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Hypertension Health Article

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Detection

HTN detection begins with proper blood pressure measurements, which should be obtained at each health care encounter. Repeated blood pressure measurements will determine whether initial elevations persist and require prompt attention or have returned to normal and need only periodic surveillance.

The auscultatory method of blood pressure measurement with a properly calibrated and validated instrument should be used. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends the following.

Patients should be seated quietly in a chair (rather than on an examination table), with feet on the floor and arm supported at heart level.
Measurement of blood pressure in the standing position is indicated periodically, especially in those at risk for postural hypotension.
An appropriate-sized cuff (cuff bladder encircling at least 80% of the arm) should be used to ensure accuracy.
At least 2 measurements should be made.
SBP is the point at which the first of 2 or more sounds is heard (phase 1), and DBP is the point before the disappearance of sounds (phase 5).
Clinicians should provide to patients, verbally and in writing, their specific blood pressure numbers and goals.

Evaluation

The evaluation of patients with documented HTN has 3 objectives: 1) to assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment; 2) to reveal identifiable causes of high blood pressure; and 3) to assess the presence or absence of target organ damage and cardiovascular disease. Data for evaluation are acquired through medical history, physical examination, laboratory tests, and other diagnostic procedures.

Medical History

A medical history should include the following.

known duration and levels of elevated blood pressure;
patient history or symptoms of coronary heart disease, heart failure, cerebrovascular disease, peripheral vascular disease, renal disease, diabetes mellitus, dyslipidemia, other comorbid conditions, gout, or sexual dysfunction;
family history of high blood pressure, premature coronary heart disease, stroke, diabetes, dyslipidemia, or renal disease;
symptoms suggesting causes of HTN;
history of recent changes in weight, leisure-time physical activity, and smoking or other tobacco use;
dietary assessment, including intake of sodium, alcohol, saturated fat, and caffeine;
history of all prescribed and over-the-counter medications, herbal remedies, and illicit drugs, some of which may raise blood pressure or interfere with the effectiveness of antihypertensive drugs;
results and adverse effects of previous antihypertensive therapy; and.
psychosocial and environmental factors (eg, family situation, employment status and working conditions, educational level) that may influence HTN control.

Physical Examination

The initial physical examination should include the following.

2 or more blood pressure measurements separated by 2 minutes with the patient either supine or seated and after standing for at least 2 minutes in accordance with the recommended techniques mentioned earlier;
verification in the contralateral arm (if values are different, the higher value should be used);
measurement of height, weight, and waist circumference;
funduscopic examination for hypertensive retinopathy;
examination of the neck for carotid bruits, distended veins, or an enlarged thyroid gland;
examination of the heart for abnormalities in rate and rhythm, increased size, precordial heave, clicks, murmurs, and third and fourth heart sounds;
examination of the lungs for rales and evidence for bronchospasm;
examination of the abdomen for bruits, enlarged kidneys, masses, and abnormal aortic pulsation;
examination of the extremities for diminished or absent peripheral arterial pulsations, bruits, and edema; and.
neurologic assessment.

Laboratory Tests And Other Diagnostic Procedures

Routine laboratory tests recommended before initiating therapy are performed to determine the presence of target organ damage and other risk factors. These routine tests include urinalysis, complete blood cell count, blood chemistry (potassium, sodium, creatinine, fasting glucose, total cholesterol, and high-density lipoprotein [HDL] cholesterol), and 12-lead electrocardiogram.

Optional tests include creatinine clearance, microalbuminuria, 24-hour urinary protein, blood calcium, uric acid, fasting triglycerides, low-density lipoprotein cholesterol, glycosylated hemoglobin, thyroid-stimulating hormone, and limited echocardiography (to determine the presence of left ventricular hypertrophy).

A more complete assessment of cardiac anatomy and function by standard echocardiography, an examination of structural alterations in arteries by ultrasonography, the measurement of the ankle/arm index, and plasma renin activity/urinary sodium determination may be useful for assessing cardiovascular status in selected patients.

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