ANSWER 92
The ECG shows left ventricular hypertrophy (R-wave in V5 and S-wave in V1 #35 mm).
Although only a single reading is given, the hypertrophy makes it likely that the blood
pressure represents sustained hypertension rather than a ‘white coat’ effect. It should be
repeated several times over the next few weeks for confirmation, but treatment is likely to
be indicated.
The risks of vascular disease are related to the presence of other risk factors. The body
mass index is 28 showing that he is overweight. He is a smoker with a positive family his-
tory of cardiovascular disease. Tables such as the Sheffield table can be used to obtain a
calculation of the risks of cardiovascular disease.
The other question is whether a search for the cause of the hypertension is indicated.
Around 85 per cent of cases are idiopathic. Most of the secondary cases are related to renal
disease, and the renal function is normal here. A number of endocrine causes (Cushing’s
syndrome, Conn’s syndrome) are associated with hypokalaemia. If the blood pressure is dif-
ficult to control, secondary causes such as renal artery stenosis should be considered and
investigated by renal ultrasound or a technique to visualize the renal arteries such as mag-
netic resonance angiography or digital subtraction angiography.
The cholesterol is at a level which would warrant treatment if there was evidence of vascu-
lar disease. The hypertension itself should be controlled according to current guidelines
which would recommend starting with an angiotensin-converting enzyme (ACE) inhibitor in
a patient younger than 55 years.
- A single elevated blood pressure needs to be remeasured over several weeks.
- All relevant risk factors should be considered in assessing cardiovascular risk and plan-
ning treatment. - Most cases of hypertension do not have an identifiable underlying cause.