HYPERTENSION   19A

A 56-year-old black man presents to the clinic for a routine physical examination. On arrival, he is noted to have a blood pressure of 160/90 mm Hg, which you verify after he has sat for 20 minutes in the exam room. You look back in his record and see that during his previous two visits, he had blood pressures of 154/91 and 161/89 mm Hg. He denies any symptoms. He also denies any recent caffeine or other stimulant use.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Elevated blood pressure on multiple occasions and after resting; African American ethnicity; no temporary cause

How to think through: Is this patient’s hypertension is likely primary or secondary? What are some causes of secondary hypertension? What prescription and over-the-counter medications and other substances might cause hypertension? (Nonsteroidal antiinflammatory drugs [NSAID], oral contraceptives, sympathomimetics.) What dietary and lifestyle factors will most impact his blood pressure? (Alcohol use, sodium intake.) In the absence of other comorbidities, what would be your first choice antihypertensive agent? Is the patient likely to need more than one medication? (With two of three readings >160 mm Hg, this is stage 2 hypertension; multiple agents will likely be necessary.) How would you assess for end-organ damage? What evidence might you find on cardiac and ophthalmic examination, standard laboratory studies, urinalysis, or electrocardiography (ECG)?

What is the treatment goal for systolic blood pressure in this patient? (<140 mm Hg.) What comorbid medical conditions would lower the treatment goal for systolic blood pressure to 130 mm Hg? (Diabetes, coronary artery disease [CAD], and chronic kidney disease.) If this patient’s blood pressure did not achieve the treatment goal despite therapy with an angiotensin-converting enzyme (ACE) inhibitor, β-blocker, and a calcium channel blocker, would of the patient’s blood pressure be characterized as “resistant hypertension?” (No. Resistant hypertension criteria mandate a regimen of three or more agents, including a diuretic. A thiazide diuretic should generally be the first or second agent.)

HYPERTENSION   19B

What are the essentials of diagnosis and general considerations regarding hypertension?

Essentials of Diagnosis

Usually asymptomatic but headache at awakening and blurry vision in severe hypertension

General Considerations

Common disease of which many patients are not aware, and most do not have good control

More common in African Americans, incidence increases with age

Classified as normal (blood pressure <120/<80 mm Hg), prehypertension (systolic blood pressure [SBP] 120–139 mm Hg or diastolic blood pressure [DBP] 80–89 mm Hg), stage 1 (SBP 140–159 mm Hg or DBP 90–99 mm Hg), or stage 2 (SBP >160 mm Hg or DBP >100 mm Hg)

Severe hypertension is usually caused by parenchymal renal disease, renal artery stenosis, endocrine abnormalities, drug use, or abrupt cessation of antihypertensive medications

Usually there is no identifiable cause of hypertension, although the cause should be searched for

Resistant hypertension is defined as failure to reach blood pressure control in patients adherent to full doses of a three-drug regimen (including a diuretic)

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