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Additional diagnostic studies are indicated only if the clinical presentation or routine tests suggest secondary or complicated hypertension These may include tests such as 24-hour urine free cortisol, plasma metanephrines and the plasma aldosterone/renin ratio for endocrine causes of hypertension, renal ultrasound to diagnose primary renal disease (polycystic kidneys, obstructive uropathy), and testing for renal artery stenosis Further evaluation may include abdominal imaging studies (ultrasound, CT scan, or MRI) or renal arteriography
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Since most hypertension is primary, few studies are necessary beyond those listed above If conventional therapy is unsuccessful or if symptoms suggest a secondary cause, further studies are indicated
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Lifestyle modification may have an impact on morbidity and mortality A diet rich in fruits, vegetables, and low-fat dairy foods and low in saturated and total fats (DASH diet) has been shown to lower blood pressure Additional measures, listed in Table 11 3, can prevent or mitigate hypertension or its cardiovascular consequences All patients with high-normal or elevated blood pressures, those who have a family history of cardiovascular complications of hypertension, and those who have multiple coronary
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Recommended testing includes the following: hemoglobin; urinalysis and renal function studies, to detect hematuria,
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medication is likely to be required for optimal blood pressure control in stage 1 hypertension
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Elmer PJ et al; PREMIER Collaborative Research Group Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial Ann Intern Med 2006 Apr 4;144(7):485 95 [PMID: 16585662] Stewart KJ et al Effect of exercise on blood pressure in older persons: a randomized controlled trial Arch Intern Med 2005 Apr 11;165(7):756 62 [PMID: 15824294] Swift PA et al Modest salt reduction reduces blood pressure and urine protein excretion in black hypertensives: a randomized control trial Hypertension 2005 Aug;46(2):308 12 [PMID: 15983240]
Table 11 3 Lifestyle modifications to manage hypertension1
Approximate Systolic BP Reduction, Range 5 20 mm Hg/10-kg weight loss 8 14 mm Hg
Modification Weight reduction
Recommendation Maintain normal body weight (BMI, 185 249) Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated fat and total fat Reduce dietary sodium intake to no more than 100 mEq/L (24 g sodium or 6 g sodium chloride) Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week) Limit consumption to no more than two drinks per day (1 oz or 30 mL ethanol [eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey]) in most men and no more than one drink per day in women and lighter-weight persons
Adopt DASH eating plan
Dietary sodium reduction
2 8 mm Hg
Who Should Be Treated with Medications
The decision to initiate drug therapy is relatively straightforward once hypertension has been unequivocally diagnosed (Table 11 1 and Figure 11 1), but less clear in persons with prehypertension (blood pressure of 120 139/80 89 mm Hg) Some experts have suggested that early blood pressure elevation, and perhaps antecedent metabolic abnormalities, lead to vascular damage that propels further blood pressure elevation in an ever accelerating spiral of progression If so, then interception early in the course might modify the natural history of the disease, leading to diminished requirements for multiple antihypertensive agents and, perhaps, a much more dramatic effect on cardiovascular risk than can be attained with initiation of treatment once hypertension is established In beginning to address this question, the TROPHY study showed that treatment of prehypertension in a population at no particular risk for cardiovascular events only seemed to delay the onset of hypertension, since blood pressure in the treated group increased toward the placebo group when treatment was discontinued The situation is a little clearer in nonhypertensive patients at elevated cardiovascular risk, in whom the HOPE and PROGRESS trials indicated improved outcomes with antihypertensive medication (ACE inhibitor and ACE inhibitor plus diuretic, respectively) These observations have prompted some to think in terms of optimizing blood pressure to a suggested 120/80 mm Hg However, the public health consequences of recommendations to treat prehypertension would be enormous Forty-eight percent of all Americans have hypertension or prehypertension, and much higher proportions fit these categories in a typical family medicine population The JNC 7 guidelines suggest that antihypertensive medications be offered to persons with prehypertension with compelling indications for treatment such as chronic kidney disease or diabetes mellitus (Table 11 4) According to the British Hypertension Society (BHS) recommendations, risk analysis should be used to target treatment to patients with borderline hypertension who are most likely to benefit, particularly individuals at high combined risk of coronary heart or stroke event (> 20 30% within 10 years) (Figure 11 2) Risk is calculated according to Framingham study criteria (calculated from several of the risk factors listed in Table 11 5) A low-risk patient with blood pressure between 120 139/80 89 mm Hg may be advised to make lifestyle
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