1. Diagnostic evaluation of hypertension Hany A. AbdelWahab (Assistant lecturer of cardiology) Zagazig University October, 2011

2. Aim of the diagnostic procedures 1) Establishing blood pressure levels. 2) Identifying secondary causes of hypertension. 3) Evaluating the overall cardiovascular risk by searching for other risk factors, target organ damage and concomitant diseases.

3. The diagnostic procedures comprise: 1) Repeated blood pressure measurements. 2) Medical history. 3) Physical examination. 4) Investigations.

4. BLOOD PRESSURE MEASUREMENTS

7. Measure BP 1 and 5 min after assumption of the standing position if postural hypotension is suspected like in elderly & diabetic patients.

11. The prognostic value of nighttime BP has been found to be superior to that of daytime blood pressure.

13. 4- Resistance to drug treatment is suspected. 5- Hypotensive episodes are suspected, particularly in elderly and diabetic patients. 6- Office BP is elevated in pregnant women and preeclampsia is suspected.

14. Home BP measurement

16. Thesemeasurements should be encouraged in order to:

17. Provide more information on the BP lowering effect of treatment at trough.

18. Improve patient’s adherence to treatment regimens.

20. Blood pressure thresholds (mmHg) for definition ofhypertension with different types of measurement

25. Guidelines for Family and Clinical History Duration and previous level of high blood pressure. Indications of secondary hypertension: - Family history of renal disease (polycystic kidney). - Renal disease, urinary tract infection, haematuria, analgesic abuse (parenchymal renal disease). - Drug/substance intake: oral contraceptives, liquorice, carbenoxolone, nasal drops, cocaine, amphetamines, steroids, NSAIDs, erythropoietin, cyclosporine. - Episodes of sweating, headache, anxiety, palpitation (phaeochromocytoma). - Episodes of muscle weakness and tetany (aldosteronism).

26. Risk factors: - Family and personal history of hypertension and cardiovascular disease. - Family and personal history of dyslipidaemia. - Family and personal history of diabetes mellitus. - Smoking. - Dietary habits. - Obesity & amount of physical exercise. - Snoring; sleep apnea ( information also from partner) - Personality.

27. Symptoms of target organ damage: - Brain and eyes: headache, vertigo, impaired vision, TIAs & sensory or motor deficit. - Heart: palpitation, chest pain, shortness of breath &swollen ankles. - Kidney: thirst, polyuria, nocturia & haematuria. - Peripheral arteries: cold extremities & intermittent claudications. Previous antihypertensive therapy: - Drug(s) used, efficacy and adverse effects.

28. Physical examination

30. Skin stigmata of neurofibromatosis (phaeochromocytoma).

31. Palpation of enlarged kidneys (polycystic kidney).

32. Auscultation of abdominal murmurs (renovascular hypertension).

34. Retina: fundoscopic abnormalities.

35. Heart: apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales & peripheral oedema.

37. Increased body mass index:body weight (Kg)/ height (m²) Overweight ≥25 Kg/m² & Obesity ≥30 Kg/m²

38. investigations

40. Fasting lipid profile:

41. Serum total cholesterol

42. Serum LDL-cholesterol

43. Serum HDL-cholesterol

44. Serum triglycerides

45. Serum potassium.

47. Estimated creatinine clearance (Cockroft-Gault formula) or glomerular filtration rate (MDRD formula).

48. Haemoglobin and haematocrit.

49. Urine analysis (complemented by microalbuminuria dipstick test and microscopic examination).

51. Carotid ultrasound.

52. Quantitative proteinuria (if dipstick test positive).

53. Ankle-brachial BP index.

54. Fundoscopy.

55. Glucose tolerance test (if fasting plasma glucose >102 mg/dL).

56. Home and 24h ambulatory BP monitoring .