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Hypertension is a major contributor to the development of cardiovascular disease and affects more than 25% of the UK population.The prevalence increases with age such that more than half of all people older than 65 years have a BP of has led to BP control becoming a major focus of primary and secondary cardiovascular disease prevention.
It is incongruous that they should be fourth line for hypertension in patients with quiescent coronary artery disease, but then receive an upgrade to first line once coronary artery disease becomes overt, despite the fact that BP lowering is the most powerful way to control both primary and secondary risk.
There are suggestions that they might be less protective against stroke and might increase the rate of diabetes.
so overdiagnosing hypertension seems generally harmless, yet underdiagnosing it might not be.
Furthermore, although ABPM and HBPM readings are better at predicting cardiovascular events than clinic readings, all of the studies demonstrating improved outcome from antihypertensive therapy have been based on a diagnosis made in a clinic setting.
Physical examination is nevertheless important since evidence of end-organ damage, such as a displaced apex beat due to left ventricular hypertrophy (LVH), or ocular changes, such as silver wiring and arteriovenous nipping, identifies patients at higher risk in whom there should be a lower threshold for treatment.
It is also useful to exclude radiofemoral delay (aortic coarctation), central obesity and abdominal striae (Cushing's syndrome) or skin thickening and bone changes (acromegaly).
The guidelines are instead selecting patients assumed to be at highest risk.
Patients with severe hypertension (clinic reading ≥180/110mm Hg), those with confirmed stage II hypertension (on ABPM) and those less than 80 years with stage i hypertension and target organ damage established cardiovascular disease renal diabetes mellitus or a 10-year risk 20 should be treated.
now fall outside diagnosis and treatment thresholds.
It is difficult to reconcile this aim with recent data suggesting that patients throughout Europe, including the UK, are frequently undertreated or not treated at all.