An approach to the young hypertensive patient

Abstract

Hypertension is the leading cause of death worldwide. Globally and locally there has been an increase in hypertension in children, adolescents and young adults <40 years of age. In South Africa, the first decade of the millennium saw a doubling of the prevalence rate among adolescents and young adults aged 15 24 years. This increase suggests that an explosion of cerebrovascular disease, cardiovascular disease and chronic kidney disease can be expected in the forthcoming decades. A large part of the increased prevalence can be attributed to lifestyle factors such as diet and physical inactivity, which lead to overweight and obesity. The majority (>90%) of young patients will have essential or primary hypertension, while only a minority (<10%) will have secondary hypertension. We do not recommend an extensive workup for all newly diagnosed young hypertensives, as has been the practice in the past. We propose a rational approach that comprises a history to identify risk factors, an examination that establishes the presence of targetorgan damage and identifies clues suggesting secondary hypertension, and a limited set of basic investigations. More specialised tests should be performed only where there is a clinical suspicion that a secondary cause for hypertension exists. There have been no randomised clinical trials on the treatment of hypertension in young patients. Expert opinion advises an initial emphasis on lifestyle modification. This can comprise a diet with reduced salt and refined carbohydrate intake, an exercise programme and management of substance abuse issues. Failure of lifestyle measures or the presence of targetorgan damage should prompt the clinician to initiate pharmacotherapy. We recommend referral to a specialist practitioner in cases of resistant hypertension, where there is severe targetorgan damage and when a secondary cause is suspected.

Topic reviews need to be robust

“…The HeFSSA guideline excluded this particular drug as no large randomised data exist for the efficacy of this drug in heart failure, not to mention the recommended dose. Perindopril 4 mg as a single drug had no benefit on reducing stroke, [5] and perindopril 8 mg was needed to reduce events in high-risk cardiovascular patients. [6] The effective dose in heart failure is unknown.…”

“…As such, in this successful collaboration, the CME articles were jointly produced by SA cardiologists and family physicians with the dual objectives of empowering doctors who manage these conditions in primary care settings in SA and improving the care of CVD patients in such settings. In the first issue, HF, [1] dyspnoea, [4] hypertension in the young [5] and valvular heart disease [6] were reviewed. In the second issue, infective endocarditis [7] and pericardial disease [8] were discussed.…”

Cardiovascular medicine in primary healthcare in sub-Saharan Africa: Minimum standards for practice (part 3)

“…It forms the third part of a series of articles jointly produced by South African (SA) cardiologists and family physicians with the dual objectives of empowering doctors who manage these conditions in primary care settings in SA and improving the care of CVD patients in such settings and emergency departments. In the first issue, heart failure, [7] dyspnoea, [8] hypertension in the young [9] and valvular heart disease [10] were reviewed. In the second issue, the important clinical problems of infective endocarditis [11] and pericardial disease [12] were discussed.…”

Cardiovascular medicine in primary healthcare in sub-Saharan Africa: Minimum standards for practice (part 1)

“…Mangena et al [7] review hyper tension in patients under the age of 40 years. In SA onethird of the population (approximately 17 million persons) are hyper tensive and in adolescents and young adults (15 24 years) the incidence of hypertension is 10%.…”