Hypertension Initial Assessment

History

During the primary care visit, it is important to take a good history and physical examination. History should be taken with an emphasis on hypertension, diabetes mellitus, dyslipidemia, premature coronary heart disease, stroke, or renal disease.  

The level and duration of elevated blood pressure, the usual range of blood pressure, current or past antihypertensive medications, and history of adherence to treatment should all be known.   

Symptoms of secondary causes of hypertension (eg sweating, headache, and palpitations in pheochromocytoma; muscle weakness and tetany in hyperaldosteronism; hypersomnolence and snoring in obstructive sleep apnea; heat intolerance, weight loss, and palpitations in hyperthyroidism; fatigue, edema, and frequent urination in kidney disease or failure) should also be noted.   

Lifestyle and environmental evaluation should be done. It includes dietary intake of fat, salt and alcohol, physical activity, smoking status, weight gain since young adulthood. Medication history of prescribed and over-the-counter medications, use of herbal supplements and illicit drugs should also be taken into account in history taking.  

Any history or current symptoms of target organ damage (TOD) (eg coronary heart disease, cerebrovascular disease, cognitive dysfunction) should be taken note of since the association between blood pressure and cardiovascular disease (CVD) in Asians is stronger than in Westerners with stroke (eg hemorrhagic stroke). Nonischemic heart failure is a common end result of hypertension-related CVD.   

The history or current symptoms of concomitant diseases (eg diabetes mellitus, renal diseases, gout, urinary tract infection, thyroid disease, etc.) which may affect prognosis should also be noted in the history. Family history of high blood pressure or hypertension, stroke, diabetes, CVD, coronary heart disease, renal disease, and dyslipidemia should also be known. History of hypertension in pregnancy or pre-eclampsia should be sought.  

Other important information that should be obtained during history-taking occupational history such as frequent travels or long trips, time changes, medication schedule, prevention of complications, and many more.  

Physical Examination

A complete physical examination should be done which includes: 

• Appropriate blood pressure measurement with verification on the contralateral arm
• Calculation of body mass index (BMI) and waist circumference since the risk for metabolic syndrome or for type 2 diabetes mellitus is high when the waist circumference is >102 cm in men or >88 cm in women
• Heart rate (patient at rest) to search for arrhythmias, respiratory rate, and temperature
• Examination of optic fundi
• Auscultation for carotid, abdominal, and femoral bruits
• Thorough examination of the heart and lungs; palpation of the thyroid gland
• Examination of the abdomen for truncal obesity, enlarged kidneys, masses, distended urinary bladder, and abnormal aortic pulsation
• Palpation of the lower extremities for edema and pulses with the determination of the ankle-brachial index (ABI)
• Neurological and mental status assessment

Screening

Clinical or Office Blood Pressure Measurement  

Blood pressure is measured at least annually in individuals who are ≥18 years old but more frequently in those at moderate or high risk of vascular diseases.   

The patient should be seated comfortably for >5 minutes in a chair, with back supported, feet on the floor, and arm supported at heart level prior to measurement of blood pressure. The measurement of blood pressure in the standing position is recommended for patients at risk of postural hypotension, patients with diabetes, and at the first visit of elderly patients.   

Two to three measurements should be taken, spaced by 1-2 minutes. Take the measurements from sitting, lying, and standing (usually after 1 minute) positions to take note of drops in blood pressure. A difference of >15 mmHg between the two arms suggests arterial problems and requires further investigation.  

A cuff with a bladder of 12-13 cm wide and 35 cm long should be used and placed at the heart level of the patient. Wider cuffs (>32 cm circumference) are needed for large arms whereas smaller cuffs (<26 cm circumference) are for thin arms¹. The bladder length should encircle at least 80% of the arm while the width should be at least 40% of the arm circumference.   

Use the appearance of the phase I Korotkoff’s sounds for systolic blood pressure (SBP) and the disappearance of phase V for diastolic blood pressure (DBP).  

¹Please also refer to the Recommended Cuff Sizes Table under Non-pharmacological Therapy.    

Confirmation of Hypertension  

In general, the diagnosis of hypertension is confirmed by taking the blood pressure 1-4 weeks after the first measurement or the average of readings on ≥2 occasions or visits. A substantially elevated blood pressure requires a shorter interval between visits, depending on the degree of blood pressure elevation, and the presence of CVD or target organ damage.  

Out-of-Office Blood Pressure Measurement

Out-of-office blood pressure measurement is recommended for the confirmation of hypertension diagnosis.   

Ambulatory Blood Pressure Monitoring (ABPM) is the preferred method as it automatically measures the patient’s blood pressure at regular intervals over a 24-hour period. Its advantages include the detection of masked or white coat hypertension, determination of nocturnal blood pressure patterns, confirmation of borderline hypertension or abnormal home blood pressure monitoring results, and evaluation of the impact of antihypertensive treatments.   

Home Blood Pressure Monitoring (HBPM) is the self-measurement of blood pressure for over 5-7 days, possibly in duplicate measurements. It may also be used to screen for masked or white coat hypertension. It may be performed in individuals with high normal blood pressure or an office blood pressure of 130-139/85-89 mmHg to detect masked hypertension. It is useful in improving hypertension awareness, improving diagnostic accuracy, determining cardiovascular risk in patients with hypertension, evaluating treatment efficacy, and improving treatment compliance and adherence. It is the basis for initiating and adjusting blood pressure control treatment in telemedicine. Its main disadvantages are the possible errors in measurement and that there are no nocturnal blood pressure readings.  

In Asians, out-of-office blood pressure management includes focusing initially on the morning blood pressure and then the nocturnal blood pressure. Morning hypertension confers cardiovascular risk independent of the 24-hour ambulatory blood pressure. It may be controlled with the use of long-acting antihypertensive agents given in appropriate, often in full doses, and in proper combinations. Bedtime dosing may be considered if morning blood pressure is not controlled.  The detection and management of masked and masked uncontrolled hypertension are important parts of hypertension treatment.