Chapter 18

Hypertension

1 How often should you screen for hypertension?

Although there is no absolutely correct answer, all people should be screened roughly every 2 years, starting at the age of 3 years.

2 Define hypertension.

Persistent blood pressure greater than 140/90 mm Hg. Individuals with a systolic blood pressure of 120 to 139 mm Hg or a diastolic pressure of 80 to 89 mm Hg should be considered as prehypertensive. Remember that 145/60 mm Hg is hypertension, as is 115/95 mm Hg (isolated systolic or diastolic hypertension, respectively). Treatment is needed. In grading the severity of hypertension, use the worst number, whether diastolic or systolic. See Table 18-1 for the 2003 Joint National Committee (JNC-7) classification.

TABLE 18-1

2003 JOINT NATIONAL COMMITTEE (JNC-7) HYPERTENSION CLASSIFICATION

SYSTOLIC BP∗ (MM HG)	DIASTOLIC BP∗ (MM HG)	CLASSIFICATION
<120	<80	Normal
120-139	80-89	Prehypertension
140-159	90-99	Stage I hypertension
≥160	≥100	Stage II hypertension

^∗Classification is based on the worst number (e.g., 168/60 mm Hg is considered stage II hypertension even though diastolic pressure is normal).

3 What is the “two-measurement” rule in the diagnosis of hypertension?

The blood pressure should be measured two times on each of two separate office visits before the diagnosis and pharmacologic treatment of hypertension. However, if asked, institute conservative measures (see question 4) and address associated comorbidities (e.g., obesity, diabetes) after the first abnormal measurement. There are a few important exceptions to the “start conservative and remeasure” strategy, however, and more aggressive approaches are gaining favor. Patients with marked blood pressure elevations (generally > 200/120 mm Hg) and acute target-organ damage (e.g., encephalopathy, myocardial infarction (MI), unstable angina, pulmonary edema, stroke) require hospitalization and parenteral drug therapy. Patients with markedly elevated blood pressure but without target organ damage usually do not require hospitalization but should be given immediate combination oral antihypertensive therapy. See question 7 for more details. In pregnant woman, preeclampsia may be the cause of hypertension. Waiting to treat in this setting can have devastating consequences to mother and fetus.

4 What are the conservative (i.e., nonpharmacologic) treatments for hypertension?

Dietary changes (i.e., low salt, low fat, low calorie), reduced smoking and alcohol intake, weight loss, and exercise may each have a positive effect on blood pressure and, in some cases, get the patient back into the normotensive range. For stage I hypertension, it is reasonable to give a 1- to 2-month trial of lifestyle modifications before starting medication. In patients with stage II hypertension or those with diabetes or renal disease, early pharmacologic treatment is often preferred.

5 List the first-line medications for treatment of hypertension.

Thiazide-type diuretics should be used as initial therapy for most patients with hypertension, either alone or in combination with one of the following classes: angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, beta blockers, or calcium channel blockers. Which medication class you should use often depends on the individual patient and his or her other medical problems. In some cases, medications from multiple classes may be needed to reach blood pressure goals.

DRUG CLASS	USE IN PATIENTS WITH:	AVOID IN PATIENTS WITH:
Thiazides	Heart failure, diabetes, high risk for coronary artery disease or stroke, osteoporosis	Gout, electrolyte disturbances (e.g., hyponatremia), pregnancy
Beta blockers	Stable angina, acute coronary syndrome/unstable angina, acute or prior MI, high risk for coronary artery disease, atrial tachycardia/fibrillation, thyrotoxicosis (short-term), essential tremor, migraines	Asthma, chronic obstructive pulmonary disease, heart block, sick sinus syndrome
ACE inhibitors	Heart failure, diabetes, acute coronary syndrome/unstable angina, acute or prior MI, high risk for coronary artery disease or stroke, chronic kidney disease	Pregnancy (and generally women of childbearing age), angioedema, renovascular hypertension (may cause renal failure)
ARBs	Heart failure, diabetes, chronic kidney disease	Pregnancy (and generally women of childbearing age), renovascular hypertension (may cause renal failure)
Calcium channel blockers	Raynaud syndrome, atrial tachyarrhythmias	Heart block, sick sinus syndrome, congestive heart failure (all related to central-acting agents), pregnancy

ACE, Angiotensin-converting enzyme; ARB, angiotensin receptor blocker; MI, myocardial infarction.

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