Advances in the Diagnosis and Treatment of Hypertension
By George A. Mansoor, M.D., and William B. White, M.D.
Diagnosis
Hypertension (or high blood pressure) is a serious public health
problem worldwide but especially in the United States and other
more developed countries. Because hypertension rarely causes
specific symptoms, it is not identified until an individual’s
blood pressure is measured by a physician or it causes a
catastrophic complication such as stroke or heart attack.
Accurate diagnosis by blood pressure measurement is
essential. However, current methods of quickly checking blood
pressure in a physician’s office may be fraught with
inaccuracies. Unfortunately, many patients will be identified as
1) having a diagnosis of hypertension when they do not or 2)
having a diagnosis of normal blood pressure when they are in
fact, hypertensive. As a result, some patients may be given
medication that provides no benefit while other patients may
fail to obtain the medication they need.
We feel that the best way to accurately measure blood
pressure is to obtain an average over an entire day by using a
combination of readings obtained in the office and outside the
office. This method is called ambulatory blood pressure
monitoring. The out-of-office readings are obtained through the
use of portable blood pressure devices that are accurate and
relatively inexpensive. The monitor cuff is won on the upper arm
for a 24-hour period and uses a small microchip to record blood
pressure readings during daytime activity and during sleep.
Assessment of Hypertension Related Damage
Hypertension and many other risk factors for the development of
cardiovascular diseases (such as high cholesterol) cause
widespread damage to blood vessels and promote and accelerate
atherosclerosis. Serious complications of hypertension include
stroke, heart attack, kidney failure leading to dialysis,
congestive heart failure, cardiac rhythm disturbances, and poor
circulation to the legs. Fortunately, most of these
complications can be prevented by timely and effective
treatment.
Goals of Antihypertensive Treatment
Treatment must be viewed within the context of a secure
physician and patient relationship. The physician provides
diagnosis, knowledge and expertise in treatment and monitoring.
The patient follows a treatment program recommended by the
physician and reports side effects or problems if they occur.
Despite many studies aiming to show that one drug for
hypertension is superior to another, it is clear the primary
initial aim of treatment is to lower blood pressure to a normal
level using whatever combination of drugs that achieve this
goal. Drug selection will be determined largely by
individual patient needs, including the presence of any
coexisting illness. Other important factors are tolerability and
cost. Nevertheless most patients with hypertension can be
managed using this approach. Commonly, two or three drugs will
be needed in combination to control high blood pressure. The
actual target of treatment may vary from 120/70 to 135/85 mmHg
depending on the individual.
All drug treatment for hypertension must be coupled with
aggressive changes in lifestyle in order to comprehensively
manage all risk factors. Important changes that should be made
include reducing dietary sodium, losing weight if necessary,
reducing alcohol intake if excessive and increasing aerobic
exercise.
The management of the patient with persistent high blood
pressure – the role of the hypertension specialist
For about one out of five patients, the desired level of
blood pressure may not be achieved even though they are taking
two to three medications for high blood pressure,. These
patients need additional investigation, including a review of
current treatments, medications and lifestyle. Our experts in
the management of hypertension and related vascular diseases at
the Pat and Jim Calhoun Cardiology Center can provide a resource
for physicians throughout Connecticut by evaluating these
patients. Not uncommonly, an internal cause of high blood
pressure is discovered in these patients and corrective
treatment may be offered. For example, if a patient has a
narrowed artery to the kidney, a balloon angioplasty procedure
can be performed to alleviate the blockage and restore blood
flow. This procedure often is associated with improvement in
blood pressure control. Other patients can be offered more
physiological and pharmacological treatments directed at the
cause of the hypertension. For example, we often make a
diagnosis of a condition called primary aldosteronism which can
be treated with specific drugs to block the effect of the
adrenal gland hormone. The treatment can lead to remarkable
improvements in blood pressure control.
Selected Articles and Books from the Hypertension
Specialists of the Pat and Jim Calhoun Cardiology Center
White WB. Blood Pressure Monitoring in Cardiovascular
Medicine and Therapeutics. Humana Press Ltd, Totowa, NJ,
2001.
Mansoor GA. Secondary Hypertension: Clinical Presentation,
Diagnosis, and Treatment. Humana Press Ltd, Totowa, NJ 2004.
White WB. Ambulatory blood pressure monitoring in clinical
practice. New England Journal of Medicine 2003; 348:
2377-2378.
White WB. Hypertension associated with therapies to treat
arthritis and pain. Hypertension. 2004;44(2):123-4.
Bansal N, Tendler BE, White WB, Mansoor GA. Blood pressure
control in the hypertension clinic. American Journal of
Hypertension 2003;16 (10):878-80. |
