The Specialist Forum Volume 13 No 11 November 2013

HYPERTENSION Stratification of total CV risk Blood pressure (mmHg) Other risk factors (RF), asymptomatic organ damage or disease High/ normal SPB 130139 or DBP 85-89 Grade I HT SBP 140159 or DBP 90-99 Grade 2 HT SBP 160-179 or DBP 100-109 Grade 3 HT SBP >180 or DBP ?110 High risk No other RF Low risk Moderate risk One to two RF Low risk Moderate risk Moderate High risk to high risk >3 RF Low to moderate risk Moderate High risk to high risk High risk Organ damage, CV, chronic kidney disease Moderate High risk (CKD) stage <4 to high risk or diabetes with OD/RFs High risk Symptomatic CVD, CKD, stage ?4 or diabetes with OD/RF Very high risk Very high risk Very high risk High risk to very high risk Very high risk In asymptomatic subjects with hypertension but free of CVD, CKD and diabetes, total CV risk stratification using the Score model is recommended as a minimum requirement As there is evidence that OD predicts CV death independently of Score, it is recommended a search for OD should be considered, particularly in individuals at moderate risk It is recommended that decisions on treatment strategies depend on the initial level of total CV risk Signs of organ damage • Brain: motor or sensory defects • Retina: fundoscopic abnormalities • Heart: heart rate, third or fourth heart sound, heart murmurs, arrhythmias, location of apical impulse, pulmonary rales, peripheral oedema • Peripheral arteries: absence, reduction, or asymmetry of pulses, cold extremities, ischaemic skin lesions • Carotid arteries: systolic murmurs. Evidence of obesity • Weight and height • Calculate BMI: body weight/height2 (kg/m2) • Waist circumference measured in the standing position, at a level midway between the lower border of the costal margin. Summary of recommendations: BP measurement, history and physical examination Recommendation Summary of recommendations: Total CV risk assessment Recommendation • Auscultation of precordial or chest murmurs (aortic coarctation; aortic disease; upper extremity artery disease) • Diminished and delayed femoral pulses and reduced femoral blood pressure compared to simultaneous arm BP (aortic coarctation; aortic disease; lower extremity artery disease) • Left–right arm BP difference (aortic coarctation; subclavian artery stenosis). Class Level I IIa I B B B Diagnostic evaluation The evaluation of a patient with hypertension should be used to: • Confirm the diagnosis • Detect causes of secondary hypertension • Assess CV risk, OD and concomitant clinical conditions. Evaluation should include office or clinic BP, out-of-office blood pressure, central blood pressure measurements, a thorough physical examination, a detailed medical family history and laboratory tests. Physical examination for secondary hypertension, organ damage and obesity Signs suggesting secondary hypertension • Features of Cushing syndrome • Skin stigmata of neurofibromatosis (pheochromocytoma) • Palpation of enlarged kidneys (polycystic kidney) • Auscultation of abdominal murmurs (renovascular hypertension) It is recommended to obtain a comprehensive medical history and physical examination in all patients with hypertension to verify the diagnosis, detect causes of secondary hypertension, record CV risk factors, and to identify OD and other CVDs I C Obtaining a family history is recommended to investigate familial predisposition to hypertension and CVDs I B Office BP is recommended for screening and diagnosis of hypertension Class Level I B It is recommended that the diagnosis of hypertension be based on at least two BP measurements per visit and on at least two visits I C It is recommended that all hypertensive patients undergo palpation of the pulse at rest to determine heart rate and to search for arrhythmias, especially atrial fibrillation B Out-of-office BP should be considered to confirm the diagnosis of hypertension, identify the type of hypertension, detect hypotensive episodes, and maximise prediction of CV risk IIa B For out-of-office BP measurements, ABPM or HBPM may be considered depending on indication, availability, ease, cost of use and, if appropriate, patient preference IIb C Recommended laboratory tests(Table) Routine tests • Haemoglobin and/or haematocrit • Fasting plasma glucose Page 12 November 2013 | Cardiology & Stroke Forum

The Specialist Forum Volume 13 No 11 November 2013 | Page 70