Hypertension: asymptomatic disorder

Hypertension is an asymptomatic disorder

It is very much like hypercholesterolemia, the vast majority of patient’s who have stage I or II hypertension, cannot feel their blood pressure, despite what they tell you.The reason that hypertension is an important problem, is not because elevated blood pressure causes people to be sick, the reason it is an important problem is because it causes arterial and atherosclerosis. It is important for the same reason that hypercholesterolemia is an important problem. Caring for the patient with hypertension without caring for their other cardiovascular disease risk factors is not an adequate management of the patient. How do we answer those three issues? First, an appropriate history and these are the key questions; does the patient have a family history of essential hypertension; if the relatives, the mother, father, grandmother and two sisters had essential hypertension onset at age 43 and your patient has elevated blood pressure at age 45, it’s a genetic disorder, we know it is and the patient probably does have essential hypertension. Knowing how high the blood pressure is and how long the patient has had it is very important. The patient who has never had an elevated blood pressure, who walks into your office for the first time with an elevated blood pressure of 143/95 is very different than the patient who tells you, for 30 years my doctors have been telling me that my blood pressure is between 140 and 150/90 to 100, two very different patient’s who require very different types of evaluation. If the patient tells you they have been on antihypertensive medication, you name it, Atenolol, Procardia and it made them sick, that’s important information because that is not medicine you want to prescribe to the patient, they won’t take it, even though you might think it’s the right medicine. If the patient says, I was on hydrochlorothiazide and it lowered my blood pressure, no it didn’t make me sick, I just ran out of medicine that might be a pill you want to consider because it worked in that patient, so take advantage of the history. If patient’s main caloric intake is out of a cellophane bag, as many of our patient’s diets are, that might raise their blood pressure. American diets are highly laid in salt and some portion of patient’s with chronic hypertension have salt sensitive hypertension, maybe 30%.

The problem is, you can’t tell which patient’s have salt sensitive hypertension. So understanding the patient’s diet is important in guiding them about life style modification, reasonable life style modifications. More than four drinks of alcohol per day activates sympathetic nervous system and can cause sustained elevations in blood pressure. Really, the only symptom suggestive of secondary hypertension are pheochromocytoma, we talked about that. Vast majority of other diseases don’t cause symptoms with the exception of rare endocrinopathies which I am not going to address. Stress is an important epidemiologic feature of chronic hypertension, my own personal bias as a primary care physician, it is important for us to understand the context of our patient’s lives. If somebody is working two jobs and they have lots of stress at home, and on the job and they have elevated blood pressure, those things may well be linked. It may not be that you can fix their psychosocial or economic issues, but understanding them, I think, helps us care for the patient. If the patient is on oral contraceptives, large doses of nonsteroidal anti-inflammatory agents or appetite suppressants, those things might raise their blood pressure. Oral nasal decongestants for upper respiratory infection do not elevate blood pressure.

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