Hypertension Evaluation

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HYPERTENSION EVALUATION
CLASSIFICATION OF BLOOD PRESSURE
Category Systolic BP (mmHg)
Diastolic BP (mmHg)
Normal <120 AND <80
Elevated 120−129 AND <80
Hypertension, Stage 1 130−139 OR 80−89
Hypertension, Stage 2 ≥140 OR ≥90
DIAGNOSTIC WORKUP OF HYPERTENSION

• Assess for identifiable causes of hypertension

• Assess for CVD risk factors and comorbidities

• Evaluate for presence of target organ damage

• Conduct history and physical examination

• Obtain laboratory tests: blood glucose, CBC, lipid profile, serum sodium, potassium, calcium, creatinine, TSH, urinalysis

• Perform ECG

Optional: urinary albumin/creatinine ratio, uric acid, echocardiogram

CAUSES OF HYPERTENSION

• Genetic predisposition

• Overweight/obesity

• Excess sodium intake

• Insufficient potassium intake

• Poor diet

• Physical inactivity

• Excess alcohol consumption

• Drug-induced

— Amphetamines

— Antidepressants

— Caffeine

— Decongestants

— Oral contraceptives

— Herbal supplements

— Recreational drugs

• Secondary to disorders

— Kidney disease

— Renal artery stenosis

— Primary aldosteronism or other mineralocorticoid excess syndromes

— Obstructive sleep apnea

— Pheochromocytoma/paraganglioma

— Cushing's syndrome

— Hypo- or hyperthyroidism

— Aortic coarctation

— Primary hyperparathyroidism

— Congenital adrenal hyperplasia

— Acromegaly

CARDIOVASCULAR DISEASE (CVD) RISK FACTORS
Modifiable risk factors: Relatively-fixed risk factors:

• Cigarette smoking

• Diabetes mellitus

• Dyslipidemia/ hypercholesterolemia

• Overweight/obesity

• Physical inactivity

• Unhealthy diet

• Chronic kidney disease (CKD)

• Family history

• Increased age

• Low socioeconomic/educational status

• Male sex

• Obstructive apnea

• Psychosocial stress

BLOOD PRESSURE MEASUREMENT
Method Notes
In-office A single reading is inadequate for clinical decision-making. Use an average of ≥2 BP readings obtained on ≥2 separate occasions. Potential for “white coat hypertension” and “masked hypertension.”
Ambulatory BP
monitoring (ABPM)
Often used to supplement in-office readings. Monitors obtain BP readings at set intervals, usually over a 24-hr period (while patient performs normal daily activities). Has shown to provide better method to predict long-term CVD outcomes than in-office BPs.
Home BP monitoring (HBPM) Regular self-monitoring by a patient at home or outside clinical setting. Need to verify use of automated validated devices. Use an average of BP readings on ≥2 occasions for clinical decision-making.
CAUSES OF RESISTANT HYPERTENSION*

Inaccurate in-office BP measurements

• “White coat hypertension”

• Obesity

• Physical inactivity

• Excessive sodium or alcohol intake

• Secondary causes of hypertension

• Medication

— Nonadherence

— Drug-induced (eg, NSAIDs, stimulants, sympathomimetics, oral contraceptives)

— Over-the-counter drugs and herbal supplements (eg, licorice, ephedra)

NOTES

Key: CBC = complete blood count; ECG = electrocardiogram; TSH = thyroid-stimulating hormone

*Defined as persistent hypertension despite therapy with 3 antihypertensive medications with complementary mechanisms of action, or controlled hypertension requiring 4 or more antihypertensive medications.

REFERENCES

James PA, Oparil S, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017;HYP.0000000000000065. doi: https://doi.org/10.1161/HYP.0000000000000065.

(Rev. 3/2018)

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