Update on the Management of Hypertension
Update on the Management of Hypertension
Progress continues on the management of hypertension. This paper reviews issues related to detection, confirmation, evaluation, and lifestyle management of hypertension. Ways to improve blood pressure control are discussed.
As the 21st century unfolds, hypertension remains a challenging medical problem. Hypertension continues to be a common reason for office, urgent care center, and emergency department visits. Yet many persons are unaware that they have hypertension, and most of those with hypertension do not have their blood pressure under control. This suboptimal control puts a tremendous burden on the health and welfare of individuals and the population, and is a source of frustration for patients and physicians. What can be done to improve the management of hypertension? This review addresses that question.
An active and aggressive blood pressure screening program has been in place for many years. Despite the many opportunities for people to have their blood pressures checked, many persons never have their blood pressure checked until they experience a cardiovascular event. What can be done to increase the detection rate? Since the prevalence of hypertension is so high, we need to use an approach that involves checking the blood pressure of most, if not all, citizens. In addition, more education might be beneficial. High school students should be instructed on the importance of checking blood pressure. Even with intensive education not everyone will have his or her blood pressure checked, so mandatory blood pressure measurement could be linked to some other activity such as driver's license renewal.
Once an elevated blood pressure is found, the diagnosis of hypertension needs to be confirmed. Patients with normal blood pressure will occasionally have an elevated reading, for example, during periods of stress. A few in- or out-of-office measurements should confirm the diagnosis. It should be pointed out that the bar is set lower for the diagnosis of hypertension based on out-of-office readings, since an out of office blood pressure of approximately 135/85 mm Hg is believed to be equivalent to an office blood pressure of 140/90 mm Hg. Therefore, as an example, a patient with out-of-office blood pressures averaging 138/88 mm Hg should be considered hypertensive. For most cases of hypertension, an ambulatory blood pressure monitor is not needed.
It should be noted that office, or white coat, hypertension carries some risk. Patients with white coat hypertension have a higher rate of hypertension-related problems and need to be followed. Often patients and their physicians minimize the elevated blood pressures, and many patients thought to have white coat hypertension are true hypertensives or at least have blood pressures higher than optimal for their cardiovascular risk profile.
The most recent report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure was published in 2003. In that report blood pressure has been reclassified. Normal blood pressure is considered to be <120/80 mm Hg and hypertension is >140/90 mm Hg. "Prehypertension" is a new term for blood pressures of 120-140/80-90 mm Hg. Patients with this level of blood pressure are very likely to develop hypertension later in life, should not be lost to follow-up, and should be instructed on lifestyle measures.
Once hypertension is confirmed, patients should be advised that they likely have a lifetime problem that requires regular follow-up and management. Appropriate follow-up will be necessary to ensure proper management. All along the management path, physicians should work to encourage compliance. Measures such as family education, ready access, and expense reduction will help. Family members need to know the patient's condition and what is expected. They can help encourage compliance. Ready access to a nurse, either by phone, e-mail, or face-to-face visit can help with management. Prescribing generic medications and limiting tests can reduce expenses.
Physicians should proceed with a focused history and physical exam. The history should evaluate duration of hypertension, associated symptoms, possible comorbidities such as cardiovascular and renal disease, family history, lifestyle, medications (including blood pressure-raising medications, such as nonsteroidal anti-inflammatory drugs and sympathomimetics), and previous treatments. The physical exam should focus on the retinae, heart, lungs, vessels, abdomen, and extremities. Tests are likely to be normal since the vast majority of patients with hypertension have essential hypertension. Even the most severe cases of hypertension are usually essential hypertension, so expenses can be reduced by discreetly ordering tests. Since significant renal disease can be asymptomatic, measurement of serum creatinine and a urinalysis are helpful. Identification of hypokalemia can lead to a diagnosis of secondary hypertension. Identification of hyperlipidemia and diabetes mellitus, important comorbidities, can be done with measurements of fasting lipids and glucose. Electrocardiograms and chest x-rays are helpful when the patient has cardiopulmonary symptoms, but when the patient is asymptomatic these tests add unneeded expense. Specialized tests, like renal ultrasound looking for renal artery disease, should be used judiciously. Although renovascular hypertension due to fibromuscular disease will respond well to angioplasty, treatment of atherosclerotic renovascular disease is often less successful and associated with morbidity. Pheochromocytoma is rare. Patients with episodic hypertension, spells, flushing, and/or headaches are much more likely to be experiencing stress or panic attacks or some other condition rather than pheochromocytoma. A revision in the thinking about evaluation of hypertension is the recognition that there are probably more cases of primary aldosteronism than once thought. The use of simultaneous measurements of serum aldosterone and plasma renin activity as a screening device has discovered more cases. Using screening criteria of suppressed renin activity along with elevated aldosterone to renin ratio, some studies have estimated a prevalence of primary aldosteronism of 10% of hypertensives. Importantly, blood pressure can often be significantly improved with treatment in patients with primary aldosteronism.
Hypertension management is a two-pronged approach, with emphasis on lifestyle measures and drug management. Treatment is successful when multiple factors in the patient's life are addressed, including stress, diet, physical activity, and insurance issues.
Lifestyle measures, although uncommonly successful alone in controlling blood pressure, are a critical step of the process. A low-sodium diet, when studied, has had variable effects. An important study was the National Cholesterol Education Program Dietary Approaches to Stop Hypertension (DASH) study, which showed that a diet low in sodium and high in fruits, vegetables, and calcium is helpful in treating hypertension. Alcohol intake should be moderated. Studies clearly show that more than 1 oz a day in men and a ½ oz a day in women will raise blood pressure. A reduction in alcohol intake is one of the quickest ways to lower blood pressure. The epidemic of obesity will have an effect on the prevalence and management of hypertension. Exercise is critically important, especially in children and young adults with hypertension who often have heightened sympathetic nervous system activity. Patients with hypertension often feel stressed, and the stress probably aggravates their blood pressure. Better ways are needed to address the stress that hypertensive patients experience.
Efforts to improve hypertension management are ongoing and important. The effects of poorly managed hypertension are far reaching. More efforts are need to improve the blood pressure of the population.
The article, "Update on the Management of Hypertension: Initial Evaluation and Lifestyle Interventions for Patients With Hypertension" originally appeared in the March 1998 issue of CVR&R (CVR&R. 1998;19:26, 29, 30, 33). Full text of this article is available at www.lejacq.com.
Progress continues on the management of hypertension. This paper reviews issues related to detection, confirmation, evaluation, and lifestyle management of hypertension. Ways to improve blood pressure control are discussed.
As the 21st century unfolds, hypertension remains a challenging medical problem. Hypertension continues to be a common reason for office, urgent care center, and emergency department visits. Yet many persons are unaware that they have hypertension, and most of those with hypertension do not have their blood pressure under control. This suboptimal control puts a tremendous burden on the health and welfare of individuals and the population, and is a source of frustration for patients and physicians. What can be done to improve the management of hypertension? This review addresses that question.
An active and aggressive blood pressure screening program has been in place for many years. Despite the many opportunities for people to have their blood pressures checked, many persons never have their blood pressure checked until they experience a cardiovascular event. What can be done to increase the detection rate? Since the prevalence of hypertension is so high, we need to use an approach that involves checking the blood pressure of most, if not all, citizens. In addition, more education might be beneficial. High school students should be instructed on the importance of checking blood pressure. Even with intensive education not everyone will have his or her blood pressure checked, so mandatory blood pressure measurement could be linked to some other activity such as driver's license renewal.
Once an elevated blood pressure is found, the diagnosis of hypertension needs to be confirmed. Patients with normal blood pressure will occasionally have an elevated reading, for example, during periods of stress. A few in- or out-of-office measurements should confirm the diagnosis. It should be pointed out that the bar is set lower for the diagnosis of hypertension based on out-of-office readings, since an out of office blood pressure of approximately 135/85 mm Hg is believed to be equivalent to an office blood pressure of 140/90 mm Hg. Therefore, as an example, a patient with out-of-office blood pressures averaging 138/88 mm Hg should be considered hypertensive. For most cases of hypertension, an ambulatory blood pressure monitor is not needed.
It should be noted that office, or white coat, hypertension carries some risk. Patients with white coat hypertension have a higher rate of hypertension-related problems and need to be followed. Often patients and their physicians minimize the elevated blood pressures, and many patients thought to have white coat hypertension are true hypertensives or at least have blood pressures higher than optimal for their cardiovascular risk profile.
The most recent report of the Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure was published in 2003. In that report blood pressure has been reclassified. Normal blood pressure is considered to be <120/80 mm Hg and hypertension is >140/90 mm Hg. "Prehypertension" is a new term for blood pressures of 120-140/80-90 mm Hg. Patients with this level of blood pressure are very likely to develop hypertension later in life, should not be lost to follow-up, and should be instructed on lifestyle measures.
Once hypertension is confirmed, patients should be advised that they likely have a lifetime problem that requires regular follow-up and management. Appropriate follow-up will be necessary to ensure proper management. All along the management path, physicians should work to encourage compliance. Measures such as family education, ready access, and expense reduction will help. Family members need to know the patient's condition and what is expected. They can help encourage compliance. Ready access to a nurse, either by phone, e-mail, or face-to-face visit can help with management. Prescribing generic medications and limiting tests can reduce expenses.
Physicians should proceed with a focused history and physical exam. The history should evaluate duration of hypertension, associated symptoms, possible comorbidities such as cardiovascular and renal disease, family history, lifestyle, medications (including blood pressure-raising medications, such as nonsteroidal anti-inflammatory drugs and sympathomimetics), and previous treatments. The physical exam should focus on the retinae, heart, lungs, vessels, abdomen, and extremities. Tests are likely to be normal since the vast majority of patients with hypertension have essential hypertension. Even the most severe cases of hypertension are usually essential hypertension, so expenses can be reduced by discreetly ordering tests. Since significant renal disease can be asymptomatic, measurement of serum creatinine and a urinalysis are helpful. Identification of hypokalemia can lead to a diagnosis of secondary hypertension. Identification of hyperlipidemia and diabetes mellitus, important comorbidities, can be done with measurements of fasting lipids and glucose. Electrocardiograms and chest x-rays are helpful when the patient has cardiopulmonary symptoms, but when the patient is asymptomatic these tests add unneeded expense. Specialized tests, like renal ultrasound looking for renal artery disease, should be used judiciously. Although renovascular hypertension due to fibromuscular disease will respond well to angioplasty, treatment of atherosclerotic renovascular disease is often less successful and associated with morbidity. Pheochromocytoma is rare. Patients with episodic hypertension, spells, flushing, and/or headaches are much more likely to be experiencing stress or panic attacks or some other condition rather than pheochromocytoma. A revision in the thinking about evaluation of hypertension is the recognition that there are probably more cases of primary aldosteronism than once thought. The use of simultaneous measurements of serum aldosterone and plasma renin activity as a screening device has discovered more cases. Using screening criteria of suppressed renin activity along with elevated aldosterone to renin ratio, some studies have estimated a prevalence of primary aldosteronism of 10% of hypertensives. Importantly, blood pressure can often be significantly improved with treatment in patients with primary aldosteronism.
Hypertension management is a two-pronged approach, with emphasis on lifestyle measures and drug management. Treatment is successful when multiple factors in the patient's life are addressed, including stress, diet, physical activity, and insurance issues.
Lifestyle measures, although uncommonly successful alone in controlling blood pressure, are a critical step of the process. A low-sodium diet, when studied, has had variable effects. An important study was the National Cholesterol Education Program Dietary Approaches to Stop Hypertension (DASH) study, which showed that a diet low in sodium and high in fruits, vegetables, and calcium is helpful in treating hypertension. Alcohol intake should be moderated. Studies clearly show that more than 1 oz a day in men and a ½ oz a day in women will raise blood pressure. A reduction in alcohol intake is one of the quickest ways to lower blood pressure. The epidemic of obesity will have an effect on the prevalence and management of hypertension. Exercise is critically important, especially in children and young adults with hypertension who often have heightened sympathetic nervous system activity. Patients with hypertension often feel stressed, and the stress probably aggravates their blood pressure. Better ways are needed to address the stress that hypertensive patients experience.
Efforts to improve hypertension management are ongoing and important. The effects of poorly managed hypertension are far reaching. More efforts are need to improve the blood pressure of the population.
The article, "Update on the Management of Hypertension: Initial Evaluation and Lifestyle Interventions for Patients With Hypertension" originally appeared in the March 1998 issue of CVR&R (CVR&R. 1998;19:26, 29, 30, 33). Full text of this article is available at www.lejacq.com.