Correct Diagnosis of Hypertension
To the Editor: The article titled "Practical Approach to the
Management of Hypertension in the Elderly" (October 2007)
is a good review of the importance, diagnosis, and treatment of
hypertension. However, several points in the article require
some comments. First, isolated systolic hypertension is defined
as a systolic blood pressure (BP) greater than 140 mm Hg and
a diastolic BP of less than 90 mm Hg; the article erroneously
says ">90 mm Hg." Second, hypertension is sustained elevation
in BP reading greater than 140/90 mm Hg. An outpatient setting
requires at least 2 separate office or clinic readings of BP
greater than 140/90 mm Hg, with an in-between BP readings
interval that ranges from 1 to 2 months, or less, depending on
the initial BP reading. In a hospital/inpatient setting, one needs
to consider anxiety, acute illness, acute stress, and insomnia as
a cause of elevated BP, which requires previous or repeat BP
readings to confirm and diagnose hypertension. So-called white
coat or isolated clinical hypertension should also be considered,
requiring the use of home or ambulatory BP monitoring. The
patient should have an appropriate-size cuff and be asked to refrain
from smoking or caffeine ingestion for 30 minutes before
BP measurement.
Finally, screening for secondary hypertension is not warranted
in most cases, because this occurs in only 5% to 10% of all
patients with hypertension. Consider screening when hypertension
occurs in one of the following categories: in those younger
than 30 years or those older than 50 years; in those with significant
end-organ target damage at diagnosis (eg, left ventricular
hypertrophy, renal insufficiency, hemorrhages, or exudates on
eye examination); those with poor response to 3 appropriate
antihypertensive drugs (with 1 being a diuretic), in addition to
the factors mentioned in the article.
Kayode C. Lawrence, MD
Maryland General Hospital, Baltimore
The Authors Reply: We thank Dr Lawrence for his valuable
comments on our paper. We agree that isolated systolic hypertension
is defined as a systolic BP more than or equal to 140 mm Hg
and a diastolic BP of less than 90 mm Hg. We regret the typographical
error, which resulted in a diastolic BP being reported as
more than 90 mm Hg. We further agree with Dr Lawrence that
clinicians should account for factors affecting the diagnosis of hypertension,
as listed in his letter. The diagnosis of hypertension requires
at least 2 separate office readings of BP more than or equal
to 140/90 mm Hg, taken at least 1 week apart. Finally, we concur
that physicians should only consider secondary causes of hypertension
when the conditions above and in our article are present;
nonessential hypertension is usually a rare entity.
Shakaib U. Rehman, MD
Jan N. Basile, MD
