Chapter 1

A comprehensive search of the medical literature was performed in January 2008. The search, limited to human subjects and English language journals, included MEDLINE®, PubMed, the Cochrane Database of Systematic Reviews, and UpToDate®. The current Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) can be found at http://www.nhlbi.nih.gov/guidelines/hypertension/

Hypertension (HTN) is both the most common reason for office visits in the United States as well as the most common indication for prescription medicines. Twenty-four percent of the adult population, or approximately 50 million people, have HTN. Although 53% of hypertensive patients are receiving pharmacotherapy, only a disappointing 14% to 25% of these patients succeed in meeting blood pressure (BP) treatment goals.1 Elevated BP is associated with a continuum of increasing risk for cardiovascular disease, stroke, and kidney disease. Each incremental rise in BP above 115/75 translates into an elevated risk of end-organ damage.2 Reduction in BP decreases the risk of stroke by 35% to 40%, myocardial infarction (MI) by 20% to 25%, and heart failure by greater than 50%.3 The successful control of BP could therefore potentially reduce the deleterious effects of three of the most common medical conditions affecting Americans.

The treatment of HTN is impossible without an awareness of the diagnosis. National Health and Nutrition Examination Survey (NHANES) III found that only 70% of patients meeting diagnostic criteria for HTN were in fact cognizant of their condition. Currently, the U.S. Preventive Services Task Force recommends screening all adults more than 18 years of age annually for HTN (grade A recommendation).4

### Proper Technique

The diagnosis of HTN requires accurate measurements of BP. The JNC VII includes recommendations for proper BP measurement based on expert guidelines.2 First, an appropriate cuff size must be selected so as to avoid falsely elevated (from very small size) or falsely decreased (from very large size) BP readings. The bladder, which is the rubber, inflatable portion of the cuff, should encircle at least 75% to 80% of the upper arm, and the width of the cuff should span at least 40% of the length of the upper arm.5 Ideally, the patient should be seated in a chair for 5 minutes prior to the measurement of BP. Ingestion of caffeine, tobacco products, or medications potentially raising the BP should be avoided for 30 to 60 minutes prior to measuring the BP. Talking during BP measurement can falsely elevate the BP, as can excessively cold temperatures or improper patient positioning. The patient’s arm should be supported at the level of the heart, and the sphygmomanometer, within 3 feet of the examiner and preferably at the eye level. With its lower edge positioned 2 to 3 cm above the brachial artery, the cuff is then inflated to approximately 30 mm Hg higher than the point at which the brachial artery ...

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