What is the clinical impression, diagnosis, and therapeutic management for a patient with hypertension?

Clinical Impression, Diagnosis, and Therapeutic Management of Hypertension

Clinical Impression

Hypertension is diagnosed when blood pressure measurements consistently show systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg on multiple occasions, though elevated BP (systolic 120-139 or diastolic 70-89 mmHg) warrants monitoring and lifestyle intervention. 1

Key Diagnostic Criteria

• Diagnosis requires at least 2 BP measurements per visit across 2-3 separate visits (or single visit if severely elevated with target organ damage) 1
• Hypertension affects approximately 116 million US adults and over 1 billion worldwide 2
• Most patients are asymptomatic, making systematic BP monitoring essential 1

Initial Assessment Components

• Measure BP using standardized technique with validated devices 1
• Calculate 10-year cardiovascular disease risk using appropriate risk calculators 3
• Screen for target organ damage: electrocardiographic or echocardiographic left ventricular hypertrophy, carotid artery wall thickening, increased arterial stiffness, elevated serum creatinine, reduced glomerular filtration rate, microalbuminuria 1
• Identify cardiovascular risk factors: diabetes, dyslipidemia, smoking, obesity, family history 1
• Evaluate for secondary causes if clinically indicated (young age, severe/resistant hypertension, sudden onset) 4

Required Laboratory Evaluation

• Urine strip test for blood and protein 3
• Blood electrolytes and creatinine 3
• Fasting blood glucose 3
• Serum total:HDL cholesterol ratio 3
• 12-lead electrocardiograph 3

Diagnosis

Blood Pressure Classification

• Normal: <120/80 mmHg 1
• Elevated BP: Systolic 120-139 or diastolic 70-89 mmHg 1
• Stage 1 Hypertension: Systolic 140-159 or diastolic 90-99 mmHg 3
• Stage 2 Hypertension: Systolic ≥160 or diastolic ≥100 mmHg 1
• Hypertensive Crisis: Systolic >180 or diastolic >120 mmHg 5

Risk Stratification

High/very high risk patients include those with: 1

• BP ≥180/110 mmHg
• Diabetes mellitus
• Metabolic syndrome
• ≥3 cardiovascular risk factors
• Subclinical organ damage
• Established cardiovascular or renal disease

Therapeutic Management

Treatment Initiation Algorithm

For Stage 1 Hypertension (140-159/90-99 mmHg):

If 10-year CVD risk <10% AND no target organ damage AND no diabetes:

• Begin with lifestyle modifications alone 3
• Reassess in 3-6 months 3

If 10-year CVD risk ≥10% OR target organ damage present OR diabetes:

• Initiate both lifestyle modifications AND pharmacological therapy immediately 3
• Follow up in 1 month 3

For Stage 2 Hypertension (≥160/100 mmHg):

• Initiate pharmacological therapy plus lifestyle modifications regardless of risk 1

Lifestyle Modifications (All Patients)

Dietary sodium restriction to <1500 mg/day 3

• This alone can reduce BP by 5-6 mmHg 2

Increase dietary potassium to 3500-5000 mg/day 3

Weight loss if overweight/obese 3

• Target BMI <25 kg/m² 2

Physical activity: 90-150 minutes/week of aerobic exercise 3

Alcohol moderation: ≤2 drinks/day for men, ≤1 for women 3

Smoking cessation 1

Pharmacological Therapy

First-Line Medication Selection

Standard first-line options (choose one to start): 3, 2

• Thiazide or thiazide-like diuretics (hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily)
• ACE inhibitors (enalapril 5-40 mg daily)
• Angiotensin receptor blockers (ARBs) (candesartan 8-32 mg daily)
• Calcium channel blockers (amlodipine 2.5-10 mg daily)

Special Population Considerations

Diabetes or chronic kidney disease:

• Prefer ACE inhibitors or ARBs as initial agents 3
• These reduce albuminuria beyond BP control 1

Stable ischemic heart disease:

• Use guideline-directed beta blockers (carvedilol, metoprolol succinate, bisoprolol), ACE inhibitors, or ARBs as first-line 1
• Avoid atenolol (less effective than other antihypertensives) 1
• Add dihydropyridine calcium channel blockers if angina persists 1

Heart failure with reduced ejection fraction:

• ACE inhibitors or ARBs plus beta blockers 1
• Consider ARNI (sacubitril-valsartan) as alternative to ACE inhibitors 1

Chronic kidney disease (eGFR <60 mL/min/1.73m²):

• RAS inhibitors (ACE inhibitors or ARBs) are first-line 1
• Add calcium channel blockers and loop diuretics (if eGFR <30) 1
• Monitor electrolytes and renal function 2-4 weeks after initiation 3

Blood Pressure Targets

Most adults <65 years: <130/80 mmHg 1, 3

Adults ≥65 years: Systolic <130 mmHg 1

Elderly patients: <140/80 mmHg 1

Diabetes: <130/80 mmHg 1

Chronic kidney disease: <130/80 mmHg 1

Stable ischemic heart disease: <130/80 mmHg 1

Titration Strategy

If BP not at goal after 1 month on monotherapy:

• Increase dose of initial medication to maximum tolerated dose 2
• OR add second agent from different class 2

If BP not at goal on 2 medications:

• Add third agent from complementary class 4
• Ensure diuretic is included if not already prescribed 4

Common effective combinations: 2

• ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic
• These have partially additive effects

Monitoring and Follow-up

Initial follow-up: 1 month after starting medication 3

Check electrolytes and renal function 2-4 weeks after initiating ACE inhibitors, ARBs, or diuretics 3

Once at goal: Follow-up every 3-6 months 3

Home BP monitoring is recommended to assess treatment response and detect white coat or masked hypertension 1

Resistant Hypertension

Definition: BP remains ≥140/90 mmHg despite 3 medications at optimal doses (including a diuretic) 4

Management approach:

• Verify medication adherence 4
• Screen for interfering substances (NSAIDs, decongestants, stimulants) 4
• Reassess for secondary causes 4
• Optimize diuretic therapy (switch to chlorthalidone if using hydrochlorothiazide) 4
• Add mineralocorticoid receptor antagonist (spironolactone 25-50 mg daily) as fourth agent 4

Hypertensive Crisis Management

Hypertensive Emergency (BP >180/120 mmHg WITH acute target organ damage):

Immediate ICU admission with continuous BP monitoring 5

Reduce mean arterial pressure by no more than 25% within first hour 5

Then reduce to 160/100-110 mmHg over next 2-6 hours 5

First-line IV medications: 5

• Labetalol: 20-80 mg IV bolus every 10 minutes or 0.4-1.0 mg/kg/h infusion
• Nicardipine: 5 mg/h initially, increase by 2.5 mg/h every 5 minutes to maximum 15 mg/h

Special BP targets:

• Aortic dissection: Systolic <120 mmHg and heart rate <60 bpm 5
• Acute pulmonary edema: Systolic <140 mmHg 5
• Pre-eclampsia/eclampsia: Systolic <160 mmHg and diastolic <105 mmHg 5

Hypertensive Urgency (BP >180/120 mmHg WITHOUT acute target organ damage):

Oral antihypertensive therapy with observation for 2 hours 6

Reduce BP by no more than 25% within first hour, then aim for <160/100 mmHg over 2-6 hours 6

First-line oral medications: 6

• Captopril (ACE inhibitor)
• Labetalol (combined alpha and beta-blocker)
• Extended-release nifedipine (calcium channel blocker)

Avoid immediate-release nifedipine 7

Schedule frequent follow-up (at least monthly) until BP controlled 6

Common Pitfalls to Avoid

Do not use atenolol for hypertension - less effective than other agents 1

Avoid excessive rapid BP reduction in hypertensive crisis - can cause cerebral, renal, or coronary ischemia 5

Do not use short-acting nifedipine for hypertensive emergencies 5

Address medication non-adherence - a major cause of uncontrolled hypertension and hypertensive urgencies 6

Monitor for hyperkalemia when using ACE inhibitors/ARBs with spironolactone 4

Avoid sodium nitroprusside when possible due to cyanide toxicity risk 6

Patient Communication

Explain the chronic nature of hypertension - requires lifelong management 1

Emphasize that most patients have no symptoms - monitoring is essential 1

Discuss that hypertension is controllable with medication and lifestyle changes 1

Explain consequences if uncontrolled - increased risk of stroke, heart attack, heart failure, kidney disease 1

Address medication necessity and concerns before starting treatment 1