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HYPERTENSION: DIAGNOSIS
Stephen Huot, MD, PhD
Week 1
Educational Objectives:
1. Describe and demonstrate proper technique for measuring blood pressure in
adults with average and with large arm circumference
2. Describe how to establish the diagnosis of hypertension
3. Discuss initial treatment strategies, lifestyle and medication, for patients with
essential hypertension
CASE ONE:
A 51-year-old woman who works as a high school teacher is seen in the office for
follow-up of a high blood pressure reading that was obtained by the nurse at the
school when she was recently evaluated for nasal congestion. She recalls that her
blood pressure reading from the nurse was 166/94 mmHg the first time she had it
checked and then 164/90 one week later. She does not recall being previously told at
physician office visits that she had elevated blood pressure. She feels that her blood
pressure was elevated because of her cold and the over-the-counter cold medications
that she was taking at the time. Her cold has since resolved. She does not take any
prescription medications and she only occasionally takes acetaminophen or
ibuprofen for rare headaches or for musculoskeletal aches. She denies severe
headaches, change in vision, exertional shortness of breath, chest pains, or swelling
of the ankles. She reports that she is not physically active and that over the last 10
years she has gained 25 lbs. She describes her diet as having no specific restrictions
though she tries to avoid foods high in saturated fats and eats out on average once
per week. Her parents are alive and generally in good health. Both take medication
for high blood pressure and high cholesterol. She has never smoked cigarettes,
drinks zero to two glasses of red or white wine with dinner, enjoys her job, and
describes her home life with her husband and three children as a source of
enjoyment and support.
Questions:
1. Describe an appropriately focused physical exam and recommended initial
laboratory data to obtain for this patient.
Residents should describe a focused physical exam that assesses for signs of endorgan damage and that describes measuring the blood pressure in both arms
seated and in one arm also in the standing position. The physical exam should
include the patient’s height, weight, and BMI, examination of the retina,
Hypertension. Yale Office-based Medicine Curriculum, Seventh Edition, Volume 1, 2009.
pulmonary, and cardiovascular systems including carotid, femoral, and distal
lower extremity pulses, and examination of the lower extremities for peripheral
edema and examination of the abdomen for pulsatile mass or bruit. Have
residents list the organs at risk of “end-organ” damage due to high blood
pressure [retina, kidneys, heart (coronary artery disease, congestive heart
failure), cerebral vascular disease, peripheral vascular disease].
Initial laboratory data should include what is needed to assess for other risk
factors for CAD, a possible secondary cause of hypertension (e.g., unsuspected
chronic kidney disease or hypokalemia as in hyperaldosteronism) or a condition
that may warrant consideration in selecting an initial medication (e.g., diabetes
mellitus or left ventricular hypertrophy) and long-term assessment for end-organ
damage (e.g., EKG for conduction system abnormality and GFR for chronic
kidney damage). Baseline tests for all patients with suspected essential
hypertension include electrolytes, BUN, creatinine, fasting glucose, CBC,
urinalysis or spot urine albumin:creatinine ratio, EKG, calcium, and fasting lipid
profile.
2. Demonstrate, on a colleague, the correct seated blood pressure measurement
technique.
Ask if residents have watched the New England Journal of Medicine blood
pressure measurement technique video. If not, recommend that they do. In the
meantime, use the print version of this clinical skills video to explain proper
technique. Have students who are serving as the “patient” provide feedback
about the comfort and overall technique used by their colleague.
CASE ONE CONTINUED:
The patient’s average seated blood pressure reading at today’s visit is 160/92
mmHg, and there is no significant difference in either arm or when standing. Her
BMI is 29, and the remainder of the physical examination is normal. Laboratory
data reveals no abnormalities.
3. Does this patient have high blood pressure, and what are your
recommendations regarding lifestyle interventions to improve her blood
pressure and to lower her risk of cardiovascular disease? What questions
should you ask the patient?
This patient has documented elevated blood pressure on at least three occasions
by medical professionals separated in time. She meets criteria for stage 2
hypertension (Table 1). Lifestyle recommendations should address sodium intake,
calorie intake and weight goal, activity level, and stress management. In this
patient, you should ask for a diet recall history to estimate sodium intake, snack
pattern, food distribution between vegetables, fruit, other carbohydrates, protein,
Hypertension. Yale Office-based Medicine Curriculum, Seventh Edition, Volume 1, 2009.
and fat, including saturated fat. Patients should be instructed in how to read food
labels and what goals to aim for in each of the aforementioned categories.
Sodium intake, for example, should be calculated in milligrams with a goal of less
that either 2500 or 2000 mg depending on your goal for the patient and the
reality of their food/seasoning preferences. It is also important to ask if the
patient is the person in the home who shops for food and who is the primary cook
– if the patient has a partner it is helpful to provide written materials and, when
possible, discuss nutrition goals in the presence of the partner. It would also be
appropriate to refer the patient to a nutritionist if they can afford this
consultation. See table 5.
4. Would you recommend initiating pharmacological treatment at this visit? If
not, explain your rationale and what your timeline is for making a decision
about initiating medications. If you would start medication at this visit, state
which one(s) and why you would make that recommendation.
This patient has stage 2 hypertension and initiating medication therapy is
indicated unless the patient is unwilling or unable to do so. If the patient wishes
to attempt lifestyle interventions before initiating medication it is important to
arrange for close follow-up with specific lifestyle goals both in term of changes in
diet and activity, as well as what outcomes will be used to determine whether or
not a medication will be indicated at future visits. The specific outcome that is
most important for a future decision about medication initiation is the blood
pressure itself.
If blood pressure is elevated despite successful lifestyle changes, then medication
is still indicated. In addition, it is important to set time goals for achieving
success with lifestyle interventions, such as a three-month period of time. It can
also be negotiated to initiate a blood pressure lowering medication with the goal
of tapering off the medication if the patient is successful with lifestyle changes to
see if the medication is still needed, although this is challenging for many patients
to accomplish. If the medicine is eventually tapered off, it is important to inform
the patient that it can take three to six weeks after stopping some blood pressure
medications in patients with well-controlled hypertension before one can be
certain that the blood pressure will not increase off of the medications.
Based on our knowledge of this patient’s history, physical exam, and laboratory
data, there is no specific reason to choose one particular medication. Reviewing
the first-line medication options and their potential side effects with this patient is
important in finding a treatment strategy that the patient will buy into and be able
to adhere to on a chronic basis. For example, we will be recommending
increased physical activity and weight loss, and there is no indication that a beta
blocker would be indicated because of a co-morbid condition – this medication
then is one where the physician might indicate that they believe this is not the
optimal choice because of potential impact on energy level and exercise
tolerance.
Hypertension. Yale Office-based Medicine Curriculum, Seventh Edition, Volume 1, 2009.
In addition, there is concern about efficacy of beta-blockers compared to calcium
channel blockers, renin-angiotensin system inhibitors, and diuretics as first line
therapy for patients with essential hypertension. A 2007 Cochrane review
concludes:
“The available evidence does not support the use of beta-blockers as
first-line drugs in the treatment of hypertension. This conclusion is
based on the relatively weak effect of beta-blockers to reduce stroke and
the absence of an effect on coronary heart disease when compared to
placebo or no treatment. More importantly, it is based on the trend
towards worse outcomes in comparison with calcium channel blockers,
renin-angiotensin system inhibitors, and thiazide diuretics. Most of the
evidence for these conclusions comes from trials where atenolol was the
beta-blocker used (75% of beta-blocker participants in this review).
However, it is not known at present whether beta-blockers have
differential effects on younger and elderly patients or whether there are
differences between the different sub-types of beta-blockers.”(Wiysonge,
2007)
Have residents offer first line medication options and when doing so ask them to
explain why they chose this medication, its mechanism of action, its most common
side effects, and when they expect a blood pressure lowering effect to start and to
plateau, when they will see the patient in follow up and whether or not they will
check any lab data because of the medication choice and if so, when and which
labs. This patient has stage 2 hypertension so it would be appropriate to
recommend initiation of therapy with two medications. One recent study found
that starting with one pill with two fixed dose agents helped patients to reach
blood pressure goals faster (Feldman, 2009), however, the tradeoff would likely
be loss of flexibility in adjusting each medicine and the need to be vigilant about
side effects. If the physician is uncomfortable starting with two medications, the
patient should be instructed that because of the level of her blood pressure, it is
unlikely that one medication will bring her hypertension under control and that it
is anticipated that an additional medication will need to be added at future visits.
This is also an opportunity to discuss that lower doses of two complimentary
medications (e.g., a diuretic plus an ACE inhibitor) are synergistic and can
improve the efficacy of either medication alone.
5. Would you recommend that this patient obtain a home blood pressure
monitor and if so, why, what type, and how would you instruct her to use the
equipment?
Home blood pressure monitors can help patients engage in the management of
hypertension as a chronic disease. Some evidence suggests that patients who
monitor at home may achieve somewhat lower blood pressures. (Cappucino,
2004) Goal blood pressure with a home monitor is lower than office blood
pressures and for patients without renal disease or other co-morbidities is 135/85
mmHg. Patients should be instructed to obtain an upper arm rather than wrist
Hypertension. Yale Office-based Medicine Curriculum, Seventh Edition, Volume 1, 2009.
blood pressure monitor, and they must be instructed in the appropriate cuff size to
obtain with their monitor (i.e., regular v. large adult cuff). They should purchase
an automated “push button” machine, and they should bring their equipment to
the office periodically to assess for accuracy of the machine and accuracy of
patient technique.
Patient technique is the same as for physicians – the patient should avoid caffeine
and tobacco products for at least one hour before measuring their blood
pressure; they should sit in a chair with a solid back support and wait four to five
minutes before taking a measurement; feet should be flat on the floor and the nondominant arm resting on a desk or table close to heart height; blood pressure and
pulse rate should be recorded. If the patient obtains a number that they feel is too
high or too low, they should record the value they obtained and wait two to three
minutes and then repeat and record those values as well. Ideally, the patient will
record blood pressure values at different times of the day on different days so that
blood pressure control throughout the day can be assessed.
Primary References:
1. JNC 7 Express. The Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf
2. New England Journal of Medicine Blood Pressure Measurement Video. (length
9:15 minutes) http://content.nejm.org/cgi/video/360/5/e6/
Additional References:
1. Cappuccio FP, Kerry SM, Forbes L, Donald A. Blood pressure control by home
monitoring: meta-analysis of randomized trials. British Medical Journal. 2004.
329(7458):145.
2. Pickering TG. Miller NH. Ogedegbe G et al. Call to action on use and
reimbursement for home blood pressure monitoring: executive summary: a joint
scientific statement from the American Heart Association, American Society of
Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension.
2008. 52:1-9.
3. Feldman RD, Zou GY, Vandervoort MK et al. A simplified approach to the
treatment of uncomplicated hypertension: A cluster randomized, controlled trial.
Hypertension. 2009. 53:646-653.
4. Wiysonge CS, Bradley HA, Mayosi BM, Maroney RT, Mbewu A, Opie L,
Volmink J. Beta-blockers for hypertension. Cochrane Database of Systematic
Reviews. 2009. Issue 2.
Hypertension. Yale Office-based Medicine Curriculum, Seventh Edition, Volume 1, 2009.
Author’s Note:
JNC 8 is anticipated to be released in 2009 or 2010 and will also be available from the
NHLBI website.
Stephen Huot attended medical school at Duke University and completed his residency
and nephrology fellowship at Yale-New Haven Hospital and Yale School of Medicine.
His scholarly interests include graduate medical education, curriculum development,
evaluation of clinical competence, and the impact of team structure on patient care
and learning. Dr. Huot attends on the general medical wards and the nephrology
consult service. He runs a hypertension referral practice and a diabetes disease
management practice.
Hypertension. Yale Office-based Medicine Curriculum, Seventh Edition, Volume 1, 2009.