Risk factors for primary hypertension, such as a positive family history or pregnancy-related hypertension, should be discussed. The medical history should also include reference to relevant lifestyle characteristics, such as weight gain, sedentary lifestyle, high dietary salt ingestion, and excessive alcohol consumption. Patients with resistant hypertension, which remains uncontrolled in the presence of an adequate multidrug regimen, are also prime candidates for secondary hypertension. Renal artery stenosis in older patients usually, but not exclusively, occurs in the context of diffuse atherosclerotic disease. Pheochromocytoma is suggested by episodic increases in hypertension often accompanied by headache, diaphoresis, and palpitations.
Primary aldosteronism is suggested by a history of hypokalemia.
The degree of target-organ damage must be documented by history and physical examination. A history of coronary artery disease, left ventricular hypertrophy, cerebrovascular disease, peripheral vascular disease, or renal insufficiency suggests long-standing, poorly controlled hypertension. Last, comorbid conditions and their treatment should be delineated so as to anticipate potential drug interactions and optimize choices of antihypertensive drugs. The physical examination should accurately determine the BP, identify signs of secondary causes of hypertension, and document the presence and degree of target-organ damage. The BP determination should be the average of a minimum of two BP readings obtained 2 to 3 minutes apart.