Clinical History

Attention should be directed to common associates of hypertension, such as diabetes mellitus, dyslipidaemia and renal disease, as well as a past history of complications associated with hypertension. In women who present with hypertension, the obstetric history should be ascertained, including use of oral contraceptives, previous pre-eclampsia or pregnancy-induced hypertension (Table 6.1).

Family history

Many patients with essential hypertension report a family history of hypertension. Any family history of coronary or cerebrovascular disease or premature vascular death should be determined, as this may help assess the patient’s cardiovascular risk profile. Younger patients with hypertension and absolutely no family history need detailed investigations to detect possible underlying renal, renovascular and adrenal causes of hypertension that are not familial. A family history of disease that may cause hypertension, such as autosomal dominant polycystic kidney disease, should be ascertained.

Drug history

Current or previous use of antihypertensive drugs should be assessed. Some drugs, such as oral contraceptives, may exacerbate hypertension. Drugs that cause sodium retention can exacerbate or impede control of hypertension and heart failure. Others may interact with antihypertensive drugs – for example, the effects of angiotensin-converting enzyme inhibitors may be attenuated by non-steroidal anti-inflammatory drugs (Table 6.2).

Social history

The social history should include risk factors for hypertension and cardiovascular disease, such as high intake of alcohol, high consumption of salt and fat, lack of exercise and smoking history. Some patients may report stressful lifestyles and domestic stress. Somewhat surprisingly, smoking is less common in patients with hypertension than the general population, but, when present, it greatly increases the risk of heart attack or stroke. The only exceptions are in patients with malignant hypertension and renal artery stenosis, which are closely associated with cigarette smoking (Table 6.2).

Physical examination

Physical examination of patients with hypertension should assess the causes and seek evidence of target organ damage (e.g. in the brain, heart, kidneys and peripheral arteries). Cardiovascular risk factors and complications that may influence management should also be assessed. Height and weight should be measured so that body mass index (weight (kg)/(height (m)²)) can be calculated to measure obesity. Body weight should be checked at every clinic visit.

Blood pressure should be measured as accurately as possible (see Chapter 4). Current guidelines recommend that it is measured routinely in all adults at least every 5 years. It should be measured annually in patients with high-normal blood pressure (systolic 130–139 mm Hg; diastolic 85–89 mm Hg) and those with previously high readings that have settled. More frequent readings should also be taken in those with existing cardiovascular disease and/or diabetes mellitus. Recent interest has been directed towards BP variability as a predictor of complications from hypertension. In one analysis, visit-to-visit variability in SBP and maximum SBP are strong predictors of stroke, independent of mean SBP. Increased residual variability in SBP in patients with treated hypertension is associated with a high risk of vascular events (Figure 6.2)