Hypertension is defined as abnormally high blood pressure, normal being 120mmHg/80mmHg with a quantitative relationship between systemic arterial pressure and morbidity, (Sharma and Kortas, 2004). As there is a varying degree of risk to an individual based upon the severity of hypertension, a decisions making classification system the JNC VII, seen in Table 1, has been developed to help determine the aggressiveness of treatment or therapeutic interventions required for an individual (Sharma and Kortas, 2004; Levy et al, 2003).

Based on recommendations of the Seventh Report of the Joint National Committee of Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII), the classification of blood pressure (expressed in mm Hg) for adults aged 18 years or older is as follows and are based on the average of 2 or more readings taken at each of 2 or more visits after initial screening. (Sharma and Kortas, 2004.)

I believe this patient could be classified as having Stage1 essential hypertension as his BP is 160/93. Individuals with Stage 1 hypertension characteristically have normal or reduced cardiac output and elevated systemic vascular resistance (Sharma and Kortas, 2004).

Sharma and Kortas, 2004, indicate that this increased vascular resistance is, “due to changes in both the structural and physical properties of resistance arteries, as well as changes in endothelial function and are probably responsible for this abnormal behavior of vasculature. Furthermore, vascular remodeling occurs over the years as hypertension evolves, thereby maintaining increased vascular resistance irrespective of the initial haemodynamic pattern.” It is these features that lead me to suggest that his condition is likely chronic in nature and it needs to be address as a mater of urgency. His pattern of constant leg pain, exasperation upon walking and his discomfort during sleep requiring movement to stimulate circulation in the extremities is also indicative of intermittent claudication resulting from peripheral arterial occlusive disease (PAOD).

Rowe, 2004 describes PAOD as, “Single or multiple arterial stenoses producing impaired hemodynamics at the tissue level in patients with peripheral arterial occlusive disease (PAOD). Arterial stenoses lead to alterations in the distal pressures available to affected muscle groups and to blood flow”.

Further, “In patients with PAOD, resting blood flow is similar to that of a healthy person. However, during exercise, blood flow cannot maximally increase in muscle tissue because of proximal arterial stenoses. When the metabolic demands of the muscle exceed blood flow, claudication symptoms ensue. At the same time, a longer recovery period is required for blood flow to return to baseline once exercise is terminated.” This condition is clearly operating in our elderly patient.

Dormandy et al,1999, in their paper on intermittent claudication, do however indicate that only 1% to 3% of claudicants will require major amputation over a 5-year period after diagnosis and this statistic is higher in diabetics (Dormandy et al,1999, p.123). They also indicated that cerebrovascular disease (CVD), coronary artery disease (CAD), and peripheral arterial occlusive disease (PAOD) coexist. Hence PAOD and IC should be regarded as a marker for increased risk from fatal and nonfatal cardiovascular event. The risk is higher in the first year after developing IC than in the stable claudicant with mortality being 30% at 5 years, 50% at 10 years, and 70% at 15 year. The risk of a cardiovascular incident is therefore high in this patient based on the assumption that IC is probably present due to his case history.

Atherosclerosis of the peripheral vasculature has been in the forefront of his deterioration which has led to the development of PAOD. Other contributing factors are his excessive smoking , poor diet and lack of exercise which has maintained high circulating LDL cholesterol levels with altered haemodynamics, I would suggest this is polygenic in nature (Isley, 2004).

His recent tightness of chest is a warning signal of developed Coronary Heart Disease (CHD) and his case history indicates that he has a number of current risk factors (see Table 2).

A recently published meta-analysis of nearly 1,000,000 people in 61 studies demonstrated that for individuals aged 40-69 years, incremental increases of 20/10 systolic/diastolic blood pressure beginning with values of 115/75 will result in a doubling of cardiovascular risk mortality (Levy et al, 2003).

The study also found that males over 60 years of age, with Stage 2 hypertension ie with a systolic blood pressure ≥160 mmHg and diastolic blood pressure <95 mmHg, had a 2.5-fold risk for cardiovascular disease (P<0.001) over 24 months when compared to those considered to have normal blood pressure (<140/95 mmHg) (Levy et al, 2003). I believe that the patient has significant risk of a cardiovascular incident and would suggest that he arranges an appointment with his GP for immediate referral to a Cardiologist. I would start an immediate treatment targeting the essential hypertension, improved peripheral circulation and cardiac output and started to reduce LDL cholesterol and improve the circulating lipids.

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