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Diagnosis and Management of Essential Hypertension

Diagnosis:

To establish the diagnosis of hypertension, blood pressure readings should be accurate.

  • Take the blood pressure with the patient seated and relaxed with the arm bared and using an appropriately sized cuff.
  • The patient should not have drunk coffee or smoked cigarettes within 30 minutes before the measurement.
  • The blood pressure should be checked in both arms on at least one occasion to confirm there is no difference in readings.
  • Take the patient's blood pressure three times at separate visits, one to several weeks after the initial elevated blood pressure reading. The average diastolic blood pressure should be at least 90 mm Hg OR the average systolic blood pressure should be at least 140 to confirm the diagnosis of hypertension. The diagnosis of hypertension can be confirmed by either systolic or diastolic blood pressure elevation, both readings do not have to be elevated.

Initial Evaluation:

1. The following appointment recommendations apply to the patient's initial elevated blood pressure readings.

  • If the systolic and diastolic categories are different, follow the recommendations for the shortest time frame for follow-up.
  • If the systolic blood pressure is >130-139 OR the diastolic pressure is >85-89 (high-normal BP) educate member regarding lifestyle changes to reduce risk for development of hypertension and recommend repeat blood pressure in one year.
  • If the systolic blood pressure is >140-159 OR the diastolic pressure is >90-99 (Stage 1-mild HBP) the pressure should be repeated within two months. Schedule the patient for a complete history and physical examination.
  • If the systolic blood pressure is >160-179 OR the diastolic pressure is >100-109 (Stage 2-moderate HBP) the pressure should be repeated within one month. Schedule the patient for a complete history and physical examination.
  • If the systolic blood pressure is >180-209 OR the diastolic pressure is >110-119 (Stage 3-severe HBP) consider an immediate evaluation including a complete history and physical exam and repeat the blood pressure within 1-2 weeks
  • If the systolic blood pressure is >210 OR the diastolic pressure is >120 (Stage 4-very severe HBP) begin immediate treatment, including a complete history and physical exam, and repeat within 3-4 days.
  • If the patient has an elevated blood pressure and evidence of target organ (heart, brain, kidney, large artery) disease, begin immediate treatment.
  • The follow-up interval and the decision to start treatment should be modified by reliable information about past blood pressure readings, other cardiovascular risk factors, or the presence of target organ disease.

2. Within 2 months of the diagnosis of hypertension a physical and lab examination should be performed. This exam and lab should be done prior to initiating drug therapy. This examination should include:

Medical History:

  • Past medical history of hypertension and treatment
  • Past medical history or symptoms of diabetes, hyperlipidemia, gout, renal disease, CV disease
  • Family history of hypertension, heart disease, stroke, diabetes
  • Tobacco use
  • Physical activity level
  • History of weight gain/loss and dietary habits -include use of alcohol, salt, potassium and calcium intake, and saturated fats

Psychosocial history:

  • family situation
  • employment status
  • working conditions Medication history
  • possible drug interactions (if treatment started)
  • possible drug related HBP (for example, oral contraceptives or steroids)

Physical exam:

  • Weight and height
  • Blood pressure
  • Fundoscopic exam
  • Carotid bruits
  • JVD
  • Thyroid palpation
  • Cardiac auscultation
  • Abdominal exam for aneurysms, renal enlargement, bruits
  • Extremity exam for edema, pulses
  • General neurologic exam Lab exam

Diagnostic Testing:

  • Urinalysis
  • CBC
  • Chem. profile (glucose, potassium, calcium, creatinine, uric acid,)
  • Lipid profile (total cholesterol, HDL, LDL, triglycerides)
  • ECG (if age 40 or older)

Follow-up:

1. Once the patient's blood pressure has stabilized, the follow-up interval should be individualized.

2. All patients with hypertension need a minimum of annual follow-up to update and reassess their hypertension control.

3. In order to assess control of hypertension the following elements should be done at least once each year.

  • Review of unresolved lifestyle issues (obesity, diet, smoking, exercise, chronic stress)
  • Blood pressure
  • Weight (and height if not previously recorded)
  • Cardiovascular exam (including cardiac auscultation)
  • Patient history of symptoms of target organ disease (chest pain, shortness of breath, etc.)
  • Lab tests as needed (based on historical findings and current treatment), including at a minimum:
    • If patient is on diuretics, electrolytes
    • If patient has a history of elevated cholesterol, a repeat lipid profile

Treatment:

1. The goal of therapy is to achieve near normal blood pressure levels with minimum negative impact on the patient. If the patient's systolic blood pressure is >140 0R the diastolic pressure is >90, the patient's blood pressure control should be assessed and appropriate actions taken to improve control. Patients may not achieve this level of control due to problems with compliance, medication side effects, or limited effectiveness of medications.

2. In all instances where the patient has been identified as at risk for, or diagnosed with hypertension, lifestyle modifications should be recommended. In patients with mild to moderate hypertension these lifestyle modifications should be attempted for three to six months prior to initiating drug therapy. If the patient's blood pressure continues to exceed 140 mm Hg systolic OR 90 mm Hg diastolic, medication therapy should be instituted. Patients on medication who meet lifestyle modification goals and whose blood pressure is less than 140/90 should be considered as candidates for a trial off of medications.

3. Lifestyle modifications include:

  • Being overweight is clearly associated with a higher risk of hypertension. Studies have shown weight losses of as little as 6-10 pounds can be effective in reducing blood pressure. Providers should document patient agreement with a weight loss plan. For hypertensive patients with a significant weight problem consider a dietary referral.
  • Patients with hypertension need to make changes in their diet. Consider a dietary referral. Reduce total fat intake to less than 30% of calories and reduce cholesterol and saturated fat intake to less than 10% of calories. Restrict ethanol intake to a maximum of 1 oz of ethanol a day (e.g., 2 oz of 100 proof spirits, 8 oz of wine, 24 oz of beer). Restrict sodium to less than two grams per day initially, however if the patient does not respond to salt restricted diet this restriction can be relaxed to six grams or eliminated entirely. Consider increasing dietary potassium and calcium as this reduces blood pressure in some patients.
  • Recommend aerobic exercise at least 20 minutes duration 3 times a week. Closely monitor exercise programs in patients with heart disease. Consider a stress test if the patient has significant risk factors for heart disease.
  • Smoking cigarettes results in elevated blood pressure. Advise patients to stop smoking. Consider a referral to a smoking cessation program. Studies have shown that repeated physician reminders to smokers impact smoking cessation success.
  • Evaluate patients for symptoms of long term stress. Instruction in stress avoidance techniques may be indicated for patients with chronic anxiety, lack of social support, or problems coping with anger or repressed emotions.

4. Choice of Therapy:

  • The initial treatment agent should generally be either a diuretic or a beta blocker. This recommendation is based on the fact that these agents have been shown to reduce the risk of stroke and other cardiovascular end points. Alternate acceptable first line treatment agents include alpha blockers, ACE inhibitors, and calcium channel blockers.
  • In patients who do not respond to initial agents there are many variables to consider which are beyond the scope of this guideline. Physicians should select appropriate agents based on the patient's medical condition.

Lifestyle Modifications:

  • Weight reduction
  • Moderation of alcohol intake
  • Regular physical activity
  • Reduction of sodium intake
  • Smoking cessation
  • If inadequate response then:
  • Continue lifestyle modifications
  • Initiate pharmacologic therapy

If inadequate response:

  • Increase drug dosage OR
  • Substitute another drug OR
  • Add a second agent from a different class

If inadequate response:

  • Add a second or third agent and/or diuretic if not already prescribed.

 

References:
The Fifth Report of the Joint National committee on Detection, Evaluation & Treatment of High Blood Pressure (JNC-V). Arch Intern Med 1993;153: 154-183.
A Review of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure, The Fifth Report, 1993.
American Journal of Hypertension 1993;6:896-898.
Individualized Prevention and Treatment of Essential Hypertension. American Family Physician Fall 1994; Monograph QI Guidelines