What are the signs and symptoms of end-organ dysfunction to inquire about in a patient with hypertension?

Signs and Symptoms of End-Organ Dysfunction in Hypertensive Patients

When evaluating a patient with hypertension, a thorough assessment for signs and symptoms of end-organ damage is essential as these indicate hypertension-mediated organ damage that significantly impacts morbidity, mortality, and quality of life. 1

Neurological System

• Headaches (particularly frequent or severe)
• Visual disturbances (blurred vision, vision changes)
• Dizziness
• Mild confusion or altered mental status
• Seizures (in severe cases)
• Focal neurological deficits (suggesting TIA or stroke)
• Lethargy (in hypertensive encephalopathy)
• Cortical blindness (in hypertensive encephalopathy)

Cardiovascular System

• Chest pain (suggesting coronary ischemia)
• Shortness of breath, especially with exertion
• Palpitations
• Peripheral edema
• Claudication (suggesting peripheral artery disease)
• Dyspnea (suggesting heart failure)

Renal System

• Nocturia
• Oliguria (decreased urine output)
• Hematuria
• Edema (suggesting fluid retention)

Ophthalmologic System

• Visual changes
• Blurred vision
• Seeing halos around lights (suggesting retinopathy)

Other Symptoms

• Epistaxis (nosebleeds)
• Fatigue
• Malaise

Physical Examination Findings to Assess

Cardiovascular Assessment

• Abnormal pulse rate/rhythm/character
• Elevated jugular venous pressure
• Displaced apex beat (suggesting LVH)
• Extra heart sounds (S3, S4)
• Basal crackles (suggesting heart failure)
• Peripheral edema
• Bruits (carotid, abdominal, femoral)
• Radio-femoral delay (suggesting aortic coarctation)

Fundoscopic Examination

• Retinal changes (arteriolar narrowing)
• Hemorrhages
• Cotton wool spots
• Papilledema
• Arteriovenous nicking
• Tortuosity of vessels

Neurological Examination

• Mental status changes
• Focal neurological deficits

Laboratory and Diagnostic Findings of End-Organ Damage

Renal

• Proteinuria or hematuria on urinalysis
• Elevated serum creatinine
• Decreased eGFR

Cardiac

• Left ventricular hypertrophy on ECG or echocardiography
• Evidence of ischemia on ECG
• Atrial fibrillation

High-Risk Patients Requiring More Thorough Evaluation

Patients with the following characteristics warrant more careful screening for end-organ damage 2:

• Age > 60 years
• History of diabetes
• History of ischemic heart disease
• History of cerebrovascular disease

Clinical Approach Algorithm

1. Assess for neurological symptoms: Headaches, vision changes, confusion, focal deficits
2. Evaluate cardiovascular symptoms: Chest pain, dyspnea, palpitations, edema
3. Check for renal symptoms: Changes in urination pattern, hematuria
4. Perform targeted physical examination:
   • Fundoscopic exam (critical for detecting retinopathy)
   • Cardiovascular exam (heart sounds, pulses, edema)
   • Neurological exam

Common Pitfalls to Avoid

1. Overlooking retinal examination: Hypertensive retinopathy is present in up to 44% of patients referred to hypertension clinics and may be the only evidence of end-organ damage in 31% of patients 3

2. Dismissing subtle symptoms: Early signs of end-organ damage may be subtle and not readily apparent in the patient's chief complaint 1

3. Focusing only on blood pressure numbers: The presence of end-organ damage, not just BP values, determines the urgency of treatment 1

4. Assuming asymptomatic patients have no end-organ damage: Studies show that approximately 8.3% of patients with asymptomatic severe hypertension have evidence of acute end-organ damage on laboratory testing 2

Remember that early detection of end-organ damage is crucial as it significantly impacts treatment decisions and long-term outcomes for patients with hypertension.