General Appearance: Note body habitus, fat distribution (central obesity?), skin lesions (striae?), signs of distress.
Vital Signs & Anthropometry:
Blood Pressure: Measure in both arms, seated, appropriate cuff size, after 5 min rest. Repeat measurement. Consider standing BP if symptoms suggest postural hypotension (though not typical here).
Explain the diagnosis: Based on readings (e.g., “Your blood pressure readings of 160/100 put you in Stage 2 Hypertension”).
Explain what hypertension is: A persistent elevation of BP, often asymptomatic (“silent killer”).
Explain the risks: Increased risk of heart attack, stroke, kidney disease, eye problems if untreated.
Address the patient’s concern about MI. Validate the concern given family history but explain treatment reduces this risk.
Address the patient’s question: Explain why medication is needed even without symptoms – to prevent future complications.
Reassure it’s common and manageable.
Risk Assessment: Briefly explain that factors like age, family history, smoking, and the BP level itself contribute to overall cardiovascular risk.
Advice / Agree on Plan / Shared Decision Making:
Explain the management options involve lifestyle changes and usually medication at this stage.
Encourage the patient to participate in decisions. Check understanding and agreement.
Prescription / Pharmacological Management:
Indication: Explain that Stage 2 HTN (≥160/100) generally requires medication alongside lifestyle changes.
Choice: Discuss initial options. Common strategies for Stage 2 include starting two drugs at low dose OR starting one drug and titrating/adding quickly if needed. Classes include:
ACE inhibitor (e.g., Ramipril) or ARB (e.g., Losartan) - often good first-line.
(Beta-blockers generally not first-line unless specific indication like post-MI or heart failure).
Counseling: Explain the chosen medication(s), how they work simply, potential side effects (common ones), importance of adherence, that they don’t cure but control HTN.
Investigations: Explain the purpose of the ordered tests (baseline health, check for causes/damage, guide treatment). Address patient’s question about needing investigations.
Stress Management: Discuss techniques if stress is a factor.
Plan / Follow-Up:
Schedule a follow-up appointment, e.g., in 2-4 weeks, to:
Review BP measurements (encourage home monitoring if possible).
Check results of investigations.
Assess medication tolerance/side effects.
Monitor adherence.
Reinforce lifestyle advice.
Explain the need for long-term monitoring and management.
Safety Netting / Referral:
Advise patient on when to seek urgent medical attention (e.g., symptoms of chest pain, stroke).
Mention indications for specialist referral (see below), though likely not needed initially unless investigations reveal secondary cause or BP is resistant.
Referral Indications
Resistant hypertension (uncontrolled on 3+ drugs including a diuretic).
Educate patient on importance and risks of non-adherence.
Use reminders (pill boxes, apps).
Involve family if appropriate.
Address side effects promptly.
Regular follow-up and reinforcement.
HTN Knowledge Base
Definitions & Classification
Hypertension Definition: Persistent SBP and/or DBP levels above which harm and increased morbidity/mortality occur if untreated.
Stages (based on Clinic BP):
Stage 1: 140/90 to 159/99 mmHg (or ABPM/HBPM average 135/85 to 149/94 mmHg).
Stage 2: 160/100 to 179/119 mmHg (or ABPM/HBPM average ≥150/95 mmHg).
Stage 3 (Severe): Clinic BP ≥180 mmHg systolic or ≥120 mmHg diastolic.
Elevated BP: 120-129 mmHg systolic AND <80 mmHg diastolic.
Blood Pressure Measurement
Standardized Technique: Requires attention to patient (rested, seated, arm supported), equipment (validated device, correct cuff size), and examiner technique.
Home Blood Pressure Monitoring (HBPM): Used for diagnosis and monitoring. Average ≥135/85 mmHg considered elevated. Typically duplicate readings, morning/evening, for 7 days (discard first day).
Ambulatory BP Monitoring (ABPM): 24hr monitoring (e.g., every 15-30 mins awake, 30-60 mins asleep). Better predictor of CV risk than office BP. Normal average daytime <135/85 mmHg. Indications include suspected white coat/masked HTN, resistance, nocturnal HTN suspicion, assessing variability, high-risk patients, etc.
Specific HTN Types
Isolated Systolic HTN: SBP ≥140 mmHg and DBP <90 mmHg. (Common in elderly; Thiazides or CCBs often preferred).
White Coat HTN: Elevated BP in clinic, normal outside (diagnosed via HBPM/ABPM).
Masked HTN: Normal BP in clinic, elevated outside (diagnosed via HBPM/ABPM).
Resistant HTN: BP above target despite 3+ drugs (including a diuretic) at optimal doses, OR controlled BP requiring 4+ drugs. Management involves confirming adherence, ruling out secondary causes, optimizing diuretic (e.g., chlorthalidone/indapamide), considering aldosterone antagonists (spironolactone).
Postural Hypotension: Systolic BP fall ≥20 mmHg (or diastolic ≥10 mmHg) on standing. Review meds, measure standing BP, consider referral if persistent symptoms.
Screening recommended for all adults ≥18 years. Frequency depends on initial BP and risk factors (e.g., annually if higher risk or BP near threshold, every 3-5 years if low risk and normal BP).
Screen individuals with risk factors (obesity, DM, family hx), pregnant women, those with suggestive symptoms or related conditions (CVD, CKD).