1. Medical Science Tanzania Lectures
Management of primary
Hypertension
1. Diagnostic procedures
March 2013 Prof. G. Hennersdorf DGK ESC SES

2. Hypertension subsets
 Primary Hypertension
 Dysregulation of neurohormonal (RAS) systems
 Triggering Target Organ Damage
 Heart
 Left ventricular hypertrophy
 Angina or prior myocardial infarction
 Prior coronary revascularization
 Heart failure
 Brain
 Stroke or transient ischemic attack
 Kidney:
 Chronic kidney disease
 Peripheral arterial disease
 Eye
 Retinopathy
March 2013 Prof. G. Hennersdorf DGK ESC SES

3. Hypertension subsets
• Secondary Hypertension
– Organ mediated
• Renal disorders (parenchymatic, vascular)
• Glands (thyroid; adrenal)
• Cardiac (aortic regurgitation)
• Vessel abnormalities (Aortic coarctation)
• Pregnancy (gestation, eclampsia)
• Others (drug addiction)
March 2013 Prof. G. Hennersdorf DGK ESC SES

4. Definition of arterial Hypertension HPT
systolic blood pressure diastolic blood pressure
Normal <140 and <90
(diabetic) <130 <80
Age =>80 150 90
mild HPT 140-179 and/or 90-104
borderline HPT 140-159 90-94
intermediate >=180 >=105
severe HPT
and/or
isolated systolic >=160 <90
HPT(ISH**) 140-159 and
*WHO 2000 ** isolated systolic hypertension
March 2013 Prof. G. Hennersdorf DGK ESC SES

5. Prevalence of arterial hypertension (%)
50
45
40 44
35
30 32 Germany
subsaharan Africans
25
26 US
20 Afroamericans
20
15
10
5
0
per cent age
March 2013 Prof. G. Hennersdorf DGK ESC SES

6. Prevalence
of hypertensive stroke
Subsaharan Africa (Tanzania) 1,6%
Western Countries (US) 1,7%
March 2013 Prof. G. Hennersdorf DGK ESC SES

7. Hypertension Diagnosis
• clinical diagnosis
• advanced measures
• pathways and flowcharts
March 2013 Prof. G. Hennersdorf DGK ESC SES

8. Hypertension Diagnosis
• Clinical Diagnosis
• Advanced Measures
• Pathways and Flowcharts
March 2013 Prof. G. Hennersdorf DGK ESC SES

9. Hypertension Diagnosis:
normal changes of BP
Sleeping: BP falls and Running: BP rises and Alcohol and tobacco
rises when waking up decreases to normal misuse, drug addiction: BP
during recovery phase with rises and triggers
positive training effects hypertension!
protecting from
hypertension
March 2013 Prof. G. Hennersdorf DGK ESC SES

10. Hypertension Diagnosis
Hypertension by itself doesn‘t hurt!
• History:
– General signs and symptoms should reveal level of risk
and suspicion of TOD*s
• Head ache, Dizziness, visus abnormalities, hst. of stroke, hst.
of fainting (syncope)  brain damage
• Palpitation, Dyspnea, chest pain, nocturnal dysuria, hst. of MI
 heart (damage) failure, CAD
• Leg pains: Walking, rest pain,  peripheral (damage) disease
• Family history, physical activity, history of smoking habits,
alcohol abuse
• History of medication *target organ damage
March 2013 Prof. G. Hennersdorf DGK ESC SES

11. Hypertension Diagnosis
• Physical examination
– Inspection, palpation and auscultation
• Chest: lungs and heart (congestion, murmurs, rhythm)
• Neurological status: consciousness, motion
abnormalities, reflexes, speech
• Peripheral pulses: carotid murmurs, abdominal
murmurs (renal disease?), ankle-brachial-index ABI
• Hyperlipidemia: xanthelasm, arcus senilis, ear lobe
creases
• Joints: gout
March 2013 Prof. G. Hennersdorf DGK ESC SES

12. Hypertension Diagnosis
• Physical examination
– Measuring blood pressure: necessary at each visit
start, whenever seeing the doctor!
This is the most important examination procedure,
therefore be careful, be skilled, be an expert
March 2013 Prof. G. Hennersdorf DGK ESC SES

13. Hypertension Diagnosis
• The correct measurement
of blood pressure depends on
– Patient
– Environment
– Device
– Procedure
March 2013 Prof. G. Hennersdorf DGK ESC SES

14. Hypertension Diagnosis
• The correct measurement of blood pressure
– Patient (first visit)
– Environment
– Device
– Procedure
March 2013 Prof. G. Hennersdorf DGK ESC SES

15. Hypertension Diagnosis
• Silence, Sedation (?)
• No coffee, no smoking for at least 60 min.
before reading
• Supine position (for at least 10 min.)
March 2013 Prof. G. Hennersdorf DGK ESC SES

16. Hypertension Diagnosis
• The correct measurement of blood pressure
– Patient
– Environment
– Device
– Procedure
March 2013 Prof. G. Hennersdorf DGK ESC SES

17. Hypertension Diagnosis
• Dry, calm, separate (?) room
• Avoid fast movements of the personnel
• Quiet, warm setting
March 2013 Prof. G. Hennersdorf DGK ESC SES

18. Hypertension Diagnosis
• The correct measurement of blood pressure
– Patient
– Environment
– Device
– Procedure
March 2013 Prof. G. Hennersdorf DGK ESC SES

19. Hypertension Diagnosis
• Devices for the physician:
– Mercury (Hg; best device!)
– Aneroid (needs regular calibrations vs. Hg)
– Ultrasound (esp. children)
– Oscillometry (forearm-wrist devices)
March 2013 Prof. G. Hennersdorf DGK ESC SES

20. Hypertension Diagnosis: mercury device
Scaled mercury manometer
Cuff
Air bulb pumping accessory
March 2013 Prof. G. Hennersdorf DGK ESC SES

21. March 2013 Prof. G. Hennersdorf DGK ESC SES

22. Hypertension Diagnosis
• Cuff size: 2/3 of arm length (smaller cuffs result in higher
pressures!)
• Cuff position: unclothed arm, tight and strong, deflated
• Choose mercury manometer; aneroid devices should be
calibrated against Hg every 6 month!
• for children choose smaller cuffs or ultrasound devices
March 2013 Prof. G. Hennersdorf DGK ESC SES

23. Hypertension Diagnosis
• The correct measurement of blood pressure
– Patient
– Environment
– Device
– Procedure
March 2013 Prof. G. Hennersdorf DGK ESC SES

24. Hypertension Diagnosis: anatomy of brachial
auskultation area
a.brachialis
membrane area
medial,just above the
joint (epicondylus
medialis)
March 2013 Prof. G. Hennersdorf DGK ESC SES

25. Hypertension Diagnosis
• Brachial measurement
– Inflation quickly 20 mm Hg over expected SBP or as
recognized by palpation of the radial pulse
(disappearance)
– Deflation slowly (3 mm Hg /s)
– Readings:
first reading both left and right arm, difference not being
above 20 mm Hg
at least 2 readings from the arm with the higher pressure
– listen to disappearance of Korotkow noise (muffling may
occur: take the attenuation point)
March 2013 Prof. G. Hennersdorf DGK ESC SES

26. Hypertension Diagnosis: anatomy of radial
palpation area
a.radialis
palpation area
March 2013 Prof. G. Hennersdorf DGK ESC SES

27. Hypertension Diagnosis
• Radial pulse palpation, if only SBP
measurements are needed:
– shock or hypotension (if palpable!)
– Posture evaluation (syncope diagnosis)
– sudden information about systolic blood
pressure
Does NOT replace regular measurements!
March 2013 Prof. G. Hennersdorf DGK ESC SES

28. Hypertension Diagnosis
Radial blood pressure devices for self measurements:
instructions, training and commitment of the patient
are necessary. Scheduled repeat calibration!!
March 2013 Prof. G. Hennersdorf DGK ESC SES

29. Hypertension Diagnosis
• How many doctor‘s readings?
– Office visit: at least 3 readings in order to reduce white
coat BPR
– At home (self control): at least 5 readings per day with
protocol):
• After bedrest,
• After breakfast
• Late in the morning
• late afternoon
• Before bed rest
March 2013 Prof. G. Hennersdorf DGK ESC SES

30. Hypertension Diagnosis:patient
commitment
Have a blood pressure protocol booklet ready,
when your patient visits office last time.
Ask the patient to use it regularly and carefully
Ask the patient to show at next visit
therapy control Pt. compliance
March 2013 Prof. G. Hennersdorf DGK ESC SES

31. Hypertension Diagnosis
date time SBP/DBP pulse remarks-medication
Main contents of BP booklet
March 2013 Prof. G. Hennersdorf DGK ESC SES

32. Hypertension Diagnosis
• Clinical Diagnosis
• Devices for measurement
• Advanced Measures
• Pathways and Flowcharts
March 2013 Prof. G. Hennersdorf DGK ESC SES

33. Hypertension Diagnosis
• Advanced BP-measures
– 24 h monitoring
– Telemetry
– Exercise (treadmill) Tests
March 2013 Prof. G. Hennersdorf DGK ESC SES

34. Hypertension Diagnosis
• Advanced BP-measures
– 24 h monitoring
– Telemetry Sleep Wake up
– Exercise Blood pressure
High incidence of
MACCE
March 2013 Prof. G. Hennersdorf DGK ESC SES

35. Hypertension Diagnosis
24h-BP-Monitoring
Daytime 7:00 am – 10:00 pm 20 min intervals
During the night 10 pm – 6:00 am 30 min intervals
minimum of 80/24 h
measurements
March 2013 Prof. G. Hennersdorf DGK ESC SES

36. Hypertension Diagnosis
24h-BP-Monitoring
Normal values
Daytime mean < 135/85 mm Hg
Frequency of values over 20 -25%
140/90 mm Hg
Night dipping 10-15%
Total mean <130/80 mm Hg
Recommendations of the german hypertension society
March 2013 Prof. G. Hennersdorf DGK ESC SES

37. Hypertension Diagnosis
• Advanced BP-measures
– 24 h monitoring
– Telemetry (mostly investigational,needs
invasive measurement)
– Exercise
future use: telemedicine
electronic data transmission by telephone and/or computer
in order to leave the patient not uncontrolled
or to give him safety to contact his doctor in case of emergency
March 2013 Prof. G. Hennersdorf DGK ESC SES

38. Hypertension Diagnosis
• Advanced BP-measures
– 24 h monitoring
– Telemetry
– Exercise
March 2013 Prof. G. Hennersdorf DGK ESC SES

39. Hypertension Diagnosis
Exercise equipment Exercise protocol
March 2013 Prof. G. Hennersdorf DGK ESC SES

40. Hypertension Diagnosis
• Validation of exercise test concerning BP changes:
if
– SBP = 200 mm Hg when reaching 100 W level (10
METS), or
– no recovery to normal values within 5 min observation
time, or
– DBP >= 110 mm Hg at any level (before: do not
perform test, during: stop test!)
Result: exercise hypertension; persistent hypertension
March 2013 Prof. G. Hennersdorf DGK ESC SES

41. Hypertension Diagnosis
• advanced diagnostic procedures:
target organ damage
– Heart: Chest Xray, ECG, Ultrasound, MD-CT, MRT
– Brain: Carotid Duplex Ultrasound, CT, MRT
– Renal: blood tests, urinalysis
– Peripheral vessels: arm-ankle-ratio (<=1), retinal
background
March 2013 Prof. G. Hennersdorf DGK ESC SES

42. Chest Xray:
left heart enlargement
Prominent aortic knob
Dilated aortic root
Enlarged (hypertrophic)
left ventricle
March 2013 Prof. G. Hennersdorf DGK ESC SES

43. ECG:Left ventricular hypertrophy
LVH
Dgn.: HOCM
March 2013 Prof. G. Hennersdorf DGK ESC SES

44. Cardiac Ultrasound: LVH
IVS
LV AO
PM
PW LA
March 2013 Prof. G. Hennersdorf DGK ESC SES

45. Magnetic resonance imaging: LVH
March 2013 Prof. G. Hennersdorf DGK ESC SES

46. Retinopathy: hypertension
Crossing phenomenon
GUNN
Silver reflecting artery
March 2013 Prof. G. Hennersdorf DGK ESC SES

47. Target Organ Damage Diagnosis
Ankle Brachial Index ABI
SBP arm
-------------------
SBP leg (ankle, a. tibialis post.)
Normal value: 120/150 = 0.8
Pathological: 120/80 = 1.5
Peripheral
arterial
disease
US flow transducer
March 2013 Prof. G. Hennersdorf DGK ESC SES

48. Hypertension Diagnosis:
Laboratory tests
• Basic tests:
– Blood tests: full blood count, thyroid gland (T3), kidney, liver,
glucose, electrolytes
– Urinary test: protein, albumin, sedimentum
– Special urinary test. microalbuminuria
• Advanced :
– (secondary Hptn.)renine, aldosterone, katecholamines
– quantitative urinalysis (quantative albuminuria, clearances, Na +,
Cl-)
March 2013 Prof. G. Hennersdorf DGK ESC SES

49. Hypertension Diagnosis
• advanced diagnostic procedures:
mainly secondary Hptn.
– Hormone assays (thyroid, adrenal, pituitary gl.)
– Vascular bed diagnosis (renovascular):
• Abdominal CT
• Abdominal angiography
March 2013 Prof. G. Hennersdorf DGK ESC SES

50. Hypertension Diagnosis
• Clinical Diagnosis
• Devices for measurement
• Advanced Measures
• Pathways and Flowcharts
March 2013 Prof. G. Hennersdorf DGK ESC SES

51. Hypertension Diagnosis:
Flow Chart
consider sec.HPTN
History, office
readings Persistently raised BP
yes
CXR, US, renal Target organ damage?
tests
no
high
patient passport Home BP measurement Start treatment
Information/instruction
low
abnormal
24h Monitoring
normal
Continue repeat visits
March 2013 Prof. G. Hennersdorf DGK ESC SES

52. Hypertension Diagnosis: pathways and
networks
BP Control, blood tests
OPD
treatment control
visit
Hospital Nurse office
admission patient Home care
Emergency, BP Control
First, advanced dgn Treatment control
Start of treatment Instructions
Clinic/office Scheduling appointments
BP Control, blood tests
treatment control

53. Cardiovascular Diseases
Hypertension Management
part I
The End
March 2013 Prof. G. Hennersdorf DGK ESC SES