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Investigations for  a patient with newly detected hypertension

 Aim of investigations

1. To establish the cause of hypertension whenever indicated and possible.

2. To detect associated risks factors which may aggravate and complicate Hypertension.

3. To assess 'Target Organ Damage' due to hypertension. (damage to organs and body systems due to undiagnosed /untreated  / severe hypertension)

4. To detect coexisting illnesses like Diabetes, Heart diseases, etc.

5. As a part of general baseline checkup to assess all round health of a person suffering from hypertension.

6. To monitor and compare results ; Pre and post treatment .

Limitations of treatment without proper investigations

1. 'Superficial treatment' of hypertension without proper investigations, may overlook important risks factors, coexisting diseases and 'Target Organ Damage'. 

2. Such half hearted treatment may apparently give short term results, in form of blood pressure control, but will fail to prevent, delay and  treat complications like angina, heart attacks, stroke, kidney failure, eye damage, nerve damage.

3. It will thus neither increase life expectancy nor quality of life.

Management of hypertension includes

1. Choosing most appropriate anti hypertensive drug based on investigations and clinical examination.

2. Controlling risk factors, detected on investigations like: lipid abnormalities, excess salts in blood.

3. Vigorous treatment of any 'Target Organ Damage'. detected on investigations.

4. Treatment of coexisting illnesses like Diabetes, Heart diseases, etc.

  Investigations for initial assessment in a patient of Hypertension.

• Lipid Profile (Total Cholesterol, LDL Cholesterol, VLDL Cholesterol, HDL Cholesterol, Triglycerides)

• Serum Electrolytes (Sodium, Potassium, Chloride, Bicarbonate)

• Kidney Function Tests. Blood Urea, Serum Creatinine, Serum Uric Acid, Blood Urea Nitrogen )

• Blood Sugar Fasting, Post Prandial (P.P)

• Urine Routine / Microscopic; Microalbumin (sign of early kidney damage)

• ECG                                                                                                                                 Electrocardiograph (ECG), a device used to record the electric activity of the heart to detect abnormal electric impulses through the muscle. Electrocardiography allows diagnosis of cardiac abnormalities. To make an ECG recording, the patient lies quietly on his or her back on a table. Leads are placed on certain spots on the patient's chest, usually with a gluey gel that helps send the electric impulse to the recording device. The ECG is also used for stress tests, which require that the patient be active (usually walking or running on a treadmill) while the machine is working

• Miscellaneous 

• Hb, TLC, DLC, ESR

• Thyroid Profile ( Whenever indicated)  

• TMT (Tread Mill Test)

TMT (Tread Mill Test)

• Exercise electrocardiogram (exercise ECG), a stress test used to diagnose disease of the arteries of the heart. An exercise electrocardiogram is recorded while a person walks on a treadmill or pedals a stationary bicycle. Abnormal changes in heart function may appear during exercise. Some abnormalities will not show on ECG during rest. 

Angiography

• Angiography, the x-ray study of the inside of the heart and blood vessels. It is done after a dye is injected. It is used to test for heart attacks (myocardial infarction), blocked vessels (vascular occlusion), hardened deposits in the arteries, stroke, high blood pressure, kidney tumors, lung clots, and lung vessel problems. 

Echocardiography.

• Also called ultrasonic cardiography. A method of diagnosis that studies the structure and motion of the heart. Ultrasonic waves directed through the heart are reflected backward, or echoed, when they pass from one type of tissue to another, as from heart muscle to blood. This test can find tumors in the upper chambers and fluid in the sac around the heart (pericardial effusion). It can measure the parts of the lower chambers (ventricles) and spot problems with the movement of the valve between the upper and lower chambers on the left side of the heart (mitral valve). 

                 Echocardiography.                                Echocardiography                                      ECG

                       CAT   Scanning                                      Angiography 

More specialized investigations should generally be reserved for those hypertensive patients who fulfill the following criteria:

1. Below 45 years of age.

2. Blood pressure resistant to the combination of two drugs.

3. Severe hypertension , that is, diastolic blood pressure > or = 120 mmHg.

4. Suspicion of a cause or complication of Hypertension from clinical assessment or routine investigations.

5. Those with retinopathic findings of  revised grading system - grade B.

Patients whose hypertension is very severe, or who are resistant to conventional treatment, need further specialist investigation. These tests include:

• Radiography of abdomen.

• Ultrasound of kidneys.

• Intravenous urography or renal Arteriography to exclude renal artery stenosis.

• CAT ( Computerized Axial Tomography ) Scanning of the adrenal gland.

• 24 hours urine specimens should be collected on three separate occasions for assessment of catecholamine excretion, urinary protein excretion or 24 hour urinary free cortisol estimation.

• Renal biopsy may be appropriate to identify a cause of renal impairment, particularly if intrinsic renal disease (for example, (Glomerulonephritis) is suspected.