Reprinted from the Archives of Internal Medicine

June 1974, Volume 133

Copyright 1974, American Medical Association

The majority of hypertensive patients fall
into the borderline and mild groups. A
smaller percentage of the hypertensive pop-
ulation falls into the groups with persistent
elevations in diastolic blood pressure of 105
mm Hg or higher. However, they are a most
important group because treatment has
been effective in reducing their high risk of
developing major complications. In mild hy-
pertension, the physician will treat those
who are at increased risk as judged by age,
race, sex, target organ damage, family his-
tory, hyperglycemia, and hypercholestere-
mia. Even though most mild and borderline
hypertensive patients are not treated, they
should be followed up since some of these
patients may progress to a more severe
stage of hypertension and should then be
treated.

he decision to treat a patient

with hypertension rests primar-
ily on the estimated risk of hyperten-
sive complications developing in the
patient. Risk varies with the degree
of severity of the hypertension. Se-
verity in hypertension is a continu-
um, beginning with the most mild or
borderline hypertensive patients at
one end of the scale and continuing to
the most severe. The purpose of this
report is to describe the character-
istics of this continuum or clinical
spectrum and to offer a guide on the
indications for treatment.

The level of blood pressure is the
most important single criterion for
correctly diagnosing the degree of
hypertension. Consequently, it is of
great importance to obtain blood
pressure data from the patient that

 

Received for publication Oct 23, 1973; accepted
Feb 12, 1974.

From the Veterans Administration Hospital
and the Department of Medicine, Georgetown
University School of Medicine, Washington, DC.

Reprint requests to 50 Irving St NW, Wash-
ington, DC 20422 (Dr. Freis).

982 Arch Intern Med/Vol 133, June 1974

The Clinical Spectrum
of Essential Hypertension

will be truly representative of his
average blood pressure.

A major difficulty in evaluating and
classifying hypertensive conditions,
particularly in office practice, is the
great variability in the level of blood
pressure. Actual continuous record-
ings of blood pressure during a 24-
hour period have indicated a variation
as great as from 150/74 to 244/105
mm Hg in one patient and 110/90 to
220/165 mm Hg in another! Even
normal persons have been found to
have occasional periods of hyperten-
sion.’ Such marked variations in blood
pressure appear to be emotionally in-

fluenced, apparently acting via the,

sympathetic nervous system. Any
sort of emotionally alarming stimulus
has been found to markedly raise the
blood pressure, while sleep is associ-
ated with the lowest levels of blood
pressure during a 24-hour period.

Patients generally visit doctor’s of-
fices because they do not feel well or
they are in pain. During such epi-
sodes, they are quite likely to expe-
rience considerable apprehension.
Therefore, it is not unusual to obtain
an unrepresentatively high blood
pressure, particularly on the initial
visit. Only through repeated visits
will enough blood pressure readings
be obtained to permit one to derive
an approximation of the average
blood pressure for that patient.

A series of blood pressure readings
is required in order to categorize and
classify patients. Let us assume, for
example, there are two patients with
a diastolic blood pressure of 110 mm
Hg on the initial visit. In one of these
patients, the diastolic readings fall to
90 and 80 mm Hg on subsequent vis-
its, whereas in the other patient the
diastolic pressures remain in the 110

Edward D. Freis, MD, Washington, DC

mm Hg range. Obviously, these two
patients are at different points in the
clinical spectrum of hypertension and
will require different management.

Borderline Hypertension.—The sub-
ject of borderline hypertension has
been extensively reviewed by Julius
and Schork,? and much of the mate-
rial presented in this section has been
drawn from their review. The term
“borderline” hypertension is used be-
cause the more traditional “labile”
hypertension is not easily defined
since it depends on the number of
blood pressure determinations and
the conditions under which they were
taken. Also the term “labile hyper-
tension” is meaningless because al-
most everyone exhibits considerable
fluctuations in blood pressure from
time to time.’ Borderline hyperten-
sion is defined by Julius and Schork as
blood pressure readings averaging
between 150/90 and 160/100 mm Hg
with occasional normal readings and
no evidence of target organ damage.

The prevalence of borderline hyper-
tension is very high, including 10% to
15% of the adult population of the
United States. The prevalence is
higher in older than in younger age
groups, approaching 30% to 40% in the
groups older than the age of 60 years.
Among women younger than 50 years,
there is a lower prevalence than
among men of the same age. After
the age of 50, borderline hypertension
becomes more common in women
than in men.’

There is no question that patients
with borderline hypertension later
develop established hypertension
with a higher frequency than the nor-
mal population. Oberman et al? car-
ried out a 24-year follow-up of naval
aviators, some of whom developed hy-

Clinical Hypertension/Freis
pertension in middle age. In the ma-
jority of the latter, blood pressures at
the time of admission to service had
been in the upper range of the normal
zone of blood pressure. With the pas-
sage of time, these graduated from
high normal to overtly hypertensive
blood pressures. Since blood pressure
normally rises with age and since the
borderline hypertensive patient be-
gins from a higher average level than
normal, it is not surprising that he is
more likely than the normal to go on
and develop a definite hypertension.
While the follow-up results vary
greatly from one study to another,
the consensus indicates that estab-
lished hypertension develops about
three times more commonly in the
borderline than in the normotensive
group with 10 to 20 years or more of
follow-up.**

Borderline or mild hypertension
carries a higher-than-normal risk of
morbidity and mortality. The most
extensive data are those supplied by
the life insurance studies.® According
to these data, the group at highest
risk are men between the ages of 30
and 39 years. At a blood pressure 90
mm Hg, the 20-year mortality is 1.4
times that of the normal population;
with a blood pressure of 152 systolic
or 95 mm Hg diastolic, it is 2.7 times
that of the normal. In women and in
men in older age groups, the risk is
not as high. For example, in men be-
tween the ages of 50 and 59, a blood
pressure of 152/95 mm Hg is associ-
ated with an increased 20-year mor-
tality of 1.7 times the standard risk.

Other studies report somewhat sim-
ilar findings. With respect to morbid-
ity, Stamler et al* found that, dur-
ing a 20- to 30-year period of follow-up
on male gas company employees, the
development of hypertensive heart
disease was three to four times as
common in those who initially had
borderline hypertension as in normal
individuals. Similarly, the Framing-
ham study disclosed that, in both
sexes, coronary heart disease was
about 1.6 times more common in pa-
tients with borderline hypertension.

Arch Intern Med/Vol 188, June 1974

While these increased risks in the pa-
tients with borderline hypertension
are important, they are not exces-
sively high and are in no way com-
parable to the risk in established hy-
pertension.

Although patients with borderline
hypertension are thought to have a
more labile blood pressure than nor-
mal persons, the available evidence
does not support this view. Blood
pressure readings taken once or twice
daily for one to three weeks in college
students failed to show any correla-
tion between the mean systolic blood
pressure and the extent of the pres-
sure fluctuation." Nevertheless, I
have observed individuals in the older
age groups, particularly women, who
can and often do display quite ele-
vated blood pressures in the physi-
cians’ offices and whose blood pres-
sures recorded at home are in the
normal range.

Unlike the cardiac output in estab-
lished essential hypertension, the out-
put in borderline hypertension fre-
quently is elevated. The elevation is
seen more often in young than in
middle-aged or old patients." The
increase in cardiac output persists de-
spite periods of rest for as long as
one hour. However, the difference be-
tween output in patients with border-
line hypertension and normal sub-
jects disappears during exercise.'*"
Total blood volume has been mea-
sured and has been found to be nor-
mal'® or low.'*”°

The mechanism of the increased
cardiac output has not been clarified.
It would appear that it is not due to
increased venous tone.’*?! After ad-
ministration of propranolol hydro-
chloride (Inderal), the difference in
cardiac output between the border-
line hypertensive and normal subjects
becomes minor, suggesting that B-
adrenergic stimulation of the heart
may be important in maintaining the
increased cardiac output.” Although
the peripheral resistance may be nor-
mal or low in borderline hypertension
with high cardiac output, it is still
higher than would occur in a normal

individual with a high cardiac out-
put.?°?? In the latter, the peripheral
resistance would adjust so that the
blood pressure could remain in the
normotensive range.

How should patients with bor-
derline hypertension be managed?
Should they be treated or should they
not? Patients with borderline hyper-
tension have approximately three
times the risk of developing estab-
lished hypertension as does the nor-
mal individual. Cardiovascular mor-
bidity and mortality are significantly
but not markedly greater than nor-
mal. There is, however, no evidence at
the present time that treatment will
prevent the subsequent development
of hypertension or the excess cardio-
vascular morbidity and mortality.
Furthermore, some individuals with
borderline hypertension revert to
normal levels of blood pressure. Prob-
ably no more than 25% of patients
with borderline hypertension later
develop established hypertension.

In view of this, it seems question-
able that treatment with antihyper-
tensive agents is justified in such pa-
tients. The exposure of the patient to
side effects and the expense of life-
long treatment are disadvantages
that should be weighed against the
undemonstrated advantages of con-
trolling an occasionally slightly ele-
vated blood pressure.

Other therapeutic approaches that
carry potentially less risk than drug
treatment have been suggested for
treating patients with borderline hy-
pertension. Qne such approach is the
use of a low-sodium diet. There is no
convincing evidence, however, that a
diet moderately restricted in sodium
will have a beneficial effect on blood
pressure. To reduce blood pressure by
dietary means alone, the sodium in-
take must be reduced to 200 mg or
less per day. A diet so low in sodium
requires such diligent care and is so
unpalatable that very few patients
will adhere to it.

Another therapeutic approach has
been to advise the patient to avoid
stressful situations on the theory that

Clinical Hypertension/Freis 983
this would avoid the stimulus that
would lead eventually to established
hypertension. In borderline hyperten-
sion in particular, it seems possible
that there may be a large emotional
component to the elevation of blood
pressure. However, it is doubtful that
the stresses of life can truly be re-
duced. The long-term use of sedatives
or tranquilizers would not appear to
be justified in treating this condition,
and there is no evidence to indicate
that such treatment would be effec-
tive in preventing progression to an
established form of hypertension.

Probably the best way to manage
the patient with borderline hyperten-
sion is to follow up on him or her for
six months or a year without under-
taking any form of therapeutic inter-
vention. During part of this time, it
would seem highly desirable to obtain
home recordings of the blood pres-
sure. The patient or, preferably, a
member of the family could be taught
to take the blood pressure. The pa-
tient either purchases a blood pres-
sure apparatus or, if he is not able to
afford this, the physician may loan
one to him for a two-week period.
Recordings should be made in the
home twice daily in the morning and
at night.

There is no need to initiate treat-
ment immediately in patients with
borderline hypertension. It is possible
and probably desirable to wait for a
year or more before deciding whether
treatment is required. If the blood
pressure falls to normal during this
period or if it remains in the border-
line range, the patient should be re-
checked in another year. However, if
the blood pressure rises and remains
in the hypertensive range, appropri-
ate treatment may then be started.
In either event, it is important to
maintain contact with the patient. He
should be followed up because of the
increased risk of developing estab-
lished hypertension in the future. By
monitoring his blood pressure period-
ically, one can determine if he devel-
ops established hypertension; if he
does, treatment can be instituted be-

984 =Arch Intern Med/Vol 133, June 1974

fore major vascular damage has oc-
curred.

Mild Hypertension.—By mild hyper-
tension I mean that the diastolic
blood pressure is persistently ele-
vated to more than 90 mm Hg, in con-
trast to borderline hypertension
where the readings are normal at
some outpatient visits. In addition to
a persistent elevation, the average of
the diastolic readings at three or
more visits is in the range of 90 to 104
mm Hg.

There is a wide divergence of opin-
ion as to how such patients should be
managed. Some physicians advocate
bringing the blood pressure down to
normal in every case. Others would
not treat any patients in the mild
group until or unless their hyperten-
sion becomes more severe. The reason
for the divergence of opinion is that
it is precisely in this group of patients
that controlled trials have failed to
supply a definitive result. The Veter-
ans Administration trial included
such mild cases.** Unfortunately, be-
cause of the higher levels of blood
pressure (diastolic pressure, 105 to 114
mm Hg), the study was terminated
after an average follow-up of only 3.3
years. At that time, there was evi-
dence of a protective effect of treat-
ment against the major hypertensive
complications that included stroke,
congestive heart failure, renal dam-

age, and accelerated hypertension. _

When the results were further ana-
lyzed, however, it was apparent that
the effectiveness of treatment,
though favorable, was not Important
in the group of patients with initial
diastolic pressures of 90 to 104 mm
Hg.

Patients with mild hypertension
develop complications less frequently
than those with higher levels of blood
pressure. When mildly hypertensive
persons develop complications, they
are often atherosclerotic in type.
Myocardial infarction or sudden
death can occur. While antihyper-
tensive drug treatment has been
shown to be effective in preventing

hypertensive complications, there is

little evidence to indicate that treat-
ment is effective in preventing ather-
osclerotic complications such as myo-
cardial infarction.

Since hypertension is known to ag-
gravate and accelerate atheroscle-
rosis, it was hoped that reduction of
blood pressure might have a benefi-
cial effect on atherosclerotic complica-
tions. However, in the Veterans Ad-
ministration Study, the incidence of
myocardial infarction was essentially
the same in the control and treated
groups. The benefits of treatment
were related more to complications
that are associated specifically with
elevated blood pressure such as con-
gestive heart failure, stroke, partic
ularly hemorrhagic stroke, renal dam-
age, accelerated hypertension, and
dissecting aneurysm. It is possible
that, if antihypertensive drug treat-
ment had been instituted at a very
early stage in the hypertension, a
beneficial effect on prevention of
myocardial infarction might have
been observed. However, on the basis
of currently available data, I have no
evidence to support the concept that
controlling blood pressure with anti-
hypertensive drugs has a favorable
effect on the atherosclerotic complica-
tions.

I take an intermediate position be-
tween those who will not treat any
patient with mild hypertension and
those who will treat all such patients.
Blood pressure is not the only indica-
tor of risk, and in the group of pa-
tients with diastolic pressure levels
averaging in the range of 90 to 104
mm Hg there are some patients who
are at much higher risk than others.
The known determinants of risk
other than blood pressure include age,
race, sex, target organ damage, fam-
ily history, hyperlipoidemia, and hy-
perglycemia.

At any given level of elevated blood
pressure, the younger the age of the
patient, the greater is the reduction
of life expectancy. For example, the
life insurance data’ indicate that, for
men between the ages of 50 and 59, a
blood pressure level of 152 systolic or

Clinical Hypertension/Freis
95 diastolic mm Hg is associated with
a 1.7 increase of the normal 20-year

mortality rate. However, in the 30- to-

39-year age group, the 20-year mor-
tality for similar levels of blood pres-
sure is 2.7 times the normal for that
age. It is apparent that even a modest
elevation of blood pressure is associ-
ated with an increased risk when the
hypertension appears at a relatively
early age.

Men have a poorer prognosis than
do women. Various follow-up studies
indicate that mortality is about 1%
times as high in men as in women."
The prognosis is not much different
than normal in women age 60 or older
who have mild elevations of blood
pressure. According to the 20-year
follow-up study of Bechgaard, the
mortality in this sex and age group
was the same as that of the normal.”

With respect to race, hypertension
is not only more prevalent in blacks
but it also tends to be more severe.
Data from the National Health Sur-
vey found definite hypertension in
27% of black adults as compared to
14% of white adults? However, the
death rates for hypertension and hy-
pertensive heart disease in blacks
were increased out of proportion to
their increased prevalence of hyper-
tension. For example, the vital statis-
tics for the year 1967 indicate a death
rate of 66 per 100,000 from hyperten-
sion in black males as compared to 16
per 100,000 in white males.” This rep-
resents a difference in mortality of
four to one in blacks as compared to
whites.

The target organs that are involved
by hypertension are the brain, the op-
tic fundi, the heart, and the kidneys.
Mortality risk is directly related to
the amount of damage detectable on
examination.”**** The control or un-
treated patients in the Veterans Ad-
ministration Cooperative Study were
divided into two groups depending on
whether they did or did not show evi-
dence of target organ damage at the
time of entry into the study. During
the follow-up period, the group with
evidence of target organ damage de-

Arch Intern Med/Vol 133, June 1974

veloped 2% times as many complica-
tions as the group that did not.”

With respect to symptoms, a his-
tory of occipital headache in the
morning is characteristic of severe or
malignant hypertension only. Head-
ache is not a characteristic symptom
of mild or moderate hypertension. Ce-
rebral vascular atherosclerosis may
be suggested by failing memory for
recent events, unsteady gait, or tran-
sient ischemic attacks. In the optic
fundi hemorrhages, exudates and
papilledema are found only in malig-
nant hypertension and never in mild
hypertension. With respect to vascu-
lar sclerotic changes, the presence of
arteriovenous nicking is a useful sign
of arteriolar sclerosis, particularly if
the nicking is seen at crossings that
are more than two disc diameters pe-
ripheral to the optic dise. Tortuosity,
irregularity, segmental spasm, and
narrowing of retinal arterioles also
are useful indicators. However, they
are not definitive because such
changes can be seen in some normal
fundi.

In the cardiac evaluation, there
may be some symptoms of early heart
failure such as a decrease in exercise
tolerance, dyspnea on mild exertion,
or recent increase in nocturia. The
presence of a third heart sound would
be confirmatory of the presence of
failure. Of equal importance is an-
gina, since coronary artery disease is
common in patients with mild hy-
pertension. A fourth heart sound is
frequently heard in hypertensive
patients; it reflects decreased
compliance of the left ventricular
wall. A most important feature of the
examination is the electrocardiogram,
in which one looks especially for evi-
dence of left ventricular hypertrophy
and for evidence of coronary artery
disease including conduction defects,
ischemic changes, rhythm distur-
bances, and evidence of old infarc-
tion. -

Renal damage is not a character-
istic finding in mild hypertension.
The type of renal damage resulting
from hypertension is nephrosclerosis,

which is generally a manifestation of
severe hypertension. Atherosclerotic
changes in the large renal arteries
may occur in mild hypertension but
only rarely lead to any clinically ap-
parent renal damage. If there is evi-
dence of renal disease, such as the
presence of proteinuria, casts, cells, or
elevated levels of blood urea nitrogen
or serum creatinine, one should sus-
pect an independent renal disorder
such as chronic pyelonephritis, rather
than renal damage secondary to the ©
mild hypertension.

In addition to the factors already
mentioned of sex, age, race, and tar-
get organ damage, it is also useful to
consider the family history. There is a
strong inherited tendency in hyper-
tension that is strikingly demon-
strated in studies on identical twins.”
Even though such twins may have
lived apart for many years, similar
levels of blood pressure have been
found in both. A family history of hy-
pertension suggests that one is deal-
ing with essential rather than second-
ary hypertension. The family history
also has prognostic value. A history of
severe or fatal hypertensive complica-
tion in a parent or sibling makes it
more likely that the patient with mild
hypertension may progress to a more
severe stage. According to Platt,** the
sibling of a patient with severe essen-
tial hypertension has an eight times
greater chance of developing a dias-
tolic blood pressure of 100 mm Hg or
greater in middle age than does the
average individual.

Knowledge of factors that affect
prognosis is useful in making the de-
cision about treatment. For example,
a 28-year-old black man with a dias-
tolic blood pressure averaging 100
mm Hg during three successive visits
should be treated, in my opinion, be-
cause of the greater chance he has of
developing a progressively more se-
vere hypertension. On the other hand,
a 65-year-old woman with no evi-
dence of hypertensive complications
and whose diastolic blood pressure
averages 95 mm Hg probably would
be observed rather than treated ac-

Clinical Hypertension/Freis 985
tively.

It should be emphasized that pa-
tients with mild hypertension are in
no immediate danger of developing
cardiovascular complications. It is
possible, therefore, to delay the deci-
sion to treat the patient until one has
had the opportunity to observe the
course of the hypertension over a pe-
riod of time. Whereas the tendency
for the blood pressure is to progress
slowly, it may remain stable or even
regress. Repeated checks of the blood
pressure at three- or six-month inter-
vals will detect the individuals who
revert spontaneously to normal levels
of blood pressure and who therefore
do not require treatment. Others who
progress during this period can be
treated. In many instances, hard and
fast guidelines as to treatment can-
not be made because there is a lack of
definitive data on the results of treat-
ment in mild hypertension. It is
hoped that such data will become
available in a few years’ time so that
therapeutic decisions can be made on
the basis of fact rather than on opin-
ion. .

Moderate Hypertension.—This is de-
fined as diastolic blood pressure aver-
aging between 105 to 114 mm Hg dur-
ing a period of three or more office
visits. Some patients may show read-
ings within this range on the initial
visit but on subsequent visits exhibit
much lower or even normal readings.
Therefore, it is always useful to see
these patients several times in order
to obtain an adequate estimate of the
average blood pressure before pro-
ceeding directly to treatment. On the
other hand, if the patient has definite
evidence of target organ damage,
such as arteriovenous nicking in the
optic fundi or left ventricular hyper-
trophy on the ECG, treatment can be
begun without delay. It is primarily
when no signs of target organ dam-
age are present that the average of a
number of blood pressure readings
taken at different visits is needed to
judge the severity of the hyperten-
sion and the consequent need for
treatment. If this average is 105 mm

986 = Arch Intern Med/Vol 183, June 1974

Hg diastolic blood pressure or higher,
the patient should be treated.

The decision to treat all patients
with average diastolic blood pressure
levels of 105 mm Hg or higher is
soundly based. The Veterans Admin-
istration Cooperative Study on Anti-
hypertensive Agents showed that, in
the group with diastolic blood pres-
sures averaging 105 to 114 mm Hg at
entry, there was a three-to-one dif-
ference in major complications be-
tween the treated and control pa-
tients during a 3.3-year follow-up.*
Marked protection was demonstrated
against stroke, congestive heart fail-
ure, accelerated hypertension, and
progressive elevation of blood pres-
sure but not against myocardial in-
farction.

The patients in the Veterans Ad-
ministration Study tended to have
more severe disease than the average
patient with moderate hypertension.
First, patients were excluded if their
diastolic blood pressure averaged
less than 90 mm Hg from the fourth
through the sixth day of hospitaliza-
tion. Thus, all the patients had fixed
hypertension. Second, they were all
male, and male hypertensives are at
higher risk than females. Third, many
patients exhibited target organ dam-
age at the time of entry into the
study. Nevertheless, it still seems jus-
tified to apply these results to the
consideration of any patient with an
average diastolic blood pressure of
105 mm Hg or more, regardless of
sex, target organ damage, or other
considerations. Epidemiologic studies
indicate that patients with this de-
gree of hypertension are at suffi-
ciently high risk of developing hyper-
tensive complications to justify
treatment. This recommendation im-
plies that the patient has a persistent
diastolic blood pressure elevation of
105 mm Hg or higher as judged by re-
peated office visits.

Moderately Severe and Severe Hyper-
tension.—A diastolic blood pressure in
the range of 115 to 129 mm Hg is as-
sociated with a very high risk of de-
veloping major complications over a

relatively short period of time. For
example, of 70 untreated patients
with this degree of hypertension fol-
lowed up in the Veterans Adminis-
tration Study, 21 developed complica-
tions during an average follow-up
period of only 18 months.*! These
complications included the develop-
ment of hemorrhages, exudates or
papilledema in the optic fundi, con-
gestive heart failure, azotemia, dis-
secting aneurysm, and stroke as well
as other complications. The degree of
risk, therefore, is unusually high in
patients with diastolic blood pres-
sures averaging 115 mm Hg or higher
during several visits. With diastolic
blood pressures of this degree, the
physician probably should not wait
for three or more visits. If a patient is
seen with a diastolic blood pressure of
115 mm Hg or higher, an appoint-
ment should be made to return in sev-
eral days for a second reading and for
completion of laboratory studies such
as chest x-ray films, ECG, urinalysis,
complete blood cell count, and tests
for levels of serum creatinine, fasting
blood sugar, serum cholesterol, serum
potassium, and uric acid. If the read-
ing on the second visit is 115 mm Hg
or higher, treatment should begin im-
mediately and should be intensively
pursued.

The effectiveness of treatment in
patients with diastolic levels aver-
aging between 115 and 129 mm Hg is
indicated by the results of the Veter-
ans Administration Study, where 21
of 70 control patients developed ma-
jor complications during a brief pe-
riod of only 18 months of follow-up.
By contrast, during the same period
of time, only one of 78 treated pa-
tients developed a complication.
There were four deaths in the control
group and none in the treated. Ob-
viously, the higher the level of blood
pressure, the more immediately ap-
parent is the benefit of treatment.

If the diastolic blood pressure is 130
mm Hg or higher on the initial exam-
ination, the patient probably should
be hospitalized as a medical emer-
gency. If the blood pressure is persist-

Clinical Hypertension/Freis
ently elevated at this level, the pa-
tient may be close to entering or may
already be in the accelerated or ma-
lignant phase of hypertension. Exam-
ination of the optic fundi is crucial in
making this diagnosis. Papilledema is
indicated by the presence of an ele-
vated optic disc or blurred disc mar-
gins with hyperemia of the disc. The

presence of accelerated hypertension
is indicated by papilledema, soft, cot-
ton-wool exudates, striate hemor-
rhages, or all three.

Patients with diastolic blood pres-
sures of 1830 mm Hg or higher gener-
ally need to be examined for a pos-
sible curable form of hypertension.
This can be accomplished during the

References

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catecholamines or their metabolites.
Because of the high level of blood
pressure, treatment should be insti-
tuted shortly after hospitalization
without waiting for the various labo-
ratory tests.

1. Richardson DW, et al: Variation in arterial
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2. Julius S, Sechork MA: Borderline hypertension:
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3. National Center for Health Statistics: Hyper-
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US 1960-62. US Dept of Health, Education, and Wel-
fare Vital and Health Statistics series II, No. 18,
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4. Boe J, Humerfelt 8, Wedervang F: The blood
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