Doctors Revision

Cardiovascular System

Hypertension

Persistently elevated resting blood pressure (BP), typically defined as ≥140 mmHg systolic or ≥90 mmHg diastolic on multiple occasions. A major risk factor for cardiovascular disease (stroke, MI, HF), kidney disease, and death.

Also known as: High Blood Pressure, HTN

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Referral and warning signs

When to refer

Refer to higher level/specialist for: Hypertensive emergency. Hypertensive urgency requiring admission/parenteral therapy. Resistant hypertension (uncontrolled despite ≥3 drugs including diuretic). Suspected secondary hypertension. Significant target organ damage requiring specialist management.

Red flags

  • Symptoms of hypertensive emergency (severe headache, confusion, seizure, visual disturbance, chest pain, severe dyspnoea, focal neurological deficit)
  • BP >180/110 mmHg with signs of acute target organ damage
  • Rapidly worsening renal function
  • Signs of severe hypertensive retinopathy (papilloedema)

Signs and symptoms

  • Usually asymptomatic (often detected during routine screening).
  • May have non-specific symptoms: Headache (especially occipital, morning), dizziness, palpitations, fatigue, epistaxis.
  • May present with symptoms of complications (Target Organ Damage):
  • - Brain: Stroke symptoms (focal deficit, confusion), hypertensive encephalopathy (severe headache, confusion, seizures, visual disturbance).
  • - Heart: Chest pain (angina/MI), dyspnoea (heart failure), palpitations.
  • - Kidneys: Oedema, symptoms of renal failure (fatigue, anorexia).
  • - Eyes: Blurred vision, visual field defects (hypertensive retinopathy).
  • - Peripheral Arteries: Claudication.

Risk factors

  • Family history of hypertension
  • Increasing age
  • African ancestry
  • Obesity / Overweight
  • Physical inactivity
  • High sodium (salt) intake
  • Excessive alcohol consumption
  • Smoking
  • Diabetes mellitus
  • Dyslipidemia
  • Chronic kidney disease
  • Stress

Diagnosis

Clinical assessment

Diagnosis requires multiple BP readings ≥140/90 mmHg taken on at least 2-3 separate occasions, 1 week apart, with proper technique (seated, rested, appropriate cuff size). Classification: Normal (<120/80), Pre-hypertension (120-139/80-89), Stage 1 (140-159/90-99), Stage 2 (≥160/100). Assess for secondary causes (rare, suspect if young onset, resistant HTN, specific features) and target organ damage. Differentiate from 'white coat hypertension'.

Investigations

  • Accurate BP measurement (multiple readings, multiple visits). Ambulatory BP monitoring (ABPM) or Home BP monitoring (HBPM) can be useful.
  • Urinalysis (proteinuria, haematuria - kidney damage).
  • Blood tests: Urea & Electrolytes (renal function, potassium levels - relevant for diuretics/ACEi/ARBs), Creatinine (calculate eGFR), Fasting Blood Glucose (diabetes), Lipid profile.
  • ECG (assess for Left Ventricular Hypertrophy - LVH, ischaemia, arrhythmia).
  • Fundoscopy (assess for hypertensive retinopathy).
  • Further investigations if secondary cause suspected (e.g., renal ultrasound, endocrine tests).

Diagnostic criteria

Average BP ≥140/90 mmHg on 2-3 office visits OR based on ABPM/HBPM criteria.

Management

Non-pharmacological management

  • Lifestyle Modifications (Foundation of management for all stages):
  • - Salt Restriction: Reduce intake (<5-6g NaCl/day, avoid adding salt).
  • - Weight Reduction: Aim for healthy BMI.
  • - Healthy Diet: Emphasize fruits, vegetables, whole grains, low-fat dairy (DASH diet principles).
  • - Regular Physical Activity: Aerobic exercise (e.g., brisk walking) ≥150 min/week.
  • - Moderate Alcohol Consumption: Limit intake.
  • - Smoking Cessation.

Pharmacological treatment

  • Initiate drug therapy based on BP level and cardiovascular risk.
  • - Stage 1 HTN: Start drugs if lifestyle modification fails (after ~3 months) OR if high cardiovascular risk/target organ damage present initially.
  • - Stage 2 HTN: Start drug therapy immediately along with lifestyle changes.
  • Stepwise Approach (UCG 2023):
  • - Step 1 (Stage 1 after lifestyle failure): Amlodipine 5mg OD.
  • - Step 2 (If uncontrolled on Step 1, or initial therapy for Stage 2): Amlodipine 5mg OD + ARB (Losartan 50mg / Valsartan 80mg / Telmisartan 40mg OD) OR ACEi (Lisinopril 20mg / Enalapril 5mg OD).
  • - Step 3 (If uncontrolled on Step 2): Increase Amlodipine to 10mg OD + ARB/ACEi (as above).
  • - Step 4 (If uncontrolled on Step 3): Amlodipine 10mg OD + ARB (Increase dose: Losartan 100mg / Valsartan 160mg / Telmisartan 80mg OD) / ACEi (Increase dose) + Thiazide diuretic (Hydrochlorothiazide 12.5-25mg OD morning / Bendroflumethiazide 2.5-5mg OD morning).
  • - Step 5 (If uncontrolled on Step 4): Refer for specialist management (consider adding Spironolactone or Beta-blocker).
  • Specific Patient Groups:
  • - High CVD Risk (Diabetes, CKD, previous Stroke/MI): Target BP <130/80 mmHg. Start statin (Atorvastatin 20-40mg or Simvastatin 20-40mg) and Aspirin 75mg (if prior MI/ischemic stroke). Consider statin if high risk.
  • - Post-MI (<3 years): Include Beta-blocker (Atenolol 50mg, Bisoprolol 5mg, Nebivolol 5mg OD).
  • - Chronic Kidney Disease (CKD): ACEi or ARB is preferred (often in combination with CCB or diuretic).
  • - Heart Failure: Include ACEi/ARB, Beta-blocker (specific ones), MRA (See HF section).
  • - Pregnancy: AVOID ACEi/ARBs, diuretics. Safe options: Methyldopa, Labetalol, Nifedipine.
  • - Secondary to Thyroid Disease: Consider adding Propranolol 40mg BID.
  • Hypertensive Urgency (BP >180/110 mmHg without acute target organ damage): Admit, use oral combination therapy, lower BP gradually over 24-72 hours.
  • Hypertensive Emergency (BP >180/110 mmHg WITH acute target organ damage): Admit, IV medications (e.g., IV Hydralazine 5-10mg slow push, IV Labetalol, IV Nitrates depending on complication), lower BP carefully (not too rapidly, except in aortic dissection). Treat specific complication (e.g., Furosemide for APO).

Monitoring

  • Monitor BP response regularly (home monitoring useful).
  • Assess adherence and side effects.
  • Monitor electrolytes and renal function periodically (esp. with ACEi/ARB/Diuretics).
  • Monitor lipids and glucose.
  • Regularly assess for target organ damage (ECG, urinalysis, fundoscopy).

Complications

  • Stroke (ischaemic and haemorrhagic)
  • Myocardial Infarction (Heart Attack)
  • Heart Failure
  • Left Ventricular Hypertrophy (LVH)
  • Chronic Kidney Disease / Renal Failure
  • Peripheral Arterial Disease
  • Aortic Aneurysm / Dissection
  • Hypertensive Retinopathy -> Vision loss
  • Hypertensive Encephalopathy

Prevention

  • Maintain healthy weight.
  • Reduce salt intake.
  • Adopt healthy diet (DASH diet).
  • Regular physical activity.
  • Limit alcohol consumption.
  • Avoid smoking.
  • Manage stress.
  • Regular BP screening, especially if risk factors present.

Patient education

  • Explain hypertension is often lifelong and usually asymptomatic.
  • Importance of lifestyle modifications (diet, exercise, salt, alcohol, smoking).
  • Rationale for medication and critical importance of adherence (even when feeling well).
  • How to take medications correctly, potential side effects.
  • Importance of regular BP monitoring (clinic or home).
  • Need for regular follow-up and lab tests.
  • Signs/symptoms of complications (stroke, MI, HF) and when to seek urgent care.
  • Risks of untreated hypertension.

Uganda-specific notes

High prevalence, often undiagnosed/uncontrolled. Lifestyle advice is crucial. Availability of different drug classes varies; UCG focuses on CCB, ACEi/ARB, Thiazides as core therapy. BP measurement technique and equipment calibration important. Secondary causes like renal disease should be considered.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 4, Section 4.1.6 (including Hypertensive Emergencies/Urgency)

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