Introduction

Hypertension is the number one principal diagnosis billed for an office visit in outpatient Family Practice in 2000. Individuals who are normotensive at age 55 have a 90% chance of developing hypertension in their lifetime. Lifestyle modifications (diet, exercise and alcohol moderation) aimed at both controlling HTN and preventing atherosclerotic disease are needed in every patient. Of those requiring medicines, about 25% will be controlled with monotherapy, but most patients will require two or more medications to reach the goal BP of <140/90, (<130/80 in DM and Renal disease). In patients with HTN and additional cardiac risk factors, with stage 1 HTN (140-159/90-99) achieving a sustained 12mm reduction in systolic BP for 10 years will prevent 1 death for every 11 treated. With established CVD or target organ damage, the same reduction and length will prevent 1 death for every 9 treated.

Initial workup visit:

The content of the initial workup is more extensive and contains:

History:

Special age or ethnic group

Diagnosis and duration of HTN and prior HTN workup

Present symptoms

ROS review for hints of secondary causes of HTN, about 10% of HTN, or symptoms of active target organ damage, i.e. angina, TIA

Medications, supplements, and herbals causing HTN

Lifestyle habits diet, exercise, alcohol, drugs, and tobacco

Past Medical History of target organ damage conditions

Past Medical History of causes of secondary HTN

Family History of HTN, CAD, CVA

Social History for stress, ability to afford medicines, motivational stage to adopt lifestyle changes

CV Risk factor review

Physical:

Repeat BP with proper size cuff, and both limbs and one leg

BMI, neck and waist circumference for sleep apnea and metabolic syndrome

Fundi exam for changes

Neck exam for thyroid and carotid bruits, and JVD

Lung, heart, peripheral CV exam for cardiopulmonary

Abd exam for renal or aortic bruits

Baseline Lab:

Electrolytes, BUN, Creatinine, glucose, calcium (Chem 7);

Urinalysis, microalbumin

Lipid profile after a 9-12 hour fast

ECG

Assessment:

JNC 7 categories of optimal, <120/80, prehypertension, 120-139/80-89, Stage 1 HTN, 140-159/90-99, and Stage 2 HTN ³ 160/100

JNC 7 compelling indications for medications, CHF, post MI, high risk for CAD, Diabetes, Chronic Kidney disease, CVA

Evidence of possible secondary cause of HTN needing workup

Reversible cardiac risks that need attention

Co morbidities

Plan/Patient education:

Lifestyle counsel of weight reduction, adopting the DASH eating plan, dietary sodium reduction, increased physical activity, and moderation of alcohol consumption

Medications and their possible side effects

Addressing other active cardiac risk factors

Need for lifelong treatment

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