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Home Books Symptom to Diagnosis: An Evidence-Based Guide, 3e

23: Hypertension

CHIEF COMPLAINT

PATIENT image

Mr. U is a 48-year-old man with a BP of 165/90 mm Hg.

image What is the differential diagnosis of hypertension? How would you frame the differential?

CONSTRUCTING A DIFFERENTIAL DIAGNOSIS

First, what is normal BP, and when is a patient hypertensive? The first step is accurately measuring the BP. Table 23-1 summarizes guidelines for obtaining valid BP measurements.

Table 23-1.Guidelines for measuring BP.
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Table 23-1. Guidelines for measuring BP.
• The patient should sit for several minutes in a quiet room before BP measurements are taken. Pain, stress, a full urinary bladder, a recent meal, and talking or active listening during measurement affect BP. Having smoked a cigarette within 15–20 minutes can elevate the BP by 5–20 mm Hg.
• Take at least 2 measurements spaced by 1–2 minutes and additional measurements if the first 2 are quite different.
• Using a bladder that is too narrow yields false high readings. Instead of the standard cuff (12–13 cm long, 35 cm wide) use an appropriate larger cuff in patients with increased arm circumference.
• Use phase I (first tapping sound) and V (disappearance) Korotkoff sounds to identify systolic and diastolic BP values, respectively.
• Do not deflate the cuff too rapidly, otherwise individual Korotkoff sounds are missed and too low a value is measured; start with a deflation rate of 2 mm/s.
• Measure the heart rate by palpation and watch out for arrhythmia, which mandates repeated BP measurements.
• At the first visit, measure BP in both arms and take the higher value as the reference; measure BP at 1 minute and 5 minutes after standing upright if the patient has a disorder that frequently causes orthostatic hypotension.

Adapted, with permission, from Messerli FH, Williams B, Ritz E. Essential hypertension. Lancet. 2007;370:591–603.

Consensus guidelines classify BP as follows, based on the mean of 2 seated BP measurements on each of 2 or more office visits:

  1. Optimal: systolic BP (SBP) < 120 mm Hg and diastolic BP (DBP) < 80 mm Hg

  2. Normal: SBP 120–129 mm Hg and DBP 80–84 mm Hg

  3. High normal: SBP 130–139 mm Hg or DBP 85–89 mm Hg

  4. Grade 1 hypertension: SBP 140–159 mm Hg or DBP 90–99 mm Hg

  5. Grade 2 hypertension: SBP 160–179 mm Hg or DBP 100–109 mm Hg

  6. Grade 3 hypertension: SBP ≥ 180 mm Hg or DBP≥ 110 mm Hg

  7. Isolated systolic hypertension: SBP ≥ 140 mm Hg and DBP < 90 mm Hg

Hypertension is either primary (essential) or secondary (resulting from a specific identifiable cause). Causes of secondary hypertension can be organized using an organ/system framework:

  1. Primary (essential) hypertension

  2. Secondary hypertension

    1. Endocrine

      1. Primary aldosteronism

      2. Pheochromocytoma

      3. Thyroid disease

      4. Hyperparathyroidism

      5. Cushing syndrome

    2. Renal

      1. Chronic kidney disease (CKD)

      2. Acute kidney injury

    3. Vascular

      1. Renovascular disease

      2. Coarctation ...

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