Essential Hypertension and Hypertensive Emergencies
How should blood pressure be measured?
What is the most likely cause of this patient's hypertension?
What laboratory tests are indicated?
Will lifestyle changes improve his blood pressure?
Is drug therapy indicated at this time?
What is the target blood pressure with treatment?
Case Discussion
How should blood pressure be measured?
The patient should be seated in a chair with his feet on the floor in a quiet place for at least 5 minutes. At least two measurements should be made with a calibrated instrument. Systolic blood pressure is defined as the blood pressure at which the first sound is heard and diastolic pressure is defined as the pressure at the disappearance of the sounds.
What is the most likely cause of this patient's hypertension?
The most likely cause of this patient's hypertension is essential hypertension.
What laboratory tests are indicated?
The laboratory investigation should include chest radiography (normal), ECG (sinus rhythm with increased voltage but no ST-T–wave changes), urinalysis, hematocrit, calcium (all normal), and measurement of the fasting blood sugar (normal), blood urea nitrogen, serum creatinine, electrolytes (normal), cholesterol [total and low-density lipoprotein (LDL) and high-density lipoprotein (HDL)], and triglyceride (total cholesterol is 240 with LDL of 170, HDL of 40, and normal triglycerides).
Will lifestyle changes improve his blood pressure?
Lifestyle modifications are an important part of blood pressure management. Beneficial lifestyle modifications include weight reduction in overweight or obese people, regular exercise, adoption of theDASH (Dietary Approaches to Stop Hypertension) diet which is high in calcium and potassium, limitation of sodium intake, and moderation of alcohol consumption.
Is drug therapy indicated at this time?
Medical therapy is indicated in this patient who has demonstrated stage 2 hypertension (Table 2-1 and Fig. 2-1). The plan of management should commence medical bookshop
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with instruction in lifestyle changes and oral antihypertensive drugs with the aim of maintaining blood pressure at less than 140/90 mm Hg. Eliminating coexisting cardiovascular risk factors (especially smoking) and treating the elevated cholesterol will not lower the blood pressure but will lower his risk of subsequent cardiovascular events.
Figure 2-1 Algorithm for treatment of hypertension. BP, blood pressure; ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; CCB, calcium channel blocker. (From Chobanian AV, Bakris GL, Black GL, etal. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. JAMA 2003;289:2560–2572.)
What is the target blood pressure with treatment?
The target blood pressure with treatment is less than 140/90 mm Hg. If the patient had diabetes or chronic kidney disease the recommended target blood pressure would be less than 130/80 mm Hg.
You instruct your patient in lifestyle changes and start him on lisinopril 10 mg once daily. In 2 weeks you increase the lisinopril to 20 mg daily because the blood pressure is still 160/98 mm Hg. Electrolytes and creatinine levels are unchanged. The increased lisinopril does not significantly alter the pressure and you add chlorthalidone at 25 mg daily. In 4 weeks his blood pressure is 139/88 mm Hg
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