What questions should be asked when evaluating a patient with hypertension?

Essential Questions for Evaluating a Patient with Hypertension

Blood Pressure History and Confirmation

When evaluating a patient with hypertension, begin by determining the duration of elevated blood pressure, previous BP levels, and whether the diagnosis has been confirmed with proper measurement technique or out-of-office monitoring. 1

• Ask specifically when hypertension was first diagnosed and what the highest recorded blood pressure readings have been 1
• Inquire about previous blood pressure control and whether readings have been consistently elevated or intermittent 1
• Determine if the patient has ever had home blood pressure monitoring or ambulatory blood pressure monitoring to exclude white coat hypertension 1
• Ask about blood pressure measurements during pregnancy or with oral contraceptive use, as these can reveal hypertension-prone individuals 1

Current and Past Antihypertensive Treatment

• Document all current antihypertensive medications, including doses and duration of therapy 1
• Ask about previous antihypertensive medications tried and reasons for discontinuation, particularly focusing on side effects or intolerances 1
• Specifically inquire about medication adherence and barriers to taking medications as prescribed, as non-compliance is a major cause of uncontrolled hypertension 1
• Ask about over-the-counter medications, herbal remedies, and supplements that may raise blood pressure (NSAIDs, steroids, sympathomimetics, erythropoietin, anabolic steroids) 1

Symptoms Suggesting Target Organ Damage

More than 50% of hypertensive patients have additional cardiovascular risk factors, and the presence of target organ damage significantly increases cardiovascular risk and influences treatment decisions. 1

• Ask about chest pain or pressure, particularly with exertion, suggesting coronary heart disease 1
• Inquire about shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, or peripheral edema indicating heart failure 1
• Ask about headaches, visual disturbances, or blurred vision that may indicate hypertensive retinopathy or severe hypertension 1
• Determine if the patient has experienced neurological symptoms such as weakness, numbness, dizziness, or transient ischemic attacks suggesting cerebrovascular disease 1
• Ask about claudication or leg pain with walking, indicating peripheral arterial disease 1
• Inquire about nocturia or hematuria, which may suggest kidney damage 1

Symptoms Suggesting Secondary Hypertension

While secondary causes account for less than 10% of hypertension cases, identifying them is critical as they may be curable. 2

• Ask about muscle weakness, tetany, cramps, or arrhythmias suggesting hypokalemia from primary aldosteronism 1
• Inquire about episodes of sweating, palpitations, and severe headaches that may indicate pheochromocytoma 1
• Ask about snoring, witnessed apneas, and daytime sleepiness suggesting obstructive sleep apnea 1
• Determine if there are symptoms of thyroid disease (heat/cold intolerance, weight changes, tremor) 1
• Ask about flash pulmonary edema episodes, which may suggest renal artery stenosis 1

Cardiovascular Risk Factor Assessment

Cardiovascular risk should be assessed in all hypertensive patients, as the presence of additional risk factors proportionally increases the risk of coronary, cerebrovascular, and renal diseases. 1

• Obtain a detailed smoking history, including current status, pack-years, and quit date if applicable 1
• Ask about diabetes diagnosis, duration, and current glucose control 1
• Inquire about known dyslipidemia or previous cholesterol testing 1
• Document alcohol consumption in units per week (>21 units/week for men, >14 units/week for women increases risk) 1
• Ask about recreational drug use, particularly cocaine and methamphetamine, which can cause severe hypertension 1
• Assess physical activity level and exercise habits 1
• Inquire about dietary habits, particularly salt intake and consumption of fruits and vegetables 1

Family History

• Ask about family history of hypertension, particularly early-onset hypertension in parents or siblings 1
• Determine if there is family history of premature cardiovascular disease (myocardial infarction, stroke before age 55 in men or 65 in women) 1
• Inquire about family history of familial hypercholesterolemia, diabetes, or kidney disease 1

Comorbid Conditions

The evaluation must identify comorbid diseases that influence treatment decisions and cardiovascular risk stratification. 1

• Ask about history of coronary heart disease, myocardial infarction, or coronary revascularization 1
• Inquire about previous stroke, transient ischemic attacks, or other cerebrovascular events 1
• Determine if the patient has heart failure, including symptoms and ejection fraction if known 1
• Ask about chronic kidney disease, including previous creatinine levels or estimated GFR 1
• Inquire about atrial fibrillation or other arrhythmias 1
• Ask about peripheral vascular disease or previous vascular procedures 1
• Determine if the patient has chronic inflammatory diseases, COPD, or psychiatric disorders, as these increase cardiovascular risk 1

Psychosocial and Socioeconomic Factors

• Assess psychosocial stressors, depression, and anxiety, as these affect blood pressure control and treatment adherence 1
• Inquire about socioeconomic status and access to healthcare, as low socioeconomic status is a risk factor for hypertensive emergencies 1
• Ask about the patient's understanding of hypertension and willingness to adopt lifestyle changes 3

Special Populations

For women of childbearing age:

• Ask about pregnancy history and whether hypertension or pre-eclampsia occurred during pregnancy 1
• Inquire about current or planned pregnancy, as this affects medication choices 1
• Ask about oral contraceptive use, as this can cause or worsen hypertension 1