This tutorial is based around a case and covers diagnosis, investigation and simple management.
A 45 year old man is referred with high blood pressure. The letter referring the patient provides the details that, on a routine work assessment check, the patient was found to have a BP of 165/95 and this was confirmed a week later at his GP’s surgery. A recheck BP today is also elevated at 170/97.
Do you think this gentleman’s diagnosis of hypertension is valid?
Yes, he had an elevated BP on three separate occasions and thus the diagnosis of hypertension is likely to be valid.
Think about this again the gentleman has now had three separate readings showing high blood pressure
Do you think that he needs a 24 hour Ambulatory BP monitor?
In an ideal world every patient with BP readings <180/120 should be referred for ambulatory blood pressure monitoring. If this cannot be carried out for whatever reason, home blood pressure readings are acceptable. It is thought that they are more representative than clinic readings where there may be an element of “white coat hypertension”.
Clinical reality means that often ambulatory BP testing cannot be undertaken. In this case we have three unequivocal elevated values. If they were more equivocal we may be more concerned to ensure ambulatory BP testing takes place.
As you can see from above there is no clear right or wrong answer. NICE guidance does advise ambulatory readings.
What details do you think are important to find out from the patient?
True. Yes this is very important. Although a lot of patients will be asymptomatic and found out at routine screens, like this man. A man of his age may have had a BP check in the recent past and this will help in determining if this is an acute rise in BP or more chronic problem
False. No this is not really that important. Although hypertension can cause headaches, this is rare and should not be considered and important symptom in hypertension. However, it is probably a question that one should ask as part of a systems review.
False. No this is not really that important. Although some heart murmurs are associate with high pulse pressures, a heart murmur in someone with hypertension is probably an incidental finding.
True. Yes, surprisingly. Processed food (ready meals, tinned food and cured meat products) generally contain a lot of salt and thus can be a major factor in contributing to hypertension
True. Yes, these are very important co-morbidities that need to be considered in the treatment of hypertension.
The most likely diagnosis for this gentleman is Primary/ Essential hypertension
What exacerbating factors are important in hypertension?
Select the correct answers
True. There is a relationship between excess body fat and hypertension. Weight loss of 1kg results in approximately 1-2mmHg reduction in BP
False. According to NHANES III studies higher calcium intake is associated with lower rates of age-related increases of systolic BP
True. According to Whelton’s studies, regular aerobic exercise is associated with reductions in both, systolic and diastolic blood pressure. It s suggested that people take 150mins of exercise a week.
True. Alcohol has a hypertensive effect which develops within a few days of excessive intake and usually recedes within a few days of abstinence. Three or more standard drinks daily causes a threefold increase in the prevalence of mild hypertension (>140/90mmHg). Patients should be encouraged to stick to safe limits.
False. Smoking a cigarette does lead to an acute increase of blood pressure but it only lasts for about 15 minutes. However, smoking increases CVD risk and thus patients should be encouraged to quit.
True. NSAIDs elevate BP approximately 5mmHg. Caution is advised if using NSAIDs as well as ACE inhibitors due to the possibility of renal impairment
True. The current average intake of sodium in the UK is 3.2g, equivalent to about 8g of salt, which can lead to raised blood pressure. The recommended daily amount of sodium (in the UK) is 2.4g (equivalent to about 6g of salt).
What symptoms/signs of end organ damage should be sought?
No, except in malignant hypertension, or when kidney disease is causing high blood pressure. Not a consequence of essential hypertension.
Maybe, although proteinuria is more likely to reflect underlying kidney disease than be a sign of end organ damage. A vicious cycle is set up so that high blood pressure worsens kidney disease.
Yes, in prolonged hypertension, left ventricular hypertrophy can occur and this can go on to cause left ventricular impairment and pulmonary oedema.
No, though it may cause high blood pressure
Yes, surprisingly. Retinopathy (changes in the vessels in the retina) are some of the earliest signs of hypertensive end-organ damage and are subclassified into early (AV nipping) and late (retinal haemorrhage and papilloedema).
Yes, there is a strong relationship between blood pressure and stroke.
What treatment would you advise for this patient (Young male – Average BP 168/95)?
False. A good treatment, but not first line treatment.
True, a good first line agent, along with lifestyle modification.
True. Lifestyle modification advice should be offered initially and then periodically to patients undergoing assessment or treatment for hypertension.
False. These are recommended in elderly or Afro-Caribbean people if HTN is resistant to lifestyle changes.
False. No indication at this stage.
What aspects of lifestyle modification would you advocate?
Select all those that apply
False. Should be encouraged in order to decrease CVD risk but does not influence BP.
True. Salt reduction from 10 to 5g per day lowers BP by about 5/2mmHg. It is important to be aware of large amount of salt in processed foods.
True. Most hypertensive patients are overweight and low-calorie diets have a modest effect on BP.
True. Exercise is recommended for hypertensive patients. Regular aerobic exercises should be advised.
False. There is a limited and inadequate evidence to support the use of garlic to lower BP.
True. Although smoking does not appear to be associated with HTN patients should be advised to stop smoking in order to decrease their CVD risk.
True. Alcohol consumption above 21 units/week is associated with BP elevation and binge drinking is associated with increased risk of stroke (note recommended guidelines for alcohol is maximum 14 units per week for males and females)
False. Do not routinely advise this to patients.
True. Hypertensive patients should increase their intake of fruit and veg to at least five portions per day which lowers BP in hypertensive patients by 7/3mmHg. This may be due to nitrate intake, but it is probably healthy for other reasons
On the next page, info about the different classes of anti-hypertension drug, and questions on their use.
For further reading
Test your skills with some more cases: