APPROACH TO THE PATIENT WITH HYPERTENSION - Gordon H.

Williams
DEFINITION Since there is no dividing line between normal and high blood pressure, arbitrary levels have been established to define persons who have an increased risk of developing a morbid cardiovascular event and/or will clearly benefit from medical therapy. These definitions should take into account not only the level of diastolic pressure but also systolic pressure, age, sex, and race. For example, patients with a diastolic pressure greater than 90 mmHg have a significant reduction in morbidity and mortality rate if they receive adequate therapy. These, then, are patients who have hypertension and who should be considered for treatment. The level of systolic pressure is also important in assessing the influence of arterial pressure on cardiovascular morbidity. Males with normal diastolic pressures (<82 mmHg) but elevated systolic pressures (>158 mmHg) have a cardiovascular mortality rate 2.5 times higher than individuals who have similar diastolic pressures but whose systolic pressures clearly are normal (<130 mmHg). A reduction in mortality and morbidity with treatment, specifically in the elderly, has been documented in these patients. This beneficial effect results mainly from a reduction in strokes and occurs in women as well. Other significant factors that modify the influence of blood pressure on the frequency of morbid cardiovascular events are age, race, and sex, with young black males being most adversely affected by hypertension. When hypertension is suspected, blood pressure should be measured at least twice during two separate examinations after the initial screening. In adults, a diastolic pressure below 85 mmHg is considered to be normal; one between 85 and 89 mmHg is high normal; one of 90 to 104 mmHg represents mild hypertension; one of 105 to 114 mmHg represents moderate hypertension; and one of 115 mmHg or greater represents severe hypertension. When the diastolic pressure is below 90 mmHg, a systolic pressure below 140 mmHg indicates normal blood pressure; one between 140 and 159 mmHg indicates borderline isolated systolic hypertension; and one of 160 mmHg or higher indicates isolated systolic hypertension. Increasing use of 12- or 24-h blood pressure monitoring may provide additional useful information in patients who are difficult to classify. However, normal values for this procedure and its usefulness in relation to therapeutic outcomes are not currently known. A

useful classification of hypertension derived from the Joint Committee on Detection, Evaluation, and Treatment of High Blood Pressure is shown in Table 35-1. Arterial pressure fluctuates in most persons, whether they are normotensive or hypertensive. Patients who are classified as having labile hypertension are those who sometimes, but not always, have arterial pressures in the hypertensive range. These patients are often considered to have borderline hypertension. Sustained hypertension can become accelerated or enter a malignant phase, although that is unusual in treated patients. Though a patient with malignant hypertension often has a blood pressure above 200/140, the condition is defined by the presence of papilledema, usually accompanied by retinal hemorrhages and exudates, rather than by the absolute pressure level. Accelerated hypertension is defined as a significant recent increase over previous hypertensive levels associated with evidence of vascular damage on funduscopic examination but without papilledema. PATIENT EVALUATION In evaluating patients with hypertension, the initial history, physical examination, and laboratory tests should be directed at (1) uncovering correctable secondary forms of hypertension (see Chap. 246), (2) establishing a pretreatment baseline, (3) assessing factors that may influence the type of therapy or be changed adversely by therapy, (4) determining if target organ damage is present, and (5) determining whether other risk factors for the development of arteriosclerotic cardiovascular disease are present (see Chap. 242). Ideally, this evaluation also would determine the underlying mechanism(s) in essential hypertension, particularly if such information leads to a more specific therapeutic program. Unfortunately, at present this aspect of the evaluation is limited by lack of knowledge of some of the underlying mechanisms, by uncertainty as to the correct treatment for a distinct subset even if the underlying mechanisms are known, or by the prohibitive cost of defining a subset of hypertensive patients even if specific therapy were available. However, with the accumulation of additional information, this sixth component of the evaluation of patients with hypertension may become increasingly important. Symptoms And Signs Most patients with hypertension have no specific symptoms referable to their blood pressure elevation and are identified only in

the course of a physical examination. When symptoms do bring the patient to the physician, they fall into three categories. They are related to (1) the elevated pressure itself, (2) the hypertensive vascular disease, and (3) the underlying disease, in the case of secondary hypertension. Though popularly considered a symptom of elevated arterial pressure, headache is characteristic only of severe hypertension; most commonly such headaches are localized to the occipital region and are present when the patient awakens in the morning but subside spontaneously after several hours. Other complaints that may be related to elevated blood pressure include dizziness, palpitations, easy fatigability, and impotence. Complaints referable to vascular disease include epistaxis, hematuria, blurring of vision owing to retinal changes, episodes of weakness or dizziness due to transient cerebral ischemia, angina pectoris, and dyspnea due to cardiac failure. Pain due to dissection of the aorta or to a leaking aneurysm is an occasional presenting symptom. Examples of symptoms related to the underlying disease in secondary hypertension are polyuria, polydipsia, and muscle weakness secondary to hypokalemia in patients with primary aldosteronism or weight gain, and emotional lability in patients with Cushing's syndrome. The patient with a pheochromocytoma may present with episodic headaches, palpitations, diaphoresis, and postural dizziness. History A strong family history of hypertension, along with the reported finding of intermittent pressure elevation in the past, favors the diagnosis of essential hypertension. Secondary hypertension often develops before the age of 35 or after 55. A history of use of adrenal steroids or estrogens is of obvious significance. A history of repeated urinary tract infections suggests chronic pyelonephritis, although this condition may occur in the absence of symptoms; nocturia and polydipsia suggest renal or endocrine disease, while trauma to either flank or an episode of acute flank pain may be a clue to the presence of renal injury. A history of weight gain is compatible with Cushing's syndrome, and one of weight loss is compatible with pheochromocytoma. A number of aspects of the history aid in determining whether vascular disease has progressed to a dangerous stage. These include angina pectoris and symptoms of cerebrovascular insufficiency, congestive heart failure, and/or peripheral vascular insufficiency. Other risk factors that should be asked about include cigarette smoking, diabetes mellitus, lipid disorders, and a family history of early deaths due to cardiovascular disease. Finally, aspects of the patient's lifestyle that could contribute to the hypertension or affect its

treatment should be assessed, including diet, physical activity, family status, work, and educational level. Physical Examination The physical examination starts with the patient's general appearance. For instance, are the round face and truncal obesity of Cushing's syndrome present? Is muscular development in the upper extremities out of proportion to that in the lower extremities, suggesting coarctation of the aorta? The next step is to compare the blood pressures and pulses in the two upper extremities and in the supine and standing positions (for at least 2 min). A rise in diastolic pressure when the patient goes from the supine to the standing position is most compatible with essential hypertension; a fall, in the absence of antihypertensive medications, suggests secondary forms of hypertension. The patient's height and weight should be recorded. Detailed examination of the ocular fundi is mandatory, as funduscopic findings provide one of the best indications of the duration of hypertension and of prognosis. A useful guide is the Keith-Wagener-Barker classification of funduscopic changes (Table 35-2); the specific changes in each fundus should be recorded and a grade assigned. Palpation and auscultation of the carotid arteries for evidence of stenosis or occlusion are important; narrowing of a carotid artery may be a manifestation of hypertensive vascular disease, and it also may be a clue to the presence of a renal arterial lesion, since these two lesions may occur together. In examination of the heart and lungs, evidence of left ventricular hypertrophy and cardiac decompensation should be sought. Is there a left ventricular lift? Are third and fourth heart sounds present? Are there pulmonary rales? A third heart sound and pulmonary rales are unusual in uncomplicated hypertension. Their presence suggests ventricular dysfunction. Chest examination also includes a search for extracardiac murmurs and palpable collateral vessels that may result from coarctation of the aorta. The most important part of the abdominal examination is auscultation for bruits originating in stenotic renal arteries. Bruits due to renal arterial narrowing nearly always have a diastolic component or may be continuous and are best heard just to the right or left of the midline above the umbilicus or in the flanks; they are present in many patients with renal artery stenosis due to fibrous dysplasia and in 40 to 50 percent of those with functionally significant stenosis due to arteriosclerosis. The abdomen also should be palpated for an abdominal aneurysm and for the enlarged kidneys of polycystic renal disease. The femoral pulses must be carefully felt, and, if they are decreased and/or delayed in comparison with the radial pulse, the blood pressure in the lower extremities must be measured. Even if the femoral pulse is normal to palpation,

arterial pressure in the lower extremities should be recorded at least once in patients in whom hypertension is discovered before the age of 30 years. Finally, examination of the extremities for edema and a search for evidence of a previous cerebrovascular accident and/or other intracranial pathology should be performed. Laboratory Investigation There is controversy as to what laboratory studies should be performed in patients presenting with hypertension. In general, the disagreement centers on how extensively the patient should be evaluated for secondary forms of hypertension or subsets of essential hypertension. The basic laboratory studies that should be performed in all patients with sustained hypertension are described below (Table 35-3). The secondary studies that should be added if (1) the initial evaluation indicates a form of secondary hypertension and/or (2) arterial pressure is not controlled after initial therapy as discussed in Chap. 246. Renal status is evaluated by assessing the presence of protein, blood, and glucose in the urine and measuring serum creatinine and/or blood urea nitrogen. Microscopic examination of the urine is also helpful. The serum potassium level should be measured both as a screen for mineralocorticoid-induced hypertension and to provide a baseline before diuretic therapy is begun. Other blood chemistry measurements also may be useful, particularly as they often can be ordered as a battery of automated tests at minimal cost to the patient. For example, a blood glucose determination is helpful both because diabetes mellitus may be associated with accelerated arteriosclerosis, renal vascular disease, and diabetic nephropathy in patients with hypertension and because primary aldosteronism, Cushing's syndrome, and pheochromocytoma all may be associated with hyperglycemia. Furthermore, since antihypertensive therapy with diuretics, for example, can raise the blood glucose level, it is important to establish a baseline. The possibility of hypercalcemia also may be investigated. Serum uric acid determination is useful because of the increased incidence of hyperuricemia in patients with renal and essential hypertension and because, as with blood glucose, the level may be raised subsequently by treatment with diuretics. Serum cholesterol, high density lipoprotein cholesterol, and triglycerides may be measured to identify other factors that predispose to the development of arteriosclerosis. An electrocardiogram should be obtained in all cases to permit assessment of cardiac status, particularly if left ventricular hypertrophy is present, and to

provide a baseline. The echocardiogram is more sensitive than either the electrocardiogram or physical examination in determining whether cardiac hypertrophy is present. Thus, in some circumstances, this modality may be a useful addition to the baseline evaluation of a hypertensive patient, particularly as left ventricular hypertrophy is an independent cardiovascular risk factor and its presence suggests the need for vigorous antihypertensive therapy. Furthermore, while a substantial increase in arterial pressure usually correlates with the presence of left ventricular hypertrophy, a mild increase may not. Thus, one cannot use the blood pressure as a surrogate marker for the presence or absence of left ventricular hypertrophy. On the other hand, because of the cost of an echocardiogram and the uncertainty as to whether the resultant information would modify therapy, it is unclear that routine follow-up echocardiograms during therapy are justified. The chest roentgenogram also may be helpful by providing the opportunity to identify aortic dilation or elongation and the rib notching that occurs in coarctation of the aorta. Certain clues from the history, physical examination, and basic laboratory studies may suggest an unusual cause for the hypertension and dictate the need for special studies are outlined in Chap 246. TREATMENT See Chap. 246.