Hypertension
Definition
-
Persistent SBP ≥140 OR DBP ≥90 mmHg on two separate occasions.
-
HTN crisis: urgency & emergency
TOD/TOC
Markdown table
| Organ | Manifestations |
|---|---|
| Heart | - LVH - CAD - HF |
| Brain | - TIA - Stroke - Dementia |
| Peripheral vasculature | - Absence of one or more major pulses in extremities (except DPA) ± intermittent claudication - Carotid bruit - AAA |
| Kidney | - GFR - Proteinuria (≥ 1+) - Microalbuminuria* |
| Retina | - Haemorrhages or exudates - Papilloedema |
TOD = Target organ damage (LVH, retinopathy, proteinuria)
TOC = Target organ complication (heart failure, renal failure)
*2 out of 3 positive tests over a period of 4-6 months. Defined as normal to mildly increased (UACR<30mg/g), moderately increased (UACR30-300mg/g) and severely increased (UACR >300mg/g)
Pathophysiology
History Taking
- Duration and level of elevated BP if known
- Secondary causes of HTN
- TOD/TOC (i.e. renal impairment and heart failure)
- CVD (e.g. CHD and cerebrovascular disease)
- Other comorbidities (e.g. DM, heart failure, renal disease, gout)
- Family history of HTN, CHD, stroke, DM, renal disease or dyslipidaemia
- Dietary history (salt, caffeine, liquorice, alcohol)
- Drug history (NSAIDs, nasal decongestants, OCP/HRT)
- Supplement, traditional or complementary medicine
- Lifestyle and environmental factors (e.g. smoking, physical inactivity, substance abuse; recreational & doping, psychosocial stressors, excessive weight gain)
- OSA (presence of snoring and/or day time somnolence)
Physical Examination
- General: height, weight and waist circumference
- Measure BP appropriately
- Fundus examination
- Palpation: presence of peripheral pulses and radio-femoral delay
- Auscultation: carotid bruit, abdominal bruit
- Cardiac: cardiomegaly, signs of HF and aortic regurgitation
- Abdominal: renal masses/bruit, aortic aneurysm
- Neurological: evidence of stroke
- Signs of endocrine disorders (e.g. Cushing syndrome, acromegaly and thyroid disease)
- ABI (if available)
Investigations
Aim: screen for secondary HTN, CV risk factors, TOD/TOC
- FBC
- Blood glucose
- Renal profile (creatinine, eGFR, serum electrolytes)
- Lipid profile (total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides)
- Uric acid
- Urinalysis (dip stick: albuminuria/microalbuminuria & microscopic haematuria)
- ECG
Management
Non-pharmacological
- Weight reduction
- Dietary intake
- Sodium intake - <5 g/day of salt (one teaspoon)
- Healthy eating - rich in fruit, vegetables, whole grains, legumes, seeds, nuts, fish and dairy products; low in meat, sweets, and alcohol
- Dietary potassium intake
- Lifestyle changes
- Smoking cessation
- Alcohol <2 drinks per day
- Regular physical activity - moderate intensity aerobic exercise at least 150 minutes per week
- Others - caffeine reduction
Pharmacological
Reference
- CPG Management of Hypertension 5th Edition (2018)