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Hypertension

Medicine > Cardiovascular

Differential Diagnosis Schema 🧠

Primary (Essential) Hypertension

  • Primary Hypertension: Most common cause of hypertension (90-95% of cases); multifactorial in origin, with no identifiable single cause.
  • Risk Factors: Includes age, family history, obesity, sedentary lifestyle, high salt diet, excessive alcohol consumption, and smoking.

Secondary Hypertension

  • Renal Causes: Includes chronic kidney disease, renal artery stenosis, and glomerulonephritis; presents with symptoms of renal dysfunction such as hematuria, proteinuria, or abnormal renal function tests.
  • Endocrine Causes: Includes primary hyperaldosteronism (Conn’s syndrome), Cushing’s syndrome, pheochromocytoma, and hyperthyroidism; often presents with additional symptoms like weight gain, striae, palpitations, or headaches.
  • Vascular Causes: Includes coarctation of the aorta; presents with hypertension in the upper limbs with low blood pressure or weak pulses in the lower limbs.
  • Medications: Includes oral contraceptives, NSAIDs, steroids, and sympathomimetics; history of medication use is key.
  • Sleep Apnea: Often associated with obesity and presents with symptoms of snoring, daytime sleepiness, and nocturnal hypoxia.
  • Pregnancy-Related: Includes pre-eclampsia and eclampsia; presents with hypertension, proteinuria, and edema after 20 weeks of gestation.
  • Other: Includes rare causes such as adrenal tumors or genetic disorders like Liddle’s syndrome.

Key Points in History 🥼

Symptom History

  • Asymptomatic: Most patients with hypertension are asymptomatic, especially in early stages.
  • Headache: Particularly in the morning or occipital region, may suggest severe hypertension.
  • Visual Disturbances: Blurred vision or transient visual loss may indicate hypertensive retinopathy.
  • Chest Pain: Suggestive of underlying ischemic heart disease or aortic dissection in severe cases.
  • Palpitations: May indicate underlying arrhythmias or pheochromocytoma.
  • Shortness of Breath: May suggest heart failure secondary to long-standing hypertension.
  • Hematuria or Nocturia: Could suggest renal causes of secondary hypertension.
  • Fatigue and Weakness: Nonspecific symptoms that may occur due to poor blood pressure control or associated conditions like sleep apnea.
  • Dizziness or Fainting: May suggest postural hypotension or adverse effects of antihypertensive therapy.
  • Neurological Symptoms: Transient ischemic attacks or stroke-like symptoms may indicate severe hypertension or hypertensive encephalopathy.

Background

  • Past Medical History: Include history of cardiovascular disease, diabetes, kidney disease, or endocrine disorders.
  • Surgical History: Relevant surgeries such as renal or vascular surgery may be pertinent.
  • Drug History: Review of current and past medications, especially those that can elevate blood pressure.
  • Family History: Consider family history of hypertension, cardiovascular disease, or genetic conditions like pheochromocytoma.
  • Social History: Smoking, alcohol use, and dietary habits, particularly salt intake, should be assessed.
  • Occupational History: Consider stress levels and physical activity, which may impact blood pressure.
  • Reproductive History: In women, include history of pregnancy-related hypertension, such as pre-eclampsia.
  • Physical Activity: Regular exercise and its impact on blood pressure control should be reviewed.
  • Dietary Habits: High salt diet, low potassium intake, and use of caffeine or stimulants should be assessed.
  • Sleep History: Consider sleep apnea, especially in obese patients or those with daytime sleepiness.
  • Stress Levels: Chronic stress can contribute to elevated blood pressure and should be considered in management.
  • Previous Investigations: Review any previous blood pressure readings, home monitoring results, or relevant imaging studies.
  • Comorbid Conditions: Review other chronic illnesses such as hyperlipidemia, obesity, or metabolic syndrome, which may complicate hypertension management.
  • Functional Impact: Assess the impact of hypertension on daily functioning, including work, family life, and mental health.
  • Immunization History: Consider relevance in cases of infectious causes, such as hepatitis or tuberculosis.
  • Psychiatric History: Consider underlying psychiatric conditions that may manifest with somatic symptoms.
  • Family Planning: In women, discuss future pregnancy plans, as this may impact management in cases like hyperemesis gravidarum.
  • Lifestyle Factors: Consider the impact of lifestyle choices on symptoms, including work stress, sleep patterns, and exercise.
  • Comorbid Conditions: Review of other chronic conditions, such as diabetes, hypertension, or renal disease, which may complicate management.

Possible Investigations 🌡️

Initial Assessments

  • Blood Pressure Measurement: Accurate measurement is crucial, including home monitoring or 24-hour ambulatory blood pressure monitoring.
  • Full Blood Count (FBC): To assess for anemia or polycythemia, which may be relevant in secondary causes.
  • Renal Function Tests: Urea, creatinine, and electrolytes to assess renal function and identify secondary hypertension causes.
  • Liver Function Tests (LFTs): To assess hepatic function, particularly if medication toxicity is a concern.
  • Fasting Blood Glucose: To assess for diabetes or impaired glucose tolerance, which are risk factors for hypertension.
  • Lipid Profile: To assess for dyslipidemia, which is often associated with hypertension.
  • Thyroid Function Tests: To rule out hyperthyroidism or hypothyroidism as a secondary cause.
  • Urinalysis: To assess for proteinuria, hematuria, or glucose, which may indicate renal or endocrine causes.
  • Electrocardiogram (ECG): To assess for left ventricular hypertrophy, arrhythmias, or ischemic changes.
  • Chest X-Ray: To assess for cardiomegaly or signs of heart failure.
  • Echocardiogram: To assess for left ventricular hypertrophy, valve abnormalities, or cardiac function.
  • 24-Hour Urine Catecholamines: To assess for pheochromocytoma in cases of suspected secondary hypertension.
  • Plasma Renin Activity and Aldosterone Levels: To assess for primary hyperaldosteronism.
  • Renal Artery Doppler Ultrasound: To assess for renal artery stenosis in secondary hypertension.
  • Sleep Study: To assess for obstructive sleep apnea, particularly in obese patients.
  • Fundoscopy: To assess for hypertensive retinopathy.
  • Cardiac MRI: To provide detailed imaging of cardiac structures if echocardiogram findings are inconclusive.
  • CT/MRI Angiography: To assess for vascular causes like coarctation of the aorta or renal artery stenosis.
  • Blood Cultures: If there is suspicion of infective endocarditis, particularly in febrile patients.
  • Ambulatory Blood Pressure Monitoring (ABPM): To confirm the diagnosis of hypertension and rule out white-coat hypertension.
  • BNP or NT-proBNP: Biomarkers of heart failure, which may be elevated in significant valvular heart disease.
  • Stress Testing: May be used to assess the functional significance of a valve lesion, particularly in aortic stenosis or mitral regurgitation.
  • Holter Monitoring: Useful in detecting arrhythmias that may be associated with valve disease.
  • Cardiac Catheterization: Invasive procedure to assess coronary artery disease and measure intracardiac pressures, often used before valve surgery.
  • Doppler Ultrasound: Assesses blood flow across the valves, helping to quantify the severity of stenosis or regurgitation.
  • Cerebral Imaging: Consider in patients with suspected embolic phenomena secondary to infective endocarditis or aortic stenosis.
  • Exercise Echocardiography: Can help assess valve function during physical stress, particularly in asymptomatic patients with severe valve disease.
  • Liver Function Tests: Especially relevant in right-sided heart failure, where hepatic congestion may occur.
  • Renal Ultrasound: Consider if there is suspicion of renal complications from chronic heart failure or systemic emboli.
  • Pulmonary Function Tests: Useful in differentiating between cardiac and pulmonary causes of dyspnoea in patients with valvular heart disease.
  • Arterial Blood Gas (ABG): In cases of severe heart failure, ABG can help assess respiratory function and acid-base balance.
  • Genetic Testing: Consider in familial cases of hypertrophic cardiomyopathy or congenital valve disease.
  • Nuclear Imaging: Such as a myocardial perfusion scan, may be used to assess the impact of valvular disease on myocardial perfusion.
  • Coronary Angiography: Indicated in patients with symptoms suggestive of ischemic heart disease or before valve surgery.
  • Endomyocardial Biopsy: Rarely indicated but may be useful in specific cases of unexplained heart failure or myocarditis associated with valve disease.
  • PET Scan: May be indicated in cases of suspected infective endocarditis to assess for metastatic infection.
  • CT Coronary Angiography: Non-invasive alternative to invasive coronary angiography, particularly useful in patients with lower risk of coronary artery disease.

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Cardiovascular