking and alcohol. If the diastolic is consistently 99 mmHg or greater, an antihypertensive medication should be utilized. Methyldopa (Aldomet) is one medication that is recommended.

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