Hypertension Diagnosis and Management

Clinical Presentation

Headache, visual disturbances, dizziness, chest pain, and dyspnea are symptoms that may occur in patients with hypertension, particularly in severe or malignant cases 1
Neurological symptoms, such as somnolence, lethargy, seizures, and cortical blindness, can occur in cases of hypertensive encephalopathy 2

The European Heart Journal defines Stage 1 hypertension as SBP 140-159 mmHg or DBP 90-99 mmHg, and Stage 2 hypertension as SBP ≥160 mmHg or DBP ≥100 mmHg 3
Pediatric hypertension is defined as BP measurements at or above the 95th percentile for gender, age, and height on 3 or more occasions, according to the Pediatrics journal 4

Hypertensive retinopathy features include flame-shaped hemorrhages, cotton wool spots, and papilledema, which reflect small vessel damage and are highly specific when present bilaterally 5, 6
Hypertensive encephalopathy presents with headache, visual disturbances, somnolence, lethargy, seizures, and cortical blindness, and MRI typically shows increased signal intensity on T2-weighted or FLAIR imaging, particularly in posterior brain regions (PRES) 1, 2
Coronary artery disease and myocardial infarction can occur in patients with hypertension 1
Acute kidney injury and chronic kidney disease with proteinuria can occur in patients with malignant hypertension 1

Hypertensive emergencies are characterized by severe BP elevation with acute hypertension-mediated organ damage, and can present with malignant hypertension, hypertensive encephalopathy, hypertensive thrombotic microangiopathy, and other severe conditions 1, 2

Key diagnostic tests for hypertension evaluation include laboratory analysis (hemoglobin, platelet count, creatinine, sodium, potassium, LDH, haptoglobin) and diagnostic examinations (fundoscopy, ECG, chest X-ray, echocardiography, brain imaging, CT-angiography, renal ultrasound) 2, 3, 6

Secondary causes of hypertension are found in 20-40% of patients with malignant hypertension, and common secondary causes include renal parenchymal disease, renal artery stenosis, and endocrine disorders 1, 6
The rate of BP increase appears more important than absolute BP value in developing hypertensive emergencies 2

Excessive or rapid BP reduction in hypertensive emergencies can lead to organ underperfusion, cerebral infarction, and damage to myocardium and kidneys 3