DIAGNOSTIC PITFALL OF HYPERTENSION
DR. MD. FARUK HOSSEN
MCPS, FCPS
CONSULTANT(MEDICINE)
UHC, ADAMDIGHI, BOGURA.
What is pitfall ?
What is pitfall ?
Defination of Hypertension
Hypertension is defined as office SBP values ≥ 140 mm-hg
and/or diastolic BP values ≥ 90 mm-hg.
Practical definition of hypertension at which the benefit of
treatment outweigh the cost and hazards of treatment.
Source: ESC/ESH guideline 2018
Classification of HTN
Category Systolic(mm-hg) Diastolic(mm-hg)
Optimal <120 and <80
Normal 120-129 and/or 80-84
High normal 130-139 and/or 85-89
Grade 1 HTN 140-159 and/or 90-99
Grade 2 HTN 160-179 and/or 100-109
Grade 3 HTN ≥ 180 and/or ≥ 110
Isolated systolic HTN ≥ 140 and <90
Source: ESC/ESH guideline 2018
Staging of HTN
• Accordig to JNC 7 HTN is staged as follows
Stage systolic Diastolic
Normal <120 <80
Prehypertension 120-139 80-89
Stage 1 HTN 140-159 90-99
Stage 2 HTN >_ 160 >_ 100
• Prehypertension :
50% of affected patient develop overt HTN in 4
years .so prehypertensive patient should be monitored annually.
Main discussion
Accurate knowledge of BP measurement
Diagnosis of HTN
Measurement of Blood Pressure
PT should be in rest for 5 mins , in sitting position , back
supported in sitting position and at least 30 mins after
smoking and taking coffee.
Bladder width of the cuff should encircle at least 75% or
2/3rd of arm circumference.
Three BP readings in 1-2 min apart from arm at heart level
after removing tight cloth.
BP should be measured in both arm.
Arm with highest BP value should be used for subsequent
measurement.
Measure the standing BP after 3 min of standing in DM and
suspected postural drop of BP.
Postural hypotension : SBP ≥ 20 mm-hg and DBP ≥10 mm-hg
drop
Home BP monitoring(HBPM)
Home BP monitoring(HBPM )overcome some pitfalls of office measurement like
Physician error
White coat HTN 20% pt have normal home BP .
Masked HTN
White coat aggravation
Suspected resistant HTN
Very labile BP recording
Home BP monitoring should become a routine part of managing HTN.
2-3 reading should be taken in morning and at night for 1 week and
total at least 12 reading averaged before clinical decision making.
Home BP is usually 5 mm 0f Hg less than of office BP.
Ambulatory BP Monitoring
Normal values
<130/80 in 24 HR
<135/85 average daytime value
<120/70 average nighttime value
About 20% of pt with elevated office BP have normal ambulatory BP.
Ambulatory BP reading is high at morning and low at night . loss of
nocturnal dip is associated with thrombotic stroke and acceleration of
morning rise associated with cerebral hemorrhage .
Ambulatory BP is 12/7 mm of Hg lower than clinic BP.
Diagnosis
A single BP reading is not sufficient to establish the diagnosis of HTN.
Diagnosis should be confirmed at an additional clinic visit 1-4 weeks
after the 1st measurement. exceptions to this rule are:
HTN with evidence of life threatening end organ damage.
BP level > 220/125 without target organ damage.
AETIOLOGY OF HTN
• 95% of pt have HTN for which no underlying cause is evident called primary or
essential HTN.
• Important compounding environmental factors are high salt intake ,heavy
consumption of alcohol ,obesity ,lack of exercise ,impaired intrauterine growth.
• 5% of hypertensive patient have some underlying cause called secondary HTN.
• Secondary HTN should be suspected :
HTN in pt <20 yr and >50 yr.
PT who were previously well controlled but now become refractory to
treatment
HTN resistant to adequate dose of 3 drug.
Causes of secondary hypertension
• Alcohol, Obesity, Pregnancy
• Renal disease: Glomerulonephritis, Renal vascular disease, Polycystic
kidney disease
• Endocrine disease
• Coarctation of the aorta
Drugs causing HTN
• OCP
• Cyclosporin
• Tacrolimus
• NSAID
• Decongestant
• Erythropoeitin
• Cocaine
• Amphetamine
• alcohol
Workup
Routine Lab. Test
Haemoglobin and or haematocrit
Fasting blood glucose and glycated haemoglobin
Lipid profile
S. Electrolye
Blood uric acid
Blood creatinine and eGFR
Liver function tests
Urine analysis for blood, protein
12 lead ECG
Investigation For Selected Patient
investigation objective
CXR Crdiomegaly, Coarctation of aorta
Echocardiogram LVH
Renal USG PKD, Asymetric kidney,CKD
Renal angiography Renal artery stenosis
Urinary cathecolamine Phaeochromocytoma
Urinary cortisol and Dexamethason suppression Cushing syndrome
test
Plasma renin activity and aldosterone Conn’s syndrome
Diagnostic pitfalls
• Accurate BP measurement.
• Most of hypertension is diagnosed by a single BP reading in clinic.
• Ideal is more then one reading on more than one occasion.
• Home and ambulatory monitoring is more appropriate.
• Cost of ambulatory BP device is 566 [Link] is it practical for third
world countries.
BP measurement
• BP should be measured in both arms in each visit.
• Only 6% physician measure BP in both arm.
Position during BP measurement
• Talking or hand fisting cause rise of 7 mm of Hg BP.
• Sitting without back support result in falsely rise of BP 6-10
mm of Hg.
• Unsupported arm result in rise of 1-7 mm of Hg.
THANK YOU
ALL