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History
During the
primary care visit, it is important to take a good history and physical
examination. History should be taken with an emphasis on hypertension, diabetes
mellitus, dyslipidemia, premature coronary heart disease, stroke, or renal
disease.
The level and
duration of elevated blood pressure, the usual range of blood pressure, current
or past antihypertensive medications, and history of adherence to treatment should
all be known.
Symptoms of
secondary causes of hypertension (eg sweating, headache, and palpitations in
pheochromocytoma; muscle weakness and tetany in hyperaldosteronism;
hypersomnolence and snoring in obstructive sleep apnea; heat intolerance,
weight loss, and palpitations in hyperthyroidism; fatigue, edema, and frequent
urination in kidney disease or failure) should also be noted.
Lifestyle and
environmental evaluation should be done. It includes dietary intake of fat,
salt and alcohol, physical activity, smoking status, weight gain since young
adulthood. Medication history of prescribed and over-the-counter medications,
use of herbal supplements and illicit drugs should also be taken into account
in history taking.
Any history or
current symptoms of target organ damage (TOD) (eg coronary heart disease,
cerebrovascular disease, cognitive dysfunction) should be taken note of since
the association between blood pressure and cardiovascular disease (CVD) in
Asians is stronger than in Westerners with stroke (eg hemorrhagic stroke).
Nonischemic heart failure is a common end result of hypertension-related CVD.
The history or
current symptoms of concomitant diseases (eg diabetes mellitus, renal diseases,
gout, urinary tract infection, thyroid disease, etc.) which may affect
prognosis should also be noted in the history. Family history of high blood
pressure or hypertension, stroke, diabetes, CVD, coronary heart disease, renal
disease, and dyslipidemia should also be known. History of hypertension in
pregnancy or pre-eclampsia should be sought.
Other important
information that should be obtained during history-taking occupational history
such as frequent travels or long trips, time changes, medication schedule,
prevention of complications, and many more.
Physical Examination
A complete physical examination should be done which includes:
- Appropriate blood pressure measurement with verification on the contralateral arm
- Calculation of body mass index (BMI) and waist circumference since the risk for metabolic syndrome or for type 2 diabetes mellitus is high when the waist circumference is >102 cm in men or >88 cm in women
- Heart rate (patient at rest) to search for arrhythmias, respiratory rate, and temperature
- Examination of optic fundi
- Auscultation for carotid, abdominal, and femoral bruits
- Thorough examination of the heart and lungs; palpation of the thyroid gland
- Examination of the abdomen for truncal obesity, enlarged kidneys, masses, distended urinary bladder, and abnormal aortic pulsation
- Palpation of the lower extremities for edema and pulses with the determination of the ankle-brachial index (ABI)
- Neurological and mental status assessment
Screening
Clinical
or Office Blood Pressure Measurement
Blood pressure is measured at least annually in individuals
who are ≥18 years old but more frequently in those at moderate or high risk of
vascular diseases.
The patient should be seated comfortably for >5
minutes in a chair, with back supported, feet on the floor, and arm supported
at heart level prior to measurement of blood pressure. The measurement of blood
pressure in the standing position is recommended for patients at risk of
postural hypotension, patients with diabetes, and at the first visit of elderly
patients.
Two to three measurements should be taken, spaced by
1-2 minutes. Take the measurements from sitting, lying, and standing (usually
after 1 minute) positions to take note of drops in blood pressure. A difference
of >10 mmHg between the two arms suggests arterial stenosis and requires
further investigation.
A cuff with a bladder of 12-13 cm wide and 35 cm
long should be used and placed at the heart level of the patient. Wider cuffs
(>32 cm circumference) are needed for large arms whereas smaller cuffs
(<26 cm circumference) are for thin arms1. The bladder length
should encircle at least 75-100% of the arm while the width should be at least 35-50%
of the arm circumference.
Use the appearance of the phase I Korotkoff sounds
for systolic blood pressure (SBP) and the disappearance of phase V for
diastolic blood pressure (DBP).
1Please also refer to the Recommended Cuff Sizes Table under Nonpharmacological.
Hypertension_Initial Assesment
Confirmation of Hypertension
In general, the diagnosis of hypertension is
confirmed by taking the blood pressure 1-4 weeks after the first measurement or
the average of readings on ≥2 occasions or visits. A substantially elevated blood
pressure requires a shorter interval between visits, depending on the degree of
blood pressure elevation, and the presence of CVD or target organ damage.
Out-of-Office Blood Pressure
Measurement
Out-of-office blood
pressure measurement is recommended for the confirmation of hypertension
diagnosis. It may also be used to measure BP in patients
with increased cardiovascular disease risk with screening office BP of 120-139/70-89
mmHg.
Ambulatory Blood Pressure Monitoring (ABPM) is the preferred
method as it automatically measures the patient’s blood pressure at regular
intervals over a 24-hour period. Its advantages include the detection of masked
or white coat hypertension, determination of nocturnal blood pressure patterns,
confirmation of borderline hypertension or abnormal home blood pressure monitoring
results, and evaluation of the impact of antihypertensive treatments.
Home Blood Pressure
Monitoring (HBPM) is the self-measurement of blood pressure for over 5-7 days, possibly
in duplicate measurements. It may also be used to screen for masked or white
coat hypertension. It may be performed in individuals with high normal blood
pressure or an office blood pressure of 130-139/85-89 mmHg to detect masked
hypertension. It is useful in improving hypertension awareness, improving
diagnostic accuracy, determining cardiovascular risk in patients with
hypertension, evaluating treatment efficacy, and improving treatment compliance
and adherence. It is the basis for initiating and adjusting blood pressure
control treatment in telemedicine. Its main disadvantages are the possible
errors in measurement and that there are no nocturnal blood pressure readings.
In Asians, out-of-office blood pressure management
includes focusing initially on the morning blood pressure and then the nocturnal
blood pressure. Morning hypertension refers to a blood pressure of
≥135/85 for both ABPM and HBPM in the morning period (between 6-10 AM)
regardless of the BP taken during the rest of the day. It confers
cardiovascular risk independent of the 24-hour ambulatory blood pressure. It
may be controlled with the use of long-acting antihypertensive agents given in
appropriate, often in full doses, and in proper combinations. Bedtime dosing
may be considered if morning blood pressure is not controlled. The detection and management of masked and
masked uncontrolled hypertension are important parts of hypertension treatment.
| BP LEVELS DEFINING HYPERTENSION | ||||
| Category | 2017 ACC/AHA* | 2024 ESH** | ||
| SBP (mmHg) and/or DBP (mmHg) | SBP (mmHg) and/or DBP (mmHg) | |||
| Clinic/Office BP | ≥130 | ≥80 | ≥140 | ≥90 |
| Daytime ABPM | ≥130 | ≥80 | ≥135 | ≥85 |
| Nighttime ABPM | ≥110 | ≥65 | ≥120 | ≥70 |
| 24-hour ABPM | ≥125 | ≥75 | ≥130 | ≥80 |
| Home BP | ≥130 | ≥80 | ≥135 | ≥85 |
| *Reference: 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. **Reference: 2024 European Society of Cardiology (ESC) Guidelines for the management of elevated blood pressure and hypertension. |
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Presence
of Secondary Cause or Evidence of Target Organ Damage (TOD)
It must be noted that majority of hypertension cases have no known
cause, ie primary or essential hypertension. Consider
screening for secondary hypertension in patients who have an abrupt development
of hypertension, onset of BP of ≥160/100
mmHg <40 years old, an onset of diastolic hypertension in patients ≥65 years old, hypertension that is either drug-resistant,
accelerated or malignant, suboptimal treatment
response, worsening hypertension, exacerbation of
a previously controlled hypertension, a target organ damage that is out of
proportion to the degree of hypertension, and excessive or unprovoked
hypokalemia, and acute worsening of BP control in pregnant women with
pre-existing hypertension. These patients should be referred to a specialist and
treated appropriately if a secondary cause of hypertension is found. Further
tests should likewise be done if target organ damage is found to evaluate the
level of its severity.