Once the diagnosis of hypertension has been appropriately made and secondary causes considered, the remainder of the evaluation should be directed toward the identification of target organ damage, an assessment of other cardiovascular risk factors, and identification of comorbid conditions that may influence the therapeutic decision-making process. In the older hypertensive patient, it may be more difficult to detect the manifestations of target organ damage that are directly attributable to elevated blood pressure because of concurrent age- or disease-associated changes in organ function. With this proviso, it is useful to determine if there is any previous history consistent with coronary artery disease, cardiac failure, cerebrovascular disease (transient ischemic attack or stroke), or peripheral vascular disease.

The patient should be assessed for any physical signs consistent with these conditions, as well as for evidence of hypertensive retinopathy or left ventricular hypertrophy. In addition to identifying the presence of hyperlipidemia or diabetes mellitus, information concerning smoking history, dietary intake of salt and fat, alcohol intake, and level of physical activity should be obtained to aid in a determination of overall cardiovascular risk. This information will affect the patient’s risk stratum assignment and the approach to his or her treatment and is also needed to advise the patient about lifestyle modifica-tions that may be recommended as nonpharmacological approaches to blood pressure control. Finally, knowledge of comorbid conditions is necessary to identify special clinical situations where a given class of antihypertensive medication would be either recommended or contraindicated (

see Table 40.2).