Hypertension is often asymptomatic, earning its reputation as the “silent killer.” When symptoms occur, they may indicate severe hypertension or organ damage, presenting as morning occipital headaches, dizziness, blurred vision, nosebleeds, shortness of breath, palpitations, fatigue, or confusion. In hypertensive emergencies (≥180/120 mmHg), symptoms can escalate to chest pain, severe headaches, nausea, vomiting, seizures, or altered consciousness, requiring urgent medical attention. Since symptoms are unreliable indicators, routine blood pressure monitoring is essential for early detection and prevention of complications.

Hypertension assessment confirms diagnosis, evaluates severity, detects complications, and identifies secondary causes, especially in resource-limited settings where late presentation is common.

Blood pressure patterns vary: sustained hypertension (persistently elevated BP), masked hypertension (normal in clinic, high at home—common in young adults, diabetics, and chronic kidney disease patients), and white coat hypertension (high in clinic, normal at home). Home monitoring (and 24-hour ambulatory BP monitoring if available) helps differentiate these cases.

General examination may reveal central obesity, moon facies (in Cushing’s syndrome), pallor (CKD/anaemia), sweating and tremors (pheochromocytoma/hyperthyroidism), xanthelasma (dyslipidaemia), or oedema (renal or cardiac involvement).

Cardiovascular findings include radio femoral delay (coarctation), bounding pulses (aortic regurgitation), thickened arterial walls (atherosclerosis), weak pulses (peripheral arterial disease), and a >20 mmHg BP difference between arms (aortic dissection). Heart sounds (loud S2, S4 gallop) suggest left ventricular hypertrophy, while carotid bruits indicate (atherosclerosis and increased) stroke risk.

Fundoscopy detects hypertensive retinopathy, ranging from arteriolar narrowing to papilledema in severe cases. Neurological signs include stroke-related deficits or cognitive impairment from chronic hypertension.

Early detection through home BP monitoring, cardiovascular assessment, and fundoscopy is crucial, especially where advanced diagnostics are limited.

Hypertension can be primary or secondary. Primary (essential) hypertension is a diagnosis of exclusion, often asymptomatic unless complications arise, and common in middle-aged adults with risk factors like genetics, obesity, and high salt intake. Secondary hypertension should be suspected in cases of abrupt onset, age <30 or >55, resistance to multiple drugs, or disproportionate end-organ damage.

Common secondary causes include:

• Renal parenchymal disease (proteinuria, abnormal creatinine)
• Renovascular hypertension (abdominal bruit, flash pulmonary oedema, worsening renal function with ACEIs/ARBs)
• Endocrine disorders: Primary aldosteronism (hypokalaemia), Cushing’s syndrome (central obesity, striae), pheochromocytoma (episodic headaches, palpitations), thyroid dysfunction (tachycardia or bradycardia)
• Coarctation of the aorta (upper limb hypertension with weak femoral pulses)
• Obstructive sleep apnoea (snoring, daytime somnolence)
• Drug-induced hypertension (NSAIDs, steroids, oral contraceptives, central stimulants found in ADHD medicines or illicit drugs abuse)
• Pregnancy-related hypertension (gestational hypertension, preeclampsia, eclampsia)

A detailed history, physical examination, and targeted investigations help differentiate these causes, with referral for suspected secondary hypertension when necessary.

Hypertension is diagnosed based on office BP readings ≥140/90 mmHg on two separate visits or home BP ≥135/85 mmHg. Routine tests include:

• Urinalysis for proteinuria
• Serum electrolytes & creatinine for kidney function and suspected primary aldosteronism if there is hypokalemia
• Fasting blood glucose/HbA1c for diabetes
• Lipid profile for cardiovascular risk assessment
• ECG for left ventricular hypertrophy and ischemic changes

Additional tests like renal ultrasound, aldosterone-renin ratio, 24-hour urinary metanephrines, thyroid function tests, and echocardiography may be needed for suspected secondary hypertension.

Lifestyle Modifications

• Salt intake <5g/day
• DASH diet rich in fruits, vegetables, and lean protein
• Exercise (≥150 minutes weekly)
• Weight control
• Smoking and alcohol cessation

Pharmacologic Therapy

First-line medications:

• ACE inhibitors/ARBs (for diabetics and CKD patients)
• Calcium channel blockers (for black patients and the elderly)
• Thiazide diuretics (for volume control)

Second-line agents:

• Beta-blockers (for heart disease)
• Spironolactone (for resistant cases, where primary aldosteronism is suspected)
• Alpha-blockers (for patients with BPH)

Referral is necessary for resistant hypertension, suspected secondary hypertension, or hypertensive emergencies (≥180/120 mmHg with organ damage).

Patients should have BP monitored every 2-4 weeks initially, then every 3-6 months once stable, with annual screenings for complications. Prevention efforts focus on lifestyle modifications, community screening, and patient education. Excess salt intake, common in African diets, should be reduced through fresh ingredients and natural spices.

For diagnosed patients, adherence to treatment is crucial, though many discontinue medications due to cost, lack of symptoms, or misconceptions. Patient-centered care, affordability-based drug selection, and regular monitoring for organ damage are key. In resource-limited settings, primary care providers and community health workers should be trained to manage uncomplicated cases.