Hypertension (FL INITIAL Autonomous Practice - Differential Diagnosis)

Hypertension is a critical risk factor for many cardiovascular diseases, including coronary heart disease, congestive heart failure, stroke, and peripheral vascular disease. It was estimated in 2010 that 1.4 billion people had hypertension (Egan et al., 2019). In the United States, sixty-seven million Americans, or 32% of adults, have high blood pressure, and only 54% of those with diagnosed hypertension have their hypertension under control. In addition, about 33 percent of Americans have prehypertension making about two in three American adults have blood pressure out of the ideal range (CDC, 2016).

Hypertension is a costly disease, both in money and in effects. High blood pressure costs Americans 48.6 billion dollars annually. Seventy percent of adults who have their first heart attack or develop congestive heart failure have hypertension, and 80 percent of those who have their first stroke have high blood pressure (CDC, 2016).

In addition to the risk of many cardiovascular diseases, hypertension can negatively impact the outcome of other diseases. Those with diabetes and hypertension are at higher risk of poor outcomes regarding cardiovascular disease and kidney failure. High blood pressure accounts for 28.4% of all cases of kidney failure (Egan et al., 2019).

Defining high blood pressure is the first step in understanding the condition. The blood pressure reading is an average of two or more readings at two separate visits after an initial screening.

Blood pressure is reported as a systolic reading over a diastolic reading. Table one describes the classification of blood pressure based on the reading. The patient is given the classification of the highest number obtained.

For example, if the average of two separate readings is 135/98 mm Hg, the patient is classified as having stage 2 hypertension because his diastolic reading is classified as stage 2, even though the systolic reading is classified as stage one.

Generally, the lower the blood pressure, the better. The cardiovascular disease risk doubles for every 20/10 mm Hg above 115/75 mm Hg.

The American College of Cardiology and American Heart Association (ACC/AHA) updated their guidelines in 2017. These guidelines lowered the definition of hypertension to 130/80 mg Hg or higher. It is recommended to manage blood pressure above 130/80 mg Hg or higher in patients with known cardiovascular disease or those with a 10-year risk of atherosclerotic cardiovascular disease of 10% or more. Patients without known cardiovascular disease should be treated with medication when the average blood pressure is 140/90 mm Hg or higher. The guidelines acknowledge that intensive blood pressure control reduces morbidity and mortality associated with cardiovascular disease but may be associated with more adverse events (Alevadeh et al., 2019).

The European Society of Cardiology and European Society of Hypertension (ESC/ESH) recently published a guideline that differs from the American College of Cardiology and the American Heart Association. This new guideline defines hypertension as office-based systolic blood pressure equal to or over 140 mm Hg or diastolic blood pressure equal to or over 90 mm Hg. Compared to the American College of Cardiology/American Heart Association which uses 130/80 as a cut-off (William et al., 2018).

In addition, the 2017 ACC/AHA guidelines suggest diagnosing hypertension when there is a 24-hour mean blood pressure of 125/75 mm Hg or above, a daytime mean of 130/80 mm Hg or above, or a nighttime mean of 110/65 mm Hg or above (Whelton et al., 2017).

Those with diabetes mellitus (DM) and chronic renal insufficiency (CRI) are at higher risk for complications. Prior guidelines set blood pressure goals lower for those with DM or CRI, but the newest guidelines from the Joint National Committee (The Eighth Joint National Committee {JNC 8}) recommend that those with DM or CRI should have a blood pressure goal of 140/90 mm Hg or lower.

Treatment guidelines suggest that those with elevated blood pressure (but not yet hypertension) are at higher risk of hypertension progression, and management with lifestyle changes is important. Currently, it is not recommended to implement pharmacological interventions in those with elevated blood pressure. Some high-risk individuals with diabetes and chronic renal insufficiency may be candidates for drug therapy when their blood pressure is in the elevated range. Close monitoring of all patients with elevated blood pressure should occur so that if they progress to hypertension, they can be caught early.

Most individuals with hypertension have primary (essential) hypertension. Primary hypertension is high blood pressure that does not have an identifiable cause. This cause accounts for about 95% of the cases of hypertension. Those with secondary hypertension have high blood pressure caused by other conditions. Common causes of secondary hypertension include hyperaldosteronism, renal artery stenosis, polycystic kidney disease, Cushing syndrome, brain tumors, pregnancy, sleep apnea, and some medications.

A 58-year-old white woman presents to her primary care doctor's office with a chief complaint of bilateral knee pain that is minimally responsive to naproxen, which she has regularly been taking for the last six months. Her past medical history is positive for dyslipidemia, glucose intolerance, and arthritis. Her physical exam is largely unremarkable except for a body weight of 223 pounds and a body mass index of 36.5 – which classifies her as obese. She also has crepitus noted in both knees. Her blood pressure reading is 158/84 mm Hg with a heart rate of 88 beats per minute.

The doctor diagnosed her with bilateral knee arthritis but elevated blood pressure also. She was diagnosed with stage 2 hypertension because her systolic reading was above 140 mm Hg.

Her physician encouraged her to lose weight and referred her to a registered dietitian to help improve her eating habits. He encouraged her to exercise and recommended a water aerobics class 3-5 times a week.

He drew some baseline labs, demonstrating that she had stage 3B renal insufficiency (creatinine 1.5 and a glomerular filtration rate of 36). She was also noted to have a fasting blood sugar of 178 mg/dl, which was confirmed on a follow-up lab draw, and she was consequently given the diagnosis of diabetes. The patient was started on medications to manage her diabetes.

He started her on a low-dose combination of hydrochlorothiazide and lisinopril and was asked to be seen back in the office in 4 weeks.

With the dietitian's help and the exercise program, the patient lost 40 pounds. Her knee pain significantly improved and is now managed with occasional acetaminophen. She could wean off the hydrochlorothiazide but continued treatment with lisinopril, and her blood pressure remained at 118/72 mm Hg. After the weight loss and exercise program, she could wean off all of her diabetes medications.

Understanding the physiological mechanisms that affect blood pressure will help the nurse understand how blood pressure occurs and how it is treated. The pathophysiology of secondary hypertension is well understood, but the pathophysiology of essential hypertension is not well understood. It is beyond the scope of this article to discuss the pathophysiology of the numerous causes of secondary hypertension.

Blood pressure is determined by the degree of systemic vascular resistance and cardiac output. Anything that affects either of these two factors directly affects blood pressure. Below is a listing of factors that affect systemic vascular resistance and cardiac output.

• Genetics – multiple genes are involved in the pathophysiology of hypertension.
• The autonomic nervous system controls many factors (cardiac output, vascular resistance, and retention of fluid) associated with blood pressure.
• The renin-angiotensin-aldosterone system regulates vascular resistance as well as fluid and salt levels. Many blood pressure medications target this system in the control of hypertension.
• The endothelium is the lining of the blood vessel, and it is involved in the production of substances – such as nitric oxide and endothelin – which are involved with blood pressure.
• Other factors that may affect blood pressure include circulating blood volume and blood viscosity.

A primary goal of hypertension management involves preventing target organ damage. Target organ damage manifests over time as blood pressure damages the body.

It is debated if the systolic or diastolic reading poses a greater risk. While both numbers need to be addressed, in those over the age of 50, a systolic reading of more than 140 mm Hg is a larger cardiovascular risk than elevated diastolic blood pressure (Madhur, 2019). Research suggests that for younger individuals (less than 50), diastolic blood pressure is a better predictor of death. In older individuals, elevated systolic blood pressure or greater pulse pressure (the difference between systolic and diastolic pressure) are predictors of risk.

Individuals with established chronic diseases are at the greatest risk for end-organ damage. Unfortunately, many with established chronic diseases have poorly controlled blood pressure. Almost 75% of American adults with chronic diseases (coronary heart disease, diabetes, stroke, and congestive heart failure) are also afflicted with hypertension. Most of these individuals are being treated but are not at goal. Only about one-third to one-half of those with chronic disease have controlled blood pressure.

Less aggressive blood pressure goals are more appropriate in certain populations. These goals include those with multiple side effects from medications, individuals older than 75 years old with multiple medical comorbidities, those with diastolic hypertension, individuals with postural hypotension, and those taking 3 antihypertensive medications at the maximum dose (William et al., 2018).

Prolonged hypertension can lead to direct damage to the heart. Enlargement of the left ventricle results from the left ventricle having to work hard over time to overcome the resistance of the blood vessels in hypertension. Those who have an enlarged left ventricle are at increased risk for death. This risk occurs for multiple reasons. Those with enlargement of the left ventricle are more commonly affected with dysrhythmias and sudden death. Those with an enlarged left ventricle may also be affected by increased coronary arteries' resistance. Managing hypertension reduces the risk of cardiovascular mortality (Madhur, 2019).

Hypertension also increases the risk of stroke. Elevated blood pressure places excess strain on the blood vessel wall, which can cause them to thicken and increases their risk for rupture. Elevated blood pressure increases the risk of embolism. Consequently, uncontrolled hypertension increases the risk of ischemic and hemorrhagic stroke.

Patients with atrial fibrillation and high blood pressure are at increased risk of ischemic stroke, and that risk increases with longer durations of high blood pressure. In patients with atrial fibrillation, long-term strict blood pressure control significantly reduces the risk of ischemic stroke (Kim et al., 2019).

Hypertension increases the risk of end-stage renal disease (ESRD). Over time, higher blood pressure increases the risk of ESRD. In the United States, the two most common causes of ESRD are diabetes and hypertension. Those afflicted with both conditions are at increased risk for complications, and the blood pressure (and blood sugar in diabetics) needs to be aggressively managed.

Hypertension may also be linked to memory loss and dementia. Individuals with hypertension and cognitive impairment have a higher risk of progression to dementia than those without hypertension. Individuals with hypertension may improve memory when hypertension is treated with diet and exercise. In a recent study, individuals who ate the DASH (Dietary Approaches to Stop hypertension) diet and participated in a weight management program showed improved executive function-memory learning and psychomotor speed.

Certain groups of people are at higher risk for hypertension than others. Adult African Americans have the highest rates of hypertension, with 42.6 percent of men and 47.0 percent of women being afflicted. White adult males are afflicted at 33.4 percent and women at 30.7 percent. Mexican Americans are afflicted at 30.1 percent in men and 28.8 percent in women (AHA, 2014).

The risk of hypertension increases with age. The prevalence of men with hypertension between the ages of 20-34 is 9.1 percent and 6.7 percent for women, while the prevalence of hypertension is 72.1 percent for men and 80.1 percent for women over the age of 74 (AHA, 2014).

Other factors may help predict who is likely to suffer from hypertension. Common risk factors include physical inactivity, obesity, diabetes, smoking, high alcohol consumption, dyslipidemia, black race, high sodium intake, family history of heart disease, older age (women over 64 and men over 54), microalbuminuria and reduced glomerular filtration rate (GFR) (<60 mL/min).

There has been much debate regarding the link between blood pressure and vitamin D status. Scientists are unclear about the link between vitamin D and blood pressure, and more research is needed before recommendations to use vitamin D to prevent or treat hypertension are made.

Stress increases the risk of hypertension. A recent study looked at the association between perceived psychological stress and hypertension among Asian Americans. Individuals with a high level of perceived stress were 61% more likely to have hypertension when compared to those with low levels of perceived stress. In addition, social support was found to have beneficial effects on hypertension (Lu et al., 2019).

Hypertension is called the silent killer because it typically does damage without causing symptoms. Individuals with severe hypertension may present with visual changes, headaches, nausea, vomiting, or chest pain.

Adults with normal blood pressure should have their blood pressure checked once a year. Patients with risk factors or systolic blood pressure readings between 120 and 129 should have their blood pressure checked semiannually.

Hypertension is typically diagnosed after screening. After an elevated blood pressure reading is noted on a screening, the average of two or more measurements on at least two separate visits over a few weeks is needed to diagnose hypertension. Individuals with a blood pressure of 180/120 mm Hg or greater can be diagnosed without confirmatory readings. In addition, individuals with blood pressures equal to or greater than 160/100 mm Hg with evidence of known target end-organ damage can be diagnosed without further readings.

When measuring blood pressure, make sure that the patient has been sitting quietly for 5 minutes before taking the blood pressure. Ideally, the blood pressure should be checked in each arm sitting, standing, and lying down. It is important to utilize the correct size blood pressure cuff. Blood pressure readings between arms should be essentially the same, and a discrepancy of more than 15 mm Hg indicates possible subclavian stenosis. If a small cuff is used on a larger arm, the reading will be falsely elevated, and if a large cuff is used on a small arm, the reading will be falsely low.

When checking blood pressure, make sure the patient's legs are not crossed. Crossing the legs elevates blood pressure. In addition, when checking blood pressure, make sure the patient has not had any recent caffeine or nicotine ingestion. Caffeine ingestion falsely elevates blood pressure above the hypertensive threshold in approximately 17% of patients with normal blood pressure.

Part of the workup for hypertension should include home blood pressure monitoring. It will minimize the limitations of office-based blood pressure monitoring. Many individuals suffer from white coat hypertension, where there is an excessive rise of blood pressure in the doctor's office due to anxiety, and measuring blood pressure in the home setting on a day-to-day basis offers advantages in a more accurate diagnosis of hypertension. The machine that is used must be validated. Measurements should be taken at different times of the day. Those with cardiac dysrhythmia, including atrial fibrillation, should not use home monitoring as a reliable method to detect hypertension. When home blood pressure monitoring is used, a minimum of 12 measurements should be taken throughout the day over one week.

Unattended automated office blood pressure monitoring is where no healthcare provider takes the blood pressure, and multiple readings are taken. This monitoring is becoming a more popular way to check blood pressure and is more likely to reduce the effects of white coat hypertension.

Ambulatory blood pressure monitoring predicts target organ damage and cardiovascular events more accurately than traditional office-based blood pressure readings. This type of measurement typically occurs at 15-20 minute intervals during the day and 30-60 minute intervals at night. Ambulatory blood pressure monitoring can help the evaluation of suspected white coat hypertension, resistant hypertension, suspected episodic hypertension, evaluation of hypotension, autonomic dysfunction, and monitoring response to treatment.

Ambulatory blood pressure monitoring has many advantages. Blood pressure typically falls at night when people are sleeping. Nondipping blood pressure is when the blood pressure does not fall at least 10% during sleep. This blood pressure is a strong predictor of adverse cardiovascular outcomes. Ambulatory blood pressure monitoring is a more accurate predictor of long-term cardiovascular outcomes when compared to outpatient blood pressure monitoring. Some experts suggest that ambulatory blood pressure monitoring should be the standard for evaluating blood pressure.

After hypertension is diagnosed, it needs to be evaluated. A critical aspect of evaluating hypertension is to rule out or determine the extent of target organ damage (TOD). TOD is damage to major organs that are fed by the circulatory system. It may include damage to the heart, brain, eyes, and kidneys. It is typically only noted after years of untreated hypertension. Unfortunately, sometimes hypertension goes undiagnosed for years, and TOD is noted at the initial diagnosis.

A physical exam can help diagnose TOD. Evaluating the eyes with a fundoscope can pick hypertensive retinopathy. The heart should be evaluated for any evidence of enlargement of the left ventricle. This evaluation can be indicated by a displaced apical impulse or the presence of an S4 heart sound. A neurological exam may help pick up any evidence of cerebrovascular atherosclerosis or damage. Findings that indicate neurological compromise include a carotid bruit or a focal neurological defect. No specific exam finding can help detect early kidney damage secondary to hypertension, and to detect renal insufficiency, the use of laboratory assessment should be done.

The next step in the workup of hypertension is to assess the other risk factors. This workup includes assessing lipid levels, tobacco use, physical activity levels, body weight, central adiposity, glucose tolerance, and dietary habits.

The workup should also include ruling out secondary causes of hypertension. The physical exam may provide some clues to a secondary cause of hypertension. Below are a few points about the workup that may indicate a secondary cause of hypertension.

• A bruit in the upper abdomen may point to renal artery stenosis.
• A reduced or absent femoral pulse or a reduced blood pressure in the leg (compared to the upper extremity) may suggest coarctation of the aorta.
• Pheochromocytoma may be suggested by labile blood pressure, sweating, and palpitations.
• Obstructive sleep apnea should be considered in an obese patient who complains of feeling tired. In obstructive sleep apnea, it is common for a bed partner to report snoring and apnea periods.
• Low energy, temperature intolerance, slow or fast heart rates, and sweating may suggest thyroid dysfunction.
• Hyperaldosteronism may be present if there is weakness and lab tests show low potassium levels.
• Hyperparathyroidism may be present in an individual with kidney stones.
• A mismatch indicates subclavian artery stenosis in blood pressure between the arms.

Other causes of secondary hypertension include polycystic kidney disease, renovascular hypertension, urinary tract obstruction, Cushing syndrome, primary hyperaldosteronism, brain tumor, pregnancy-induced hypertension, and some medications such as alcohol, cocaine, and decongestants.

Laboratory evaluation is a critical aspect of the management of hypertension. Lab work is done for multiple reasons, including to rule out a secondary cause of hypertension, evaluate other risk factors, and monitor medication therapy. Common blood tests include:

• Complete blood count
• Kidney function tests
• Electrolytes
• Uric acid level
• Thyroid panel to test for hyper or hypothyroidism
• Glucose level
• Lipid panel
• Uric Acid levels

More specialized tests may be indicated in certain situations. Testing for microalbuminuria in people with diabetes will further define the presence of diabetic nephropathy. Measuring aldosterone and plasma renin could help define primary hyperaldosteronism. Primary hyperaldosteronism may also present with low potassium levels and metabolic alkalosis. Urine catecholamines and fractionated metanephrines can help detect pheochromocytoma.

Uric acid levels may be associated with hypertension. Uric acid increases fat storage and lipogenesis and increases salt sensitivity. Elevated uric acid levels in the blood affect approximately 20% of adults and are thought to be related to insulin resistance, the typical western diet, and renal dysfunction. Controlling uric acid levels, particularly in patients with prehypertension or hypertension, may help manage high blood pressure. In addition, avoiding medications that increase uric acid levels is beneficial (DeBecker et al., 2018).

Except for electrocardiograms (EKGs), imaging studies are not typically done in routine cases of hypertension but can be used to evaluate select patients for TOD or a secondary cause of hypertension. An echocardiogram can help detect left ventricle hypertrophy. Computed tomography angiography or magnetic resonance angiography can identify renovascular stenosis. Captopril radionuclide scanning is done to evaluate for renovascular hypertension.

Hypertension is a disease that becomes more common as people age. With the increasing numbers of older adults, it is important to understand how to treat blood pressure in the elderly. In years past, physicians have considered high blood pressure a consequence of aging. More recent data has suggested that treating blood pressure is critical for preventing cardiovascular and other complications regardless of age.

A major recommendation of JNC 8 modifies the way blood pressure is controlled in older adults. According to JNC 7, the goal of blood pressure in those over 60 years old was to treat less than 140/90 mm Hg. According to JNC 8, individuals over 60 years old should utilize medications to lower blood pressure to less than 150/90 mm Hg. Lower blood pressure is reasonable if medications are well tolerated (no negative side effects) (Reboussin, 2018).

Treatment in older adults needs to treat blood pressure and reduce complications of hypertension, including stroke and coronary heart disease. This population should strongly consider thiazide diuretics and dihydropyridine CCB as first-line agents. If a second drug is needed, adding an agent based on a comorbid condition or one of the risk factors should be considered. The use of once-a-day atenolol should be avoided.

Treatment guidelines for hypertension in older adults are cautious due to concerns about benefits versus risks. This problem is compounded by the fact that little research is available on managing hypertension in older adults. Aggressive management of hypertension may increase the risk of hypotension, which will increase the risk of syncope and falls. A recent study showed that generally, treating hypertension lowers the risk of falls. Only one class of blood pressure medications, beta-blockers, was associated with an increased risk of falls.

A study that used a thiazide diuretic and an ACE-I in treating older adults (mean age of 83.6 years old) with hypertension was conducted that resulted in a significant reduction in blood pressure and complications of hypertension. The actively treated group had lowered their blood pressure by 15/8.6 mm Hg. The study was cut short after 1.8 years because of a reduction in death rates by 21% in the treated group. The study also showed a 39% reduction in fatal stroke and a 64% reduction in heart failure. Despite the concern of adverse effects of therapy, few negative effects were noted.

While JNC8 guidelines suggest more conservative blood pressure treatment in older adults, other guidelines are more aggressive.

While antihypertensive medication classes are relatively equal in ineffectiveness, individual variability in effectiveness is individual. It is generally agreed that blood pressure control is most important in reducing complications of hypertension and the choice of agent is a secondary consideration unless there is a compelling indication.

As part of the hypertension workup, it is important to determine other comorbidities in the individual with hypertension because they can influence which medications to use. Those with certain diseases will derive extra benefits from the addition of blood pressure medications regarding the comorbid condition. For example, those with heart failure and systolic hypertension will see an improvement in their blood pressure and heart failure with the addition of an ACE-I. Table three highlights some medications that should be considered when certain conditions are present.

Patients with osteoporosis and hypertension may benefit from thiazide diuretics as they stimulate the distal tubular resorption of calcium, reducing urinary excretion of calcium. The ALLHAT trial showed that individuals treated with chlorthalidone had fewer hip and pelvic fractures when compared to patients treated with amlodipine or lisinopril.

Those who suffer from blood pressure more than 20/10 mm Hg over goal should be considered for combination therapy. One major concern with combination therapy is the potential for a large drop in blood pressure and resultant hypotension, especially in those who have not been on medications before.

Before initiating two medications, it is important to evaluate the risk of orthostatic hypotension, more common in patients with diabetes or older age. Assess these patient groups with orthostatic blood pressure readings. Orthostatic hypotension is considered when there is a 20 mm Hg fall in systolic blood pressure or a 10 mm Hg fall in diastolic blood pressure, with an increase in heart rate of 10 beats a minute or a feeling of dizziness upon standing.

To improve patient compliance, some medications are combined into one pill. Some examples include: Diovan® HCT combines valsartan and hydrochlorothiazide; Exforge® combines amlodipine and valsartan; Lotrel® combines amlodipine and benazepril, and Vaseretic® combines enalapril and hydrochlorothiazide.

Certain medications work well together, and others do not. Below is a list of medications that are frequently combined.

• Diuretics with most other medications
• ACE-I or ARB and a calcium channel blocker
• Dihydropyridine calcium channel blocker and a beta-blocker (but not a non-dihydropyridine CCB)
• Thiazide diuretic and a potassium-sparing diuretic

Agents that do not work well together include:

• Beta-blocker and alpha1-blocker
• Beta-blocker with a non-dihydropyridine CCB (verapamil/diltiazem) may lead to heart block or bradycardia
• ACE-I and an ARB

Combining an ACE-I and a CCB may be the most effective combination. A recent study compared the combination of an ACE-I and diuretic versus an ACE-I plus a CCB. The ACE-I/CCB combination was more effective than ACE-I/diuretic in lowering cardiovascular events. This effect was first noted in the ACCOMPLISH trial, which showed that amlodipine plus an ACE inhibitor was associated with a 20% lower rate of cardiovascular events when compared with an ACE inhibitor and hydrochlorothiazide. This benefit was noted without any significant blood pressure difference. Of note, blood pressure was slightly higher in those taking amlodipine. This benefit was most pronounced in non-obese individuals.

Individuals on three or more separate classes of medications to control blood pressure and who are not at goal are considered to have resistant hypertension (Madhur, 2019). In order to be classified as resistant, each agent should be prescribed at the optimal dose, and one of the drugs should be a diuretic. If an individual is on 4 antihypertensive medications but controlled blood pressure, they are classified as having controlled resistant hypertension (Carey et al., 2019).

Resistant hypertension is more common in older adults and those with certain medical conditions such as diabetes, chronic kidney disease, and obesity. Resistant hypertension is more commonly an uncontrolled systolic reading than a diastolic reading.

Many things cause resistant hypertension. A common cause of resistant hypertension is inadequate treatment (not giving the right combination of drugs or giving an inadequate dose). A patient not taking the medications as prescribed is another common cause of resistant hypertension. An undiagnosed secondary cause of hypertension should be considered when resistant hypertension is present. Whitecoat hypertension should also be considered. The use of certain substances can also contribute to resistant hypertension. These may include alcohol, cocaine, decongestants, nicotine, amphetamines, and certain prescription drugs, including oral contraception, antidepressants, and nonsteroidal anti-inflammatory drugs.

Pseudo hypertension, a contributing factor to resistant hypertension, may occur in older patients with thick calcified arteries, leading to falsely elevated blood pressure. This symptom often requires intra-arterial pressure to assess the actual blood pressure.

Excessive fluid may contribute to resistant hypertension. This excessive fluid may occur for many reasons, including:

• Eating a diet high in salt
• Renal insufficiency
• Sodium retention
• Inadequate dose of a diuretic

A 64-year-old black male is being evaluated for resistant hypertension. He was diagnosed with hypertension two and a half years ago. His past medical history includes diabetes, mild renal insufficiency, depression, and a transient ischemic attack history. He had a stent placed in his left anterior descending artery four years ago.

He reports feeling well and specifically denies chest pain, shortness of breath, dizziness, vision changes, fatigue, weakness, urinary changes, or abdominal pain. He takes all of his medicines and denies any significant side effects.

He denies the use of alcohol and quit smoking 10 years ago. He is a widower and has one son who lives in another state. He walks approximately 2 miles, 2-3 times a week and eats a diet that contains a reasonable amount of fruits and vegetables, but does not cook and eats a lot of processed and frozen food.

A physical exam reveals a blood pressure of 150/96 mm Hg and a heart rate of 68 beats per minute. He is 6' 1" and weighs 219 pounds with a body mass index of 28.9, classifying him as overweight.

A current list of medications includes lisinopril 20 mg once a day, amlodipine 10 mg once a day, metoprolol 50 mg twice a day, aspirin 81 mg every day, and simvastatin 40 mg once a day.

Recent laboratory analysis showed serum creatinine of 1.4 mg/dl, blood urea nitrogen of 24 mg/dl, serum potassium of 4.2 mEq/L and serum sodium of 136 mEq/L. His blood sugar was 134 mg/dl, and his cholesterol was within normal limits. There is no protein in the urine.

Treatment plan

A main treatment goal is to prevent any complications of hypertension. This patient is at high risk for stroke due to his history of TIAs. He is also at high risk for renal failure because of his renal insufficiency and diabetes. Due to his diagnosis of diabetes, his blood pressure goal is to get the pressure at least below 140/90 mm Hg (some guidelines recommend lower blood pressure readings).

The first step in managing this patient's blood pressure is to review lifestyle modifications. He was encouraged to:

• Increase exercise to at least 30 minutes 4 to 5 times a week
• Continue to eat fresh fruits and vegetables and reduce the amount of processed and frozen food due to its high sodium content
• Lose weight which will aid in blood pressure control

Medical Management

The patient is currently on three medications to manage his hypertension, and his blood pressure is still not controlled. The lifestyle interventions will help but will not likely get the patient to the goal. Augmenting his blood pressure medications is likely necessary to adequately manage his blood pressure and prevent long-term complications. The one major medication class that has not been added to his regime is a diuretic. The physician adds hydrochlorothiazide 25 mg once a day. A follow-up appointment is scheduled in two weeks for a blood pressure check and laboratory assessment.

At the follow-up appointment, his blood pressure was noted to be 128/84 mm Hg, and his laboratory evaluation is stable. He reports that he has cut down on processed and frozen food, lost 4 pounds, and exercised 5 days a week.

He is asked to follow up in one month for a recheck on his blood pressure and laboratory work. His blood pressure is 124/80 mm Hg at this follow-up appointment, and his labs are stable. He is maintaining the lifestyle interventions discussed above.

Resistant hypertension is a vexing problem. This individual does not technically suffer from resistant hypertension because he does not meet the strict guidelines. While his blood pressure was not controlled on three medications, there was no diuretic in his regime, and the doses of metoprolol and lisinopril were not maximized.

If blood pressure could not be managed on the above regime, the dose of lisinopril or metoprolol could be increased, or the addition of spironolactone 25 mg daily could be considered.

Hypertensive urgency is when there is very high blood pressure (such as a systolic reading over 180 mm Hg or a diastolic reading above 120 mm Hg) in an asymptomatic patient without end-organ damage. In this situation, a rapid reduction in blood pressure is not necessary. An important aspect of evaluating a patient with ongoing hypertensive urgency is to assure that blood pressure is accurately measured, and there is no end-organ damage.

The management of severe asymptomatic hypertension is not optimally defined. It is reasonable to lower blood pressure for hours to days. Lowering blood pressure too rapidly may reduce the body's ability to autoregulate to maintain adequate tissue perfusion, increasing the risk of heart attack, acute kidney injury, or stroke.

The blood pressure should likely be lowered to less than 160/100, but the mean arterial blood pressure should not be more than 30% over the first 2-4 hours (Varon & Elliott, 2019). Simply placing the patient in a quiet room may lower blood pressure. One study showed that 32% of individuals who rested 30 minutes in a quiet room had blood pressure lowered more than 20/10 mm Hg.

Fast-acting medications, such as oral clonidine or oral captopril, will lower blood pressure over hours. It is not unreasonable to use longer-acting medications and follow-up in the primary care office over 1-2 days.

Complications associated with hypertensive urgency include retinal hemorrhage, papilledema, kidney injury, or hypertensive encephalopathy. Much more commonly, significantly elevated blood pressure is asymptomatic. At times there may be a slight headache, but rarely.

In patients with severe asymptomatic hypertension, rapidly lowering blood pressure has minimal benefit. A recent study of 60,000 people with severe asymptomatic hypertension evaluated in the emergency department compared immediate emergency department referral to sending the patient home for outpatient blood pressure management. This study demonstrated at 6-months, similar rates of blood pressure control and similar rates of cardiovascular events.

A hypertensive emergency is a severe hypertension (>180/120 mm Hg) with evidence of end-organ damage. This emergency is a potentially life-threatening situation that requires aggressive management, typically in the intensive care unit.

Other situations necessitate blood pressure needing to be lowered quickly. This situation includes individuals at high risk for imminent cardiovascular events from high blood pressure. This situation includes those with aortic aneurysms or intracranial aneurysms. These individuals should have blood pressure lowered over hours. Multiple parental agents may be used in these emergencies.

A healthy lifestyle will aid in the prevention of hypertension. To prevent hypertension, maintaining healthy body weight, engaging in regular aerobic exercise, and eating a generous amount of fruits and vegetables will help. Assure that the diet contains adequate amounts of potassium, calcium, and magnesium. This lifestyle is accomplished by a balanced diet, including recommended amounts of fruits and vegetables. Reducing sodium intake – through reducing processed, frozen, or canned foods - will assist in the prevention of hypertension. Eliminating or limiting alcohol intake will likely reduce the risk of hypertension. Avoiding illicit drug use – particularly amphetamines, anabolic steroids, and cocaine – will help prevent high blood pressure.

Hypertension is a major problem that is a risk factor for many diseases and is partly responsible for morbidity and mortality. It is a disease that typically causes no symptoms, and therefore regular screening of blood pressure is critical in its diagnosis. Many treatment options are available, including lifestyle changes and medications. Determining which medication to use in the treatment of hypertension is often challenging and requires some trial and error. Continued follow-up is critical to assure adequate control of the blood pressure and monitor for any hypertension complications.

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