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C H A P T E R
4
CLINICAL EVALUATION CLINICAL EVALUATION OF HYPERTENSIVE PATIENTS Objectives Of Clinical Evaluation 1. Establish the presence of hypertension. 2. Assess the severity of hypertension. 3. Detect target organ damage. 4. Identify other cardiovascular risk factors. 5. Diagnose other conditions that might influence prognosis and treatment. 6. Find possible etiologic factors and curable causes for the hypertension. Establish the Presence of Hypertension - Accurate blood pressure measurement (chapter 3). - Repeat measurement on at least three separate occasions on different office visits few days or weeks apart . - The frequency of office visits and the duration of intervening periods depends upon the level of blood pressure, presence of target organ damage and other cardiovascular risk factors . Assess the Severity of Hypertension - History of patient’s previous blood pressure readings. - Adequacy of blood pressure control and response to therapy. - Symptoms and signs of target organ damage. History and Symptomatology - There are no symptoms for established uncomplicated essential
- Symptoms are usually secondary to target organ damage, drugs, associated anxiety or underlying cause. Interrogation of a Hypertensive Patient 1. Duration and Severity of Hypertension - When and how was high blood pressure discovered ? - Was it because of symptoms or on routine examination ? - What were the highest and lowest blood pressure readings ? - Were these readings while on treatment or not ? 2. Symptoms Suggestive of Target Organ Damage A. Cardiac: - Left ventricular dysfunction: e.g., shortness of breath. - Myocardial ischemia: Chest pain (angina). - Myocardial infarction: Pain, hospitalization, ECG. B. Cerebral: - Transient ischemic attack: Transient neurologic deficit. - Brain infarction. C. Renal: - Renal failure: Headache, thirst, anorexia, nausea, vomiting. - Edema. D. Peripheral Vascular: - Claudication. - Cold extremities. 3. Secondary Hypertension A. Renal: - Abdominal or flank pain, difficult micturition. Clinical Evaluation of Hypertensive Patients - Urine: Colour, stones, blood, volume. - Edema of face and limbs. - Abdominal operation or accidents. B. Endocrine: - Weight changes: Loss or gain. - Pheochromocytoma: Sweating, palpitation, headache, tremors. - Primary Aldosteronism: Weakness, polyuria, nocturia. C. Pregnancy and Menstrual History: - Preeclampsia: Edema, excessive weight gain, proteinuria, hypertension. - Frequent miscarriage, premature labor, infant death. D. Drugs: - Drug induced hypertension, chapter 3. 4. History of Previous Antihypertensive Therapy A. Drugs that proved effective. B. Drugs that were not effective or could not be tolerated. C. Unusual drug sensitivity or adverse reaction. D. Drug compliance. E. Side effects: Impotence, presyncope, ankle edema, cough, skin rash, depression. 5. Headache - Common in hypertensive as in normotensive individuals. - Does not correlate with the level of blood pressure. - Causes of headache in a hypertensive patient: 1. Anxiety and depression: common in hypertensive patients. 2. Drugs: vasodilators and dihydropyridine calcium antagonists. 1. Sudden rise in blood pressure: severe emotions, drugs, isometric (static) exercise, sexual intercourse. 2. Hypertensive encephalopathy. 5. Malignant hypertension. 6. Pheochromocytoma. Clinical Evaluation of Hypertensive Patients 7. Other causes of headache. 6. Other Cardiovascular Risk Factors a. Diabetes mellitus. b. Cigarette smoking. c. Dyslipidemia. d. Family history (first degree relatives), sudden death, coronary artery disease or stroke in young age. e. Sedentary life style. 7. Other Conditions That May Influence Choice of Therapy a. Gout. b. Impaired glucose tolerance. c. Bronchial asthma. d. Depression. e. Peripheral arterial disease. f. Migrain. g. Benign prostatic hypertrophy. h. Tremors. Physical examination A. General Features 1. Obesity and Body Fat - Check body weight and height in all patients and report about body fat distribution, i.e. in upper abdomen or buttocks. - Body mass index (body weight in Kg/height in meters square) is related to blood pressure. - Obesity, i.e., BMI > 30 Kg/m2 is an established independent risk factor.
2. Peripheral Arterial Pulsations - Reduced amplitude and delayed femoral arterial pulsations in coarctation of the aorta: Palpate simultaneously the radial and the femoral pulses. - Peripheral arterial disease (absent or weak peripheral pulses, bruits heard over femoral, iliac or carotid arteries). - A sign of target organ damage. - Associated with generalized atherosclerosis. - Part of arteritis: collagen or autoimmune diseases. - Need caution when using beta adrenergic blockers in therapy. - Auscultation of major arteries: Carotids, femoral and renal - a systolic - early diastolic bruit suggests tight stenosis. 3. Heart Rate a. Sinus Tachycardia (heart rate > 90 beats/min) Causes: 1. Anxiety. 2. Early and borderline hypertension. 3. Heart failure. 4. White coat hypertension. 5. Drugs: Vasodilators, antidepressants. 6. Hyperthyroidism. 7. Blood volume depletion: Excessive diuresis. Clinical Evaluation of Hypertensive Patients
8. Pheochromocytoma. 9. Other Causes: Infection, collagen disease, etc. b. Rhythm Disturbances Atrial Fibrillation: - Hypertensive cardiovascular disease is the most frequent cause of atrial fibrillation. - Can be related to elevations in blood pressure. - Left atrial abnormalities are common in hypertension. - Suspect underlying myocardial ischemia or hyperthyroidism. - May revert spontaneously to sinus rhythm with control of hypertension.
- Renal masses: Polycystic kidneys, hydronephrosis, tumours. - Renal (loin) tenderness: Pyelonephritis. - Urinary bladder swelling: Prostatic enlargement. - Abdominal aortic aneurysm. - Auscultation for renal artery bruits. · Systolic bruits without a diastolic component are not important and are usually of aortic origin. · Systolic and diastolic bruits in epigastrium or upper quadrants of abdomen suggests renal artery stenosis: For auscultation of bruits secondry to renal artery stenosis press the diaphragm of the stethoscope firmly against the abdominal wall starting from the umbilical region and proceeding upwards andlaterally to the lower costal cartilage.
- No abnormal physical signs in the majority of patients. - Left ventricular hypertrophy. - Atrial gallop (fourth heart sound): A sign of cardiac involvement – reduced left ventricular compliance leads to more forcible atrial contraction. - Ventricular gallop (third heart sound): A sign of a more severe impairement in left ventricular function and a late manifestation of hypertensive heart disease. It is an indication of cardiac failure after exclusion of other causes of third heart sound. Systolic Murmurs: - Common especially in elderly hypertensives. Causes: - Aortic causes: Aortic valve disease - stenosis, calcification, sclerosis, aortic ring dilatation. - Mitral annulus calcification with mitral regurgitation: Common in old females. - Associated hypertrophic cardiomyopathy. - Coarctation of the aorta. - Hyperdynamic circulation. Other Murmurs: - Aortic Regurge: An early diastolic murmur, sometimes very faint, may be present in hypertensive patients due to dilatation of the aortic ring and severe hypertension. - Continuous murmurs heard over the back and interscapular area and below the angle of the scapula are present in patients with coarctation of the aorta.
- Recommended in all newly detected hypertensives. - Mandatory in all patients with diastolic pressure greater than 120 mmHg to exclude malignant hypertension.
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