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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
in the clinic
Hypertension
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
What long-term health risks are associated
with hypertension?
 Cardiovascular disease
 Retinopathy
 Cerebrovascular disease
 Ischemic heart disease
 Left ventricular hypertrophy
 Atrial fibrillation
 Heart failure
 Chronic kidney disease
 Peripheral vascular disease
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
Should clinicians screen for hypertension?
 USPS Task Force
 Screen the general adult population
 No specific screening interval recommended
 JNC 7 Guidelines
 Screen every 2 years if <120/80 mm Hg
 Annually if >139/89 mm Hg
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
What is prehypertension, and what is its
proper management?
 Blood pressure 120/80 to 139/89 mm Hg
 “Prehypertension” is not in 2014 evidence-based
guideline for management of adult high blood pressure
 Drug therapy is not recommended for prehypertension
 Evidence lacking on whether it decreases or prevents
cardiovascular events
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
CLINICAL BOTTOM LINE: Screening
and Prevention...
 Cardiovascular risk increases as blood pressure increases
 Screen all adults for hypertension at 1- to 2-yr intervals
 Lifestyle modification can delay hypertension + CVD onset
 No evidence for adding pharmacotherapy for prevention
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
How should clinicians diagnose and stage
hypertension?
 When to diagnose hypertension:
 ≥2 readings obtained at 3 visits 2-4 wk apart
 Average ≥140mmHg (systolic) or ≥90mmHg (diastolic)
 Hypertension stages (JNC 7)
 Normal blood pressure: ≤120/80 mm Hg
 Prehypertensive: 120/80 to 139/89 mm Hg
 Stage 1: 140/90 to 159/99 mm Hg
 Stage 2: ≥160/100 mm Hg
 If >50y, systolic blood pressure >140 mmHg more
important CVD risk factor than diastolic hypertension
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
Instructions for Taking Blood Pressure
 Have patient relax, sitting for >5 min
 Support patient’s arm
 Use stethoscope bell, not diaphragm, for auscultation
 Check blood pressure first in both arms: Use arm with
higher reading for all other + future readings
 Measure blood pressure in sitting, standing, and lying
positions (separate measurements by 2 min)
 Use correct cuff size and note if special cuff size needed
 Record systolic and diastolic pressures
 Record exact results to nearest even number
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
Common errors that lead to falsely increased readings
 Failure to have patient sit quietly for 5 min before reading
 Failure to support limb
 Using a cuff that is too small or deflating cuff too rapidly
 To detect pseudohypertension, use Osler’s maneuver
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
What is white coat hypertension?
 Elevated blood pressure at the office
 Lower blood pressure at home or with 24-h ambulatory
blood pressure monitor
 Prevalence: 10% to 20%
 Poses elevated risk for overt hypertension and CVD
 Lifestyle modifications and regular follow-up recommended
 Pharmacologic treatment not recommended
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
What is masked hypertension?
 Normotensive in the office but elevated blood pressure
out of the office
 Prevalence: 10% to 40%
 Increases sustained hypertension and CV death risk
 Screen for suspected masked hypertension
 Home readings
 Ambulatory blood pressure monitoring
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
When is ambulatory blood pressure
monitoring indicated?
 Possible white coat hypertension
 Unusual variability of blood pressure
 Evaluation of nocturnal hypertension
 Evaluation of drug-resistant hypertension
 Determining the efficacy of drug treatment over 24h
 Diagnosis and treatment of hypertension in pregnancy
 Evaluation of symptomatic hypotension on various medications
 Evaluation of episodic hypertension or autonomic dysfunction
 Possible masked hypertension
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
What are the key elements of the history?
 Assess duration, rapidity of onset, hypertension severity
 Ask about cardiovascular risk factors, concomitant
medical conditions, symptoms of target organ damage
 Ask about past treatment and its effects
 Ask about lifestyle
 Ask about increased stress, physical inactivity, salt
 Note any family history of hypertension, renal disease,
cardiovascular problems, stroke, and diabetes
 Review current medications (including OTC)
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
What are the essential elements of the
physical examination?
 Height, weight, BMI, waist circumference, skin lesions
 Fundoscopy
 Examination of neck
 Cardiopulmonary examination
 Abdominal examination
 Neurologic examination
 Peripheral pulses
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
Which laboratory tests should be done in
newly diagnosed cases?
 Newly diagnosed hypertension
 Measure hemoglobin or hematocrit, serum electrolytes,
serum creatinine, serum glucose, and fasting lipid levels
 Urinalysis with microscopic examination
 12-lead electrocardiography
 Tests indicated by clinical factors or anticipated treatment
 Echocardiography (more sensitive than EKG for LVH)
 Serum uric acid levels (if patient has gout)
 Microalbuminuria (if patient has diabetes)
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
Which patients should be evaluated for
secondary hypertension, and how should
they be evaluated?
Symptoms and Signs that Suggest Secondary Hypertension
 New-onset hypertension at age <25 or >55 years
 Drug-resistant hypertension
 Spontaneous hypokalemia
 Palpitations, headaches, and sweating
 Severe vascular disease
 Epigastric bruit
 Radial-femoral pulse delay
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
 Work-up for Possible Secondary Hypertension
 Coarctation of aorta
 The Cushing syndrome
 Primary aldosteronism
 Pheochromocytoma
 Renal vascular disease
 Renal parenchymal disease
 Parathyroid disorders
 Thyroid disease
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
CLINICAL BOTTOM LINE: Diagnosis...
 ≥140mmHg systolic or ≥90mmHg diastolic
 Measure blood pressure on several occasions, then average
 Goals of the diagnostic evaluation
 Search for a secondary cause
 Detect other CVD risk factors
 Detect damage to target organs
 History: past treatment, current meds, lifestyle factors
 Physical: eyegrounds, cardiovascular and nervous system
 Routine labs: hemoglobin, serum creatinine, glucose, lipid,
and electrolyte levels; urinalysis; EKG
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
What are treatment goals for patients with
hypertension?
 Goal: <140/90mmHg in patients with hypertension
 Guidelines for Blood Pressure Goals from JNC 7
 <140/90mmHg if <60 years old
 <150/90mmHg if ≥60 years old
 Kidney Disease Improving Global Outcomes (KDGO)
 130/80mmHg for patients with CKD
 <130/80mmHg if excreting >30 mg urine albumin/d
 AHA/ACC
 <140/90mmHg
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
What are the recommended lifestyle
modifications for treating hypertension?
 Salt restriction
 Weight loss (to <20% above ideal weight for height)
 Exercise (≥30 minutes aerobic exercise most days)
 Smoking cessation
 Alcohol intake limited to no more than 2 drinks daily
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
When is antihypertensive drug therapy
indicated, and which drugs should
clinicians prescribe as initial therapy?
Drug treatments for hypertension
 Diuretics (thiazide)
 Reserpine
 ACE-inhibitors
 Central β-agonists
 Angiotensin-receptor
blocker
 Guanethidine
 Potassium-sparing diuretics
 β-blockers
 α-blockers
 Hydralazine
 Direct renin inhibitor
 Calcium-channel blockers
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
How should clinicians modify treatment on
the basis of patient characteristics and
comorbid conditions?
Compelling Indications for Individual Drug Classes
Heart failure: Diuretic, ß-blocker, ACE inhibitor, ARB,
aldosterone antagonist
Postmyocardial infarction: ß-blocker, ACE inhibitor,
aldosterone antagonist
High coronary disease risk: Diuretic, ß-blocker, ACE
inhibitor, ARB + CCB
Diabetes: Diuretic, ß-blocker, ACE inhibitor, ARB, CCB
Chronic kidney disease: ACE inhibitor, ARB
Recurrent stroke prevention: Diuretic, ACE inhibitor
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
What is the role of combination therapies?
 Advantages
 Better adherence
 May cost less for patients than individual prescriptions
 ACE inhibitors or ARBs + hydrochlorothiazide
 Good initial therapy if blood pressure >160/100mmHg
 ACE inhibitors and ARBs + nonhydropyridine CCBs
 Adding ACE inhibitor or ARB avoids edema of amlodipine
monotherapy
 ACE inhibitor-ARB combination therapy
 ACE inhibitor-ARB combinations don’t seem to have
clinical advantages
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
When blood pressure is poorly controlled,
how should clinicians decide among
increasing dose, adding an additional
agent, or switching to another drug class?
 Consider ambulatory blood pressure monitoring
 Ask about co-medication with blood pressure-increasing
drugs
 Ask about excessive alcohol or salt intake
 Reconsider secondary causes of hypertension
 Evaluate medication adherence
 Treat uncontrolled hypertension: use several drugs,
each targeting different disease mechanism
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
Drug therapy for specific disease
mechanisms of hypertension
 Volume overload
 Thiazide; loop diuretic; aldosterone antagonist
 Sympathetic overactivity
 ß-blocker (use to counteract reflex tachycardia from
vasodilators or in heart failure)
 Increased vascular resistance
 ACE inhibitor or ARB (use in heart failure)
 Smooth-muscle contraction
 Dihydropyridine CCBs; ß-blocker; hydralazine
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
How often should patients with hypertension
be seen?
 Stable, well-controlled hypertension
 Recheck at 6- to 12-month intervals
 Blood pressure 140/90 to 159/99mmHg
 Recheck at 2 months intervals
 Blood pressure ≥160100mmHg
 Recheck at ≤1 month intervals
 After adjusting medications: allow 2-4 weeks for blood
pressure to stabilize
 Lab testing: intervals depend on number and type of
medications and medical comorbidity
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
What is the value of home blood pressure
monitoring?
 Inexpensive way to monitor blood pressure
 Especially before and after changing therapy
 More accurate than in-office measurement
 Instruct on correct technique
 Have patient chart blood pressure once or twice per day
 Brachial artery blood pressure cuff measurements more
accurate than wrist cuff measurements
 Helps confirm diagnosis in untreated patient
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
When should clinicians consider
hospitalization?
Situations in which severe hypertension constitutes crisis
 Cardiovascular
 Left-ventricular failure; myocardial infarction
 Unstable angina; aortic dissection
 After vascular surgery or coronary artery bypass grafting
 Neurologic
 Hypertensive encephalopathy; thrombotic stroke
 Subarachnoid or intracranial hemorrhage
 Other
 Severe catecholamine excess
 Eclampsia in pregnancy
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
When should clinicians consider referral to
a hypertension specialist?
 Drug-resistant hypertension uncontrolled with ≥3 drugs
 Uncertainty about how to evaluate or manage suspected
secondary hypertension
 Need for assistance assessing target organ damage
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
How should clinicians distinguish between
a hypertensive emergency and a
pseudocrisis?
 Hypertensive urgency
 Blood pressure >180/110mmHg w/o target organ damage
 Patients can usually be managed with oral medications
 Usually sent home after a few hours of observation
 Hypertensive emergency
 Elevated blood pressure with impending or acute
progressive target organ damage
 Usually requires admission to ICU and IV medication
 Several drugs available to decrease blood pressure quickly
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.
CLINICAL BOTTOM LINE: Treatment...
 Blood pressure goal if patient <60y: <140/90 mmHg
 Blood pressure goal if patient >60y: <150/90 mmHg
 Lifestyle modifications can decrease blood pressure
 Most patients also need at least 1 drug to reach goal
 Severe hypertension requires urgent treatment if:
 Acute cardiovascular or neurologic events are present
 Patient is pregnant
 Severe catecholamine excess is present
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (6): ITC6-1.