Physiology Unmasks Hypertension
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When giving classes on diagnosis and treatment of hypertension to medical students or doctors in training, we receive the impression from their glassy-eyed looks that this important entity no longer has luster. Apparently, hypertension is considered an easy fix, both in terms of diagnosis and clinical management. Why even bother to think about human cardiovascular physiology when the disease mechanisms are largely unknown? Have the nurse measure brachial blood pressure (BP), prescribe a guideline-recommended drug, and add drugs as needed to attain target BP. The patient minority refusing to respond to such treatment undergoes standardized test batteries according to the diagnostic algorithm of choice to rule out secondary hypertension.
Indeed, hypertension management has made great strides in the past decades such that in many patients BP can be controlled with effective, safe, and well-tolerated drugs or combinations. Whether or not device-based treatments will have a role in tougher cases remains to be shown.1,2 Suffice it to say that on the population level, poor BP control rates largely result from failure to measure BP, to initiate proper treatment, or to convince the patient that BP control is beneficial. Yet, there is a smaller population of patients in whom BP is particularly difficult to control. In this population, unusual disease mechanisms are enriched that are not uncovered by routine diagnostic testing. Textbooks and clinical guidelines are little help. Instead, perseverance and physiological reasoning are required. Hypertension that occurs at home but not at the office is said to increase cardiovascular risk and is termed masked hypertension. We have borrowed the term to describe a patient with swinging hypertensive episodes at the office that made little sense. We used cardiovascular physiology to unmask the matter.
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