Lesson topic №21 Синдром артериальной гипертензии (Arterial hypertension in the outpatient setting) (1)

Comprehensive physical examination for hypertension

Body habitus

Weight and height measured on a calibrated scale, with calculation of BMI

Waist circumference

Comprehensive physical examination for hypertension

Signs of hypertension-mediated organ damage

Neurological examination and cognitive status

Fundoscopic examination for hypertensive retinopathy in emergencies

Auscultation of heart and carotid arteries

Palpation of carotid and peripheral arteries

Ankle–brachial index

Comprehensive physical examination for hypertension

Signs of secondary hypertension

Skin inspection: cafe-au-lait patches of neurofibromatosis (pheochromocytoma)

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 renovascular hypertension

Signs of Cushing's disease or acromegaly

Signs of thyroid disease

Selected standard laboratory tests for work-up of hypertensive patients

Hemoglobin and/or hematocrit

Fasting blood glucose/HbA1c

Blood lipids: total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides

Blood creatinine (and/or cystatin C) for estimating glomerular filtration rate (GFR)

Blood uric acid

Blood potassium and sodium

Urine analysis (first voided urine in the morning), multicomponent dipstick test in all patients, urinary albumin/creatinine ratio, microscopic examination in selected patients

Other investigations in hypertension

SECONDARY HYPERTENSION

Secondary forms of hypertension account for only a small fraction of the overall hypertension prevalence

Despite their limited prevalence, detection and management of secondary forms of hypertension is of utmost importance, because these forms often carry a high or very-high risk of morbidity and mortality and can possibly be cured by timely treatment of their cause

Secondary forms of hypertension are a frequent cause of severe or trueresistant hypertension, worsening of previously controlled hypertension or increased severity of HMOD, which may appear as disproportionate to the duration of hypertension

SECONDARY HYPERTENSION

 Incidence of selected forms of secondary hypertension according to age

Patient characteristics that should raise the suspicion of secondary hypertension

Younger patients (<40 years) with grade 2 or 3 hypertension or hypertension of any grade in childhood

Sudden onset of hypertension in individuals with previously documented normotension

Acute worsening of BP control in patients with previously well controlled by treatment

True resistant hypertension hypertension

Hypertensive emergency

Severe (grade 3) or malignant hypertension

Severe and/or extensive HMOD, particularly if disproportionate for the duration and severity of the BP elevation

Clinical or biochemical features suggestive of endocrine causes of hypertension

Clinical features suggestive of renovascular hypertension or fibromuscular dysplasia

Clinical features suggestive of obstructive sleep apnea

Severe hypertension in pregnancy (>160/110 mmHg) or acute worsening of BP control in pregnant women with preexisting hypertension

LIFESTYLE INTERVENTIONS

Smoking cessation

Weight reduction

should ideally be achieved through a combination of a low-caloric diet and exercise  Increase levels of daily physical activity and regular exercise

The acute pressor effect of dynamic and isometric exercise does not contraindicate regular exercise on a chronic basis. Recommended minimum physical activity level of 150 min per week. Moderate-intensity aerobic exercise (40–60% heart rate reserve) is recommended to prevent and treat hypertension

Restriction of sodium intake

Augmentation of dietary potassium intake

Moderation of alcohol intake

Smoking cessation

Tobacco smoking is the single largest preventable cause of death and is known to significantly increase the risk of CVD.

Attention should also be given to passive exposure to smoking, which has been associated with the risk of CVD and a 24 h BP elevation.

In recent decades, water pipe smoking has developed into a major and rapidly growing alternative to traditional tobacco smoking within the global tobacco epidemic. The few available studies showed no clear difference in the CV disease incidence between waterpipe smoking and traditional tobacco smokers.

E-cigarettes originally marketed as potential aids in smoking cessation, have attracted a lot of consumers. Recent meta-analyses now highlight that these

‘so-called safer’ alternatives acutely increase BP, heart rate and may also be associated with increased risk of CV disease.