d.

Diagnosis

I. History. Patients with hypertension should be questioned closely about a

number of personal and family issues. The extent of the diagnostics
evaluation will depend on a number of clinical parameters: (a) the
patient’s family, race and age; (b) the severity of the hypertension; (c) the
likelihood of finding a treatable cause for the hypertension; and (d) the
cost, time and risk of the workup. The majority of the patients with
hypertension present without symptoms referable to their blood pressure.
Elevated levels of the blood pressure in these patients generally are
discovered during a workup for another disease, during routine physical
examination, or during blood pressure screening in community or at work.
Nonetheless, a careful history is important for at least two reasons: (a) to
determine possible curable underlying disease and (b) to assess possible
complications and end organ damage associated with the elevated blood
pressure. Significant items in the history of a hypertensive patient are
listed below:
 II. Physical examination. Most patients with mild and moderate hypertension
have no physical findings referable to their disease early in the course of
the illness. Abnormalities develop with time. Careful physical
examination – with particular emphasis on the cardiovascular system,
fundi and central nervous system – is essential to assess possible end-
organ damage and to look for typical findings of underlying curable
disease. Example: funduscopic, central and peripheral cardiovascular
examination, and abdominal examination.
III. Laboratory test. Many laboratory tests are available, some of which are
costly and may involve risk to the patient a rational sequence of tests
should be developed for each patient based on the likely benefit of each
investigation. The nature and extent of the laboratory investigation will be
suggested by findings in the history and physical examination. General
guidelines are given below:
 (Alpert & Ewy, 2002)

Diagnosis of hypertension algorithm

(BristishColumbia, 2016)
e. Desired outcomes (Goal of treatment)

The overall goal of treating hypertension is to reduce hypertension associated

morbidity and mortality. This morbidity and mortality is related to target-organ
damage (e.g., CV events, heart failure, and kidney disease). Reducing risk remains
the primary purpose of hypertension therapy and the specific choice of drug therapy
is significantly influenced by evidence demonstrating such risk reduction.

Most patients have a goal BP of less than 140/90 mm Hg for the general prevention
of CV events or CV disease (e.g., coronary artery disease).

The most important strategy to prevent CV morbidity and mortality in hypertension

is BP control to goal values. Routine goal BP values should be attained in elderly
patients and in those with isolated systolic hypertension, but actual BP lowering can
occur at a very gradual pace over a period of several months to avoid orthostatic
hypotension. Modifying other CV risk factors (e.g., smoking, dyslipidemia, and
diabetes) is also important.

Clinical monitoring. Routine ongoing monitoring to assess disease progression, the

desired effects of antihypertensive therapy (efficacy), and undesired adverse side
effects (toxicity) is needed in all patients treated with antihypertensive drug therapy.

 Disease Progression: Patients should be monitored for signs and symptoms of

progressive target-organ disease. A careful history for chest pain (or
pressure), palpitations, dizziness, dyspnea, orthopnea, headache, sudden
change in vision, one-sided weakness, slurred speech, and loss of balance
should be taken to assess for the presence of hypertensive complications.
Other clinical monitoring parameters that may be used to assess target-organ
disease include funduscopic changes on eye examination, left ventricular
hypertrophy on electrocardiogram, proteinuria, and changes in kidney
function. These parameters should be monitored periodically because any
sign of deterioration requires immediate assessment and follow up.
 Efficacy: Clinic-based BP monitoring remains the standard for managing
hypertension. BP response should be evaluated 2 to 4 weeks after initiating or
making changes in therapy. Once goal BP values are attained, assuming no
signs or symptoms of acute target-organ disease are present, BP monitoring
can be done every 3 to 6 months.
 Toxicity: Patients should be monitored routinely for adverse drug effect.
Monitoring should typically occur 2 to 4 weeks after starting a new agent or
 dose increases, and then every 6 to 12 months in stable patients. Additional
monitoring may be needed for other concomitant diseases if present (e.g.,
diabetes, dyslipidemia, gout). The occurrence of an adverse drug event may
require dosage reduction or substitution with an alternative antihypertensive
agent (Dipiro, et al., 2008).

f. General approaches to treatment:

I. Non-pharmacological treatment: Lifestyle modifications

Therapeutic lifestyle modifications consisting of non-pharmacologic

approaches to blood pressure reduction should be an active part of all
treatment plans for patients with hypertension. The most widely studied
interventions demonstrating effectiveness include:

 Weight reduction in overweight or obese individuals

 Adoption of a diet rich in potassium and calcium
 Dietary sodium restriction
 Physical activity
 Moderation of alcohol consumption
Implementation of lifestyle modifications successfully lowers blood
pressure, often with results similar to those of therapy with a single
antihypertensive agent.

(Chisholm-Burns, et al., 2008)

Works Cited
Alpert, J. & Ewy, G., 2002. Manual of Cardiovascular Diagnosis and Therapy. 5th ed. USA:
Lippincott Williams & Wilkins.

BristishColumbia, 2016. Hypertension - Diagnosis and Management. [Online]

Available at: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-
resources/bc-guidelines/hypertension
[Accessed 8 April 2017].

Chisholm-Burns, M. et al., 2008. Pharmacotheraphy: Principles & Practice. New York: The
McGraw-Hill Companies, Inc.

Dipiro, J. et al., 2008. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. USA: The
McGraw-Hill Companies, Inc..