Management of Hypertension: Diagnosis, Evaluation, When to Treat and Non-Pharmacological Therapy

Ari Kostadaras, M.D.

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Accurate measurement of Blood Pressure (BP)

• Use a mercury manometer
• Use a larger cuff for larger people or you will get an incorrectly high reading
• BP should be taken at least once in both arms and the higher pressure used

Formal diagnosis of hypertension

• If initial BP is high in someone not previously known to have hypertension, then at least two further readings should be taken during that same session
• If BP is mildly elevated but the patient does not require treatment (i.e. they do not have target organ damage) then BP should be measured at least twice on each of at least 3 occasions over a period of 6 months
• If the diastolic BP is elevated on some occasions but not others, reassess yearly. These patients should not be told that they have hypertension

Evaluation of the patient with confirmed hypertension:

1. Is it primary or secondary (i.e. reversible) hypertension?
2. Is there target organ damage? If so, then treatment should be more aggressive
3. Are there other risk factors for cardiovascular disease? This can influence the decision to treat in borderline cases.

What is Target Organ Damage?

1. LVH with strain seen on ECG
2. history or symptoms of angina
3. history or ECG evidence of myocardial infarction
4. history of stroke or TIA
5. evidence of peripheral vascular disease
6. serum creatinine level >150µmol/L

Risk Factors for Cardiovascular Disease

• cigarette smoking
• diabetes
• male sex
• family history of premature coronary heart disease
• cholesterol levels (total and high-density lipoprotein)

Recommended investigations for newly diagnosed hypertensives and the reason(s) for the test:

Test:	Looking For:
Potassium	Baseline for treatment; screen for adrenal hypertension (rare)
Blood sugar	Screen for diabetes; as a cardiovascular risk factor will influence the choice of drugs
Creatinine	Target organ damage; screen for renal cause for hypertension. May influence drug choice
Uric acid	Thiazide diuretics should be avoided in patients with gout
Cholesterol	Cardiovascular risk factor; may influence choice of drugs
Urinalysis	Target organ damage; screen for renal cause for hypertension
EKG	Target organ damage; baseline
CBC	? (Often ordered, but not usually helpful

Non-pharmacological therapy:

Treatment should always start with lifestyle modification

• weight loss
• regular moderate aerobic activity
• reduce alcohol intake
• reduce dietary salt intake
• review concomitant medications for interactions (including OTC agents used) e.g. NSAIDs, oral contraceptives, cough and cold preparations, diet pills, stimulants for fatigue

Effectiveness of Life-style modifications

• In recent studies 50 - 70% of patients with mild hypertension receiving placebo and nutritional information did not require the addition of drug therapy to control their blood pressure

Drug Treatment:

a) Complicated Hypertension

Conditions which commonly "complicate" the treatment decision in hypertension include heart disease (angina, heart failure, recent myocardial infarction), diabetes peripheral vascular disease, renal disease, gout, dyslipidemias, and asthma. More information on suggested drugs can be found in "Pharmacological Treatment of Hypertension with Co-existing Conditions"

b) Uncomplicated Hypertension

Almost 70% of adults who report themselves to be hypertensive are free of complicating conditions and in most cases, their initial drug therapy should be a low dose diuretic or beta blocker. Diuretics are the first choice in those aged 65 to 80.

Why are diurectics and beta blockers recommended for the treatment of hypertension in otherwise healthy patients?

1. Long term treatment of hypertension with diuretics has been shown to decrease the incidence of stroke and coronary events.
2. Studies currently available have not shown that ACE inhibitors and calcium antagonists are any better than diuretics and/or beta blockers at reducing the morbidity and mortality caused by hypertension.
3. Recent studies have shown no significant difference in quality of life indices between patients taking diuretics and/or beta blockers as compared to those taking calcium antagonists and/or ACE inhibitors.

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This information sheet is intended to provide assistance in examining, diagnosisng and treating the patient. The indications and dosages of drugs and recommendations for diagnostic tests and treatments are based on the best available evidence at the time of publication. The package insert for each drug should be consulted for approved use and dosage. Because standards change, it is advisable to keep abreast of revised recommendations, particularly those concerning new drugs.

References

1. Haynes RB, Lacourciere Y, Rabkin SW et al. Report of the Canadian Hypertension Society Consensus Conference: 2. Diagnosis of hypertension in adults. Can Med Assoc J 1993;149(4):409-418.
2. Neaton JD, Grimm RH, Prineas RJ et al. Treatment of Mild Hypertension Study (TOMHS). JAMA 1993;270(6):713-724.

Other references

• Hypertension Detection and Follow-up Program Cooperative Group: Persistence of reduction in blood pressure and mortality of participants in the hypertension detection and follow-up program. JAMA 1988;259:2113-2122.
• Prisant LM, Carr AA, Bottini PB et al. Sexual dysfunction with antihypertensive drugs. Arch Intern Med 1994;154:730-736.
• Dahlof B, Lindholm LH, Hanson L et al. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). Lancet 1991;338:1281-1285.

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