Hypertension is termed as "silent killer" because most patients do not have symptoms. The diagnosis of hypertension cannot be made based on just one elevated blood pressure measurement. An average of two or more measurements which are taken during two or more clinical encounters should be used to diagnose hypertension. Thereafter, this blood pressure average can be used to establish a diagnosis and then classify the stage of hypertension.

The approach of the general physician towards the patient

Most patients with hypertension have no specific high blood pressure symptoms referable to their increased blood pressure. The general physician may then implore about the patient's history. It is best not to withhold any information from the physician, as the principle of patient-doctor confidentiality protects the patient from stigma. The doctor may enquire about the following: 

• Medical history of the patient.
• Duration of hypertension (history of high blood pressure).
• Previous therapies: both responsive, non-responsive and side effects.
• Family history of high blood pressure and cardiovascular disease.
• Dietary and psychosocial history.
• Alcohol consumption (alcohol and hypertension).
• Other risk factors: 
• Weight change
• Dyslipidaemia
• Smoking (smoking and hypertension)
• Diabetes (diabetes and hypertension)
• Physical inactivity (sedentary lifestyle and hypertension)
• Evidence of secondary hypertension
• History of renal disease (renal artery stenosis and hypertension)
• Change in appearance.
• Muscle weakness (muscle weakness, high blood pressure)
• Spells of sweating
• Palpitations
• Tremor (high blood pressure and tremors)
• Erratic sleep
• Snoring (snoring and high blood pressure)
• Daytime somnolence
• Symptoms of hypo- or hyperthyroidism
• Drugs that may increase blood pressure
• Evidence of target organ damage (usually cardiovascular)
• History of transient ischemic attack
• Stroke (hypertension and ischemic stroke)
• Transient blindness
• Angina
• Myocardial infarction
• Congestive heart failure
• Sexual function

Other comorbidities

Process of establishing hypertension

1. In most healthcare centres, it is the medical healthcare personnel other than general physicians who are likely to take the readings to establish hypertension. The nursing diagnosis for hypertension is measured using a well-maintained sphygmomanometer of validated accuracy. 
2. Upon getting comfortable, the evaluation of blood pressure will be initiated. 
3. It should initially be measured in both arms and the arm with the highest value used for subsequent readings. 
4. At least at the first presentation, the blood pressure will be measured for the relaxed patient in both the sitting and the standing positions. 
5. The laboratory technician finds the appropriately sized cuff since.

• A too-small cuff results in an overestimation of the patient's blood pressure.
• A too-loose cuff may result in an underestimation of the patient's blood pressure.

  6.  The arm should be rested at the level with the heart, and it is important that the patient does not hold their             arm out since isometric exercise increases blood pressure. 

  7.  The blood pressure is measured using the Korotkov sounds, appearing (the first phase) and disappearing (the          fifth phase) over the brachial artery as the pressure in the cuff is released. 

 8.   The laboratory technician deflates the cuff at approximately 2 mmHg to allow accurate measurement of the             systolic and diastolic blood pressures. 

 9.  The fourth Korotkov phase (muffling of sound) has previously been used for diastolic blood pressure                           measurement but is not currently recommended unless Korotkov V cannot be defined. 

 10. Having established that the blood pressure is increased, the measurement should be repeated several times           over several weeks unless the initial measurement is at dangerously increased levels, in which case several               measurements should be made during the same clinic attendance.

It is recommended that all adults have their blood pressure measured once every five years. Once the diagnosis of hypertension is established, an annual measurement must be done.

The other necessary lab tests a general physician may consider establishing hypertension-associated diseases

Frequently, the only sign of essential hypertension is elevated blood pressure. The rest of the physical examination may be completely normal. However, a complete medical evaluation is recommended after diagnosis to: 

• Identify any secondary causes.
• Find cardiovascular risk factors or comorbid conditions for prognosis and therapy guide.
• Assess the presence or absence of hypertension-associated target-organ damage.
• All patients with hypertension must undertake the following measurements prior to initiating therapy: 
• 12-lead electrocardiogram
• Spot urine albumin-to-creatinine ratio
• Blood glucose and haematocrit
• Serum potassium
• Serum creatinine (with estimated glomerular filtration rate [GFR])
• Serum calcium
• Fasting lipid panel

For patients without a history of coronary artery disease, noncoronary atherosclerotic vascular disease (also referred to as coronary artery disease risk equivalents), left ventricular dysfunction, or diabetes, it is also important to estimate a 10-year risk of fatal coronary heart disease or nonfatal myocardial infarction using Framingham Risk scoring.

While the normal readings of blood pressure are <130 /<85 mm Hg (millimetres of mercury), which can be maintained by a steady balanced diet and regular exercise, the stages of hypertension recognised by the American Heart Association are:

• Elevated blood pressure: When the diastolic pressure falls between 85-89 mm Hg and the systolic pressure is 130-139 mm Hg or above consistently, the patient can be diagnosed with elevated hypertension. Unless necessary actions are taken, these patients could develop progressive high blood pressure.
• Hypertension Stage 1: If the systolic blood pressure ranges from 140-159 and the diastolic blood pressure is 90 to 99 mm Hg consistently, the patients could be experiencing Hypertension Stage 1. In this stage, medications and lifestyle modifications are prescribed. 
• Hypertension Stage 2: If the readings of blood pressure show a constant ≥160/≥100 mm Hg or higher values, it is hypertension Stage 2. In these cases, medications and lifestyle modifications are suggested, considering the risk of various potential atherosclerotic cardiovascular diseases. 
• Hypertensive crisis: It is the medical phenomenon of a sudden escalation of high blood pressure exceeding >200/120 mm Hg. During these cases, it is imperative to check the blood pressure once again after a gap of 5 minutes. If the reading is still the same, medical consultation must be done at once. The patients may experience potential organ damage symptoms such as breathlessness, chest pain, change in vision, numbness/weakness, difficulty speaking, etc.
  

Considerations of a general physician in developing the accurate therapeutic drug regimen for hypertension treatment

The healthcare team chooses the drugs on the basis of efficacy, safety, convenience to the patient and cost. For assessing efficacy, essential evidence is from hard endpoints such as the incidence of stroke and other cardiovascular events or death.

Future treatment strategy: Since the diagnosis of hypertension is usually accompanied by various associated diseases, the healthcare team actively look out for various guidelines to understand the effects of drugs on blood pressure and surrogate markers such as left ventricular hypertrophy or carotid artery stenosis. Many studies pursue generating a hypothesis of a future high blood pressure treatment strategy.

Safety: When considering safety, the healthcare team understands and recognises that these drugs will be taken in the long term, and the prescription of the same will be done after confirming their long-established safety records and advantages. The healthcare personnel also recognise the importance of symptomatic adverse effects since these may reduce adherence. There is no ideal safest medicine for high blood pressure as the drug of choice in hypertension differs according to the stage of hypertension, associated comorbidities, age of the patient etc.

Patient inclusion: The healthcare personnel take necessary measures to make the patients feel at ease during treatment of their blood pressure as they did before drug treatment was initiated. Patient convenience is another important factors that PACE Hospitals excels, which is why we prioritise the usage of once-daily preparations that will result in better adherence than more frequent regimens, taking into consideration the patient's safety.

Pharmacoeconomic considerations: Despite the conscious prescription of once-daily preparations, polypharmacy is one common attribute of hypertensive treatment which the patient cannot escape. Understanding the same, healthcare personnel often prescribe drug combinations for high blood pressure.

Goals of therapy for hypertension

The overall goal of treating hypertension is to reduce hypertension-associated mortality and morbidity which not only confer in treating hypertension but also the morbidity and mortality related to target-organ damage such as cardiovascular events and kidney disease. Reducing risk still remains the primary purpose of hypertension therapy, although the specific drug of choice for hypertension is significantly influenced by evidence demonstrating such risk reduction. 

Usually, the treating physician divides goals into short-term and long-term goals for convenience. While short term goal for hypertension initiates the patient into a treatment discipline, long-term goals aid in the prevention or progression of hypertensive complications.

A sensible dietary program is designed for a gradual reduction in weight for overweight and obese patients by restricting sodium intake with only moderate alcohol consumption. The following pieces of evidence can serve as a rationale for designing a high-blood-pressure diet intervention:

• Hypertension is two to three times more likely in overweight than in lean persons.
• More than 60% of patients with hypertension are overweight. 
• As little as 10 pounds (4.5 kg) of weight loss can decrease blood pressure significantly in overweight patients.
• Abdominal obesity is associated with metabolic syndrome, a precursor to diabetes, dyslipidaemia, and, ultimately, cardiovascular disease.
• Diets rich in fruits and vegetables and low in saturated fat lower blood pressure in patients with hypertension.
• Most people experience some degree of systolic blood pressure reduction with sodium restriction.
  

Dash diet for hypertension

The Dietary Approaches to Stop Hypertension (DASH) eating plan is a diet of fruits, vegetables, and low-fat dairy products with decreased saturated and total fat. The doctor may reduce the sodium intake as much as possible, ideally to 1.5 g/day, although an interim goal of less than 2.3 g/day may be reasonable considering the difficulty in achieving these low intakes. Potassium intake is encouraged (ideally 4.7 g/day) if kidney function seems normal. Excessive alcohol use can either cause or worsen hypertension. Alcoholic intake will also be restricted.

An Indian study published in 2020 reported the effectiveness of the DASH diet in improving the various health aspects that has been obtained from various other studies.

• DASH Diet and Bone Health: The prevalence of osteoporosis has increased with the rising elderly population due to the increasing life span resulting from medical advancements. Incorporating fruits, vegetables, and low-fat dairy products, the DASH diet easily supports calcium enrichment, leading to a reduction in bone remodelling.
• DASH Diet and Cardiovascular Diseases: Studies demonstrated the significant reduction of diastolic and systolic blood pressure with favourable changes in the lipid profile by ingesting the DASH diet. The combination of DASH plus weight management is more helpful in reducing hypertension when compared with DASH diet alone. Recent evidence points to the role of DASH diet in supporting nutrition in Alzheimer’s Disease (improves neurocognitive functions), especially if it is combined with aerobic exercise.
• DASH Diet and Risk for Kidney Damage: DASH diet adherence can lower the risk of kidney damage with the reduction of salt intake. Due to the incorporation of vegetables and fruits in DASH diet, urinary citrate is increased, causing an increase in the pH of the urine, thus reducing the formation of renal stones and uric acid crystals.
• DASH Diet and Obesity: DASH diet can positively induce weight management with a reduction in body weight and waist circumference. A low-calorie-dense DASH diet (particularly high fibre content) and low glycaemic index cannot only induce satiety but also decrease the overall food intake. A hypocaloric DASH diet with supplementation of 100 mmol/d sodium can reduce 4.9 kilograms of weight just within nine weeks. 
• DASH Diet and Diabetes: Diabetics are projected to increase to 59.2 crore by the year 2035. Economic growth from rapid urbanisation shifted the dietary pattern of various countries with high caloric intake and an overall decrease in diet quality. DASH diet with low energy and low glycaemic index foods with a higher amount of dietary fibre can reduce diabetes and high blood pressure. Dash diet has improved insulin sensitivity with weight loss exercise in overweight hypertensive patients. A study demonstrated better glycaemic control and reduced risk of cardiovascular diseases with a DASH diet of 2400 mg sodium/day supplementation given to type 2 diabetics for eight weeks.
• DASH Diet and Gout: The most common inflammatory arthritis – gout, is caused due to concentrated uric acid in the serum. Its complications include cardiovascular and metabolic comorbidities. It was demonstrated that the DASH diet reduces serum uric acid concentration, while the Western diet, on the other hand, can increase uric acid levels. The effect of the DASH diet not only reduces serum uric acid levels but also prolongs the effect for at least 90 days.