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Make the Diagnosis: Hypertension

Prior Probability

Approximately 25% of all US adults have hypertension. The prevalence is much greater at older ages. The JNC-VII review observed that a normotensive 55-year-old individual has a 90% lifetime risk of developing hypertension. More than half of patients aged 60 to 69 years have hypertension, with the estimate increasing to 75% by age 70 years.

Population for Whom Hypertension Should Be Considered

All persons older than 18 years.

Detecting the Likelihood of Hypertension

Indirect auscultation is the reference standard for detecting hypertension. Because prehypertension and grade 1 hypertension produce no symptoms, there are no screening tests and there is a universal recommendation to evaluate all adults for high BP at least every 2 years. Patients with prehypertensive values should be monitored more frequently. Self-monitored BPs may be used for diagnosis when the patient uses appropriate measurement techniques.

Despite proper measurement techniques, inaccurate results at a single visit may be attributed to biologic variability or white coat hypertension. Thus, patients should have values repeated at several visits to confirm stage 1 hypertension. Assessment of white coat hypertension may use self-monitored BP measurement. In addition, continuous ambulatory BP measurement may be obtained as an additional diagnostic test.

Reference Standard Tests

Indirect auscultation with a mercury or well-calibrated aneroid sphygmomanometer provides the pragmatic reference standard. Oscillometric measures for diagnosis should be confirmed with indirect auscultation. Self-monitored BPs may be used, although the threshold should be less than 135 mm Hg systolic and less than 85 mm Hg diastolic.

Original Article: Does This Patient Have Hypertension?

Clinical Scenario

Is This Patient's Blood Pressure Really Elevated?

A 46-year-old man who has recently moved to your neighborhood presents with a painful ankle sprain. Before he leaves, you decide to check his blood pressure (BP) and obtain an initial reading of 164/102 mm Hg. He denies having high BP previously.

Why Is Accurate BP Measurement Important?

Elevated arterial BP, or hypertension, is important because it is common, it is clinically silent, it leads to cardiovascular disease (CVD), and it decreases life expectancy. Because surveys find that approximately 20%1, 2, and 3 of North American adults have an elevated BP (systolic BP [SBP] ≥ 140 mm Hg or diastolic BP [DBP] ≥ 90 mm Hg) or are taking antihypertensive medication, physicians are advised to check all patients periodically for BP elevation.3, 4, 5, 6, and 7 On the other hand, overestimation of BP can erroneously label people as hypertensive and potentially result in unnecessary dietary restrictions, exposure to adverse effects from drug treatment, medication expense, and adverse socioeconomic ...

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