How to Monitor Progress in Hypertensive Patients
Hypertension is a major risk factor for cardiovascular morbidity and mortality. The risk of cardiovascular morbidity and mortality is remarkably increased by the coexistence of hypertension with other risk factors. These are mainly diabetes mellitus, hypercholesterolemia, smoking, obesity, and positive family history. The existence of target organ damage such as left ventricular hypertrophy, congestive heart failure, ischemic heart disease, stroke or transient ischemic attack, renal failure or proteinuria, peripheral vascular disease, and retinopathy also increases remarkably the risk of cardiovascular morbidity and mortality. Lowering blood pressure reduces the risk of stroke by about 40% and the risk of coronary heart disease by about 20%. Controlling additional risk factors may even increase the benefit obtained from lowering blood pressure. Because hypertension is frequently associated with other risk factors, it is therefore important to identify and control all these risk factors as well. When a patient has elevated blood pressure levels, repeated measurements will determine whether initial elevations persist and require prompt attention or have returned to normal and need only periodic surveillance.
Confirmation of hypertension and determination of severity
Unless blood pressure levels are extremely elevated (above 180/110 mmHg), a 1- to 3-mo period is allowed for confirming the existence and to define the severity of hypertension. During this period blood pressure levels should be measured repeatedly in the clinic in a standardized fashion using equipment that meets certification criteria. Alternatively, 24-h ambulatory blood pressure measurements, or self-administered blood pressure measurements at home can be performed. While the patient is in the process of confirmation and determination of the severity of hypertension, lifestyle modifications should be encouraged. These include losing weight if the patient is overweight (body mass index > 25 kg/m2), cessation of smoking, increasing the level of physical activity such as 30-45 min of brisk walking most days of the week, and moderating alcohol and dietary sodium intake. Additional dietary changes such as increasing potassium and calcium intake and other measures such as relaxation and biofeed-back, meditation, and yoga may be tried.
Once the diagnosis of hypertension has been confirmed, an initial evaluation should be performed. The purpose of the evaluation is to exclude secondary hypertension, to assess the presence or absence of target organ damage, and to identify associated diseases and other cardiovascular risk factors. Important information can be obtained from medical history, physical examination, and laboratory tests. Medical history and physical examination should be directed mainly to answering specific questions. Laboratory work-up should include urinalysis, complete blood cell count, blood chemistry (potassium, sodium, creatinine, fasting glucose, fasting triglycerides, total cholesterol, and high- and low-density lipoprotein cholesterol), and 12-lead electrocardiogram.
Optional tests include urine analysis for microalbumin, blood calcium, uric acid, glycated hemoglobin, limited echocardiography, and renal ultrasound. Additional diagnostic procedures may be indicated when the initial evaluation raises the suspicion of secondary hypertension, or when blood pressure is resistant to treatment. When the diagnosis of essential hypertension is confirmed, a decision should be made whether to start antihypertensive medication or to continue with lifestyle modification.
Table Taking a Medical History of a Patient with Hypertension
| Severity of Hypertension |
| Duration and levels of elevated blood pressure (when was the last time normal blood pressure was measured) |
| Symptoms and factors suggesting secondary hypertension |
| Muscle weakness (hypokalemia, hyperaldosteronism) |
| Tachycardia, tremor, and perspiration (pheochromocytoma) |
| Intermittent claudication (peripheral vascular disease, renal artery stenosis) |
| Use of agents or chemicals that may raise blood pressure or interfere with the effectiveness of antihypertensive drugs |
| History of weight gain |
| Snoring and day somnolence suggesting sleep apnea |
| Dietary assessment including intake of sodium, alcohol, saturated fat, and caffeine |
| Psychosocial and environmental factors |
| Associated risk factors |
| Smoking, lack of physical activity, diabetes mellitus, hyperlipidemia |
| Detailed family history (hypertension or premature cardiac disease, stroke, diabetes, dyslipidemia, renal disease, or pheochromocytoma) |
| Evidence of target organ damage |
| History or symptoms of coronary heart disease, heart failure, cerebrovascular accident, peripheral vascular disease, renal disease |
| Data that may guide treatment |
| Response and adverse effects of previous antihypertensive therapy |
| Sexual function |
| Prostatism |
The decision should be based on blood pressure levels, associated risk factors, and target organ damage. The management of hypertensive patients should include, in addition to lowering blood pressure, recommendations to control other risk factors and to treat associated diseases. Close monitoring to assess blood pressure control, compliance, quality of life, possible side effects or treatment complications, development of other risk factors, and target organ damage is mandatory.
Table Important Parameters of Physical Examination
| • Two or more blood pressure measurements in the sitting and standing position on both arms |
| • Height, weight, and waist circumference |
| • Funduscopic examination for hypertensive retinopathy |
| • Examination of the neck for carotid bruits, distended veins, or an enlarged thyroid gland |
| • Examination of the heart for abnormalities in rate and rhythm, increased size, precordial heave, clicks, murmurs, and third and fourth heart sounds |
| • Examination of the lungs for evidence of congestive heart failure or bronchospasm |
| • Examination of the abdomen for bruits, enlarged kidneys, masses, and abnormal aortic pulsation |
| • Examination of the extremities for peripheral arterial pulsations, bruits, and edema |
| • Neurologic assessment |
Table Indications to Start Antihypertensive Drug Therapy
| Blood pressure level (mmHg) | Associated conditions* |
| al60/al00 | Regardless of risk factors, or target organ damage/Cardiovascular disease |
| 140-159/90-99 | DM, two risk factors, target organ damage/Cardiovascular disease |
| 130-139/85-89 | DM, congestive heart failure, renal failure |
Follow-up
Hypertension is a chronic risk factor that requires long-term treatment, and this should be explained to the patient when antihypertensive treatment is initiated. It is noteworthy that blood pressure increases with age and antihypertensive treatment lowers blood pressure but does not prevent the increase over time. Therefore, even if blood pressure is well controlled and stable, it may become uncontrolled over time, and additional treatment may be required.
Monitoring Adequacy of Blood Pressure Control
Monitoring Laboratory Parameters
Monitoring compliance, adverse effects, associated risk factors, and target organ damage
Most patients should be seen within 1 to 2 mo after the initiation of therapy to confirm compliance and identify the presence of adverse effects. A targeted history and physical examination should be done to recognize adverse effects and target organ damage. The frequency of patient follow-up depends on the findings of the last visit.
Table Physical Examination and Additional Tests During Follow-up
| 1. blood pressure — sitting and standing blood pressure on the arm where blood pressure is higher. |
| 2. Heart rate — to adjust the dose of |3-blocker and to guide the treatment. |
| 3. Weight — to identify weight gain that may explain uncontrolled blood pressure and to encourage patients to lose weight. |
| 4. Venous engorgement and other signs of congestive heart failure. |
| 5. Bruits over the carotid arteries and abdomen. |
| 6. Legs for peripheral pulses and edema. |
| 7. Fundoscopy — once a year if the initial evaluation showed hypertensive retinopathy, or when there is doubt whether the patient is well controlled. If the initial evaluation is normal and the patient is well controlled, less frequent evaluation is required. |
| 8. Electrocardiogram — once a year to detect arrhythmia or signs of Left ventricular hypertrophy and strain. |
| 9. Echocardiogram — should be done when a decision should be made whether or not to start medication, such as in patients with borderline hypertension, or when white coat hypertension is suspected. It should also be done for patients with Left ventricular hypertrophy to observe reduction in ventricular mass (indirect evidence of the efficacy of treatment) and to assess left ventricular function in patients with dyspnea. |
A patient whose blood pressure is stable and who has no target organ damage or associated risk factors can be seen once in 6 mo. Any change in drug regimen requires an additional visit within 1 to 2 mo after the change.
Monitoring and treatment of associated risk factors is part of the management of hypertensive patients. About 10% of the patients with hypertension also have diabetes mellitus. These patients require close monitoring of their diabetes, and therefore frequent measurements of glucose levels, glycated hemoglobin, and microalbumin in the urine should be done. In addition, a more thorough physical examination including fundoscopy should be performed more frequently. Many hypertensive patients also suffer from hyperlipidemia. These patients also should be evaluated frequently until lipid profile is normal.
Encouraging a patient to lose weight, exercise, stop smoking, and avoid alcohol should be emphasized on each visit. The physician should, however, be aware that smoking withdrawal is associated with weight gain and trying to convince patients to do both at the same time will usually fail. Therefore, it may be better to encourage patients first to stop smoking and only after 6 mo to try a weight reduction program.
Conclusion
Adequate control of blood pressure and additional risk factors requires prudent and cost-effective monitoring of the patients’ progress. Following the recommendations given herein will improve and prolong the patient’s life.
This post has been viewed 158 times.
Comments are closed.
