Hypertension significantly increases the risk of developing coronary disease, heart failure, renal failure, and stroke. Risk further increases dramatically in the presence of smoking, glucose intolerance, hyperlipidemia, left ventricular hypertrophy (LVH), male gender, African American race, or increasing age. Treatment of hypertension greatly reduces its morbidity and mortality risks
The definition of hypertension is somewhat arbitrary because actuarial data show that morbidity and mortality related to complications of hypertension increase almost linearly with increasing levels of either systolic blood pressure (SBP) or diastolic blood pressure (DBP).
Classification
The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC), a national consensus group, has issued several reports that include recommendations of the classification of hypertension. they designate three stages:
• Prehypertension: DBP 80 to 89 mm Hg, SBP 120 to 139 mm Hg
• Stage 1: DBP 90 to 99 mm Hg, SBP 140 to 159 mm Hg
• Stage 2: DBP 100 mm Hg or greater, SBP 160 mm Hg or greater.
Establishing the Diagnosis
1. Measurement of Blood Pressure
Blood pressure is properly measured in both arms while the patient is seated comfortably, with feet on the floor, and after resting for 5 minutes. Coffee intake and smoking should be halted at least 30 minutes before taking the pressure
2. Number of Blood Pressure Determinations and Settings
Use of proper technique for measurement of the blood pressure is essential (see Chapter 14 and later discussion). Except in patients with severely elevated blood pressure, the diagnosis of hypertension should almost always be based on multiple determinations of blood pressure, preferably not only on different visits, but also by different personnel and in different settings. As noted earlier, there is a tendency for blood pressures to be higher when taken by a physician than when taken by a nurse or other medical worker
3. Home and Office Determinations
Teaching the patient to check his or her pressure at home and at work can greatly facilitate diagnosis and management, but home determinations should be viewed as an adjunct, not as a replacement for office-based measurements. Home determinations are diagnostically useful when there is concern the office reading might represent white-coat hypertension caused by patient anxiety. Home determinations are usually lower than those obtained in the office
4. Ambulatory Blood Pressure Monitoring
When there is a marked discrepancy between home and office pressures or a wide variation in pressures obtained throughout the day, 24-hour ambulatory monitoring may be useful, though usually it is unnecessary and quite expensive
Recomendation
• On encountering blood pressure elevation, confirm the diagnosis, but do not test for underlying pathophysiology (except in cases of suspected secondary hypertension) because such testing is not yet sufficiently accurate to aid in clinical decision making.
• Check for and rule out any clinically suggested secondary causes.
• Assess the severity of the blood pressure elevation.
• Identify any target-organ (end-organ) damage.
• Identify any and all concurrent cardiovascular risk factors, including clinically overt cardiovascular disease.
• Combine these risk determinations into an overall estimate of cardiovascular risk
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The definition of hypertension is somewhat arbitrary because actuarial data show that morbidity and mortality related to complications of hypertension increase almost linearly with increasing levels of either systolic blood pressure (SBP) or diastolic blood pressure (DBP).
Classification
The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC), a national consensus group, has issued several reports that include recommendations of the classification of hypertension. they designate three stages:
• Prehypertension: DBP 80 to 89 mm Hg, SBP 120 to 139 mm Hg
• Stage 1: DBP 90 to 99 mm Hg, SBP 140 to 159 mm Hg
• Stage 2: DBP 100 mm Hg or greater, SBP 160 mm Hg or greater.
Establishing the Diagnosis
1. Measurement of Blood Pressure
Blood pressure is properly measured in both arms while the patient is seated comfortably, with feet on the floor, and after resting for 5 minutes. Coffee intake and smoking should be halted at least 30 minutes before taking the pressure
2. Number of Blood Pressure Determinations and Settings
Use of proper technique for measurement of the blood pressure is essential (see Chapter 14 and later discussion). Except in patients with severely elevated blood pressure, the diagnosis of hypertension should almost always be based on multiple determinations of blood pressure, preferably not only on different visits, but also by different personnel and in different settings. As noted earlier, there is a tendency for blood pressures to be higher when taken by a physician than when taken by a nurse or other medical worker
3. Home and Office Determinations
Teaching the patient to check his or her pressure at home and at work can greatly facilitate diagnosis and management, but home determinations should be viewed as an adjunct, not as a replacement for office-based measurements. Home determinations are diagnostically useful when there is concern the office reading might represent white-coat hypertension caused by patient anxiety. Home determinations are usually lower than those obtained in the office
4. Ambulatory Blood Pressure Monitoring
When there is a marked discrepancy between home and office pressures or a wide variation in pressures obtained throughout the day, 24-hour ambulatory monitoring may be useful, though usually it is unnecessary and quite expensive
Recomendation
• On encountering blood pressure elevation, confirm the diagnosis, but do not test for underlying pathophysiology (except in cases of suspected secondary hypertension) because such testing is not yet sufficiently accurate to aid in clinical decision making.
• Check for and rule out any clinically suggested secondary causes.
• Assess the severity of the blood pressure elevation.
• Identify any target-organ (end-organ) damage.
• Identify any and all concurrent cardiovascular risk factors, including clinically overt cardiovascular disease.
• Combine these risk determinations into an overall estimate of cardiovascular risk
