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I. Importance of the subject

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I. Importance of the subject:

Arterial hypertension (АH) is one of the most common reasons of a myocardial infarction and the disorder that results in early invalidity and lethality of patients. So timely diagnostics of АH became the major task not only for therapeutists, but also doctors of each speciality. During differential diagnostics of АH it is necessary to differentiate primary АH - essential hypertension (EH) and secondary (symptomatic) АH. Despite of the certain similarity, these diseases are different by etiology, a pathogenesis, clinical features and management. Secondary hypertension is potentially curable disease when used adequate therapy. New powerful drugs could slow down the progression of EH. So correct diagnostics and management of such patients determine the prognosis of the disease, duration and quality of patients’ life.

To prove the importance of the topic let’s discuss the clinical observation.

Patient В., 45 years old, was admitted to therapeutic department with complaints of a headache, palpitation, elevation of blood pressure (BP), chest discomfort. She took Raunatinum occasionally, but there were repeated attacks of elevation of BP up to 200/100 mm Hg with tachycardia, segment ST depression in leads V5-V6. In hospital adequate doses of angotensine converting enzyme (ACE) inhibitors and beta-blockers were prescribed. Chest discomfort disappeared, the BP stabilized at a level of 130/80-120/80 mm Hg, heart rate - 75-85 beats per minute.

If the importance of the subject has been understood, proceed to studying the learning objectives.

^ II. Learning Objectives

Key objective: to develop skills in making a differential diagnosis of arterial hypertension, and planning a patient management.

^ Specific Objectives

Pre-Practice Knowledge and Skills

To gain knowledge of and develop skills in:

1. Identifying basic syndromes in AH.

1. Selecting the data from the complaints and case history findings showing the presence of cardiovascular disease (Covered by Propaedeutics and Therapy Course).

2. Making up an individual diagnostic chart and interpreting the obtained findings in AH. Determining degree of severity and stage of disease according to classification.

2. Determining the necessary amount and sequence of investigative methods. Sphygmomanometry, auscultation of heart, neck and renal vessels, complete blood count, biochemical blood analysis, urine analysis, Addis sediment count, X-ray and ultrasound examination, ECG, echocardiography (Covered by the Physiology and Pathophysiology Course and Roentgenology Course and Propaedeutics and Therapy Course).

3. Making a differential diagnosis of AH.

3. Determining syndromes in chronic cardiovascular diseases.

4. Diagnosing the urgent conditions with elevation of BP (hypertension stroke)

4. Determining syndromes in urgent conditions of cardiovascular system.

4. Explaining the principles of the AH patient management and doing first aid during hypertension stroke.

5. Applying medications of pathogenetic and symptomatic therapy (Explained in the Pharmacology Course).

The information necessary for reviewing and revising the basic knowledge and skills can be found in the following references:

  1. Oxford Handbook of Clinical Medicine. Murray Longmore, Ian B.Wilkinson, Supray Rajagopalan. New York, 2004.

  2. Montgomery H., Holdright D. 100 Questions in Cardiology. BMJ Publishing Group, 2001. 222 pp.

  3. Klabunde R.E. Cardiovascular Physiology Concepts. Lippincott, 2004. 256 pp.

  4. Internal diseases. An introductory course. Edited by V.Vasilenko and A.Grebenev. Moscow, 2006.

Pre-Practice Knowledge and Skills Test Questions

Q1. Patient А., 61 years old, complains of breathlessness, chest pain, cough and dyspnea attacks in horizontal position, edemas of legs. What complaint is typical for cardiovascular disease?

А) breathlessness;

B) chest pain;

C) cough and dyspnea attacks in horizontal position;

D) edemas of legs;

E) all above-listed.

Q 2. Patient D., 20 years old, suffering from AH has systolic murmur at the right hypochondrium. Doctor has suspected a right renal artery stenosis. What instrumental method can confirm this diagnosis?

А) renal angiography;

B) excretory urography;

C) plain abdomen radiography;

D) urine analysis;

E) Addis sediment count.

Q 3. On sphygmomanometry BP of 160/40 mm Hg was registered. On auscultation diastolic murmur on aorta was revealed. What diagnosis are these symptoms typical for?

А) aortic insufficiency;

B) mitral insufficiency;

C) EH;

D) mitral valve prolapse;

E) mitral stenosis.

Q 4. In urine analysis of patient E., 34 years old, suffering from secondary (renal) АH, the following changes were found: relative density -1015, protein - 1,0 g/l, erythrocytes - 1/2 of vision field, leucocytes - 2-3 in vision field, hyaline cylinders - 3-4 in vision field. What symptoms are present?

А) proteinuria, hematuria, cylindruria.

B) proteinuria, hematuria, leukocyturia;

C) proteinuria, leukocyturia;

D) cylindruria, leukocyturia;

E) cylindruria, leukocyturia, hematuria.

Q 5. Patient А., 42 years old, suffering from EH, with high elevation of BP suddenly experienced a dyspnea, bubbling respiration, foamy sputum, on auscultation - large bubbling rales in both sides of lungs. What condition are these symptoms typical for?

А) acute insufficiency of left ventricle;

Б) acute insufficiency of right ventricle;

В) asthmatic status;

Г) total heart failure;

Д) spontaneous pneumothorax.

Q 6. Patient К., 48 years old, was prescribed amlodipine for treatment of EH. What mechanism of action is typical for this drug?

А) peripheral vasodilation;

B) decrease in heart contractility;

C) decrease in heart rate;

D) decrease in blood volume;

E) all above-listed.

Key Answer 1.

Right answer E) - all above-listed complaints are typical for cardiovascular disease: breathlessness, cough and dyspnea attacks in horizontal position, edemas of legs – are signs of heart failure, chest pain is a symptom of angina pectoris.

Key Answer 2.

Right answer А) - excretory urography allows to visualize pyelocaliceal system of kidneys; survey plain abdomen radiography does not give the information about renal vessels, the urine analysis and Addis sediment count show concentration function of kidneys and contents of leucocytes and erythrocytes in urine. Only renal angiography can show renal artery stenosis.

^ IV. Theory Topics on the Subject

To reach the learning objectives it is essential to master the following theory issues:

  1. Methods of clinical, laboratory and instrumental diagnostics of AH.

  2. Differential diagnostics of AH.

  3. Classification of AH.

  4. Urgent conditions at AH.

  5. Management of the patients affected by AH and first aids of urgent conditions.

The information necessary for mastering the theory issues may be found in the following references:

  1. Montgomery H., Holdright D. 100 Questions in Cardiology. BMJ Publishing Group, 2001. 222 pp.

  2. Klabunde R.E. Cardiovascular Physiology Concepts. Lippincott, 2004. 256 pp.

  3. Usuf S.Y., Cairns J., Camm J., Fallen E.L. Gersh B. Evidence Based Cardiology. BMJ Publishing Group, 2002. 1024 pp.

  4. Lecture notes on hospital therapy.

  5. A Flow Chart “Arterial hypertension” (see Appendix 1).

  6. Diagnostic Algorithm of Arterial hypertension (see Appendix 2).

  7. Classification of Arterial hypertension (see Appendix 3).

Then, proceed to solving some test questions and checking test question 5 with the key answer.

Q 1. Patient Е., 36 years old, complains of paroxysmal headache, tremor, palpitation. On examination paroxysmal elevation of BP with hypercatecholaminemia, hyperglycemia and a leukocytosis were revealed. What diagnosis is the most probable?

А) pheochromocytoma;

B) Conn's syndrome;

C) essential hypertension;

D) Itsenko-Cushing syndrome;

E) Takayasu's disease.

Q 2. On examination of patient C., 16 years old, developmental lagging of lower half of the body, systolic murmur and accent of 2-nd tone on aorta, elevated BP on arms and decreased BP on legs were observed. The coarctation of aorta was suspected. What diagnostic method can confirm this diagnosis?

А) laboratory;


C) phonocardiography;

D) echocardiography;

E) chest roentgenography.

Q 3. Patient G., 20 years old, complains of headache, fever, arthralgias, weight loss. On examination: systolic murmur on aorta, different levels of BP on extremities. What disease are these symptoms typical for?

A) Takayasu's disease.

B) coarctation of aorta;

C) thyrotoxicosis;

D) essential hypertension;

E) Conn's syndrome;

Q 4. Patient К. complains of weakness of left leg and arm, flatness of right nasolabial fold. BP-230/120 mm Hg. He suffers from essential hypertension for 10 years, takes hypotensive drugs irregularly. What drug will you administer first of all?

А) Sodium nitroprussidum;

B) Adelphanum;

C) Clophelinum;

D) Furosemidum;

E) Atenolol.

Q 5. In patient D., 51 years old, for the first time EH was diagnosed. Despite of nonmedicamental methods of correction AH, the BP was kept on level of 150/80 - 160/90 mm Hg, heart rate 65-70 beats per minute. What drug do you start medicamental treatment with?

А) diuretics;

B) ACE inhibitors;

C) alkaloids of Rauwolfia;

D) Ca channel blockers;

E) α - adrenoblockers.

Key answer 5.

Right answer А) - if nonmedicamental methods aren’t effective it is necessary to use drugs. In this case diuretics are the drugs of the first line for АH treatment.

^ Teaching Guidelines for Practice Activities on

Arterial Hypertension

At the beginning of the class, the instructor gives tests to check and correct the pre-practice level of knowledge. Then, the students start to see patients under the instructor’s supervision after which the students give an analysis of the practice patients and the instructor checks the mastering of the practice topics. A final tests are provided to strengthen the knowledge gained. At the end of the class, the instructor reviews the students’ self-learning activity, considers and corrects the students’ typical mistakes with a subsequent improvement of knowledge and skills.

Flow Chart of

«Arterial hypertension»

Arterial hypertension

Main symptoms and syndromes

Accent of S2




Displacing of heart border laterally

Arterial hypertension syndrome

Additional investigation findings




CBC, urine analysis, Addis sediment count, biochemical blood analysis: creatinine, potassium, sodium, cholesterol, triglycerides

Auscultation of heart, neck and renal vessels, measurement of BP on arms and legs, ECG, ophthalmoscopy, US of heart and kidneys

Differential diagnosis according to diagnostic algorithm: coarctation of aorta, Itsenko-Cushing syndrome, pheochromocytoma, Conn's syndrome, renal parenchymal hypertension, renovascular hypertension, essential hypertension, systolic АH


Urgent conditions








hypertension stroke: complicated, noncomplicated

Patient Management

Drug treatment

Nonmedicamental treatment

First line drugs: diuretics, beta-blockers.

Second line drugs:

ACE-inhibitors, Ca channel blockers, α-blockers, angiotensin II receptor blockers

Weight loss, decrease of alcohol consumption, regular aerobic physical activity, restriction of salt, diet rich in fruits, vegetables, and low-fat

^ First aid at hypertension stroke

Complicated: iv sodium nitroprusside, esmolol, nitroglycerine, enalaprilate;


orally: diuretics, beta-blockers, ACE-inhibitors etc.

Diagnostic Algorithm For

« Arterial hypertension »

The list of nosological units

  1. Coarctation of aorta

  2. Itsenko-Cushing syndrome

  3. Pheochromocytoma

  4. Conn's syndrome

  5. Renal parenchymal hypertension

  6. Renovascular hypertension

  7. Essential hypertension

  8. Systolic АH

Arterial hypertension

constriction of aorta on echocardiogram


Advice of cardiosurgeon




Increase in excretion 17-hydroxycorticosteroids in 24 hours' urine


Increase in catecholamine level in blood during elevation of BP





Advice of endocrinologist

Increase of aldosterone level in plasma





proteinuria, hematuria, leukocyturia


Advice of nephrologist



constriction of renal artery on angiogram


Elevation of systolic BP only



Essential hypertension


Classification of an arterial hypertension (the CART, 1996.)

Depending on etiology:

  1. Initial АH (essential АГ, an idiopathic hypertensia).

  2. Secondary АH (symptomatic, associated with certain organs damage).

Classification of Blood Pressure in Adults


BP (mm Hg)


< 120/80



Stage 1

140–159 (systolic)


90–99 (diastolic)

Stage 2

≥ 160 (systolic)


≥ 100 (diastolic)

^ Classification of arterial hypertension depending on presence and severity of target-organs damage

1 stage Objective attributes of target-organs damage are absent.

II stage One of following signs is present:

  • Hypertrophy of a left ventricle (on ECG data, EchoCG, Chest X-ray);

  • Generalized or focal narrowing of retinal vessels;

  • Microalbuminuria, proteinuria, and/or slight increase in serum concentration of a creatinine - up to 177 mkmol/L

  • Atherosclerotic changes (presence of plaques) in carotids, an aorta, ileal or femoral arteries (according to angiography or ultrasonic data)

III stage Presence of clinical attributes of irreversible changes of target-organs

  • Heart - myocardial infarction, heart failure of IIА-III stage.

  • Brain - stroke, transitional ischemic attack, acute hypertonic encephalopathy, chronic hypertonic encephalopathy III st., vascular dementia.

  • Eye grounds - hemorrage and exudates in retina with or without papilledema.

  • Kidneys - concentration of a plasma creatinine level more than 177 mkmol/L.

  • Vessels - a dissecting aortic aneurysm, occlusive damages of arteries with clinical manifestations.

At the end of the practice class, you shall solve final tests, and with this aim in mind, pay attention to the following example tests.

Final Test Questions

Q 1. Patient С., 21 years old, suffer from coarctation of aorta. How does the BP change?

А) decreased BP on arms and legs;

B) elevated BP on arms and legs;

C) decreased BP on arms and elevated on legs;

D) elevated BP on arms, decreased on legs;

E) normal BP on arms and legs.

Q 2. Patient К., 50 years old, has BP of 220/100 mm Hg, on ECG - scarring after myocardial infarction, left ventricle hypertrophy, on ophthalmoscopy – hemorrhages on fundus of eye, edema of optic nerve. What stage of essential hypertension is there?

А) I





Q 3. Patient К., 39 years old, has BP 170/100 mm Hg. Arterial hypertension of what degree has he?

А) mild;

B) moderate;

C) severe;

D) perihypertension;

E) isolated systolic.

Q 4. Patient with arterial hypertension and a diabetes mellitus during treatment by ACE inhibitor Captoprilum had been marked increasing of creatinine blood level. What disease can be suspected in this case?

А) diabetic glomerulosclerosis;

B) renal artery stenosis;

C) glomerulonephritis;

D) pyelonephritis;

E) pheochromocytoma.

Q 5. Hypertension stroke in patient D., 57 years old, was complicated by pulmonary edema. What drug should be used first in this situation?

А) nitroglycerinum;

B) furosemidum;

C) verapamilum;

D) anaprilin;

E) enalapril.


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