Hypertension

Hypertension: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ Essential hypertension

❑ White coat hypertension

❑ Renal artery stenosis

❑ Drug-induced hypertension

❑ Atherosclerotic vascular noncompliance

❑ Pheochromocytoma

❑ Cushing syndrome

❑ Hyperaldosteronism

❑ Aortic coarctation

❑ Acute renal artery obstruction

❑ Toxemia

Diagnostic Approach

The level of blood pressure associated with 50% increase in cardiovascular mortality: men younger than 45 years old, 130/90; men older than 45 years, 140/95; women, 160/95. An ankle-brachial systolic blood pressure ratio of less than 0.9 predicts a fourfold increase in cardiovascular mortality.

Clues to secondary hypertension include onset at a young age (,35), abrupt onset of hypertension, blood pressure difficult to control requiring high dosages of two or more drugs, and very high or labile blood pressure. Hypertension with relative tachycardia may be a clue to sympathetic effect or diastolic dysfunction. Headaches with severe hypertension are occipital and worse in the morning.

Hypertensive end organ damage must be searched for when the diastolic BP is greater than 130 mm Hg and the patient exhibits confusion, dyspnea, restlessness, or blurred vision. Perform fundoscopy looking for papilledema or retinal hemorrhages, and cardiopulmonary exam for third heart sound or bibasilar rales. Clues to hypertension-associated left ventricular hypertrophy include a fourth heart sound, an apical impulse greater than two intercostal spaces, a holosystolic sustained apical impulse diameter, and a hypertensive response to exercise ( .210 systolic). Cotton wool spots, which are caused by anoxic edema with axon degeneration, are seen in advanced hypertension (also in diabetes, dysproteinemia, and fat emboli).

Grading hypertensive retinopathy provides a marker of end-organ damage, which is tied to prognosis:

Clinical Findings

Essential hypertension  Gradual onset, an increase in diastolic blood pressure with standing, and a family history of hypertension are clues.

White coat hypertension  High blood pressure readings are found when measured by the physician, but not when the patient measures at home. Evidence of anxiety-induced sympathetic phenomena such as tachycardia, perspiration, cold hands, tremor, and/or pupil dilation will usually be present.

Renal artery stenosis  A bruit is heard in the upper abdomen over the kidneys in 40% to 50% of patients and is more specific with a diastolic component and when it lateralizes to one side. Evidence of widespread arterial disease is usually present.

Drug-induced hypertension  Hypertension can be caused by amphetamines, steroids, licorice, L-thyroxine, cocaine, and oral contraceptives.

Atherosclerotic vascular noncompliance  Systolic hypertension with a wide pulse pressure is found. Osler maneuver is positive: The radial arterial pulse remains palpable with the blood pressure cuff inflated.

Pheochromocytoma  Systemic sympathetic symptoms such as severe paroxysmal headache, anxiety, perspiration, palpitation, postural hypotension, and weight loss are seen. Blood pressure is often normal between paroxysms, but orthostatic hypotension may be found without medications. Abdominal palpation may reveal a suprarenal mass or cause a rise in blood pressure.

Cushing syndrome  The usual precipitant is chronic steroid use. The patient has truncal obesity with thin limbs, a plethoric moon face, easy bruising, purple striae, and hirsutism.

Hyperaldosteronism  Hypokalemia may cause muscle weakness, polyuria, and polydipsia.

Aortic coarctation  Simultaneous palpation of radial and femoral pulses reveals a pulse delay and volume and blood pressure decrement. An interscapular bruit can be heard. The feet will be cold, and there will often be bilateral lower extremity claudication.

Acute renal artery obstruction  The onset of hypertension will be acute, with high, labile blood pressure readings. There is usually evidence of atherosclerotic disease or atrial fibrillation.

Toxemia  Accelerated hypertension, edema, and proteinuria occur at the end of pregnancy.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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