Initial diagnostic evaluation of hypertension

A. 12 lead electrocardiography may document evidence of ischemic heart disease, rhythm and conduction disturbances, or left ventricular hypertrophy.

B. Screening labs include a complete blood count, glucose, potassium, calcium, creatinine, BUN, and a fasting lipid panel.

C. Urinalysis. Dipstick testing should include glucose, protein, and hemoglo-

bin.

D. Selected patients may require plasma renin activity, 24 hour urine catecholamines, or renal function testing (glomerular filtration rate and blood flow).

III. Secondary hypertension

A. Only 1-2% of all hypertensive patients will prove to have a secondary cause of hypertension. Age of onset greater than 60 years, age of onset less than 20 in African-American patients, or less than 30 in white patients suggests a secondary cause. Blood pressure that is does not respond to a three-drug regimen or a sudden acceleration of blood pressure suggests secondary hypertension.

B. Hypokalemia (potassium <3.5 mEq/L while not taking diuretics) suggests primary aldosteronism. Cushingoid features suggests Cushing's disease. Spells of anxiety, sweating, or headache suggests pheochromocytoma.

C. Aortic coarctation is suggested by a femoral pulse delayed later than the radial pulse, or by posterior systolic bruits below the ribs. Renovascular stenosis is suggested by paraumbilical abdominal bruits.

D. Pyelonephritis is suggested by persistent urinary tract infections or costovertebral angle tenderness. Renal parenchymal disease is suggested by an increased serum creatinine >1.5 mg/dL and proteinuria.

Evaluation of Secondary Hypertension

Renovascular Hypertension

Captopril Test: Plasma renin level before and 1 hr after captopril 25 mg. A greater than 150% increase in renin is positive Captopril Renography: Renal scan before and after

25 mg MRI angiography Arteriography (DSA)

Hyperaldosteronism

Serum potassium

Serum aldosterone and plasma renin activity CT scan of adrenals

Pheochromocytoma

24 hr urine catecholamines CT scan

Nuclear MIBG scan

Cushing's Syndrome

Plasma cortisol

Dexamethasone suppression test

Hyperparathyroidism

Serum calcium

Serum parathyroid hormone

IV. Non-pharmacologic treatment of hypertension A. Lifestyle modification

1. The mean drop in blood pressure with lifestyle modification is 9 mm Hg. Weight loss, in the range of 10 pounds, can lead to a significant reduction in blood pressure. Exercise should consist of a minimum of 30 minutes of brisk walking, 3 times per week. Limitation of liquor to 2 oz a day has been shown to reduce blood pressure.

2. Sodium intake should be limited to 2 gm per day by omitting high sodium foods, salt seasoning, and prepackaged fast-foods.

3. Smoking cessation is recommended in patients who smoke.

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