2 min read - Hypertension



A 45 years old female patient presents to you saying, 'Dr. I think I have blood pressure'. You measures her blood pressure and it's 160/100mmHg.

What are you going to do?

 Your first task is to establish the diagnosis of hypertension.

How can you diagnose a patient to have hypertension?

  • Blood pressure should be properly measured!
    • it's not easy.
    • Things that we often miss are
      • Quite/calm room
      • Bladder not full
      • Correct patient position
      • Rest the arm on the table
      • Correct cuff size
      • NO talking during procedure
      • Avoid caffeine, exercise, smoking for minimum 30 min
      • Measure BP in both arms, select the arm with the higher value for future measurements
      • Take two values 1-2min apart and calculate the average.
  • Confirm the high blood pressure on a second occasion/ confirm that it's not transient
    • Sometimes a second measurement is not necessary if there's evidence to say patient had chronic hypertension
      • Retinal changes
      • ECG - LV hypertrophy
      • Hypertensive emergency/ urgency at first presentation
What are the abnornalities?

What can you see here?

Has the patient got a secondary cause for hypertension?
What is the diagnosis?
  • Not all patients need to be evaluated for secondary causes
  • Consider secondary causes in patients 
    • Who are younger than 30-35 years
    • Poorly controlled hypertension with drugs
    • Who have features that suggest a secondary cause such as,
      • Hypokalemia - Primary hyperaldosteronism
      • Episodic flushing/ palpitations - Pheochromocytoma
      • Diabetes, obesity, striae - Cushings syndrome
      • Elevated creatinine - CKD
      • Abdominal bruits - Renal artery stenosis
      • Radio femoral delay - Coarctation of aorta
      • Thin built, tachycardia - Thyrotoxicosis
    • We can discuss how to evaluate for secondary causes on a later date.
    • Don't forget to look for
      • Obstructive sleep apnoea, which is a common cause for hypertension!
      • Sometimes drugs can cause hypertension. People take many over-the-counter medications
Evaluate the patient for other risk factors
  • Obesity - BMI, Waist circumference
  • Diabetes
  • Hyperlipidemia
  • Smoking
Encourage all patients to
  • Loose weight if necessary
  • Exercise - minimum 150min/week
  • Reduce salt intake
  • Healthy (affordable!) diet 
  • Stop smoking
Drug treatment
  • There are so many drugs that can be prescribed
  • Read the pharmacology note!
  • Some tips
    • Calcium channel blockers are very safe and convenient first line drugs
      • Side effects that patients usually encounter are leg edema and postural symptoms.
      • Amlodipine 5mg daily which can be increased to 10mg is a good choice for many patients. (it's quite cheap to buy also!)
    • ACEI/ ARBs can also be used as first line drugs
      • Make sure they have no renal impairment/ hyperkalemia.
      • If you suspect secondary causes, better not use these drugs until workup is complete
      • Losartan 50mg daily/bd, Captopril 25mg tds/ 50mg tds are available in most hospitals.
    • Diuretics can also be given as first line
      • HCT - 12.5-25mg daily
        • In ederly it can cause severe hyponatremia. Better to avoid.
        • Better not to combine with ACEI/ARB for the same reason.
  • If you like fancy names you may try - Telmisartan, Irbesartan, Ramipril, Lisinopril, Perindopril, Indepamide.
Don't try to bring down the pressure too fast unless indicated for specific reasons. They've lived with those blood pressures for many years. Waiting for couple of weeks won't do any harm.

Read about the blood pressure goals in patients with different comorbidities.


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