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in the clinic

Hypertension
Screening and Prevention Diagnosis Treatment Practice Improvement CME Questions
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Section Editors Christine Laine, MD, MPH David Goldman, MD Harold C. Sox, MD Physician Writers Debbie L. Cohen, MD Raymond R. Townsend, MD

The content of In the Clinic is drawn from the clinical information andeducation resources of the American College of Physicians (ACP), including PIER (Physicians’ Information and Education Resource) and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP’s Medical Education and Publishing Division and with the assistance of science writers and physicianwriters. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://pier.acponline.org and other resources referenced in each issue of In the Clinic. The information contained herein should never be used as a substitute for clinical judgment. © 2008 American College of Physicians

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ypertension affects more than 65 million people in the United States, with about 2 million new cases diagnosed annually (1, 2). Most patients have primary or essential hypertension and are likely to remain hypertensive for life. Risk factors for hypertension include a family history of hypertension, African-American ethnicity, obesity, a high sodium or alcohol intake, and a sedentarylifestyle. Treatment to control blood pressure level reduces the risk for cardiovascular, cerebrovascular, and renal outcomes of hypertension. Unfortunately, many people with hypertension do not receive optimal therapy.

H
Screening and Prevention

1. Ong KL, Cheung BM, Man YB, et al. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999-2004.Hypertension. 2007;49:69-75. [PMID: 17159087] 2. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-52. [PMID: 14656957] 3. U.S. Preventive Services Task Force. Screening for high blood pressure: U.S. Preventive Services TaskForce reaffirmation recommendation statement. Ann Intern Med. 2007;147:783-6. [PMID: 18056662] 4. Julius S, Nesbitt SD, Egan BM, et al. Feasibility of treating prehypertension with an angiotensin-receptor blocker. N Engl J Med. 2006;354:168597. [PMID: 16537662] 5. Cook NR, Cutler JA, Obarzanek E, et al. Long term effects of dietary sodium reduction on cardiovascular disease outcomes: observationalfollow-up of the trials of hypertension prevention (TOHP). BMJ. 2007;334(7599):885.

What long-term health risks are associated with hypertension? The relationship between blood pressure level and cardiovascular disease is linear, continuous, and independent of and additive to other risk factors. For persons age 40 to 70 years, each increment of either 20 mm Hg in systolic blood pressure levelor 10 mm Hg in diastolic blood pressure level doubles the risk for cardiovascular disease (CVD) across the range of blood pressure levels from 115/75 mm Hg to 185/115 mm Hg (2). When other cardiovascular risk factors, such as diabetes or chronic kidney disease, are present, the CVD risk associated with hypertension is even higher. Complications of hypertension include retinopathy, cerebrovasculardisease, ischemic heart disease, atrial fibrillation, heart failure, chronic kidney disease, and peripheral vascular disease. Should clinicians screen for hypertension? The U.S. Preventive Services Task Force recommends screening the adult general population for hypertension. It does not recommend a specific screening interval because of lack of evidence to support one (3). The Joint National...