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LEARNING OBJECTIVES

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  1. Identify appropriate standards for the diagnosis of hypertension and target blood pressure goals for patients already diagnosed with hypertension.

  2. Accurately measure a patient's blood pressure using a sphygmomanometer.

  3. Evaluate and identify environmental factors and errors in technique that reduce the accuracy of blood pressure measurements potentially leading to misdiagnosis, over- or undermedication, and poor disease control.

  4. Describe the importance of home blood pressure readings in the management of hypertension including patient education on the accuracy and use of home blood pressure devices, and the evaluation of the accuracy of those home measurements.

  5. Conduct a comprehensive follow-up visit for a patient with hypertension using appropriate history-taking techniques, physical examination, and laboratory tests. The visit includes assessment of disease control, assessment and support of compliance with lifestyle modifications, and medication regimens, plus evaluate patients for complications from the disease and medication regimen.

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Essential hypertension is one of the most common chronic diseases affecting adults. It can occur alone or in combination with comorbidities such as diabetes, dyslipidemia, congestive heart failure, and renal disease.

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ETIOLOGY

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Hypertension is a state of persistently elevated blood pressure (BP) due to a wide variety of contributory factors. Excess sodium intake, sodium sensitivity, excessive neurohormonal production, or hypersensitivity (e.g., the renin-angiotensin-aldosterone and sympathetic nervous systems) are well-identified contributory factors. Because of the complexity of the etiology, it is referred to as essential hypertension (EHT) to differentiate it from numerous much less common and in many cases curable, secondary causes such as pheochromocytoma, primary hyperaldosteronism, and coarctation of the aorta. There are also some medications (including OTC and herbal products) that may cause or aggravate BP elevations.

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DIAGNOSIS

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It is important to understand the basics of blood pressure readings in order to effectively diagnose and assist patients in managing their hypertension. The top number of the reading refers to the systolic blood pressure and the bottom number refers to diastolic blood pressure. Systolic blood pressure is the amount of pressure exerted when the heart contracts. Diastolic blood pressure refers to the pressure in the arteries when the heart is at rest, passively filling. A diagnosis of hypertension is made in patients under 60 years of age with a blood pressure reading of greater than 140/90 on multiple occasions. New guidelines set greater than 150/90 as the diagnostic cutoff for patients 60 years of age and older. A single reading of a patient's blood pressure above 140/90 and below 180/110 is not diagnostic as blood pressure can be raised during stress, infections, medication use, and exercise, or there are a myriad of errors in technique that can also provide falsely elevated blood pressure readings. However, a single blood pressure measurement >180/110 should be considered diagnostic of hypertension and a referral made so that therapeutic interventions can be initiated immediately.

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For most patients, the blood pressure goals are <140/90, even for patients with diabetes mellitus or chronic kidney disease. Accurate measurements of blood pressure are essential to the proper diagnosis and treatment of hypertension. Blood pressure measurements elevated by 5 to 10 mm over the diagnostic criteria should be reassessed at different times of the day because many natural factors such as low blood glucose or a full bladder may cause blood pressure to vary throughout the day. In addition, many patients develop “white coat hypertension,” blood pressures elevations that only occur in the physician's office and/or in association with a health care provider. To obtain more accurate and meaningful results, blood pressure readings at home should be measured if possible. If a total of at least three readings done at different times of the day and in different settings are all consistently above 140/90, then the diagnosis of hypertension can accurately be made and therapeutic interventions can be initiated. Marked differences in BP readings may be an indication for ambulatory BP monitoring to more accurately assess whether or not the patient has sustained blood pressure values in the hypertension range. An additional consideration in patients with borderline blood pressure levels is to make sure that the cuff size is accurate and that the cuff is centered over the cubital fossa.

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