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Like symptoms, physical findings depend on the cause of hypertension, its duration and severity, and the degree of effect on target organs 1 Blood pressure Blood pressure is taken in both arms and, if lower extremity pulses are diminished or delayed, in the legs to exclude coarctation of the aorta An orthostatic drop is present in pheochromocytoma Older patients may have falsely elevated readings by sphygmomanometry because of noncompressible vessels This may be suspected in the presence of Osler s sign a palpable brachial or radial artery when the cuff is inflated above systolic pressure Occasionally, it may be necessary to make direct measurements of intra-arterial pressure, especially in patients with apparent severe hypertension who do not tolerate therapy 2 Retinas Narrowing of arterial diameter to less than 50% of venous diameter, copper or silver wire appearance, exudates, hemorrhages, or papilledema are associated with a worse prognosis 3 Heart A left ventricular heave indicates severe or longstanding hypertrophy Aortic insufficiency may be auscultated in up to 5% of patients, and hemodynamically insignificant aortic insufficiency can be detected by Doppler echocardiography in 10 20% A presystolic (S4) gallop due to decreased compliance of the left ventricle is quite common in patients in sinus rhythm 4 Pulses Radial-femoral delay suggests coarctation of the aorta; loss of peripheral pulses occurs due to atherosclerosis, less commonly aortic dissection, and rarely Takayasu arteritis, all of which can involve the renal arteries

Additional diagnostic studies are indicated only if the clinical presentation or routine tests suggest secondary or complicated hypertension These may include tests such as 24-hour urine free cortisol, plasma metanephrines and the plasma aldosterone/renin ratio for endocrine causes of hypertension, renal ultrasound to diagnose primary renal disease (polycystic kidneys, obstructive uropathy), and testing for renal artery stenosis Further evaluation may include abdominal imaging studies (ultrasound, CT scan, or MRI) or renal arteriography

Since most hypertension is primary, few studies are necessary beyond those listed above If conventional therapy is unsuccessful or if symptoms suggest a secondary cause, further studies are indicated

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Lifestyle modification may have an impact on morbidity and mortality A diet rich in fruits, vegetables, and low-fat dairy foods and low in saturated and total fats (DASH diet) has been shown to lower blood pressure Additional measures, listed in Table 11 3, can prevent or mitigate hypertension or its cardiovascular consequences All patients with high-normal or elevated blood pressures, those who have a family history of cardiovascular complications of hypertension, and those who have multiple coronary

Recommended testing includes the following: hemoglobin; urinalysis and renal function studies, to detect hematuria,

Elmer PJ et al; PREMIER Collaborative Research Group Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial Ann Intern Med 2006 Apr 4;144(7):485 95 [PMID: 16585662] Stewart KJ et al Effect of exercise on blood pressure in older persons: a randomized controlled trial Arch Intern Med 2005 Apr 11;165(7):756 62 [PMID: 15824294] Swift PA et al Modest salt reduction reduces blood pressure and urine protein excretion in black hypertensives: a randomized control trial Hypertension 2005 Aug;46(2):308 12 [PMID: 15983240]

Recommendation Maintain normal body weight (BMI, 185 249) Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated fat and total fat Reduce dietary sodium intake to no more than 100 mEq/L (24 g sodium or 6 g sodium chloride) Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week) Limit consumption to no more than two drinks per day (1 oz or 30 mL ethanol [eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey]) in most men and no more than one drink per day in women and lighter-weight persons

The contract has its configuration settings maintained in the same manner as a standard sales document Use the following menu path

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