What is the best approach to manage hypertension in an adult patient with no prior medical history?

Hypertension Review of Systems (ROS)

Cardiovascular System

When evaluating hypertension, systematically assess for target organ damage and cardiovascular complications that directly impact morbidity and mortality. 1

• Chest pain or pressure: Assess for coronary artery disease, which is a primary target of BP control to reduce myocardial infarction risk 1
• Palpitations or irregular heartbeat: Screen for arrhythmias and heart failure, as hypertension is a leading cause of systolic heart failure 2
• Dyspnea on exertion or at rest: Evaluate for heart failure, a major complication of uncontrolled hypertension 2
• Orthostatic symptoms: Specifically ask about dizziness, lightheadedness, near-syncope, or falls when standing, as orthostatic hypotension carries a 64% increase in age-adjusted mortality 3
• Edema: Lower extremity swelling may indicate heart failure or volume overload 1

Neurological System

Stroke prevention is the largest and most consistent cardiovascular outcome benefit of BP control, making neurological assessment critical. 1

• History of stroke or TIA: Prior cerebrovascular events require aggressive secondary prevention with target BP <130/80 mm Hg 1
• Headaches: Particularly severe or new-onset headaches may indicate hypertensive emergency or increased intracranial pressure 4
• Visual changes: Screen for hypertensive retinopathy and target organ damage 1
• Cognitive changes or memory problems: Intensive BP control prevents cognitive decline in older adults 5
• Focal neurological deficits: Weakness, numbness, or speech difficulties suggest cerebrovascular disease 1

Renal System

Chronic kidney disease is both a cause and consequence of hypertension, requiring specific screening and management. 1

• Changes in urination: Frequency, nocturia, or decreased output may indicate renal dysfunction 1
• Hematuria: Screen for renal parenchymal disease, a common secondary cause of hypertension 1
• History of kidney disease: Patients with CKD are automatically in the high-risk category for ASCVD 1
• Foamy urine: May indicate proteinuria/albuminuria, requiring ACE inhibitor or ARB therapy 1

Endocrine System

Secondary hypertension accounts for 5-10% of cases and is potentially curable with targeted treatment. 1

• Heat or cold intolerance: Screen for thyroid disease, which affects BP regulation 1
• Weight changes: Rapid weight gain or loss may indicate endocrine disorders 1
• Excessive sweating, palpitations, or headaches: Classic triad suggests pheochromocytoma 1
• Muscle weakness or cramping: Hypokalemia may indicate primary aldosteronism, present in 15-20% of resistant hypertension 5
• Polyuria and polydipsia: Screen for diabetes mellitus, which places patients in high-risk category 1

Respiratory System

Obstructive sleep apnea is present in ≥80% of patients with resistant hypertension. 5

• Snoring or witnessed apneas: Screen for sleep apnea, a major secondary cause of resistant hypertension 5
• Daytime somnolence: Suggests poor sleep quality from sleep apnea 1
• Dyspnea: May indicate heart failure or pulmonary complications 2

Medication and Substance History

Medication interference accounts for up to 50% of apparent treatment failure in resistant hypertension. 5

• NSAIDs: Over-the-counter ibuprofen, naproxen can elevate BP 5
• Decongestants: Pseudoephedrine and phenylephrine raise BP 5
• Stimulants: Amphetamines, methylphenidate, cocaine increase BP 5
• Oral contraceptives: Estrogen-containing pills can elevate BP 5
• Herbal supplements: Many contain sympathomimetic compounds 4
• Alcohol consumption: Excessive intake (>2 drinks/day for men, >1 for women) raises BP 6
• Medication adherence: Up to 25% of patients don't fill initial prescriptions and only 20% maintain adequate adherence 5

Constitutional Symptoms

• Fatigue: May indicate inadequate BP control or medication side effects 1
• Exercise tolerance: Reduced capacity suggests cardiovascular deconditioning or heart failure 1

Family History

Genetic predisposition significantly influences hypertension risk and guides screening intensity. 7

• Family history of early-onset hypertension: Particularly in patients <30 years, suggests secondary causes 1
• Family history of cardiovascular disease: Premature MI, stroke, or sudden cardiac death increases ASCVD risk 1
• Family history of kidney disease: Polycystic kidney disease or other hereditary renal conditions 1

Social History and Lifestyle Factors

Lifestyle modification is first-line therapy for all patients with elevated BP, with effects that are partially additive to pharmacologic therapy. 6

• Dietary sodium intake: Target <2,000 mg/day can lower BP by 5-6 mmHg 5
• Physical activity level: Sedentary lifestyle increases hypertension risk 8
• Smoking status: Active smoking amplifies cardiovascular risk 1
• Occupational exposures: Stress, shift work, or chemical exposures may affect BP 7

Common Pitfalls to Avoid

• Failing to use proper BP measurement technique: Patients must be seated with back supported, arm at heart level, appropriate cuff size, after 3-5 minutes of rest, with at least two measurements per visit 5
• Missing white coat hypertension: Use ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to confirm diagnosis, as office readings can overestimate true BP by 10-15 mmHg 1, 5
• Not screening for secondary causes in young patients: Early-onset hypertension (<30 years) without risk factors warrants investigation 1
• Overlooking medication non-adherence: Assess objectively through pharmacy refill records rather than patient self-report 5