4.2 Clinical Evaluation and Assessment of Hypertension

The goals of the initial evaluation of the hypertensive patient are to

1. Establish the diagnosis and grade of hypertension.
2. Screening for potential secondary causes of hypertension.
3. Identify factors that potentially contribute to development of hypertension (lifestyle, concomitant medications, or family history).
4. Identify concomitant CV risk factors (including lifestyle and family history) (Table 4)
5. Identify concomitant diseases and establish whether there is evidence of HMOD or existing cardiovascular, cerebrovascular, or renal disease. (Table 5)

These goals are usually accomplished by a thorough medical history, physical examination, and simple laboratory investigations. While waiting for confirmation of a diagnosis of hypertension, carry out some routine investigations for assessment of HMOD. If hypertension is not diagnosed but there is evidence of HMOD, consider carrying out investigations for alternative causes of HMOD.

History

Most patients with hypertension are asymptomatic, the high blood pressure usually having been noted during an incidental clinical examination. A proportion of patients will present with a major complication of hypertension such as stroke or myocardial infarction, but only a small number will present with symptoms directly attributable to hypertension such as breathlessness or headache. That is why hypertension is called a ‘Silent killer’. The key issues that need to be addressed in the history include:

Risk factors assessment:

• Family and personal history of hypertension, CVD, stroke, or renal disease.
• Family and personal history of associated risk factors (e.g., familial hypercholesterolaemia)
• Dietary history and salt intake
• Smoking history
• Alcohol consumption
• History of physical exercise/sedentary lifestyle
• History of erectile dysfunction
• Sleep history, snoring, sleep apnoea (information also from partner)
• Previous hypertension in pregnancy/pre-eclampsia
• History of oral contraceptive use

History of symptoms of HMOD, CVD, stroke, and renal disease

• For Brain and eyes: headache, vertigo, syncope, impaired vision, TIA, sensory or motor deficit, stroke, carotid revascularization, cognitive impairment, dementia (in the elderly).
• Heart: chest pain, shortness of breath, oedema, myocardial infarction, coronary revascularization, syncope, history of palpitations, arrhythmias (especially AF), heart failure.
• Kidney: thirst, polyuria, nocturia, haematuria, urinary tract infections.
• Peripheral arteries: cold extremities, intermittent claudication, pain free walking distance, pain at rest, peripheral revascularization, patient or family history of CKD (e.g., polycystic kidney disease).

History of Antihypertensive Drug Treatment

• Current/past antihypertensive medication including effectiveness, intolerance or side effects of previous medications.
• Adherence to therapy and in non-compliant patients the reason behind it (including financial constraint).

Physical Examination

The physical examination should include the following:

• Weight and height measured on a calibrated scale, with calculation of BMI
• Waist circumference
• Neurological examination and cognitive status
• Fundoscopic examination for hypertensive retinopathy
• Palpation and auscultation of heart and carotid arteries
• Palpation of peripheral arteries
• Comparison of BP in both arms (at least once)
• Skin inspection: cafe-au-lait patches of neurofibromatosis (phaeochromocytoma)
• Kidney palpation for signs of renal enlargement in polycystic kidney disease
• Auscultation of heart and renal arteries for murmurs or bruits indicative of aortic coarctation, or renal artery stenosis
• Comparison of radial with femoral pulse: to detect radio-femoral delay in aortic coarctation
• Signs of Cushing’s disease or acromegaly
• Signs of thyroid disease

All hypertensive patients should undergo a limited number of investigations. However, when starting pharmacological therapy for hypertension, WHO suggests obtaining tests to screen for comorbidities and secondary hypertension, but only when testing does not delay or impede starting treatment. In low-resourced areas or non-clinical settings, where testing may not be possible because of additional costs, and lack of access to laboratories and ECG, treatment should not be delayed, and testing can be done subsequently. Some medicines, such as long-acting dihydropyridine calcium-channel blockers (CCBs) are more suitable for initiation without testing, compared to diuretics or angiotensin-converting enzyme inhibitors(ACEi)/angiotensin-II receptor blockers (ARBs)¹².

All hypertensive patients should undergo a limited number of investigations, these include:

• Blood test
  • Sodium, potassium, serum creatinine and estimated glomerular filtration rate, (eGFR)
  • If available lipid profile and fasting glucose
• Urine analysis: Dipstick urine test
• 12-lead ECG for detection of atrial fibrillation, left ventricular hypertrophy (LVH), ischemic heart disease.

For most patients:

• Haemoglobin and/or haematocrit
• Chest X-ray: to detect cardiomegaly, heart failure, coarctation of the aorta
• Echocardiogram: to detect or quantify left ventricular hypertrophy

The nature and scale of further investigations will be determined by the index of suspicion of a secondary cause for hypertension and assessment for HMOD.

Tests for assessment for HMOD

• Urine albumin: creatinine ratio: To detect elevations in albumin excretion indicative of possible renal disease.
• Blood creatinine and eGFR: To detect possible renal disease.
• Fundoscopy: To detect hypertensive retinopathy, especially in patients with grade 2 or 3 hypertension.
• Echocardiography: To evaluate cardiac structure and function when this information will influence treatment decisions.
• Carotid ultrasound: To determine the presence of carotid plaque or stenosis, particularly in patients with cerebrovascular disease or vascular disease elsewhere.
• Abdominal ultrasound and Doppler studies:

i)   To evaluate renal size and structure (e.g., scarring) and exclude renal tract obstruction as possible underlying causes of CKD and hypertension

ii)   Evaluate abdominal aorta for evidence of aneurysmal dilatation and vascular disease.

iii)  Examine adrenal glands for evidence of adenoma or phaeochromocytoma (CT or MRI preferred).

iv)  Renal artery Doppler studies to screen for the presence of renovascular disease, especially in the presence of asymmetric renal size

• Pulse Wave velocity (PWV): An index of aortic stiffness and underlying arteriosclerosis
• Ankle Branchial Index (ABI) Screen for evidence of Lower Extremity Artery Disease (LEAD)
• Cognitive function testing: To evaluate cognition in patients with symptoms suggestive of cognitive impairment.
• Brain imaging: To evaluate the presence of ischaemic or haemorrhagic brain injury, especially in patients with a history of cerebrovascular disease or cognitive decline.