A 35-year-old man presents with a blood pressure of 140/90 mm Hg. He has been generally healthy, is sedentary, drinks several cocktails per day, and does not smoke cigarettes. He has a family history of hypertension, and his father died of a myocardial infarction at age 55. Physical examination is remarkable only for moderate obesity. Total cholesterol is 220, and high-density lipoprotein (HDL) cholesterol level is 40 mg/dL. Fasting glucose is 105 mg/dL. Chest X-ray is normal. Electrocardiogram shows left ventricular hypertrophy. How would you treat this patient?
Hypertension is the most common cardiovascular disease. Using National Health and Nutrition Examination Survey (NHANES) data from 2011 to 2014, and a definition of ≥130/90 mm Hg recommended by the 2017 ACC/AHA High Blood Pressure Clinical Practice Guideline, hypertension was found in 46% of American adults and 76% of adults age 65 years or older. The prevalence varies with age, race, education, and many other variables. Sustained arterial hypertension damages blood vessels in kidney, heart, and brain and leads to an increased incidence of renal failure, coronary disease, heart failure, stroke, and dementia. More than 50% of deaths from coronary heart disease and stroke occur in people with hypertension. Effective pharmacologic lowering of blood pressure has been shown to prevent damage to blood vessels and to substantially reduce morbidity and mortality rates. However, NHANES found that, unfortunately, only one-half of Americans with hypertension had adequate blood pressure control. Many effective drugs are available. Knowledge of their antihypertensive mechanisms and sites of action allows accurate prediction of efficacy and toxicity. The rational use of these agents, alone or in combination, can lower blood pressure with minimal risk of serious toxicity in most patients.
HYPERTENSION & REGULATION OF BLOOD PRESSURE
The diagnosis of hypertension is based on repeated, reproducible measurements of elevated blood pressure (Table 11–1). Blood pressure may be elevated in the office but not at home (“white coat hypertension”), so it is best to confirm a diagnosis of hypertension with home or ambulatory blood pressure measurement. The diagnosis serves primarily as a prediction of consequences for the patient; it seldom includes a statement about the cause of hypertension.
TABLE 11–1Categories of blood pressure in adults. ||Download (.pdf) TABLE 11–1 Categories of blood pressure in adults.
|BP Category ||Systolic Blood Pressure || ||Diastolic Blood Pressure |
|Normal ||<120 mm Hg ||and ||<80 mm Hg |
|Elevated ||120–129 mm Hg ||and ||<80 mm Hg |
|Stage 1 ||130–139 mm Hg ||or ||80–89 mm Hg |
|Stage 2 ||≥140 mm Hg ||or ||≥90 mm Hg |