Essential Hypertension

The term primary or essential hypertension is used when no specific cause can be identified. That is the case in 94% of patients with hypertension. Of the remaining 6%, 5% are due to renal parenchymal disease and 1% is due to all other causes. In addition to its statistical likelihood, the diagnosis is supported in our patient by the fact that no secondary cause is suggested by his history. His positive family history and the chronicity of his hypertension further support the diagnosis.

Our patient's mild exertional dyspnea is most likely due to his weight gain, smoking and poor physical fitness. Although left ventricular systolic failure must be considered, his history does not define the diagnosis. Breathless hypertension may, however, also suggest diastolic dysfunction. It is not uncommon for patients with hypertension to complain of headaches as well as tinnitus and nose bleeds. These symptoms are not of diagnostic value, as they are no more frequent in hypertensive patients than in the general population. Our patient's headaches are not typical of those that may be seen with severe hypertension. Anxiety may have played a role, as they were more frequent after he was turned down for insurance.

Secondary hypertension must still be considered, including renal and endocrine disease, coarctation of the aorta and the use of certain drugs. Target organ damage from hypertension must also be assessed, including the effect on the blood vessels, brain, kidneys, heart and eyes. By history alone, target organ damage has not been defined in our patient. In most cases, secondary hypertension may be excluded and target organ damage assessed by the history, the physical examination and simple laboratory tests.