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PATIENT CASE

A 52-year-old Caucasian man presents for an annual physical examinaion. He complains of fatigue and daytime sleepiness. He has a sedentary job and a long daily commute. He eats fast food once a day. He drinks 2 to 3 bottles of beer most nights. His past medical history is significant for essential hypertension and hypercholesterolemia. His medications include lisinopril 10 mg daily, hydrochlorothiazide 25 mg daily, and atorvastatin 40 mg daily. His cardiovascular review of systems is negative.

His body mass index is 33. He has a pulse rate of 82 and a seated blood pressure of 148/92 mm Hg. Neck size is 18 inches. His cardiac and pulmonary examinations are normal and he has no pitting edema in the lower extremities.

  1. What lifestyle modification issues should be discussed?

  2. What additional diagnostic information is needed?

  3. Are changes to his medications indicated at this time?

EPIDEMIOLOGY

Hypertension (HTN) is defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. Hypertensive heart disease is the response of the heart to elevated arterial pressure and peripheral vascular resistance. There is an increase in afterload on the left ventricle. There are several cardiac manifestations of this, including left ventricular hypertrophy (LVH), cardiac dysrhythmias, ischemic heart disease, and congestive heart failure (CHF).

The prevalence of HTN in the United States is estimated to be 29%. The prevalence among Americans older than age 60 years is 65%. HTN is more common in non-Hispanic black adults, who are 40% to 50% more likely to have HTN. There is no difference in prevalence between women and men. The rate of control of diagnosed HTN in the United States has been improving. The rate of control was 31.5% in the year 2000 and is now 54%. The Healthy People 2020 target is 61.2% controlled by the year 2020.1

Resistant HTN is defined as a blood pressure above goal in spite of concurrent use of 3 antihypertensive medications of different classes. One of those medications should be a diuretic, and all should be at optimal doses. If a patient’s blood pressure is controlled on 4 or more medications, then that patient is still considered to have treatment-resistant HTN. Some patient factors associated with resistant HTN are older age, obesity, excessive dietary sodium intake, chronic kidney disease, diabetes mellitus, black race, and female sex.

ETIOLOGY AND PATHOPHYSIOLOGY

Blood pressure = Cardiac output × Peripheral resistance

Blood pressure is a function of cardiac output and peripheral resistance. An increasing cardiac output or an increase in peripheral resistance will lead to an increase in blood pressure. The pathogenesis of essential HTN is multifactorial and complex. Excessive dietary sodium or renal sodium retention results in increased intravascular fluid volume and elevated blood pressure. An increase in sympathetic nervous system activity will ...

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