Hypertension
Hypertension: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Duane D. Bland and Jay S. Roitman
One of four American adults has hypertension (HTN) (1). Despite its well-recognized role in cardiovascular disease, close to one-third of those with HTN are still unaware of it. Further, of those diagnosed with HTN, less than one-third have their condition under adequate control. HTN is most often found when the patient presents for an unrelated problem or for healthcare screening. The unfortunate exception may be when the patient presents with end-organ damage or with an acute hypertensive emergency.
Approach
In the evaluation of HTN, the most important tasks are to determine the severity, assess for other cardiovascular risk factors, and look for evidence of secondary causes.
A. Essential HTN. Most patients will have essential HTN. Further, most patients who present with HTN have mildly elevated values. Therefore, usually ample opportunity exists to assess for variation in readings and to stage the patient’s HTN, to assess for other cardiovascular risk factors and for comorbid disease, and to distinguish primary from secondary HTN.
B. Special concerns. A small percentage of patients will present with a hypertensive emergency. In general, these patients have severe HTN with symptoms and signs indicating end-organ involvement (e.g., encephalopathy, congestive heart failure, angina). These patients require immediate management of their blood pressure and associated medical problems.
History
A. Assessment for comorbid conditions. The patient’s past medical history should include an assessment for previous blood pressure readings. Any history of secondary disease or comorbid conditions should be documented: age more than 60 years, obesity, ischemic heart disease (IHD), cerebrovascular disease, peripheral vascular disease, retinopathy, nephropathy, dyslipidemia, diabetes mellitus, and menopausal status in women. A family history of these problems should also be documented, with particular emphasis on premature IHD in women aged less than 65 years, and in men aged less than age 55 years.
B. Medication history. The medication history should document the use of prescription, over-the-counter, and herbal preparations that may have hypertensive side effects.
C. Social history or habits. In addition, determine the use of tobacco, alcohol, or street drugs. The social history should also address leisure time physical activity and relevant psychosocial factors, which could affect ongoing HTN management.
D. Dietary history. Explore the ingestion of salt and saturated fats. Note recent weight changes, which can have significant effects on blood pressure.
Physical examination
A. Blood pressure measurement. Use a standardized technique (2,3) when measuring blood pressure to avoid spuriously high or low values. Patients should be seated in a chair, upright with back support, feet flat on the floor, arms bared, and supported at heart level. The patient should be resting at least 5 minutes before blood pressure measurements are taken. Stimulants such as nicotine and caffeine should be avoided at least 30 minutes prior to measurement. Appropriate cuff size is very important; the bladder within the cuff should circle at least 80% of the arm. Initial blood pressure measurements should include both arms; the arm with the higher reading should be used thereafter. It is recommended that two or more readings, separated by 2 minutes, be averaged. If the first two readings differ by more than 5 mm Hg, then additional readings should be obtained and averaged.
B. Additional physical examination. Height and weight should be measured. In a focused physical examination, pay particular attention to the fundi (for hemorrhages or vascular changes), the carotid arteries (for bruits), the heart (for murmurs), the abdomen (for bruits), and the extremities (for pulses, bruits, edema).
Testing
A. Routine clinical laboratory tests. These include a urinalysis, hemoglobin, serum electrolytes, blood urea nitrogen, creatinine, blood glucose, total cholesterol, and high density lipoprotein (HDL) cholesterol. Obtain a 12-lead electrocardiogram.
B. Optional laboratory tests and studies. Additional testing may be warranted given the findings on history, physical examination, or the initial laboratory screening. Specifically, for patients with diabetes, urine microalbumin and serum glycohemoglobin. For patients with an elevated screening cholesterol, low-density lipoprotein (LDL) cholesterol and triglycerides. For patients with proteinuria on initial screening, 24-hour urinary protein and creatinine clearance (Chapter 16.6).
C. Blood pressure measurement outside the office. Self-measurement and ambulatory blood pressure monitoring are generally unnecessary but may be useful in certain circumstances. Self-measurement can help identify patients with “white coat hypertension.” Potentially, it may help assess response to antihypertensive medications and improve patient compliance. Ambulatory blood pressure monitoring is significantly more expensive and should not be used routinely; however, it can also be useful in evaluating suspected “white coat hypertension.”
Diagnostic assessment
A. Table 7.6 provides a summary of the sixth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI).
B. Important considerations in the assessment of high blood pressure:
1. The patient should not be acutely ill or already on antihypertensive agents.
2. Classification should be based on the average of two or more readings taken at each of two or more visits after an initial screening.
3. When the systolic and diastolic blood pressures fall into different classifications, the higher classification should be used.
4. For patients with renal insufficiency and greater than 1 g/d of proteinuria, a blood pressure of 125/75 is recommended.
5. For blood pressures greater than 160–170 over 105–110, the diagnosis of HTN is probable even without additional measurements.
6. Follow-up may need to be modified based on the patient’s cardiovascular risk factors, history of prior blood pressure measurements, or evidence of target organ disease.
C. Secondary HTN. Secondary causes of HTN should be considered in patients responding poorly to medications, (particularly those with previously well-controlled HTN); in patients with stage 3 HTN; and those with sudden onset HTN. Many potential causes are found for secondary HTN. Some of the relatively more common causes and possible findings found during screening include:
1. Aortic coarctation
a. Short, rough systolic murmur in the second left interspace (Chapter 7.7)
b. Bruits heard over the back
c. Marked decrease in femoral pulses or blood pressures in the legs
2. Cushing’s disease
a. Central obesity with wasted extremities
b. Atrophic skin with abdominal striae and poor wound healing
c. Hyperglycemia (Chapter 14.1)
3. Exogenous substances. History of prescription drug, illicit drug, or alcohol use.
4. Primary hyperaldosteronism
a. Muscle weakness and cramps
b. Serum potassium less than 3.5 mEq/L off diuretics or less than 3.0 mEq/L on diuretics
5. Renal disease
a. Proteinuria
b. Elevated creatinine
6. Renal vascular hypertension
a. New onset HTN over the age of 55 years (particularly with history of smoking) or HTN in a child aged less than 12 years
b. Sudden increase in previously well-controlled blood pressure
c. Failure of triple drug therapy
d. Periumbilical bruit with radiation to the flanks
7. Pheochromocytoma
a. Anxiety, headaches, palpitations tremor, and excessive sweating
b. Weight loss (Chapter 2.13)
c. Orthostatic hypotension
d. Rapid pulse (Chapter 7.12)
References
1. American Heart Association [Web Page]. http://www.amhrt.org
2. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. The sixth report of Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 1997;157: 2413–2446.
3. Izzo JL, Black HR. Hypertension primer: the essentials of high blood pressure, 2nd ed. Chicago: American Heart Association, 1997.
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Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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