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Hypertension

Diagnosis of hypertension

The evaluation of a patient with elevated BP requires more than the diagnosis of hypertension. It should also include the assessment of the CVD risk, target-organ damage and concomitant clinical conditions that could affect the BP or related target-organ damage, as well as recognition of features suggestive of secondary hypertension1.

The Taiwan Hypertension Society (THS) and the Taiwan Society of Cardiology (TSOC) recommend the “722” principle to obtain reliable HBP measurement to confirm the diagnosis of hypertension and guide the adjustment of antihypertensive medications2. That is, high BP should be measured for “7” (at least 4) consecutive days, in the morning (taken within 1 hour after awakening, but before taking food and medication) and the evening (within 1 hour before bedtime) (“2” occasions), and with ≥ “2” (≥ 3, if atrial fibrillation is present) BP readings, 1-min apart, on each occasion. Morning and evening high BP estimates are the averages of all morning and evening BP readings, respectively, except those obtained on the first day2.

Diagnostic criteria of hypertension according to office, home, and ambulatory blood pressure from THS and TSOC2

Blood pressure OBP, mmHg HBP, mmHg ABP, mmHg
24-hr average Daytime average Nighttime average
Systolic ≥ 140 ≥ 135 ≥ 130 ≥ 135 ≥ 120
Diastolic ≥ 90 ≥ 85 ≥ 80 ≥ 85 ≥ 70

Medical History3

Patients with hypertension are often asymptomatic, however specific symptoms can suggest secondary hypertension or hypertensive complications that require further investigation. A complete medical and family history is recommended and should include3:

  • Blood pressure: new onset hypertension, duration, previous BP levels, current and previous antihypertensive medication, other medications/over-the counter medicines that can influence BP, history of intolerance (side-effects) of antihypertensive medications, adherence to antihypertensive treatment, previous hypertension with oral contraceptives or pregnancy.
  • Risk factors: personal history of CVD (myocardial infarction, heart failure, stroke, transient ischemic attacks, diabetes, dyslipidemia, chronic kidney disease, smoking status, diet, alcohol intake, physical activity, psychosocial aspects, history of depression). Family history of hypertension, premature CVD, (familial) hypercholesterolemia, diabetes.
  • Assessment of overall cardiovascular risk: in line with local guidelines/recommendations.
  • Symptoms/signs of hypertension/coexistent illnesses: Chest pain, shortness of breath, palpitations, claudication, peripheral edema, headaches, blurred vision, nocturia, hematuria, dizziness.
  • Symptoms suggestive of secondary hypertension: Muscle weakness/tetany, cramps, arrhythmias (hypokalemia/primary aldosteronism), flash pulmonary edema (renal artery stenosis), sweating, palpitations, frequent headaches (pheochromocytoma), snoring, daytime sleepiness (obstructive sleep apnea), symptoms suggestive of thyroid disease.

Physical Examination3

A thorough physical examination can assist with confirming the diagnosis of hypertension and the identification of HMOD and/or secondary hypertension and should include3:

  • Circulation and heart: Pulse rate/rhythm/character, jugular venous pulse/pressure, apex beat, extra heart sounds, basal crackles, peripheral edema, bruits (carotid, abdominal, femoral), radio-femoral delay.
  • Other organs/systems: Enlarged kidneys, neck circumference >40 cm (obstructive sleep apnea), enlarged thyroid, increased body mass index (BMI)/ waist circumference, fatty deposits and colored striae (Cushing disease/syndrome).

Laboratory Investigations and ECG3

  • Blood tests: Sodium, potassium, serum creatinine and estimated glomerular filtration rate (eGFR). If available, lipid profile and fasting glucose.
  • Urine test: Dipstick urine test.
  • 12-lead ECG: Detection of atrial fibrillation, left ventricular hypertrophy (LVH), ischemic heart disease.

High BP monitoring2

The term “High BP monitoring” indicates measurement of own blood pressures, not exclusively by oneself, at home. HBP monitoring is referred to measurement of BP at home, usually by himself/herself, or on occasion, by caregivers or research assistants. While self-measured BP is referred to BP taken in non-medical out-of-office environments, such as at home, at a work place, at a pharmacy, or at a convenience store. High BP and self-measured BP are not entirely the same, though they are often deemed interchangeable2.

High BP monitoring is used to identify sustained hypertension, white-coat hypertension (effect), and masked (uncontrolled) hypertension. Other hypertension phenotypes, such as morning, evening, and nighttime hypertension, also predict cardiovascular risks2.

Footnotes:

  • BMI, body mass index; BP, blood pressure; CVD, cardiovascular disease; ECG, electrocardiogram; eGFR, estimated glomerular filtration rate; HBP, home blood pressure; HMOD, hypertension-mediated organ damage; LVH, left ventricular hypertrophy; OBP, office blood pressure; THS, Taiwan Hypertension Society; TSOC, Taiwan Society of Cardiology.

References:

  1. Oparil S, et al. Nat Rev Dis Primers. 2018;4:18014.

  2. Lin HJ, et al. Acta Cardiol Sin. 2020;36(6):537-561.

  3. Unger T, et al. Hypertension. 2020;75(6):1334-1357.

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