More often than not, Hypertension is diagnosed as an incidental finding when, for instance, attending the GP for unrelated reasons or booking in at the gym. The vast majority of patients with hypertension are asymptomatic and have what is called primary hypertension which simply means that no underlying cause of their hypertension (such as an adrenal tumour or some form of kidney disease) can be elucidated. Nonetheless most clinical guidelines would recommend that patients should be screened for underlying causes of hypertension with simple investigations and that treatment decisions should be based upon an estimation of an individual’s overall risk of developing cardiovascular disease. It is well worth seeing a hypertension specialist even at such an early stage in order to be more thoroughly evaluated for underlying causes of hypertension and to undertake comprehensive assessment of the patient’s future risk of developing cardiovascular disease such as stroke/heart attack or kidney failure.
In some patients blood pressure readings are not consistently elevated and those that are may not be strikingly hypertensive. In this case a diagnosis of borderline hypertension is made and often such patients are kept under routine surveillance by their GPs. However it is important to investigate individuals with borderline hypertension further as they may have higher BP than is recognised or even masked hypertension in which case the BP may be lower when recorded by their doctor but higher after leaving the surgery. The gold standard test here is 24 hour ambulatory BP monitoring which will assist in both making the diagnosis and in aiding treatment decisions too.
‘White coat hypertension’ or ‘white coat effect’ are terms used to describe the artificial elevation in BP that arises in some patients due to the stress of attending the physician for a consultation. Clearly such patients will not wish to be treated for their BP if it is not permanently elevated in the community. A diagnosis of white coat hypertension can only be reliably made by undertaking 24 hour ambulatory BP monitoring (ABPM) which Dr Lobo can easily organize. It is important to emphasize that patients who exhibit the ‘white coat’ phenomenon are at increased risk of developing sustained hypertension later on and therefore should be monitored on an annual basis with ABPM.
Patients whose BP does not respond to treatment with multiple agents (>3 antihypertensives) are often described as having resistant hypertension. This is something of a misnomer as often such patients have simply been treated with the wrong medications or too low a dose of the correct medications. Dr Lobo has a great deal of experience in the management of such patients and has a number of cases where such patients have been referred to him by other specialists – sometimes on up to 7 or 8 antihypertensive drugs! Dr Lobo and his team have established a protocol for safely withdrawing antihypertensive medications in such cases and re-investigating the patients and thereafter restarting them on tailored therapy depending on the outcome of the investigations. In many cases this has resulted in BP control being achieved with only 2 or 3 drugs which not only leads to improved prognosis but also to better quality of life with reduced tablet taking and side effects.
The vast majority of patients with hypertension have what is commonly called ‘essential’ hypertension for which no cause can be found. In less than 3% of all hypertensives, an underlying cause can be found after careful investigation. In some cases this can lead to a cure for hypertension which would mean that the patients may no longer have to take antihypertensive medications!
There are numerous causes of secondary hypertension (link to appendix 1) and it is important that your hypertension specialist has comprehensive experience of ALL of them as rarer causes of secondary hypertension are sometimes missed/inappropriately treated due to lack of experience in the correct investigational procedures or misinterpretation of results. Dr Lobo has extensive experience of investigating all forms of secondary hypertension and has developed close working relationships with internationally renowned experts in the fields of nephrology, endocrinology and neurology/neurosurgery to enable him to provide best care to patients with complex forms of secondary hypertension.
Hypertension is a major cause of maternal morbidity and mortality in pregnancy. There are several different forms of high blood pressure problems which can arise in pregnancy and Dr Lobo has extensive experience of dealing with all of these in both the inpatient and outpatient settings. He co-manages all pregnant hypertensive patients in Bart’s &The London NHS Trust along with his Consultant colleagues from Obstetrics and Gynaecology and continues their long term follow up post-partum as such patients are at increased risk of cardiovascular disease in later life.
Hypertension is sadly becoming increasing prevalent in younger people and Dr Lobo is seeing more and more teenagers in his practice as time goes by. He has developed close working relationships with his Consultant Paediatrician colleagues to improve the provision of ambulatory BP monitoring services to adolescents and to assist them in their investigation/management planning. Dr Lobo is happy and competent to take on the long term management of young patients with hypertension.
Severe hypertension can lead to rapid damage to various organs including the eyes (hypertensive retinopathy), brain (hypertensive encephalopathy), the heart (hypertensive heart failure) and the aorta (aortic dissection/aneurysm). In such cases rapid but controlled BP lowering is of critical importance to prevent a fatal outcome. These patients therefore need to be admitted to hospital for emergency control of blood pressure often requiring intravenous infusions of blood pressure lowering medications. Dr Lobo has considerable experience of hypertensive urgencies and emergencies and has facilities to admit patients with such diagnoses to both the NHS and Private Hospitals he practices in. Unusually for a hypertension specialist he looks after up to 5 – 10 admissions per month with a diagnosis of hypertensive urgency/emergency and has developed tried and trusted protocols for emergency BP lowering which are successful in 100% of cases.