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Cardiovasculaire risicobepaling in de eerste lijnPublished by: Domus MedicaLast published: 2020Évaluation du risque cardiovasculaire en première lignePublished by: Domus MedicaLast published: 2010

Most patients diagnosed with hypertension are asymptomatic; therefore, screening is essential. Patients are usually evaluated through history, physical examination, and routine laboratory tests. The three objectives are to:

  • Assess risk factors

  • Reveal identifiable causes

  • Detect target-organ damage, including evidence of cardiovascular disease.

Clinical evaluation

History may elicit family history of hypertension or chronic coronary disease risk factors. It is important to assess overall cardiac risk burden.[1] The age of onset may be of value when considering etiology, as the proportion of secondary causes diminishes with increasing age. Patients at increased risk for essential hypertension include those over 60 years of age, or with diabetes, or of black ancestry.[3][45]​ Excess alcohol intake or lack of exercise should be documented. A thorough medication history should be taken including screening for use of oral contraceptive pills, nonsteroidal anti-inflammatory drugs, sympathomimetics, or herbal medications. Most patients are asymptomatic, but clinical indications of hyperthyroidism, hypothyroidism, or catecholamine excess (e.g., tachycardia, weight loss, sweating, or palpitations), or end-organ damage (e.g., shortness of breath, chest pain, or sensory/motor deficits), should be sought. Headache or visual changes are unusual.

The physical examination should include:[1][2][63]​​[64][65]​​

  • Office blood pressure (BP) measurement: the patient should be seated quietly for at least 5 minutes, with feet on the floor and arm supported at heart level. Caffeine, smoking, and exercise should be avoided for 30 minutes prior to measurement. An appropriately sized cuff should be used and the patient's arm should be supported (e.g., resting on a desk). The bladder should encircle at least 80% of the arm. At the first visit, BP should be recorded in both arms, using the arm that gives the higher reading for subsequent visits. Two or more measurements should be made on two or more occasions and the average recorded. Verification should be obtained in the contralateral arm. The American College of Cardiology (ACC)/American Heart Association (AHA) guideline defines hypertension as any systolic BP measurement of ≥130 mmHg or any diastolic BP measurement of ≥80 mmHg.[2] The European Society of Cardiology (ESC) and European Society of Hypertension (ESH) guidelines define hypertension as office systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg.[1][63]

  • Examination of optic fundi

  • Calculation of BMI from height and weight

  • Auscultation for possible carotid, abdominal, or femoral bruits

  • Palpation of the thyroid gland

  • Examination of the heart and lungs

  • Examination of the abdomen for enlarged kidneys, masses, distended urinary bladder, or abnormal aortic pulsation

  • Palpation of the lower extremities for edema and pulses

  • Neurologic assessment.

Physical exam may reveal end-organ damage associated with untreated hypertension: for example, retinopathy, vascular bruits, signs of congestive heart failure, evidence of aortic aneurysm (pulsatile mass/bruit), left ventricular hypertrophy (displaced point of maximal impact), or neurologic deficit(s). Absence of femoral pulses suggests coarctation of the aorta. An abdominal bruit may suggest aortic aneurysm or renal artery stenosis. Occasionally, patients may have stigmata of endocrinopathy such as Cushing disease (moon face, centripetal obesity, striae), acromegaly (acral enlargement), Graves disease (goiter, exophthalmos, pretibial myxedema), or hypothyroidism (dry skin, delayed return of deep tendon reflexes), indicating a secondary cause of hypertension.

US and European guidelines recommend the use of out-of-office BP measurement in addition to office BP measurement prior to diagnosis of hypertension, using ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), or both.[2][63]​​[66]​​​​[67]​ With ABPM, patients go about their normal daily activities wearing a monitor, and measurements are taken periodically to provide a mean BP during the monitoring period. With HBPM, the patient takes BP measurements in the morning and evening while seated and resting, and this is repeated over a period of days to provide a mean BP. Thresholds for elevated BP measured by ABPM and HBPM differ to thresholds used in the office; guidelines provide corresponding values.[1][2][63]​​[67]​ For example, according to ACC/AHA guidelines, an office BP measurement of 130/80 mmHg corresponds to home BP 130/80 mmHg, daytime ABPM 130/80 mmHg, nighttime ABPM 110/65 mmHg, and 24-hour ABPM 125/75 mmHg.[2]​ In ESH guidelines, hypertension is defined as an office BP measurement of ≥140 mmHg (systolic) and/or ≥90 mmHg (diastolic), which corresponds to mean awake ABPM ≥135 mmHg and/or ≥85 mmHg, mean asleep ABPM ≥120 mmHg and/or ≥70 mmHg, mean 24-hour ABPM ≥130 mmHg and/or ≥80 mmHg, and mean HBPM ≥135 mmHg and/or ≥85 mmHg.[63]

Auscultatory devices (e.g., mercury, aneroid) are not generally useful for HBPM because patients rarely master the required technique for BP measurement using these devices. Automated validated devices should be used instead. European guidelines also now recommend that automatic electronic devices are used for office measurement, rather than manual devices.[63]

Unattended automated office blood pressure (AOBP) is another option that has been designed to more accurately measure BP.[64] Multiple measurements are taken while the patient is alone in a quiet room, sitting with legs uncrossed, back supported, and arm supported at heart level. Depending on the device used, 3 to 6 measurements are taken over a short time period and the mean BP is calculated.[68] AOBP measures about 5 mmHg lower than research-quality BPs, and 10 to 15 mmHg lower than routine office BP measurements.[69][70]​ When using AOBP, hypertension is defined as ≥135/85 mmHg.

White-coat hypertension is suspected when BP readings in the office exceed those outside of the clinical setting. Masked hypertension is suspected when out-of-office BP measurements exceed those taken in the clinical setting. ABPM or HBPM can be used to identify these patients.[2][63]

Tests

Routine metabolic panel and lipid levels, and urine albumin to creatinine ratio are required. Serum creatinine and estimated glomerular filtration rate (eGFR) should be calculated according to the race-free Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation (formulas available with and without cystatin).[1] [ 2021 race-free CKD-EPI equations for glomerular filtration rate (GFR) Opens in new window ] ​​​​​​​​​​​​​​​​​​​​ In particular, features of metabolic syndrome (hyperglycemia, dyslipidemia) or hyperuricemia should be noted. For patients with moderate-to-severe chronic kidney disease (CKD), it is recommended to repeat serum creatinine, eGFR, and UACR at least annually to monitor disease progression.[1]​ Hemoglobin and routine urinalysis are also recommended for possible identification of causes of hypertension. An ECG should be obtained. 

Extensive testing for secondary causes of hypertension is generally not indicated, unless BP is difficult to control or clinical or routine lab data suggest identifiable secondary causes such as signs of unprovoked hypokalemia or renal insufficiency.​[2]​ Echocardiogram and carotid Dopplers may have prognostic implications, but they are not routinely recommended except as recommended by guidelines. There was increased risk of mortality and cardiovascular events in patients with increased left ventricular mass and abnormal geometric left ventricular hypertrophy on echocardiogram.[71][72]​ Increased cardiovascular events were associated with higher intima media thickness values on carotid Dopplers.[73]​ Urinary albumin to creatinine ratio is useful for evaluation of target organ damage.[2][63]

Sleep study may be considered in cases of resistant hypertension, and also for patients with signs or symptoms of obstructive sleep apnea.[46]

If secondary hypertension is suggested by history, or physical or routine laboratory testing, further testing can be performed.[1]

  • Signs/symptoms of catecholamine excess require pheochromocytoma screen.

  • Signs/symptoms of hyper- or hypothyroidism require thyroid-stimulating hormone.

  • Unprovoked hypokalemia prompts measurement of plasma renin activity/aldosterone, catecholamines, and a search for clues (such as striae) to suggest hypercortisolism.

  • Measurement of plasma aldosterone and renin is also indicated in the following situations: BP is sustained above 150/100 mmHg on 3 measurements over different days, with hypertension resistant to 3 conventional antihypertensive drugs (including a diuretic), or controlled BP (140/90 mmHg) on 4 or more antihypertensive drugs; hypertension and spontaneous or diuretic-induced hypokalemia; hypertension and adrenal incidentaloma; hypertension and sleep apnea; hypertension and a family history of early-onset hypertension or cerebrovascular accident at a young age (40 years); hypertensive first-degree relatives of patients with primary aldosteronism.[74] The 2024 ESC guidelines recommend that screening for primary aldosteronism by renin and aldosterone measurements should be considered in all adults with confirmed hypertension (BP ≥140/90 mmHg).​[1]

  • Renal artery imaging is done for young patients with difficult-to-control hypertension or who have abdominal bruits.[1] Imaging may show renal scarring or lesions.

How to perform an ECG: animated demonstration
How to perform an ECG: animated demonstration

How to record an ECG. Demonstrates placement of chest and limb electrodes.

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