Red flag symptoms: Hypertension

Consider the cause and know when to treat aggressively.

Hypertensive retinopathy: damage to the retina due to high BP
Hypertensive retinopathy: damage to the retina due to high BP

Around 95 per cent of patients with hypertension have essential hypertension. This is often asymptomatic and will lead to gradual and progressive end-organ damage. Acute or malignant hypertension has immediate risks to health.

Red flag symptoms
  • Papilloedema
  • Pregnancy
  • Signs of end-organ damage
  • Very elevated BP with headache
  • Fits or coma
  • Heart failure

Elevated BP is common over the age of 65. However, secondary causes of hypertension should be considered in younger patients, such as coarctation of the aorta, polycystic kidney disease or endocrinopathies such as Conn's syndrome, phaeochromocytoma or Cushing's syndrome.

Gestational hypertension and pre-existing hypertension in pregnancy need particular attention as they can affect the normal function of the placenta and may indicate pre-eclampsia.

Lifestyle advice may be the first and only necessary step when treating mild to moderate hypertension.

This includes moderation of alcohol and salt intake, achieving and maintaining a healthy weight, taking regular exercise and using appropriate stress management.

Medical treatment
Active medical treatment should be considered at a BP persistently of 160/100mm Hg or above in healthy and asymptomatic patients with increased cardiovascular risk. The thresholds for patients with diabetes, renal disease or other cardiovascular risk factors are lower.

Immediate treatment is necessary in all patients with a BP of >220mmHg or >120mm-Hg diastolic, even if this has been measured as a one-off.

Many patients will require a combination of at least two or three different medications. Patients may improve considerably after modifying lifestyle factors such as smoking, obesity and stress. Occasionally this is so successful they can stop medication altogether.

It can be important to pick up any significant BP difference between both arms (aortic coarctation).

Newly diagnosed hypertensive patients with possible signs of end-organ damage should be treated aggressively and considered for referral.

Malignant hypertension
Malignant (or accelerated) hypertension is a rare situation of hypertensive crisis for usually no apparent specific reason. It is defined by NICE as BP higher than 180/110mmHg with signs of papilloedema or retinal haemorrhage (hypertensive retinopathy). It requires an immediate admission as this can be a life-threatening condition.

Patients may experience severe headaches, visual symptoms, fits and sometimes even coma. BP needs to be monitored and lowered gradually to prevent adverse effects.

Probably less than 10 per cent of patients with diagnosed hypertension have 'white coat syndrome' with consistently normal readings at home.

  • Dr Jacobi is a salaried GP in York
Possible causes
  • Idiopathic
  • Endocrine causes
  • Pre-eclampsia in pregnancy
  • Malignant hypertension
  • Renal causes

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