Hypertension: measuring, confirming and staging

Hypertension is a silent disease that is diagnosed, staged and treated on a number, so everything rests on that number being true: the pressure is measured with the patient rested, seated with the back and arm supported and the arm at heart level, the bladder empty and no caffeine, tobacco or exertion just beforehand, with a cuff sized to the arm, in both arms on first assessment and in the higher arm thereafter, and a raised reading found at a routine check is re-measured properly rather than acted on, then repeated and averaged, confirmed on separate occasions and confirmed by home or ambulatory monitoring before anyone is labelled, so that a pressure raised only in front of the clinician and a pressure raised only away from the clinician are each recognized for what they are; the stage is then set by whichever of the systolic or diastolic reading falls in the higher category, an isolated systolic elevation counting in full rather than being excused as ageing; and the response is graded to the stage and to the patient's overall cardiovascular risk and existing organ disease rather than to the pressure alone, with lifestyle change — restricting sodium, eating a potassium-rich pattern, losing weight, regular aerobic activity, limiting alcohol and stopping smoking — as the foundation at every stage and drug therapy added where the stage or the risk calls for it and brought to and held at target, the pressure checked lying and standing before an antihypertensive is given because the fall on standing is the drug's commonest harm, and the patient taught that a disease without symptoms still needs its tablets, that stopping an antihypertensive abruptly can rebound the pressure above where it started, and that dizziness on standing is reported rather than managed by skipping doses; whether the treatment is working is judged on the trend of the patient's home readings held at target and on the lifestyle changes being kept up, not on one reading at one visit, and the patient is assessed at intervals for the damage the pressure does silently — the retina, the heart enlarging or failing, the kidneys leaking protein and losing function, and the brain — because the damage arrives without symptoms in the same way the disease did; and while measuring the pressure can be delegated to an assistant who has been taught the technique, reading the result, deciding what it means and what happens next stays with the nurse, who checks a reading that does not fit the patient before acting on it.