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Despite widespread efforts to improve education and enhance public awareness, up to 33% of persons with hypertension remain undiagnosed, and only about 50% of those known to have hypertension are adequately controlled. The percentages of patients who are aware that they have hypertension, who are treated, and who are controlled have increased since the 1970s. Most have stage 1 hypertension, and controversy still exists concerning the appropriate approach to these patients. Nonpharmacologic therapy is often the first choice, and this approach continues to evolve. Of the 20 to 30 million hypertensives who receive pharmacologic therapy, fewer than 50% adhere to their therapeutic regimen for more than 1 year, and 60% of these patients reduce the dosage of their drug owing to adverse effects.
A negative impact on the patient’s quality-of-life may occur as a result of just making the diagnosis. Effects such as increased absenteeism, sickness behavior, hypochondria, and decreased selfesteem have been noted in cohorts of previously well individuals who have been told they were hypertensive.2 A 1987 survey of physicians revealed that they regarded quality-of-life changes to be the primary impediment to effective pharmacologic treatment of hypertension.
The challenge to the clinician is to provide patient education and develop a hypertension regimen that effectively lowers blood pressure or reduces cardiac risk factors, minimizes changes in concomitant disease states, and maintains or improves quality of life. Putting the patient first necessitates integrating the individual patient’s lifestyle and current disease states with a thorough understanding of the effect of drug and nondrug therapy on quality of life.
Detection
The diagnosis of hypertension should not be based on any single measurement but should be established on the basis of at least three readings with an average systolic blood pressure of 140 mm Hg and a diastolic pressure of 90 mm Hg. Mechanisms should be established to standardize the measurement process:
(1) The patient should be seated comfortably with the arm positioned at heart level.
(2) Caffeine or nicotine should not have been ingested within 30 minutes before measurement.
(3) The patient should be seated in a quiet environment for at least 5 minutes.
(4) An appropriate sphygmomanometer cuff should be used (i.e., the rubber bladder should encircle at least two-thirds of the arm).
(5) Measurement of the diastolic blood pressure should be based on the disappearance of sound (phase V Korotkoff sound).
Evaluation
Evaluation is directed toward establishing the etiology of hypertension, identifying other cardiovascular risk factors, and evaluating the possibility of target organ damage. Although most hypertension is considered “essential,” primary, or idiopathic, it is necessary to eliminate secondary causes of hypertension, including renovascular disease, polycystic renal disease, aortic coarctation, Cushing syndrome, and pheochromocytoma. It is important to ensure that the patient is not on medications that may result in increased blood pressure, such as oral contraceptives, nasal decongestants, appetite suppressants, nonsteroidal antiinflammatory drugs (NSAIDs), steroids, and tricyclic antidepressants.
Medical History
The medical history should include a review of the family history for hypertension and cardiovascular disease, previous measurements of blood pressure, symptoms suggestive of secondary causes of hypertension, and other cardiovascular risk factors including smoking, hyperlipidemia, obesity, and diabetes. Environmental and psychosocial factors that may influence blood pressure control or the ability of the individual to comply with therapy should also be considered.
Physical Examination and Laboratory Tests
The physical examination should include more than one blood pressure measurement in both standing and seated positions with verification in the contralateral arm. (If a discrepancy exists, the higher value is used.) The rest of the physical examination includes (1) an evaluation of the optic fundi with gradation of hypertensive changes; (2) examination of the neck for bruits and thyromegaly; (3) a heart examination to evaluate for hypertrophy, arrhythmias, or additional sounds; (4) abdominal examination to search for evidence of aneurysms or kidney abnormalities; (5) examination of the extremities to check the pulses; and (6) a careful neurologic evaluation. Some baseline laboratory tests may be helpful for the initial evaluation. They might include urinalysis and serum potassium, blood urea nitrogen, and creatinine levels. A lipid panel may help evaluate cardiovascular risk.
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