Hypertension is a lifelong disease that causes few symptoms until the advanced stage.
For effective treatment, medications must be consumed daily.
Diminished stroke, myocardial infarction, kidney failire and death are achieved by achieving blood pressure of 120/80 in high risk patients and 140/90 in low risk patients.(?)
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Assessment of major cardiovascular risk factors: See Table 56-2.
A successful reduction in cardiovascular morbidity and mortality depends not only on adequate blood pressure control but also, more importantly, on the modification of all other risk factors that together increase cardiovascular events. Patients should have a thorough history and physical examination that focus on the identification of smoking, physical inactivity, obesity, and a family history of premature cardiovascular disease. Laboratory tests for assessment of risk factors should include screening for diabetes, dyslipidemia, and proteinuria. Management of identified risk factors should be done according to established evidence-based guidelines.
Assessment of target organ damage: See Table 56-3.
Heart: Left ventricular hypertrophy caused by long-standing high blood pressure is the initial pathologic change that predisposes to systolic and diastolic heart failure and increases cardiac oxygen demand. High blood pressure promotes atherosclerosis of all vascular beds including the coronary arteries decreasing myocardial oxygen supply and leading to ischemic heart disease. A 12-lead EKG is a useful test for identification of left ventricular hypertrophy and previous or current ischemia or infarction. An abnormal EKG and/or symptoms and signs suggestive of heart failure should be evaluated with an echocardiogram.
Brain: High blood pressure is the number 1 cause of ischemic and hemorrhagic strokes in this country. History should focus on previous symptoms suggestive of transient ischemic attacks or stroke. If present, evaluation of the cerebral circulation and brain parenchyma including carotid Doppler, head and neck magnetic resonance angiogram (MRA), and brain MRI should be considered.
Kidneys: Microalbuminuria (urinary albumin excretion of 30–300 mg/g Cr) is not only an established cardiovascular risk factor but also likely the earliest marker of nephropathy. Chronic hypertension increases glomerular pressure with the development of nephrosclerosis and continuous loss of nephrons. Hypertension is a major cause of end-stage renal disease. The JNC-7 report lists microalbuminuria as an optional test but the European Society of Hypertension and other organizations recommend it routinely as part of the initial evaluation for hypertensive patients. The urine dipstick is an insensitive test for identification of small amounts of proteinuria.
Retina: Uncontrolled or long-standing hypertension can cause retinopathy and risk for blindness. Patients should have a baseline dilated eye examination at the time of diagnosis.
PAD: As mentioned above, hypertension promotes atherosclerosis in all vascular beds. Patients with symptoms of intermittent claudication should be screened for PAD with an ankle-brachial index. A recent study found that measurement of blood pressure in both arms might help identify patients with PAD. A difference of more than 10 to 20 mm Hg strongly correlated with PAD in this study.
Identification of secondary causes of hypertension: See Table 56-4.
A minority of patients (approximately 5%–15%) have an identifiable disease causing hypertension. Thorough history and review of systems along with basic laboratory tests are indicated for all new patients diagnosed with hypertension. The JNC-7 report recommends hematocrit, potassium, creatinine, GFR, and calcium for all patients. In practicality, a CBC and a BMP are inexpensive and include those tests recommended by the JNC-7 providing clues for secondary hypertension. Examples include the association of metabolic alkalosis and hypokalemia with hyperaldosteronism and Cushing, an abnormal creatinine and GFR for chronic kidney disease or renovascular disease, an elevated calcium for hyperparathyroidism, and polycythemia in patients with chronic hypoxia. Patients who do not achieve blood pressure goals or patients with abnormal initial laboratory tests should undergo formal screening for secondary causes of hypertension. In recent years, obstructive sleep apnea has become one of the most commonly recognized causes of secondary hypertension.
All patients with a diagnosis of HTN should have the following laboratory tests ordered: CBC, BMP, fasting blood sugar (or HbA1C), lipid profile, urinalysis or urine microalbumin, and EKG.