The syndrome of a systemic hypertension and hypotension (complaints, classification, criteria of diagnostics). The syndrome of a pulmonary hypertension and pulmonary heart (complaints, classification, criteria of diagnostics).
Reading Document
Medical Text Search
systemic hypertension classification diagnostic criteria symptoms complaints
Medical Text Search
arterial hypotension classification diagnostic criteria symptoms orthostatic
GradeResponse
GradeResponse
Medical Text Search
pulmonary arterial hypertension classification WHO diagnostic criteria symptoms
Medical Text Search
cor pulmonale pulmonary heart disease right heart failure diagnosis criteria
Below is a comprehensive structured overview of all four syndromes based on retrieved sources and established clinical knowledge.
I. SYNDROME OF SYSTEMIC HYPERTENSION
Definition
Systemic (arterial) hypertension is a sustained elevation of blood pressure (BP) to ≥140/90 mmHg measured on at least 2 separate occasions. It is divided into primary (essential) (~90–95%) and secondary (~5–10%) forms.
Complaints (Symptoms)
Most patients are asymptomatic for years ("the silent killer"). When symptoms occur:
| Category | Symptoms |
|---|---|
| Headache | Occipital, typically morning, pulsating |
| Neurological | Dizziness, tinnitus, visual blurring ("spots"), impaired concentration |
| Cardiac | Palpitations, chest discomfort, dyspnea on exertion |
| General | Fatigue, epistaxis, flushing |
| Hypertensive urgency/emergency | Severe headache, nausea/vomiting, confusion, visual loss, focal neurological deficits |
Classification
By BP Level — ACC/AHA 2017 Guidelines
| Category | Systolic (mmHg) | Diastolic (mmHg) | |
|---|---|---|---|
| Normal | < 120 | and | < 80 |
| Elevated | 120–129 | and | < 80 |
| Stage 1 HTN | 130–139 | or | 80–89 |
| Stage 2 HTN | ≥ 140 | or | ≥ 90 |
| Hypertensive Crisis | > 180 | and/or | > 120 |
Note: ESC/ESH 2018 retains the threshold of ≥140/90 mmHg for Grade 1 hypertension.
ESC/ESH Grading
| Grade | SBP (mmHg) | DBP (mmHg) |
|---|---|---|
| Grade 1 (Mild) | 140–159 | 90–99 |
| Grade 2 (Moderate) | 160–179 | 100–109 |
| Grade 3 (Severe) | ≥ 180 | ≥ 110 |
| Isolated systolic HTN | ≥ 140 | < 90 |
By Etiology
- Primary (Essential): No identifiable cause; multifactorial (genetic, environmental)
- Secondary: Renal (renovascular, parenchymal), endocrine (primary hyperaldosteronism, pheochromocytoma, Cushing's, hyperthyroidism), coarctation of aorta, obstructive sleep apnea, drug-induced
By Target Organ Damage (Risk Stratification)
- Stage A – No TOD, no CV risk factors
- Stage B – Risk factors present, no TOD
- Stage C – TOD/CVD present (LVH, retinopathy, nephropathy, atherosclerosis)
Diagnostic Criteria
- Office BP ≥ 140/90 mmHg on ≥ 2 readings at ≥ 2 visits
- 24-hour ABPM (ambulatory): Mean ≥ 130/80 mmHg (daytime ≥ 135/85, nighttime ≥ 120/70)
- Home BP monitoring (HBPM): ≥ 135/85 mmHg
- White-coat hypertension excluded with ABPM/HBPM
- Workup includes: CBC, urinalysis, BMP (creatinine, K⁺), fasting glucose/lipids, ECG (LVH), echocardiography, fundoscopy, renal ultrasound if secondary cause suspected
Hypertensive Urgency vs Emergency
| Feature | Urgency | Emergency |
|---|---|---|
| BP | >180/120 | >180/120 |
| Target organ damage | Absent | Present (AKI, encephalopathy, pulmonary edema, dissection, stroke) |
| Management | Oral agents, lower over hours | IV agents, ICU, lower within minutes–1 hour |
II. SYNDROME OF SYSTEMIC HYPOTENSION
Definition
Arterial hypotension is a sustained or symptomatic reduction in systolic BP < 90 mmHg and/or diastolic BP < 60 mmHg, or a fall sufficient to cause end-organ hypoperfusion.
Complaints (Symptoms)
| System | Symptoms |
|---|---|
| CNS | Lightheadedness, dizziness, presyncope, syncope, blurred vision, cognitive slowing |
| Cardiovascular | Palpitations (reflex tachycardia), chest pain (if coronary hypoperfusion) |
| General | Weakness, fatigue, cold extremities, pallor, diaphoresis |
| Orthostatic | Symptoms triggered by standing (within 3 min): dizziness, "black-out," falls |
| Postprandial | Dizziness/syncope 15–60 min after eating |
Classification
| Type | Definition | Key Causes |
|---|---|---|
| Primary (Constitutional) Hypotension | Chronic low BP without identifiable cause; asthenic body habitus, more common in young women | Idiopathic; constitutional tendency |
| Orthostatic (Postural) Hypotension | ↓ SBP >20 mmHg or ↓ DBP >10 mmHg within 3 min of standing | Dehydration, autonomic neuropathy (DM, Parkinson's), medications (antihypertensives, diuretics, α-blockers), Addison's disease |
| Postprandial Hypotension | BP fall ≥20 mmHg within 2 h after eating | Elderly, autonomic dysfunction |
| Neurally Mediated (Vasovagal/Reflex) Syncope | Reflex-mediated vasodilation and/or bradycardia | Pain, prolonged standing, emotional stress |
| Secondary Hypotension | Due to identifiable disease | Cardiogenic shock, Addison's, hypothyroidism, sepsis, severe hemorrhage, pulmonary embolism |
| Drug-Induced | Iatrogenic | Antihypertensives, diuretics, nitrates, antidepressants |
| Orthostatic Hypotension with autonomic failure | Associated with absent compensatory tachycardia | DM, Parkinson's, MSA (Shy-Drager) |
Diagnostic Criteria
Per Harrison's Principles of Internal Medicine (p. 6764):
"Orthostatic hypotension is defined by a fall in systolic pressure >20 mmHg or in diastolic pressure >10 mmHg in response to assumption of the upright posture from a supine position within 3 min. There may also be a lack of a compensatory tachycardia, an abnormal response that suggests autonomic insufficiency."
General Diagnostic Criteria for Hypotension
| Criterion | Threshold |
|---|---|
| Systolic BP | < 90 mmHg |
| Diastolic BP | < 60 mmHg |
| Mean Arterial Pressure | < 70 mmHg |
| Orthostatic drop (SBP) | > 20 mmHg on standing |
| Orthostatic drop (DBP) | > 10 mmHg on standing |
Diagnostic Workup
- Tilt-table test – gold standard for vasovagal/neurally mediated syncope
- Active stand test – orthostatic hypotension
- 24-hour ABPM – to identify pattern
- Holter monitor – if arrhythmia-related syncope suspected
- Laboratory: cortisol, ACTH stimulation (Addison's), TSH, CBC, BMP
- Echocardiography – if cardiogenic cause suspected
III. SYNDROME OF PULMONARY HYPERTENSION
Definition
Pulmonary hypertension (PH) is defined hemodynamically as a mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg at rest (recent ESC/ERS 2022 updated threshold: > 20 mmHg), measured by right heart catheterization (RHC).
Complaints (Symptoms)
| Stage | Symptoms |
|---|---|
| Early | Exertional dyspnea (most common, insidious onset), fatigue, reduced exercise tolerance |
| Intermediate | Exertional chest pain (anginal — RV ischemia), exertional syncope/presyncope, palpitations |
| Advanced | Dyspnea at rest, peripheral edema (ankle swelling), ascites, right upper quadrant pain (hepatic congestion), cyanosis |
| Associated with underlying disease | Hemoptysis (in PAH, CTEPH), Raynaud's, dry cough |
Key hallmark: dyspnea out of proportion to the underlying lung or cardiac disease.
Classification (WHO/ESC 2022 — 5 Groups)
| Group | Etiology |
|---|---|
| Group 1 — PAH | Idiopathic, heritable (BMPR2 mutation), drug/toxin-induced (anorexigens, meth), connective tissue disease (SSc, SLE, MCTD), congenital heart disease, portopulmonary, HIV, schistosomiasis |
| Group 2 — Left Heart Disease | HFpEF, HFrEF, valvular disease (mitral stenosis, aortic stenosis) |
| Group 3 — Lung Disease/Hypoxia | COPD, ILD, sleep-disordered breathing, high altitude |
| Group 4 — CTEPH | Chronic thromboembolic pulmonary hypertension (post-PE) |
| Group 5 — Miscellaneous/Unclear | Hematologic disorders (PV, ET), sarcoidosis, metabolic disorders, fibrosing mediastinitis |
WHO Functional Class (FC) — Severity of PH Symptoms
| FC | Description |
|---|---|
| I | No limitation; ordinary activity causes no symptoms |
| II | Slight limitation; comfortable at rest; ordinary activity causes dyspnea/fatigue |
| III | Marked limitation; comfortable at rest; less-than-ordinary activity causes symptoms |
| IV | Unable to perform any physical activity; symptoms at rest; signs of RV failure |
Diagnostic Criteria
Hemodynamic Thresholds (Right Heart Catheterization)
| Parameter | Threshold | Type |
|---|---|---|
| mPAP | > 20 mmHg | All PH |
| mPAP | ≥ 25 mmHg | Classic threshold (pre-2022) |
| PAWP | ≤ 15 mmHg | Pre-capillary PH (Groups 1, 3, 4, 5) |
| PAWP | > 15 mmHg | Post-capillary PH (Group 2) |
| PVR | > 2 Wood Units | Pre-capillary PH component |
Diagnostic Algorithm
- Echocardiography – screening tool; estimate RVSP via tricuspid regurgitation jet velocity:
- Low probability: TRV ≤ 2.8 m/s
- Intermediate: TRV 2.9–3.4 m/s
- High probability: TRV > 3.4 m/s or multiple indirect signs
- Right Heart Catheterization (RHC) – gold standard (mandatory before initiating PAH-specific therapy)
- V/Q scan – CTEPH screening (Group 4)
- HRCT chest – lung disease, ILD (Group 3)
- PFTs, 6-minute walk test (6MWT), BNP/NT-proBNP
- Connective tissue disease serologies (ANA, anti-Scl70, anti-centromere)
IV. SYNDROME OF PULMONARY HEART (COR PULMONALE)
Definition
Cor pulmonale is right ventricular hypertrophy (RVH) and/or dilation and dysfunction secondary to pulmonary hypertension caused by diseases of the lung parenchyma, pulmonary vasculature, or thoracic cage — excluding left heart disease or congenital heart disease.
- Acute cor pulmonale: Sudden RV pressure overload (e.g., massive pulmonary embolism)
- Chronic cor pulmonale: Gradual RVH/dilation due to chronic lung disease (COPD most common)
Complaints (Symptoms)
| Phase | Symptoms |
|---|---|
| Compensated | Exertional dyspnea, fatigue, cough (from underlying lung disease), reduced exercise tolerance |
| Decompensated (Right Heart Failure) | Peripheral edema (bilateral, pitting), weight gain, ascites, right upper quadrant pain/fullness (hepatomegaly), anorexia, nausea |
| Advanced | Orthopnea (due to ascites), syncope on exertion, central cyanosis, hemoptysis |
| Physical exam findings | JVD, hepatojugular reflux, loud P₂, tricuspid regurgitation murmur, S3/S4 (right-sided), Kussmaul's sign, parasternal heave |
Classification
| Type | Mechanism | Common Causes |
|---|---|---|
| Acute | Sudden RV pressure overload | Massive PE, ARDS, severe pneumonia |
| Chronic | Longstanding PH → RVH → RV dilation | COPD (~50%), ILD, obstructive sleep apnea, kyphoscoliosis, CTEPH, neuromuscular disease |
Diagnostic Criteria
Clinical Criteria
- Evidence of RVH/RV dysfunction on imaging
- Evidence of pulmonary hypertension as the underlying cause
- Exclusion of left heart disease as the primary etiology
ECG Findings (RVH Pattern)
| Finding | Significance |
|---|---|
| Right axis deviation (> +110°) | RVH |
| R/S ratio > 1 in V1, R > 7 mm in V1 | RVH |
| S1Q3T3 pattern | Acute cor pulmonale (PE) |
| P pulmonale (P > 2.5 mm in II, tall peaked) | Right atrial enlargement |
| Incomplete/complete RBBB | RV strain |
| ST depression + T-wave inversion V1–V4 | RV strain |
Echocardiography (Key Findings)
- RV dilation and hypertrophy (RV wall > 5 mm)
- Paradoxical interventricular septal motion ("D-sign" on short-axis)
- Elevated RVSP (via TR jet)
- Dilated right atrium, dilated IVC (> 2.1 cm, < 50% collapse with inspiration → elevated RAP)
- Tricuspid regurgitation
- Reduced RV fractional area change (FAC) and TAPSE (< 17 mm = RV dysfunction)
Chest X-Ray
- Enlarged main pulmonary artery and hilar vessels ("pruning" peripherally)
- Right ventricular enlargement (filling of retrosternal space on lateral view)
- Evidence of underlying lung disease (hyperinflation in COPD, reticular pattern in ILD)
Laboratory Markers
| Test | Finding |
|---|---|
| BNP / NT-proBNP | Elevated (RV wall stress) |
| Polycythemia (CBC) | Chronic hypoxia |
| ABG | Hypoxemia ± hypercapnia |
| LFTs | Elevated in hepatic congestion |
Right Heart Catheterization (Definitive)
- mPAP > 25 mmHg
- Normal PAWP (≤ 15 mmHg) — pre-capillary origin
- Elevated RAP and RV end-diastolic pressure
- Reduced cardiac output in decompensated cor pulmonale
Summary Comparison Table
| Feature | Systemic HTN | Systemic Hypotension | Pulmonary HTN | Cor Pulmonale |
|---|---|---|---|---|
| Key definition | BP ≥140/90 mmHg | SBP <90, DBP <60 mmHg | mPAP >20 mmHg (RHC) | RVH/RV dysfunction from pulmonary cause |
| Primary symptom | Often asymptomatic → headache | Dizziness, syncope | Exertional dyspnea | Dyspnea + RV failure signs |
| Diagnostic gold standard | Office/ABPM BP measurement | Tilt table test (vasovagal); RHC excluded | Right heart catheterization | Echo + RHC |
| Key ECG finding | LVH (Sokolow-Lyon, Cornell) | None specific | RVH pattern | RVH, P pulmonale, S1Q3T3 |
| Biomarker | None specific | Cortisol (if Addison's) | BNP/NT-proBNP | BNP/NT-proBNP, polycythemia |
| Classification basis | BP level (Grades 1–3) | Type (orthostatic, vasovagal, secondary) | WHO Groups 1–5 | Acute vs. Chronic |
Sources: ACC/AHA 2017 High Blood Pressure Guidelines (p. 64); Harrison's Principles of Internal Medicine, 21st Ed. (p. 6764); ESC/ERS 2022 Pulmonary Hypertension Guidelines; WHO/Dana Point Classification.
This is a shared conversation. Sign in to Orris to start your own chat.