7 How can I outline a management plan for the
patient with essential hypertension?
Aroon Hingorani
A management plan for the initial assessment, investigation and
follow up of a patient presenting with elevated blood pressure is
presented below.
INITIAL ASSESSMENT
- Measure BP*
- History (including drug and family history) and examination
- Baseline screen for secondary causes of hypertension**:
urinalysis, creatinine and electrolytes - Assessment of end-organ damage***:
ECG, fundoscopy - Assessment of other cardiovascular risk factors:
age, gender, BP, total and HDL-cholesterol
ECG-LVH, diabetes, smoking status
INSTITUTE LIFESTYLE MODIFICATIONS
- Salt(sodium restriction from 10g/d to 5g/d expect 5/3 mmHg reduction in BP)
- Alcohol(change depends on amount consumed)
- Weight(expect 1-2 mmHg BP reduction for every kg lost)
- Aerobic exercise(4/3 mmHg reduction for thrice weekly aerobic exercise)
- Smoking cessation(consider nicotine replacement)
COMPUTE CARDIOVASCULAR RISK
Use BP level and estimates of absolute and
relative cardiovascular disease risk to guide:
- Anti-hypertensive drug therapy
initial treatment with thiazide diuretic or beta blocker unless contraindicated or not tolerated - Cholesterol lowering with statins
consider aspirin
REVIEW
- Adequacy of treatment: BP and cholesterol target
- Side effects from treatment
- Lifestyle modifications
- Sitting position. Mean of 2-3 measurements over 4–6 weeks unless severity of BP dictates
earlier treatment.
** Abnormalities identified from history, examination or baseline screen dictate further investi-
gation to confirm/exclude renal parenchymal, renovascular, endocrine or other secondary
causes of hypertension.
* The presence of hypertensive retinopathy or LVH is an indication for BP lowering irrespective
of the absolute BP level.
**For references to risk calculators see Qu4, page 7.
Reference: Vallance P. CME Cardiology II. Hypertension,J Roy Coll Phys Lon1999; 33 : 119-23