The AHA Guidelines and Scientifi c Statements Handbook
the medical history, physical examination, routine
laboratory tests, and other diagnostic procedures.
The physical examination should include an
appropriate measurement of BP, with verifi cation
in the contralateral arm; examination of the optic
fundi; body mass index calculated as weight in kilo-
grams divided by the square of height in meters
(measurement of waist circumference also may be
useful); auscultation for carotid, abdominal, and
femoral bruits; palpation of the thyroid gland; thor-
ough examination of the heart and lungs; examina-
tion of the abdomen for enlarged kidneys, masses,
bruits, and abnormal aortic pulsation; palpation of
the lower extremities for edema and pulses; and a
neurological assessment.Laboratory tests and other diagnostic
procedures
Routine laboratory tests recommended before initiat-
ing therapy include an electrocardiogram; urinalysis;
hematocrit; serum potassium, creatinine (or the esti-
mated glomerular fi ltration rate), and calcium; and
blood glucose and a lipid profi le (after a 9–12 hour
fast) that includes total cholesterol, high-density lipo-
protein cholesterol, low-density lipoprotein choles-
terol, and triglycerides. Optional tests include
measurement of urinary albumin excretion or
albumin/creatinine ratio. More extensive testing for
identifi able causes is not indicated generally unless BP
control is not achieved.Treatment
In patients with hypertension with diabetes, chronic
kidney disease, coronary artery disease, coronary
artery disease equivalents, or a Framingham
Risk score of ≥10% in 10 years, the BP goal is
≤130/80 mm Hg [4,6,7]. In hypertensive patients
with none of these indications, the goal is
<140/90 mm Hg. The European guidelines [9] are
essentially in agreement with these recommenda-
tions: BP should be lowered to <140/90 mm Hg, but
to lower values if tolerated. The European target is
also <130/80 mm Hg in diabetics, “or in high or very
high-risk patients” such as those with associated
conditions (renal disease, stroke, myocardial
infarction).Table 11.3 Identifi able causes of secondary hypertension
Sleep apnea
Drug-induced or drug-related
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushing syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease
Reproduced, with permission, from Chobanian et al. (2003) [2].
Table 11.4 Hypertension target-organ damage
Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy
Reproduced, with permission, from Chobanian, et al. (2003) [2].
Table 11.5 Major cardiovascular risk factors
Hypertension†
Cigarette smoking
Obesity (BMI ≥30)†
Physical inactivity
Dyslipidemia†
Diabetes mellitus†
Microalbuminuria or estimated GFR <60 mL/min
Age (>55 years for men, >65 years for women)
History of premature cardiovascular disease in fi rst degree relatives
(men <55 years or women <65 years)
BMI, Body mass index calculated as weight in kilograms divided by the square
of the height in meters.
GFR, Glomerular fi ltration rate.
† Components of the metabolic syndrome.
Reproduced, with permission, from Chobanian, et al. (2003) [2].