Hypertension symptoms and signs

The clinical and laboratory findings are mainly referable to involvement of the target organs: heart, brain, kidneys, eyes, and peripheral arteries.

A. SYMPTOMS

Mild to moderate primary (essential) hypertension is largely asymptomatic for many years. The most frequent symptom, headache, is also very nonspecific. Suboccipital pulsating headaches, occurring early in the morning and subsiding during the day, are said to be characteristic, but any type of headache may occur. Accelerated hypertension is associated with somnolence, confusion, visual disturbances, and nausea and vomiting (hypertensive encephalopathy).

Hypertension in patients with pheochromocytomas that secrete predominantly norepinephrine is usually sustained but may be episodic. The typical attack lasts from minutes to hours and is associated with headache, anxiety, palpitation, profuse perspiration, pallor, tremor, and nausea and vomiting. Blood pressure is markedly elevated, and angina or acute pulmonary edema may occur. In primary aldosteronism, patients may have muscular weakness, polyuria, and nocturia due to hypokalemia; malignant hypertension is rare. Chronic hypertension often leads to left ventricular hypertrophy, which may be associated with diastolic or, in late stages, systolic dysfunction. Exertional and paroxysmal nocturnal dyspnea may result, and ischemic heart disease is more common (especially when concomitant coronary artery disease is present).

Cerebral involvement causes (1) stroke due to thrombosis or (2) small or large hemorrhage from microaneurysms of small penetrating intracranial arteries. Hypertensive encephalopathy is probably caused by acute capillary congestion and exudation with cerebral edema. The findings are usually reversible if adequate treatment is given promptly. There is no strict correlation of diastolic blood pressure with hypertensive encephalopathy; but it usually exceeds 130 mm Hg.

B. SIGNS

Like symptoms, physical findings depend on the cause of hypertension, its duration and severity, and the degree of effect on target organs.

1. Blood pressure - On initial examination, pressure is taken in both arms and, if lower extremity pulses are diminished or delayed, in the legs to exclude coarctation of the aorta. An orthostatic drop is present in pheochromocytoma. Older patients may have falsely elevated readings by sphygmomanometry because of noncompressible vessels. This may be suspected in the presence of Osler's sign - a palpable brachial or radial artery when the cuff is inflated above systolic pressure. Occasionally, it may be necessary to make direct measurements of intra-arterial pressure, especially in patients with apparent severe hypertension who do not tolerate therapy.