initial presentation of hypertension

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Essential hypertension.

Arshad Muhammad Iqbal ; Syed F. Jamal .

Affiliations

Last Update: July 20, 2023 .

Continuing Education Activity

The current definition of hypertension (HTN) is systolic blood pressure (SBP) values of 130 mm Hg or more and/or diastolic blood pressure (DBP) of more than 80 mm Hg. Hypertension ranks among the most common chronic medical condition characterized by a persistent elevation in arterial pressure. Hypertension has been among the most studied topics of the previous century and has been one of the most significant comorbidities contributing to the development of stroke, myocardial infarction, heart failure, and renal failure. The definition and categories of hypertension have been evolving over the years, but there is a consensus that persistent BP readings of 140/90 mm Hg or more should undergo treatment with the usual therapeutic target of 130/80 mm Hg or less. This activity reviews the etiology, presentation, evaluation, and management of essential hypertension and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition.

Describe the criteria for normotensive, pre-hypertensive, and hypertensive blood pressure.
Summarize the pathophysiology of essential hypertension and its pathological sequelae on organ systems throughout the body.
Review the various treatment options for treating essential hypertension, both pharmacological as well as lifestyle modification strategies.
Explain possible interprofessional team strategies for improving care coordination and communication to advance the evaluation and treatment of essential hypertension and improve outcomes.
Introduction

Hypertension has been among the most studied topics of the previous century and has been one of the most significant comorbidities contributing to the development of stroke, myocardial infarction, heart failure, and renal failure.

The definition and categories of hypertension have been evolving over the years, but there is a consensus that persistent BP readings of 140/90 mm Hg or more should undergo treatment with the usual therapeutic target of 130/80 mm Hg or less.

This article will attempt to review the available knowledge derived from RCTs and the recent updates and guidelines on hypertension put forward by major societies, including those from the 8th report of the Joint National Committee (JNC-8), American College of Cardiology (ACC), American Society of Hypertension (ASH), European Society of Cardiology (ESC) and European Society of Hypertension (ESH).

Most cases of hypertension are idiopathic, which is also known as essential hypertension. It has long been suggested that an increase in salt intake increases the risk of developing hypertension. [1] One of the described factors for the development of essential hypertension is the patient's genetic ability to salt response. [2] [3] About 50% to 60% of the patients are salt sensitive and therefore tend to develop hypertension. [4]

Epidemiology

More than one billion adults worldwide have hypertension, with up to 45% of the adult populace being affected by the disease [5] . The high prevalence of hypertension is consistent across all socio-economic and income strata, and the prevalence rises with age, accounting for up to 60% of the population above 60 years of age. [5]

In the year 2010, the global health survey report published in Lancet, which was comprised of patient data from 67 countries, reported Hypertension as the leading cause of death and disability-adjusted life years worldwide since the year 1990.

In the United States, HTN alone accounts for more cardiovascular disease-related deaths than any other modifiable risk factor and is second only to cigarette smoking as a preventable cause of death for any reason. [6]

Recent estimates have suggested the number of patients with hypertension could increase as much as 15% to 20%, which could reach close to 1.5 billion by 2025. [7]

Pathophysiology

There are various mechanisms described for the development of hypertension, which include increased salt absorption resulting in volume expansion, an impaired response of the renin-angiotensin-aldosterone system (RAAS), and increased activation of the sympathetic nervous system. These changes lead to the development of increased total peripheral resistance and increased afterload, which in turn leads to the development of hypertension.

History and Physical

Most cases of hypertension are asymptomatic and are diagnosed incidentally on blood pressure recording or measurement.

Some cases present directly with symptoms of end-organ damage as stroke-like symptoms or hypertensive encephalopathy, chest pain, shortness of breath, and acute pulmonary edema.

Physical examination may be unyielding other than occasional pedal edema or raised blood pressure, but one needs to look for signs of:

Coarctation of the aorta (radio-radial delay, radio-femoral delay, differences in left and right arm BP or upper and lower limb BP more than 20 mm Hg)
Aortic valve disease (systolic ejection murmur, 4th heart sound)
Renovascular disease or fibromuscular dysplasia (FMD) - (renal bruit, carotid bruit)
Polycystic kidneys (enlarged kidneys bilaterally)
Endocrine disorders [hypercortisolism(thin skin, easy bruising, hyperglycemia)
Thyroid disorders(palpable/ painful or enlarged thyroid] make up the common treatable causes of secondary hypertension

The presence of a 4th heart sound, which represents a stiff and non-compliant left ventricle, hints towards left ventricular hypertrophy and diastolic dysfunction.

The presence of lung rales and/or peripheral edema suggests cardiac dysfunction and gives a clue to the chronicity of hypertension.

The ACC recommends at least two office measurements on at least two separate occasions to diagnose hypertension.

The ESC/ESH recommends three office BP measurements at least 1 to 2 minutes apart and additional measurements only if the initial two readings differ by greater than or equal to 10 mm Hg. BP is then recorded as the average of the last two readings.

Both societies endorse the use of higher BP readings and putting patients into higher stages/grades for adequate medical therapy.

The patient should remain seated quietly for at least 5 minutes before taking the blood pressure, and proper technique is necessary. The blood pressure cuff should cover 80% of the arm circumference because larger or smaller pressure cuffs can falsely underestimate or overestimate blood pressure readings.

Ambulatory blood pressure measurement is the most accurate method to diagnose hypertension and also aids in identifying individuals with masked hypertension as well as the white coat effect.

The evaluation consists of looking for signs of end-organ damage and consists of the following,

12 lead ECG (to document left ventricular hypertrophy, cardiac rate, and rhythm)
Fundoscopy to look for retinopathy/ maculopathy
Blood workup including complete blood count, ESR, creatinine, eGFR, electrolytes, HbA1c, thyroid profile, blood cholesterol levels, and serum uric acid
Urine albumin to creatinine ratio
Ankle-brachial pressure index - ABI (if symptoms suggestive of peripheral arterial disease)
Imaging including carotid Doppler ultrasound, echocardiography, and brain imaging (where clinically deemed feasible)
Treatment / Management

The management of hypertension subdivides into pharmacological and nonpharmacological management.

Non-pharmacological and lifestyle management are recommended for all individuals with raised BPs regardless of age, gender, comorbidities, or cardiovascular risk status.

Patient education is paramount to effective management and should always include detailed instructions regarding weight management, salt restriction, smoking management, adequate management of obstructive sleep apnea, and exercise. Patients need to be informed and revised at every encounter that these changes are to be continued lifelong for effective disease treatment.

Weight reduction is advisable if obesity is present, although optimum BMI and optimal weight range are still unknown. Weight reduction alone can result in decreases of up to 5 to 20 mm Hg in systolic blood pressure.

Smoking may not have a direct effect on blood pressure but will help in reducing long-term sequelae if the patient quits smoking.

Lifestyle changes alone can account for up to a 15% reduction in all cardiovascular-related events.

Pharmacological therapy consists of angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), diuretics (usually thiazides), calcium channel blockers (CCBs), and beta-blockers (BBs), which are instituted taking into account age, race and comorbidities such as the presence of renal dysfunction, LV dysfunction, heart failure, and cerebrovascular disease. JNC-8, ACC, and ESC/ ESH have their separate recommendations for pharmacological management.

JNC-8 recommends the following:

Starting pharmacological therapy for individuals with DM and CKD with BP greater than or equal to 140/90 mm Hg to therapeutic target BP less than 140/90 mm Hg
Starting pharmacological therapy for individuals 60 years of age and over with BP greater than or equal to 150/90 mm Hg to therapeutic target BP less than 150/90 mm Hg
Starting pharmacological therapy for individuals 18 to 59years of age with SBP greater than or equal to 140 mm Hg to therapeutic target SBP less than 140 mm Hg
individuals with DM and non-black population, treatment should include a thiazide diuretic, CCB, and an ACEi/ARB
individuals in the black population, including those with DM, treatment should include a thiazide diuretic and CCB
individuals with CKD, treatment should be started with or include ACEi/ARB, and this applies to all CKD patients irrespective of race or DM status

ACC recommends the following. [8] [9] [10] [11]

Ten-year atherosclerotic cardiovascular disease (ASCVD) risk should be estimated
Antihypertensive medications are usually initiated when BP readings are persistently greater than or equal to 140/90 mm Hg
For high-risk populations (patients with diabetes, CKD, individuals with ASCVD) or in those individuals with a 10-year ASCVD risk greater than or equal to 10%, therapy can be initiated at lower BP cutoffs
The goal of treatment is to keep blood pressure as close to the normal range as possible, ie, BP less than or equal to 130/80 mm Hg

ESC/ ESH recommends the following:

Starting pharmacological therapy for grade 2 or 3 hypertension, regardless of the level of risk
Starting pharmacological therapy for grade 1 hypertension when there is hypertension-mediated end-organ damage (HMOD)
Grade 1 hypertension in the absence of HMOD requires either a high risk for CVD or failure of lifestyle interventions for initiating pharmacological therapy
Starting pharmacological therapy for individuals greater than or equal to 80 years of age with BP greater than or equal to 160/90 mm Hg to a therapeutic target less than 160/90 mm Hg regardless of DM, CKD, CAD, or TIA/CVA
Starting pharmacological therapy for individuals 18 to 79 years of age with BP greater than or equal to 140/90 mm Hg to a therapeutic target less than 140/90 mm Hg regardless of DM, CKD, CAD, or TIA/CVA

Researchers have also studied renal denervation is a form of interventional treatment where renal sympathetic supply is ablated, via specialized catheter equipment, as a potential treatment for resistant hypertension (where adequate blood pressure control is not achieved despite adequate compliance to two or three anti-hypertensive drugs and lifestyle measures).

Multiple randomized trials, including SPYRAL, RADIANCE, and SIMPLICITY-HTN trials, have shown equivocal results, so this remains an investigational therapy.

Differential Diagnosis

Secondary hypertension should always be sought for as the differential, especially if the patient is at extremes of age (young or older).

Hyperaldosteronism, coarctation of the aorta, renal artery stenosis, chronic kidney disease, and aortic valve disease should always be kept in the differential.

Pertinent Studies and Ongoing Trials

The SYST-EUR trial, HYVET, and SHEP studies were amongst the large RCTs that formed the basis for recommendations from the 8th report of JNC.

The SPRINT trial, HOPE-3 trial, Gubbio population study, and Framingham heart study, along with other RCTs, formed the basis for recommendations from ACC and ESC/ESH guidelines.

Treatment Planning

Polytherapy has become the mainstay of treatment and is endorsed and recommended by ACC as well as ESC/ ESH.

There have been two main approaches:

Either instituting two or more drugs (usually an ACEi or an ARB along with thiazide diuretic and calcium channel blocker) simultaneously, or
Stepwise titration approach with single therapy being up-titrated to maximum dosage before instituting a second drug.

Both have been successful in improving patient outcomes, provided there is adequate compliance and treatment adherence.

All the societies recommend at least an 8 to 12-week duration of anti-hypertensive medication before assessing BP control and reviewing patients for complications.

There is a consensus that home BP measurements or ABPM should be checked at or before initiation of therapy and then three months after starting therapy for monitoring and documentation of adequate BP control.

Toxicity and Adverse Effect Management

Side effects are generally mild and resolve promptly upon decreasing the dosage or discontinuing the drug for short intervals.

Patients should be frequently monitored for side effects, more so in the early initiation phase of therapy when they are much more frequent. Side effects are usually self-limited and include hypotension (more common with calcium channel blockers (CCBs) and ACEi/ ARBs), electrolyte imbalances, pedal edema (more common with CCBs), and renal dysfunction. Renal dysfunction and electrolyte imbalance, especially hyponatremia and hyperkalemia, are frequent with ACEi and ARBs and need to be monitored periodically until the achievement of static levels of Cr, K, and Na.

For patients with severe side effects like symptomatic hyperkalemia or hyponatremia, syncope, and acute kidney injury (AKI), treatment needs to be discontinued, and inpatient management is advised. Nephrologist and cardiologist opinions also need to be sought in such cases. Once the issues settle, treatment needs to be re-instituted gradually and cautiously with careful monitoring and frequent follow-ups.

Angioedema has been a potentially life-threatening side effect of ACEi and ARBs in susceptible individuals and warrants prompt discontinuation and is also a lifelong contra-indication for ACEi/ ARB usage.

Classification and stages of hypertension, as defined in recent American College of Cardiology (ACC) guidelines, are as under [12]

Normal: SBP less than 120 and DBP less than 80 mm Hg;
Elevated: SBP 120 to 129 and DBP less than 80 mm Hg;
Stage 1 hypertension: SBP 130 to 139 or DBP 80 to 89 mm Hg;
Stage 2 hypertension: SBP greater than or equal to 140 mm Hg or DBP greater than or equal to 90 mm Hg.

White coat hypertension is an office BP of 130/80 mm Hg or more but less than 160/100 mm Hg, which comes down to 130/80 mm Hg or less after at least 3 months of anti-hypertensive therapy. Ambulatory or home blood pressure measurement is usually necessary for this diagnosis.

Masked hypertension is an elevated office systolic BP of 120 to 129 mm Hg and diastolic BP of less than 80 mm Hg but raised BP on ambulatory or home measurements (130/80 mm Hg or more).

The ACC classification came out in 2017, received an endorsement from the ASH, and was recommended for individuals aged 20 years and above.

The recent ESC/ESH guidelines came out in 2018 and defined Hypertension as under [13]

Optimal: SBP less than 120 mm Hg and DBP less than 80 mm Hg
Normal: SBP 120 to 129 mm Hg and/or DBP 80 to 84 mm Hg
High normal: SBP 130 to 139 mm Hg and/or DBP 85 to 89 mm Hg
Grade 1 hypertension: SBP 140 to 159 mm Hg and/or DBP 90 to 99 mm Hg
Grade 2 hypertension: SBP 160 to 179 mm Hg and/or DBP 100 to 109 mm Hg
Grade 3 hypertension: SBP greater than or equal to 180 mm Hg and/or DBP greater than or equal to 110 mm Hg
Isolated systolic hypertension: SBP greater than or equal to 140 mm Hg and DBP less than 90 mm Hg (further classified into Grades as per the above ranges of SBP)

ESC/ESH recommendations also shed light on home (HBPM) and ambulatory BP measurements (ABPM), and following cut-offs were given

Daytime (or awake) mean SBP greater than or equal to 135 mm Hg and/or DBP greater than or equal to 85 mm Hg
Night-time (or asleep) mean SBP greater than or equal to 120 mm Hg and/or DBP greater than or equal to 70 mm Hg
24 hr mean SBP greater than or equal to 130 mm Hg and/or DBP greater than or equal to 80 mm Hg
Home BP mean SBP greater than or equal to 135 mm Hg and/or DBP greater than or equal to 85 mm Hg

The ESC/ESH recommendations applied to individuals aged 16 years and above.

The 8th report of the Joint National Committee (JNC) came out in 2014 and received heavy criticism across the globe, did not address the definition of hypertension but put forward its recommendations based on previous definitions put forward by JNC-7. [14] The ESC/ ESH classification came out in 2018 and is to be used in all individuals of ages 16 years and above.

Normal: SBP less than 120 mm Hg and DBP less than 80 mm Hg
Pre-Hypertension: SBP 120 to 139 mm Hg and DBP 80 to 89 mm Hg
Stage 1 Hypertension: SBP 140 to 159 mm Hg and DBP 90 to 99 mm Hg
Stage 2 Hypertension: SBP greater than or equal to 160 mm Hg and DBP greater than or equal to 100 mm Hg

The JNC-8 recommendations were exclusively for individuals aged 18 years and above.

Large-scale metanalyses have also shown the rising CVD and vascular disease risk with a rise in systolic and diastolic blood pressures, with almost doubling of the risk of death from heart disease and stroke with rising SBP of as much as 20 and DBP of 10 mm Hg. [15]

The prognosis depends on blood pressure control and is favorable only if the blood pressures attain adequate control; however, complications may develop in some patients as hypertension is a progressive disease.

Adequate control and lifestyle measures only serve to delay the development and progression of sequelae such as chronic kidney disease and renal failure.

Complications

The following complications have been reported with uncontrolled hypertension in multiple large-scale population trials. [15] [16]

Coronary heart disease (CHD)
Myocardial infarction (MI)
Stroke (CVA), either ischemic or intracerebral hemorrhage
Hypertensive encephalopathy
Renal failure, acute versus chronic
Peripheral arterial disease
Atrial fibrillation
Aortic aneurysm
Death (usually due to coronary heart disease, vascular disease, or stroke-related)
Consultations

In the case of resistant hypertension, a multi-disciplinary approach merits consideration.

A cardiologist, nephrologist, and hypertension specialist should manage such patients in consort.

Often patients will also require psycho-social counseling and consultation with nutritionists and dieticians.

Deterrence and Patient Education

Hypertension is a chronic disorder and requires long-term care and management. Detailed education regarding lifestyle modification and pharmacological therapy is the key to success for better control of blood pressure and to prevent complications. Weight management, physical activity, limiting alcohol/tobacco/smoking is a critical strategy to decrease cardiovascular risk.

Enhancing Healthcare Team Outcomes

Often hypertension is picked up by nurses charting the patients in ERs and outpatient settings, where prompt recognition and referral to a physician is essential as most of these hypertensive patients might be unaware of their disease, hence the name "silent killer."

Inter-professional communication is of prime importance, especially in picking up cases of resistant or difficult-to-treat hypertension where referral and inter-specialty approach will benefit a patient the most. Effective communication in an interprofessional team approach, including nursing staff and nurse practitioners, primary referring physician, cardiologist, nephrologist, and pharmacists, is essential for ensuring blood pressure control. This team can also monitor for adequate patient compliance as well as potential toxicities and adverse effects, all of which will result in minimizing future complications and reducing health care costs as well as improving patient outcomes. [Level 5]

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Disclosure: Arshad Muhammad Iqbal declares no relevant financial relationships with ineligible companies.

Disclosure: Syed Jamal declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Iqbal AM, Jamal SF. Essential Hypertension. [Updated 2023 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Related editorial: Treatment of Mild Hypertension: Seeing Through SPRINT

Published online September 13, 2023.

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Hypertension is a leading modifiable risk factor for cardiovascular disease and the most common chronic condition seen by family physicians. Treatment of hypertension reduces morbidity and mortality due to coronary artery disease, myocardial infarction, heart failure, stroke, and chronic kidney disease. The use of ambulatory and home blood pressure monitoring improves diagnostic accuracy. Assessment of adults with hypertension should focus on identifying complications of the condition and comorbid cardiovascular risk factors. Physicians should counsel all patients with elevated blood pressure about effective lifestyle interventions, including the Dietary Approaches to Stop Hypertension (DASH) diet, dietary sodium restriction, potassium enrichment, regular exercise, weight loss, and moderation of alcohol consumption. First-line antihypertensive medications include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics. Thresholds for pharmacologic intervention and blood pressure goals differ according to various guidelines. Evidence strongly supports reducing blood pressure to less than 140/90 mm Hg to reduce the risk of all-cause and cardiovascular mortality in adults with hypertension. Lowering blood pressure to less than 135/85 mm Hg may further reduce the risk of myocardial infarction. Clinical judgment and shared decision-making should guide treatment of patients with mild hypertension and older adults who may be more susceptible to adverse effects of antihypertensive medications and tight blood pressure control.

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Reboussin DM, Allen NB, Griswold ME, et al. Systematic review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Hypertension . 2018; 71(6): e145]. Hypertension. 2018;71(6):e116-e135.

Jaeger BC, Bress AP, Bundy JD, et al. Longer-term all-cause and cardiovascular mortality with intensive blood pressure control: a secondary analysis of a randomized clinical trial. JAMA Cardiol. 2022;7(11):1138-1146.

Jones DW, Clark D, Hall ME. Blood pressure control after SPRINT— back to reality [comment]. JAMA Cardiol. 2022;7(11):1146-1147.

LeFevre M. ACC/AHA hypertension guideline: what is new? What do we do?. Am Fam Physician. 2018;97(6):372-373.

Sheppard JP, Stevens S, Stevens R, et al. Benefits and harms of antihypertensive treatment in low-risk patients with mild hypertension. JAMA Intern Med. 2018;178(12):1626-1634.

Arguedas JA, Leiva V, Wright JM. Blood pressure targets in adults with hypertension. Cochrane Database Syst Rev. 2020(12):CD004349.

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Smetana GW, Beach J, Lipsitz L, et al. What should be the target blood pressure for this older patient with hypertension? Grand rounds discussion from Beth Israel Deaconess Medical Center. Ann Intern Med. 2018;169(3):175-182.

Weinfeld JM, Hart KM, Vargas JD. Home blood pressure monitoring [published correction appears in Am Fam Physician . 2022; 105(2): 115]. Am Fam Physician. 2021;104(3):237-243.

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Taler SJ. Initial treatment of hypertension. N Engl J Med. 2018;378(7):636-644.

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High blood pressure (hypertension)

On this page, when to see a doctor, risk factors, complications.

What is hypertension? A Mayo Clinic expert explains.

High blood pressure is a common condition that affects the body's arteries. It's also called hypertension. If you have high blood pressure, the force of the blood pushing against the artery walls is consistently too high. The heart has to work harder to pump blood.

Blood pressure is measured in millimeters of mercury (mm Hg). In general, hypertension is a blood pressure reading of 130/80 mm Hg or higher.

The American College of Cardiology and the American Heart Association divide blood pressure into four general categories. Ideal blood pressure is categorized as normal.)

Normal blood pressure. Blood pressure is 120/80 mm Hg or lower.
Elevated blood pressure. The top number ranges from 120 to 129 mm Hg and the bottom number is below, not above, 80 mm Hg.
Stage 1 hypertension. The top number ranges from 130 to 139 mm Hg or the bottom number is between 80 and 89 mm Hg.
Stage 2 hypertension. The top number is 140 mm Hg or higher or the bottom number is 90 mm Hg or higher.

Blood pressure higher than 180/120 mm Hg is considered a hypertensive emergency or crisis. Seek emergency medical help for anyone with these blood pressure numbers.

Untreated, high blood pressure increases the risk of heart attack, stroke and other serious health problems. It's important to have your blood pressure checked at least every two years starting at age 18. Some people need more-frequent checks.

Healthy lifestyle habits —such as not smoking, exercising and eating well — can help prevent and treat high blood pressure. Some people need medicine to treat high blood pressure.

Blood pressure is measured in millimeters of mercury (mm Hg). In general, hypertension is a blood pressure reading of 130/80 millimeters of mercury (mm Hg) or higher.

The American College of Cardiology and the American Heart Association divide blood pressure into four general categories. Ideal blood pressure is categorized as normal.

Normal blood pressure. Blood pressure is lower than 120/80 mm Hg .
Elevated blood pressure. The top number ranges from 120 to 129 mm Hg and the bottom number is below, not above, 80 mm Hg .
Stage 1 hypertension. The top number ranges from 130 to 139 mm Hg or the bottom number is between 80 and 89 mm Hg .
Stage 2 hypertension. The top number is 140 mm Hg or higher or the bottom number is 90 mm Hg or higher.

Blood pressure higher than 180/120 mm Hg is considered a hypertensive emergency or crisis. Seek emergency medical help for anyone with these blood pressure numbers.

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Most people with high blood pressure have no symptoms, even if blood pressure readings reach dangerously high levels. You can have high blood pressure for years without any symptoms.

A few people with high blood pressure may have:

Shortness of breath

However, these symptoms aren't specific. They usually don't occur until high blood pressure has reached a severe or life-threatening stage.

More Information

Pulse pressure: An indicator of heart health?

Blood pressure screening is an important part of general health care. How often you should get your blood pressure checked depends on your age and overall health.

Ask your provider for a blood pressure reading at least every two years starting at age 18. If you're age 40 or older, or you're 18 to 39 with a high risk of high blood pressure, ask for a blood pressure check every year.

Your care provider will likely recommend more-frequent readings if have high blood pressure or other risk factors for heart disease.

Children age 3 and older may have blood pressure measured as a part of their yearly checkups.

If you don't regularly see a care provider, you may be able to get a free blood pressure screening at a health resource fair or other locations in your community. Free blood pressure machines are also available in some stores and pharmacies. The accuracy of these machines depends on several things, such as a correct cuff size and proper use of the machines. Ask your health care provider for advice on using public blood pressure machines.

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Blood pressure is determined by two things: the amount of blood the heart pumps and how hard it is for the blood to move through the arteries. The more blood the heart pumps and the narrower the arteries, the higher the blood pressure.

There are two main types of high blood pressure.

Primary hypertension, also called essential hypertension

For most adults, there's no identifiable cause of high blood pressure. This type of high blood pressure is called primary hypertension or essential hypertension. It tends to develop gradually over many years. Plaque buildup in the arteries, called atherosclerosis, increases the risk of high blood pressure.

Secondary hypertension

This type of high blood pressure is caused by an underlying condition. It tends to appear suddenly and cause higher blood pressure than does primary hypertension. Conditions and medicines that can lead to secondary hypertension include:

Adrenal gland tumors
Blood vessel problems present at birth, also called congenital heart defects
Cough and cold medicines, some pain relievers, birth control pills, and other prescription drugs
Illegal drugs, such as cocaine and amphetamines
Kidney disease
Obstructive sleep apnea
Thyroid problems

Sometimes just getting a health checkup causes blood pressure to increase. This is called white coat hypertension.

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High blood pressure has many risk factors, including:

Age. The risk of high blood pressure increases with age. Until about age 64, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
Race. High blood pressure is particularly common among Black people. It develops at an earlier age in Black people than it does in white people.
Family history. You're more likely to develop high blood pressure if you have a parent or sibling with the condition.
Obesity or being overweight. Excess weight causes changes in the blood vessels, the kidneys and other parts of the body. These changes often increase blood pressure. Being overweight or having obesity also raises the risk of heart disease and its risk factors, such as high cholesterol.
Lack of exercise. Not exercising can cause weight gain. Increased weight raises the risk of high blood pressure. People who are inactive also tend to have higher heart rates.
Tobacco use or vaping. Smoking, chewing tobacco or vaping immediately raises blood pressure for a short while. Tobacco smoking injures blood vessel walls and speeds up the process of hardening of the arteries. If you smoke, ask your care provider for strategies to help you quit.
Too much salt. A lot of salt — also called sodium — in the body can cause the body to retain fluid. This increases blood pressure.
Low potassium levels. Potassium helps balance the amount of salt in the body's cells. A proper balance of potassium is important for good heart health. Low potassium levels may be due to a lack of potassium in the diet or certain health conditions, including dehydration.
Drinking too much alcohol. Alcohol use has been linked with increased blood pressure, particularly in men.
Stress. High levels of stress can lead to a temporary increase in blood pressure. Stress-related habits such as eating more, using tobacco or drinking alcohol can lead to further increases in blood pressure.
Certain chronic conditions. Kidney disease, diabetes and sleep apnea are some of the conditions that can lead to high blood pressure.
Pregnancy. Sometimes pregnancy causes high blood pressure.

High blood pressure is most common in adults. But kids can have high blood pressure too. High blood pressure in children may be caused by problems with the kidneys or heart. But for a growing number of kids, high blood pressure is due to lifestyle habits such as an unhealthy diet and lack of exercise.

The excessive pressure on the artery walls caused by high blood pressure can damage blood vessels and body organs. The higher the blood pressure and the longer it goes uncontrolled, the greater the damage.

Uncontrolled high blood pressure can lead to complications including:

Heart attack or stroke. Hardening and thickening of the arteries due to high blood pressure or other factors can lead to a heart attack, stroke or other complications.
Aneurysm. Increased blood pressure can cause a blood vessel to weaken and bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.
Heart failure. When you have high blood pressure, the heart has to work harder to pump blood. The strain causes the walls of the heart's pumping chamber to thicken. This condition is called left ventricular hypertrophy. Eventually, the heart can't pump enough blood to meet the body's needs, causing heart failure.
Kidney problems. High blood pressure can cause the blood vessels in the kidneys to become narrow or weak. This can lead to kidney damage.
Eye problems. Increased blood pressure can cause thickened, narrowed or torn blood vessels in the eyes. This can result in vision loss.
Metabolic syndrome. This syndrome is a group of disorders of the body's metabolism. It involves the irregular breakdown of sugar, also called glucose. The syndrome includes increased waist size, high triglycerides, decreased high-density lipoprotein (HDL or "good") cholesterol, high blood pressure and high blood sugar levels. These conditions make you more likely to develop diabetes, heart disease and stroke.
Changes with memory or understanding. Uncontrolled high blood pressure may affect the ability to think, remember and learn.
Dementia. Narrowed or blocked arteries can limit blood flow to the brain. This can cause a certain type of dementia called vascular dementia. A stroke that interrupts blood flow to the brain also can cause vascular dementia.
High blood pressure and sex
High blood pressure dangers
Hypertensive crisis: What are the symptoms?

Feb 29, 2024

High blood pressure. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/high-blood-pressure. Accessed July 18, 2022.
Flynn JT, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017; doi:10.1542/peds.2017-1904.
Physical Activity Guidelines for Americans. 2nd ed. U.S. Department of Health and Human Services. https://health.gov/our-work/physical-activity/current-guidelines. Accessed June 15, 2022.
Hypertension in adults: Screening. U.S. Preventive Services Task Force. https://uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening. Accessed July 18, 2022.
Thomas G, et al. Blood pressure measurement in the diagnosis and treatment of hypertension in adults. https://www.uptodate.com/contents/search. Accessed July 18, 2022.
Muntner P, et al. Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension. 2019; doi:10.1161/HYP.0000000000000087.
Basile J, et al. Overview of hypertension in adults. https://www.uptodate.com/contents/search. Accessed July 22, 2022.
Know your risk factors for high blood pressure. American Heart Association. https://www.heart.org/en/health-topics/high-blood-pressure/why-high-blood-pressure-is-a-silent-killer/know-your-risk-factors-for-high-blood-pressure. Accessed July 18, 2022.
Rethinking drinking. Alcohol and your health. National Institute on Alcohol Abuse and Alcoholism. https://www.rethinkingdrinking.niaaa.nih.gov/Default.aspx. Accessed July 18, 2022.
Libby P, et al., eds. Systemic hypertension: Mechanisms, diagnosis, and treatment. In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 12th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed July 18, 2022.
AskMayoExpert. Hypertension (adult). Mayo Clinic; 2021.
About metabolic syndrome. American Heart Association. https://www.heart.org/en/health-topics/metabolic-syndrome/about-metabolic-syndrome. Accessed July 18, 2022.
Understanding blood pressure readings. American Heart Association. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings. Accessed July 18, 2022.
Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018; doi:10.1161/HYP.0000000000000065.
Monitoring your blood pressure at home. American Heart Association. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home. Accessed July 18, 2022.
Mann JF. Choice of drug therapy in primary (essential) hypertension. https://www.uptodate.com/contents/search. Accessed July 18, 2022.
Agasthi P, et al. Renal denervation for resistant hypertension in the contemporary era: A systematic review and meta-analysis. Scientific Reports. 2019; doi:10.1038/s41598-019-42695-9.
Chernova I, et al. Resistant hypertension updated guidelines. Current Cardiology Reports. 2019; doi:10.1007/s11886-019-1209-6.
Forman JP, et al. Diet in the treatment and prevention of hypertension. https://www.uptodate.com/contents/search. Accessed July 18, 2022.
Goldman L, et al., eds. Cognitive impairment and dementia. In: Goldman-Cecil Medicine. 26th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed July 18, 2022.
Managing stress to control high blood pressure. American Heart Association. https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/managing-stress-to-control-high-blood-pressure. Accessed July 18, 2022.
Brenner J, et al. Mindfulness with paced breathing reduces blood pressure. Medical Hypothesis. 2020; doi:10.1016/j.mehy.2020.109780.
Grundy SM, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019; doi:10.1161/CIR.0000000000000625.
Monitoring your blood pressure at home. American Heart Association. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home. Accessed July 22, 2022.
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Saper RB, et al. Overview of herbal medicine and dietary supplements. https://www.uptodate.com/contents/search. Accessed July 18, 2022.
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Börjesson M, et al. Physical activity and exercise lower blood pressure in individuals with hypertension: Narrative review of 27 RCTs. British Journal of Sports Medicine. 2016; doi:10.1136/bjsports-2015-095786.
Lloyd-Jones DM, et al. Life's essential 8: Updating and enhancing the American Heart Association's construct of cardiovascular health: A presidential advisory from the American Heart Association. Circulation. 2022; doi:10.1161/CIR.0000000000001078.
American Heart Association adds sleep to cardiovascular health checklist. American Heart Association. https://newsroom.heart.org/news/american-heart-association-adds-sleep-to-cardiovascular-health-checklist. Accessed July 15, 2022.
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Hypertension

Pathophysiology |
Symptoms and Signs |
Diagnosis |
Treatment |
Prognosis |
Key Points |
More Information |

Hypertension is sustained elevation of resting systolic blood pressure ( ≥ 130 mm Hg), diastolic blood pressure ( ≥ 80 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential, hypertension) is most common. Hypertension with an identified cause (secondary hypertension) is usually due to primary aldosteronism. Sleep apnea, chronic kidney disease, obesity, or renal artery stenosis are other causes of secondary hypertension. Usually, no symptoms develop unless hypertension is severe or long-standing. Diagnosis is by sphygmomanometry. Tests may be done to determine cause, assess organ damage, and identify other cardiovascular risk factors. Treatment involves lifestyle changes and medications, including diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, and calcium channel blockers.

Hypertension is defined as a systolic blood pressure (BP) ≥ 130 mm Hg or a diastolic blood pressure ≥ 80 mm Hg or taking medication for hypertension. Nearly half of adults in the United States have hypertension. Many of these people are not aware that they have hypertension. About 80% of adults with hypertension have been recommended treatment with medication and lifestyle modification, but only about 50% with hypertension receive treatment ( 1 ).

Even with medication and lifestyle modification only 26% of patients have their BP at goal (under control), and of treated adults whose BP is not at goal, almost 60% have a BP ≥ 140/90 mm Hg ( 1 ).

High blood pressure is more common in non-Hispanic Black adults (58%) than in non-Hispanic White adults (49%), non-Hispanic Asian adults (45%), or Hispanic adults (39%— 1 ). Among those recommended to take blood pressure medication and make lifestyle modifications, blood pressure control is higher among non-Hispanic White adults (31%) than in non-Hispanic Black adults (20%), non-Hispanic Asian adults (24%), or Hispanic adults (23%— 1 ).

Blood pressure increases with age. About two thirds of people > 65 years have hypertension, and people with a normal BP at age 55 have a 90% lifetime risk of developing hypertension ( 2 ). Because hypertension becomes so common with age, the age-related increase in BP may seem innocuous, but higher BP increases morbidity and mortality risk.

Hypertension during pregnancy has special considerations because complications are different; hypertension that develops during pregnancy may resolve after pregnancy (see Hypertension in Pregnancy and Preeclampsia and Eclampsia ).

Categories of BP in adults defined by the American College of Cardiology/American Heart Association (ACC/AHA) include normal, elevated BP, stage 1 (mild) or stage 2 hypertension ( 3 ) (see table Classification of Blood Pressure in Adults ). Normal blood pressure in infants and adolescents is much lower ( 4 ).

Hypertension is defined as resistant when BP remains above goal despite use of 3 different antihypertensive medications at maximally tolerated doses. Patients with resistant hypertension have higher cardiovascular morbidity and mortality ( 5 ).

Classification of Blood Pressure in Adults*


Normal blood pressure	< 120/80 mm Hg
Elevated blood pressure	120–129/
Stage 1 hypertension	130–139 mm Hg (systolic) OR 80–89 mm Hg (diastolic)
Stage 2 hypertension	≥ 140 mm Hg (systolic) OR ≥ 90 mm Hg (diastolic)

. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Hypertension. 2018 Jun;71(6):e136-e139] [published correction appears in Hypertension. 2018 Sep;72(3):e33]. 2018;71(6):1269-1324. doi:10.1161/HYP.0000000000000066

Normal blood pressure

< 120/80 mm Hg

Elevated blood pressure

120–129/

Stage 1 hypertension

130–139 mm Hg (systolic)

80–89 mm Hg (diastolic)

Stage 2 hypertension

≥ 140 mm Hg (systolic)

≥ 90 mm Hg (diastolic)

. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Hypertension. 2018 Jun;71(6):e136-e139] [published correction appears in Hypertension. 2018 Sep;72(3):e33]. 2018;71(6):1269-1324. doi:10.1161/HYP.0000000000000066

General references

1. Million Hearts : Estimated Hypertension Prevalence, Treatment, and Control Among U.S. Adults. https://millionhearts.hhs.gov/data-reports/hypertension-prevalence.html March 21, 2021. Accessed September 5, 2023. https://millionhearts.hhs.gov/data-reports/hypertension-prevalence.html

2. Vasan RS, Beiser A, Seshadri S, et al . Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA 287(8):1003-1010, 2002. doi:10.1001/jama.287.8.1003

3. Whelton PK, Carey RM, Aronow WS, et al . 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Hypertension. 2018 Jun;71(6):e136-e139] [published correction appears in Hypertension. 2018 Sep;72(3):e33]. Hypertension 71(6):1269-1324, 2018. doi:10.1161/HYP.000000000000006

4. Flynn J.T, Kaelber DC, Baker-Smith CM, et al; Subcommittee on Screening and Management of High Blood Pressure in Children : Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 140(3):e20171904, 2017.

5. Carey RM, Calhoun DA, Bakris GL, et al : Resistant hypertension: Detection, evaluation, and management: A Scientific Statement From the American Heart Association. Hypertension 72:e53–e90, 2018. doi: 10.1161/HYP.0000000000000084

Etiology of Hypertension

Hypertension may be

Primary (no specific cause—85% of cases)

Secondary (an identified cause)

Primary hypertension

Hemodynamics and physiologic components (eg, plasma volume, activity of the renin-angiotensin system) vary, indicating that primary hypertension is unlikely to have a single cause. Even if one factor is initially responsible, multiple factors are probably involved in sustaining elevated blood pressure (the mosaic theory). In afferent systemic arterioles, malfunction of ion pumps on sarcolemmal membranes of smooth muscle cells may lead to chronically increased vascular tone. Heredity is a predisposing factor, but the exact mechanism is unclear. Environmental factors (eg, dietary sodium, stress) seem to affect only people who are genetically susceptible at younger ages; however, in patients > 65 years, high sodium intake is more likely to precipitate hypertension.

Secondary hypertension

Common causes include

Primary aldosteronism (1)

Obstructive sleep apnea

Renal parenchymal disease (eg, chronic glomerulonephritis or pyelonephritis , polycystic renal disease, lupus nephritis, obstructive uropathy )

Renovascular disease

Other, much rarer, causes include pheochromocytoma , Cushing syndrome , congenital adrenal hyperplasia , hyperthyroidism , hypothyroidism (myxedema), primary hyperparathyroidism , acromegaly , coarctation of the aorta , and mineralocorticoid excess syndromes other than primary aldosteronism.

Excessive alcohol intake and use of oral contraceptives are common reversible causes of hypertension.

Also, use of sympathomimetics, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, cocaine , or licorice may contribute to worsening of blood pressure control.

Although hypertension is common in patients with diabetes , diabetes is not considered a cause.

Etiology reference

1. Brown JM, Siddiqui M, Calhoun DA, et al : The unrecognized prevalence of primary aldosteronism: A cross-sectional study. Ann Intern Med 173(1):10–20, 2020. doi:10.7326/M20-0065

Pathophysiology of Hypertension

Because blood pressure equals cardiac output (CO) × total peripheral vascular resistance (TPR), pathogenic mechanisms involve

Increased CO

Increased TPR

In most patients, CO is normal or slightly increased, and TPR is increased. This pattern is typical of primary hypertension and hypertension due to primary aldosteronism , pheochromocytoma , renovascular disease, and renal parenchymal disease.

In other patients, CO is increased (possibly because of venoconstriction in large veins), and TPR is inappropriately normal for the level of CO. Later in the disorder, TPR increases and CO returns to normal, probably because of autoregulation. Some disorders that increase CO (eg, thyrotoxicosis , arteriovenous fistula , aortic regurgitation ), particularly when stroke volume is increased, cause isolated systolic hypertension. Some older patients have isolated systolic hypertension with normal or low CO, probably due to inelasticity of the aorta and its major branches. Patients with high, fixed diastolic pressures often have decreased CO.

Plasma volume tends to decrease as BP increases; rarely, plasma volume remains normal or increases. Plasma volume tends to be high in hypertension due to primary aldosteronism or renal parenchymal disease and may be quite low in hypertension due to pheochromocytoma.

Renal blood flow gradually decreases as diastolic BP increases and arteriolar sclerosis begins. Glomerular filtration rate (GFR) remains normal until late in the disorder; as a result, the filtration fraction is increased.

Coronary, cerebral, and muscle blood flow is maintained unless severe atherosclerosis coexists in these vascular beds.

Abnormal sodium transport

In many cases of hypertension, sodium transport across the cell wall is abnormal, because the sodium-potassium pump (Na+, K+-ATPase) is defective or inhibited or because permeability to sodium ions is increased. The result is increased intracellular sodium, which makes the cell more sensitive to sympathetic stimulation. Calcium follows sodium, so accumulation of intracellular calcium may be responsible for the increased sensitivity. Because Na+, K+-ATPase may pump norepinephrine back into sympathetic neurons (thus inactivating this neurotransmitter), inhibition of this mechanism could also enhance the effect of norepinephrine , increasing BP. Defects in sodium transport may occur in children who are normotensive but have a parent with hypertension.

Sympathetic nervous system

Sympathetic stimulation increases blood pressure, usually more in patients with elevated BP and hypertension than in patients who are normotensive. Whether this hyperresponsiveness resides in the sympathetic nervous system or in the myocardium and vascular smooth muscle is unknown.

A high resting pulse rate, which may result from increased sympathetic nervous activity, is a well-known predictor of hypertension.

In some patients with hypertension, circulating plasma catecholamine levels during rest are higher than normal.

Renin-angiotensin-aldosterone system

The renin-angiotensin-aldosterone system helps regulate blood volume and therefore blood pressure. Renin, an enzyme formed in the juxtaglomerular apparatus, catalyzes conversion of angiotensinogen to angiotensin I. This inactive product is cleaved by angiotensin-converting enzyme (ACE), mainly in the lungs but also in the kidneys and brain, to angiotensin II , a potent vasoconstrictor that also stimulates autonomic centers in the brain to increase sympathetic discharge and stimulates release of aldosterone and vasopressin . Aldosterone and vasopressin cause sodium and water retention, elevating BP. Aldosterone also enhances potassium excretion; low plasma potassium ( < 3.5 mEq/L [ angiotensin II but has much less pressor activity. Because chymase enzymes also convert angiotensin I to angiotensin II , medications that inhibit ACE do not fully suppress angiotensin II production.

Renin secretion is controlled by at least 4 mechanisms, which are not mutually exclusive:

A renal vascular receptor responds to changes in tension in the afferent arteriolar wall

A macula densa receptor detects changes in the delivery rate or concentration of sodium chloride in the distal tubule

Circulating angiotensin has a negative feedback effect on renin secretion

Sympathetic nervous system stimulates renin secretion mediated by beta-receptors (via the renal nerve)

Angiotensin is generally acknowledged to be responsible for renovascular hypertension , at least in the early phase, but the role of the renin-angiotensin-aldosterone system in primary hypertension is not established. However, in patients with African ancestry and older patients with hypertension, renin levels tend to be low ( 1 ). Older patients also tend to have low angiotensin II levels.

Hypertension due to chronic renal parenchymal disease (renoprival hypertension) results from the combination of a renin-dependent mechanism and a volume-dependent mechanism. In most cases, increased renin activity is not evident in peripheral blood. Hypertension is typically moderate and sensitive to sodium and water balance.

Vasodilator deficiency

Deficiency of a vasodilator (eg, bradykinin, nitric oxide) rather than excess of a vasoconstrictor (eg, angiotensin, norepinephrine ) may cause hypertension. Reductions in nitric oxide occur with aging, and this reduction contributes to salt sensitivity (ie, lesser amounts of salt ingestion will raise BP higher compared to younger people— 2 ).

Reduction in nitric oxide due to stiff arteries is linked to salt-sensitive hypertension, an inordinate increase of > 10 to 20 mm Hg systolic BP after a large sodium load (eg, a salty meal).

If the kidneys do not produce adequate amounts of vasodilators (because of renal parenchymal disease or bilateral nephrectomy), blood pressure can increase.

Vasodilators and vasoconstrictors (mainly endothelin) are also produced in endothelial cells. Therefore, endothelial dysfunction greatly affects blood pressure.

Pathology and complications

No pathologic changes occur early in hypertension. Severe or prolonged hypertension damages target organs (primarily the cardiovascular system, brain, and kidneys), increasing risk of

Coronary artery disease (CAD) and myocardial infarction (MI)

Heart failure

Stroke (particularly hemorrhagic)

Renal failure

The mechanism involves development of generalized arteriolosclerosis and acceleration of atherogenesis. Arteriolosclerosis is characterized by medial hypertrophy, hyperplasia, and hyalinization; it is particularly apparent in small arterioles, notably in the eyes and the kidneys. In the kidneys, the changes narrow the arteriolar lumen, increasing TPR; thus, hypertension leads to more hypertension. Furthermore, once arteries are narrowed, any slight additional shortening of already hypertrophied smooth muscle reduces the lumen to a greater extent than in normal-diameter arteries. These effects may explain why the longer hypertension has existed, the less likely specific treatment (eg, renovascular surgery) for secondary causes is to restore blood pressure to normal.

Because of increased afterload, the left ventricle gradually hypertrophies, causing diastolic dysfunction. The ventricle eventually dilates, causing dilated cardiomyopathy and heart failure due to systolic dysfunction often worsened by arteriosclerotic coronary artery disease. Thoracic aortic dissection is typically a consequence of hypertension; almost all patients with abdominal aortic aneurysms have hypertension.

Pathophysiology references

1. Williams SF, Nicholas SB, Vaziri ND, Norris KC . African Americans, hypertension and the renin angiotensin system. World J Cardiol 6(9):878-889, 2014. doi:10.4330/wjc.v6.i9.878

2. Fujiwara N, Osanai T, Kamada T, et al : Study on the relationship between plasma nitrite and nitrate level and salt sensitivity in human hypertension: modulation of nitric oxide synthesis by salt intake. Circulation 101:856–861, 2000.

Symptoms and Signs of Hypertension

Hypertension is usually asymptomatic until complications develop in target organs. Dizziness, facial flushing, headache, fatigue, epistaxis, and nervousness are not caused by uncomplicated hypertension. Severe hypertension (typically defined as systolic blood pressure ≥ 180 mm Hg and/or diastolic blood pressure ≥ 120 mm Hg) can be asymptomatic (hypertensive urgency). When severe hypertension causes severe cardiovascular, neurologic, renal, and retinal symptoms (eg, symptomatic coronary atherosclerosis, heart failure, hypertensive encephalopathy, renal failure), it is referred to as a hypertensive emergency .

A 4th heart sound is one of the earliest signs of hypertensive heart disease.

Retinal changes may include arteriolar narrowing, hemorrhages, exudates, and, in patients with encephalopathy, papilledema ( hypertensive retinopathy ). Changes are classified (according to the Keith, Wagener, and Barker classification) into 4 groups with increasingly worse prognosis:

Grade 1: Constriction of arterioles only

Grade 2: Constriction and sclerosis of arterioles

Grade 3: Hemorrhages and exudates in addition to vascular changes

Grade 4: Papilledema

Diagnosis of Hypertension

Multiple measurements of BP to confirm

Testing to diagnose causes and complications

Hypertension is diagnosed by sphygmomanometry. History, physical examination, and other tests help identify etiology and determine whether target organs are damaged.

Blood pressure measurement

The blood pressure used for formal diagnosis should be an average of 2 or 3 measurements taken at different times with the patient:

Seated in a chair (not examination table) for > 5 minutes, feet on floor, back supported

With their limb supported at heart level with no clothing covering the area of cuff placement

Having had no exercise, caffeine , or smoking for at least 30 minutes

At the first visit, measure BP in both arms; subsequent measurements should use the arm that gave the higher reading.

A properly sized BP cuff is applied to the upper arm. An appropriately sized cuff covers two thirds of the biceps; the bladder is long enough to encircle > 80% of the arm, and bladder width equals at least 40% of the arm’s circumference. Thus, patients with obesity usually require large cuffs. The clinician inflates the cuff above the expected systolic pressure and gradually releases the air while listening over the brachial artery. The pressure at which the first heartbeat is heard as the pressure falls is systolic BP. Total disappearance of the sound marks diastolic BP. The same principles are followed to measure BP in a forearm (radial artery) and thigh (popliteal artery). Mechanical devices should be calibrated periodically; automated readers are often inaccurate ( 1 ).

BP is measured in both arms because BP that is > 15 mm Hg higher in one arm than the other requires evaluation of the upper vasculature.

BP is measured in a thigh (with a much larger cuff) to rule out coarctation of the aorta , particularly in patients with diminished or delayed femoral pulses; with coarctation, BP is significantly lower in the legs.

If BP is in the stage 1 hypertensive range or is markedly labile, more BP measurements are desirable. BP measurements may be sporadically high before hypertension becomes sustained; this phenomenon probably accounts for “white coat hypertension,” in which BP is elevated when measured in the physician’s office but normal when measured at home or by ambulatory BP monitoring.

Home or ambulatory BP monitoring is indicated when "white coat hypertension" is suspected. In addition, ambulatory BP monitoring also may be indicated when "masked hypertension" (a condition in which BP measured at home is higher than values obtained in the clinician's office) is suspected, typically in patients who demonstrate sequelae of hypertension without evidence of hypertension according to in-office measurements.

The history includes the

Duration of hypertension and previously recorded BP levels

History or symptoms of coronary artery disease , heart failure , or obstructive sleep apnea

Symptoms of or personal or family history of other relevant coexisting disorders (eg, stroke , renal dysfunction, peripheral arterial disease , dyslipidemia , diabetes , gout )

Use of medications that predispose to hypertension (eg, NSAIDs, estrogen -containing oral contraceptives)

Sleep duration

Social history includes exercise levels and use of tobacco, alcohol, and stimulants (including medications and illicit drugs).

A dietary history focuses on intake of salt and stimulants (eg, tea, coffee, caffeine -containing sodas, energy drinks).

Physical examination

The physical examination includes measurement of height, weight, and waist circumference; funduscopic examination for retinopathy ; auscultation for bruits in the neck and abdomen; and a full cardiac, respiratory, and neurologic examination. The abdomen is palpated for kidney enlargement and abdominal masses. Peripheral arterial pulses are evaluated; diminished or delayed femoral pulses suggest aortic coarctation, particularly in patients < 30 years. A unilateral renal artery bruit may be heard in thin patients with renovascular hypertension .

After hypertension is diagnosed based on blood pressure measurements, testing is needed to

Detect target-organ damage

Identify cardiovascular risk factors

The more severe the hypertension and the younger the patient, the more extensive is the evaluation. Tests may include

Urinalysis and urinary albumin :creatinine ratio; if abnormal, consider renal ultrasonography

Lipid panel, complete metabolic panel (including creatinine, potassium, and calcium), fasting plasma glucose

Sometimes measurement of thyroid-stimulating hormone levels

Sometimes measurement of plasma free metanephrines (to detect pheochromocytoma)

Sometimes a sleep study

Depending on results of the examination and initial tests, other tests may be needed.

Renal ultrasonography to evaluate kidney size may provide useful information if urinalysis detects albuminuria (proteinuria), casts, or microhematuria, or if serum creatinine or cystatin C is elevated.

Patients with hypokalemia unrelated to diuretic use are evaluated for high salt intake and for primary aldosteronism by measuring plasma aldosterone levels and plasma renin activity. Primary aldosteronism is present in about 10 to 20% of patients with resistant hypertension, which is much higher than previous estimates ( 2, 3 ).

On ECG, a broad, notched P-wave indicates atrial hypertrophy and, although nonspecific, may be one of the earliest signs of hypertensive heart disease. Elevated QRS voltage with or without evidence of ischemia, may occur later and indicates left ventricular hypertrophy (LVH). When LVH is seen on ECG, echocardiography is often done.

If coarctation of the aorta is suspected, echocardiography, CT, or MRI helps confirm the diagnosis.

Patients with labile, significantly elevated BP and symptoms such as headache, palpitations, tachycardia, excessive perspiration, tremor, and pallor are screened for pheochromocytoma by measuring plasma free metanephrines and for hyperthyroidism , first by measuring thyroid-stimulating hormone (TSH). A sleep study should also be strongly considered in those whose history suggests sleep apnea.

Patients with symptoms suggesting Cushing syndrome , systemic rheumatic diseases, eclampsia , acute porphyria , hyperthyroidism , myxedema , acromegaly , or central nervous system (CNS) disorders also require further evaluation.

Diagnosis references

1. Muntner P, Shimbo D, Carey RM, et al : Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension 73:e35–e66, 2019.

2. Burrello J, Monticone S, Losano I, et al : Prevalence of Hypokalemia and Primary Aldosteronism in 5100 Patients Referred to a Tertiary Hypertension Unit. Hypertension 2020;75(4):1025-1033. doi:10.1161/HYPERTENSIONAHA.119.14063

3. Mulatero P, Stowasser M, Loh KC, et al : Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents. J Clin Endocrinol Metab 2004;89(3):1045-1050. doi:10.1210/jc.2003-031337

Treatment of Hypertension

Weight loss and exercise

Smoking cessation

Adequate sleep duration (> 6 hours/night)

Diet: Increased fruits and vegetables, decreased salt, limited alcohol

Medications: Depending on BP and presence of cardiovascular disease or risk factors

Primary hypertension has no cure, but some causes of secondary hypertension can be corrected. In all cases, control of blood pressure can significantly limit adverse consequences.

Goal blood pressure for the most patients, including patients with a kidney disorder or diabetes, is

BP < 130/80 mm Hg regardless of age up to age 80 years

Lowering BP below 130/80 mm Hg appears to continue to reduce the risk of vascular complications. However, decreasing systolic pressure further also increases the risk of adverse medication effects. Thus, the benefits of lowering BP to levels approaching 120 mm Hg systolic should be weighed against the higher risk of dizziness and light-headedness and possible worsening of kidney function. This is a particular concern among patients with diabetes, in whom BP < 120 mm Hg systolic or a diastolic BP approaching 60 mm Hg increases risk of these adverse events ( 1 ).

Even older patients, including frail older patients, can tolerate a diastolic BP as low as 60 to 65 mm Hg well and without an increase in cardiovascular events ( 2, 3 ). Ideally, patients or family members measure BP at home, provided they have been trained to do so, they are closely monitored, and the sphygmomanometer is regularly calibrated.

Treatment of hypertension during pregnancy requires careful medication selection because some antihypertensive medications can harm the fetus.

Lifestyle modifications

Lifestyle modifications are recommended for all patients with elevated BP or any stage hypertension (see also Table 15. Nonpharmacological Interventions in 2017 Hypertension Guidelines ). The best proven nonpharmacologic interventions for prevention and treatment of hypertension include the following:

Increased physical activity, ideally with a structured exercise program

Weight loss if the patient has overweight or obesity

Healthy diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced saturated and total fat content

Reduced dietary sodium to < 1500 mg/day ( < 3.75 g sodium chloride ) optimally, but at least a 1000 mg/day reduction

Enhanced dietary potassium intake, unless contraindicated due to chronic kidney disease or use of medications that reduce potassium excretion

Moderation in alcohol intake in those who drink alcohol to ≤ 2 drinks daily for men and ≤ 1 drink daily for women (one drink is about 12 oz of beer, 5 oz of wine, or 1.5 oz distilled spirits)

Adequate sleep duration (> 6 hours/night) is also recommended. Short sleep duration (typically defined as < 5 or 6 hours per night in adults, has been associated with hypertension ( 4 ). For example, data suggest that optimizing sleep quality and duration (> 6 hours/night) improves blood pressure control in patients with chronic kidney disease ( 5 ).

Dietary modifications can also help control diabetes, obesity, and dyslipidemia. Patients with uncomplicated hypertension do not need to restrict their activities as long as blood pressure is controlled.

Medications

(See also Medications for Hypertension .)

The decision to treat with medication is based on the BP level and the presence of atherosclerotic cardiovascular disease (ASCVD) or its risk factors (see table Initial Approach to Management of High Blood Pressure ). The presence of diabetes or kidney disease is not factored in separately because these diseases are part of ASCVD risk assessment.

An important part of management is continued reassessment. If patients are not at goal BP, clinicians should strive to optimize adherence before switching or adding medications.

Initial Approach to Management of High Blood Pressure

	< 10%	≥ 10%
Elevated: 120–129/	Lifestyle changes, reassess in 3 to 6 months	Lifestyle changes, reassess in 3 to 6 months	Lifestyle changes, reassess in 3 to 6 months
Stage 1 Hypertension: 130–139/80–89	Lifestyle changes, reassess in 3 to 6 months	Monotherapy, reassess in 1 month†	Monotherapy, reassess in 1 month†
Stage 2 hypertension‡: Systolic ≥ 140 OR Diastolic ≥ 90	Combination therapy (2 antihypertensive medications), reassess in 1 month†	Combination therapy, reassess in 1 month†	Combination therapy, reassess in 1 month†



. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Hypertension 2018 Jun;71(6):e136-e139] [published correction appears in Hypertension 2018 Sep;72(3):e33]. 71(6):1269-1324, 2018. doi:10.1161/HYP.0000000000000066

< 10%

≥ 10%

Elevated: 120–129/

Lifestyle changes, reassess in 3 to 6 months

Stage 1 Hypertension: 130–139/80–89

Lifestyle changes, reassess in 3 to 6 months

Monotherapy, reassess in 1 month†

Stage 2 hypertension‡:

Systolic ≥ 140

Diastolic ≥ 90

Combination therapy (2 antihypertensive medications), reassess in 1 month†

Combination therapy, reassess in 1 month†

. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Hypertension 2018 Jun;71(6):e136-e139] [published correction appears in Hypertension 2018 Sep;72(3):e33]. 71(6):1269-1324, 2018. doi:10.1161/HYP.0000000000000066

Medication selection is based on several factors, including comorbidities and contraindications. For most patients, when selecting an agent for monotherapy , initial treatment may be with any of the following medication classes:

Angiotensin-converting enzyme (ACE) inhibitor

Angiotensin II receptor blocker (ARB)

Dihydropyridine calcium channel blocker

In addition, some experts recommend that for patients of African ancestry who are candidates for monotherapy, a calcium channel blocker or a thiazide diuretic should be used initially (unless patients also have stage 3 or higher chronic kidney disease). The preference for a calcium channel blocker or a thiazide diuretic in patients of African ancestry is based on evidence from randomized trials showing that these classes of medications have superior efficacy in lowering blood pressure and rates of cardiovascular events than ACE inhibitors or ARBs ( 6, 7, 8, 9 ). However, subsequent data suggest that despite the use of this race-based approach, control of hypertension and racial disparities in blood pressure control have not improved ( 10 ). Thus, some experts favor an individualized approach to therapeutic selection rather than a race-based approach. In addition, there is substantial variability in blood pressure response within racial groups ( 11 ).

When combination therapy with 2 antihypertensive agents is selected, options include either an ACE inhibitor or ARB combined with either a diuretic or a calcium channel blocker. Many combinations are available as single pills, which are preferable to improve patient adherence ( 12, 13 ).

Signs of hypertensive emergencies require immediate blood pressure reduction with parenteral antihypertensives.

Some antihypertensives are avoided in certain disorders (eg, ACE inhibitors in severe aortic stenosis ) whereas others are preferred for certain disorders (eg, calcium channel blockers for angina pectoris , ACE inhibitors or ARBs for diabetes with proteinuria —see tables Initial Choice of Antihypertensive Medication Class and Antihypertensives for Patients With Comorbidities ).

If the goal BP is not achieved within 1 month, assess adherence and reinforce the importance of following treatment. If patients are adherent, the dose of the initial medication can be increased or a second medication added (selected from among the medications recommended for initial treatment). Note that an ACE inhibitor and an ARB should not be used together. Therapy is titrated frequently. If target BP cannot be achieved with 2 medications, a third medication from the initial group is added. If such a third medication is not tolerated or is contraindicated, a medication from another class (eg, aldosterone antagonist) can be used. Patients with such difficult to control BP may benefit from consultation with a hypertension specialist.

Initial Choice of Antihypertensive Medication Class


ACE inhibitors*	Youth due to systolic dysfunction† Albumin:creatinine ratio > 30 mg/gram (> 33.9 mg/mmol) in patients with or due to other medications
Angiotensin II receptor blockers*	Youth Conditions for which ACE inhibitors are indicated but not tolerated because of cough or Diabetes with nephropathy Left ventricular failure with systolic dysfunction Secondary
Long-acting calcium channel blockers	Older age African or Black American ancestry Arrhythmias (eg, , ) Isolated systolic hypertension in older patients (dihydropyridines)† High risk (nondihydropyridines)†
	Older age African or Black American ancestry


= coronary artery disease.

ACE inhibitors*

Youth

due to systolic dysfunction†

Albumin:creatinine ratio > 30 mg/gram (> 33.9 mg/mmol) in patients with or

due to other medications

Angiotensin II receptor blockers*

Youth

Conditions for which ACE inhibitors are indicated but not tolerated because of cough or

Diabetes with nephropathy

Left ventricular failure with systolic dysfunction

Secondary

Long-acting calcium channel blockers

Older age

African or Black American ancestry

Arrhythmias (eg, , )

Isolated systolic hypertension in older patients (dihydropyridines)†

High risk (nondihydropyridines)†

Older age

African or Black American ancestry

= coronary artery disease.

If initial systolic BP is > 160 mm Hg, 2 medications should be initiated regardless of cardiovascular disease risk. An appropriate combination and dose are determined. For resistant hypertension (BP remains above goal despite use of 3 different antihypertensive medications), 4 or more medications are commonly needed.

Achieving adequate blood pressure control often requires several evaluations and changes in pharmacotherapy. Reluctance to titrate or add medications to control BP must be overcome. Nonadherence to therapy, particularly because lifelong treatment is required, can interfere with adequate BP control. Education, with empathy and support, is essential for success.

Antihypertensives for Patients With Comorbidities



	ACE inhibitors
	Diuretics ACE inhibitors Angiotensin II receptor blockers Calcium channel blockers
	ACE inhibitors Angiotensin II receptor blockers Beta-blockers Other diuretics*
Post-	ACE inhibitors Beta-blockers
Risk of recurrent	ACE inhibitors Angiotensin II receptor blockers Calcium channel blockers Diuretics

ACE inhibitors

Diuretics

ACE inhibitors

Angiotensin II receptor blockers

Calcium channel blockers

ACE inhibitors

Angiotensin II receptor blockers

Beta-blockers

Other diuretics*

Post-

ACE inhibitors

Beta-blockers

Risk of recurrent

ACE inhibitors

Angiotensin II receptor blockers

Calcium channel blockers

Diuretics

Devices and physical interventions

Percutaneous catheter-based radiofrequency ablation of the sympathetic nerves in the renal artery is used in Europe and Australia for resistant hypertension. Several industry-funded sham-controlled studies with different patient populations (eg, those with untreated hypertension [ 14 ], treated hypertension [ 15 ], or resistant hypertension [ 16 ]) have demonstrated statistically and/or clinically significant reductions in systolic blood pressure. However, whether these devices reduce major cardiovascular events remains uncertain. Thus, sympathetic ablation should be considered experimental and used only in centers with extensive experience.

A physical intervention to lower blood pressure involves stimulating the carotid baroreceptor with a device surgically implanted around the carotid body. A battery attached to the device, much like a pacemaker, is designed to stimulate the baroreceptor and, in a dose-dependent manner, lower blood pressure. Long-term follow-up of patients with resistant hypertension who were included in earlier pivotal trials suggests that baroreflex activation therapy maintained its efficacy for persistent reduction of office BP without major safety issues ( 17 ). However, the 2017 American College of Cardiology/American Heart Association guidelines concluded that studies have not provided sufficient evidence to recommend the use of these devices in managing resistant hypertension ( 18 ).

Treatment references

1. Gomadam P, Shah A, Qureshi W, et al . Blood pressure indices and cardiovascular disease mortality in persons with or without diabetes mellitus. J Hypertens 36(1):85-92, 2018. doi:10.1097/HJH.0000000000001509

2. Williamson JD, Supiano MA, Applegate WB, et al . Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged ≥ 75 Years: A Randomized Clinical Trial. JAMA 315(24):2673-2682, 2016. doi:10.1001/jama.2016.7050

3. White WB, Wakefield DB, Moscufo N, et al . Effects of Intensive Versus Standard Ambulatory Blood Pressure Control on Cerebrovascular Outcomes in Older People (INFINITY). Circulation 140(20):1626-1635, 2019. doi:10.1161/CIRCULATIONAHA.119.041603

4. Thomas SJ, Calhoun D . Sleep, insomnia, and hypertension: current findings and future directions. J Am Soc Hypertens 11(2):122-129, 2017. doi:10.1016/j.jash.2016.11.008

5. Ali W, Gao G, Bakris GL . Improved Sleep Quality Improves Blood Pressure Control among Patients with Chronic Kidney Disease: A Pilot Study. Am J Nephrol 51(3):249-254, 2020. doi:10.1159/000505895

6. Materson BJ, Reda DJ, Cushman WC, et al . Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents [published correction appears in N Engl J Med 1994 Jun 9;330(23):1689]. N Engl J Med 1993;328(13):914-921. doi:10.1056/NEJM199304013281303

7. Yamal JM, Oparil S, Davis BR, et al J Am Soc Hypertens 2014;8(11):808-819. doi:10.1016/j.jash.2014.08.003

8. Wright JT Jr, Harris-Haywood S, Pressel S, et al . Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med 2008;168(2):207-217. doi:10.1001/archinternmed.2007.66

9. Hall WD, Reed JW, Flack JM, Yunis C, Preisser J . Comparison of the efficacy of dihydropyridine calcium channel blockers in African American patients with hypertension. ISHIB Investigators Group. International Society on Hypertension in Blacks. Arch Intern Med 158(18):2029-2034, 1998. doi: 10.1001/archinte.158.18.2029

10. Egan BM, Li J, Sutherland SE, Rakotz MK, Wozniak GD . Hypertension Control in the United States 2009 to 2018: Factors Underlying Falling Control Rates During 2015 to 2018 Across Age- and Race-Ethnicity Groups. Hypertension 78(3):578-587, 2021. doi:10.1161/HYPERTENSIONAHA.120.16418

11. Mokwe E, Ohmit SE, Nasser SA, et al . Determinants of blood pressure response to quinapril in black and white hypertensive patients: the Quinapril Titration Interval Management Evaluation trial. Hypertension 2004;43(6):1202-1207. doi:10.1161/01.HYP.0000127924.67353.86

12. Parati G, Kjeldsen S, Coca A, Cushman WC, Wang J . Adherence to Single-Pill Versus Free-Equivalent Combination Therapy in Hypertension: A Systematic Review and Meta-Analysis. Hypertension 77(2):692-705, 2021. doi:10.1161/HYPERTENSIONAHA.120.15781

13. Williams B, Mancia G, Spiering W, et al . 2018 Practice Guidelines for the management of arterial hypertension of the European Society of Hypertension and the European Society of Cardiology: ESH/ESC Task Force for the Management of Arterial Hypertension [published correction appears in J Hypertens 2019 Feb;37(2):456]. J Hypertens 8;36(12):2284-2309, 2018. doi:10.1097/HJH.0000000000001961

14. Böhm M, Kario K, Kandzari DE, et al . Efficacy of catheter-based renal denervation in the absence of antihypertensive medications (SPYRAL HTN-OFF MED Pivotal): a multicentre, randomised, sham-controlled trial. Lancet 395(10234):1444-1451, 2020. doi:10.1016/S0140-6736(20)30554-7

15. Mahfoud F, Kandzari DE, Kario K, et al . Long-term efficacy and safety of renal denervation in the presence of antihypertensive drugs (SPYRAL HTN-ON MED): a randomised, sham-controlled trial. Lancet 399(10333):1401-1410, 2022. doi:10.1016/S0140-6736(22)00455-X

16. Bhatt DL, Vaduganathan M, Kandzari DE, et al . Long-term outcomes after catheter-based renal artery denervation for resistant hypertension: final follow-up of the randomised SYMPLICITY HTN-3 Trial. Lancet 400(10361):1405-1416, 2022. doi:10.1016/S0140-6736(22)01787-1

17. de Leeuw PW, Bisognano JD, Bakris GL, Nadim MK, Haller H, Kroon AA, DEBuT-T and Rheos Trial Investigators : Sustained reduction of blood pressure with baroreceptor activation therapy: Results of the 6-year open follow-up. Hypertension 69:836–843, 2017.

18. Whelton PK, Carey RM, Aronow WS, et al : 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 71(6):e13–e115, 2018. doi: 10.1161/HYP.0000000000000065

Prognosis for Hypertension

The higher the blood pressure and the more severe the retinal changes and other evidence of target-organ involvement, the worse the prognosis. Systolic BP predicts fatal and nonfatal cardiovascular events better than diastolic BP ( 1, 2 ).

Without treatment, 1-year survival is < 10% in patients with retinal sclerosis, cotton-wool exudates, arteriolar narrowing, and hemorrhage (grade 3 retinopathy), and < 5% in patients with the same changes plus papilledema (grade 4 retinopathy [ 3 ]).

Coronary artery disease is the most common cause of death among treated patients. Ischemic or hemorrhagic stroke is a common consequence of inadequately treated hypertension. However, effective control of hypertension prevents most complications and prolongs life.

Prognosis references

1. Bourdillon MT, Song RJ, Musa Yola I, Xanthakis V, Vasan RS . Prevalence, Predictors, Progression, and Prognosis of Hypertension Subtypes in the Framingham Heart Study. J Am Heart Assoc 11(6):e024202, 2022. doi:10.1161/JAHA.121.024202

2. Kannel WB, Gordon T, Schwartz MJ . Systolic versus diastolic blood pressure and risk of coronary heart disease. The Framingham study. Am J Cardiol 27(4):335-346, 1971. doi:10.1016/0002-9149(71)90428-0

3. Dziedziak J, Zaleska-Żmijewska A, Szaflik JP, Cudnoch-Jędrzejewska A . Impact of Arterial Hypertension on the Eye: A Review of the Pathogenesis, Diagnostic Methods, and Treatment of Hypertensive Retinopathy. Med Sci Monit 28:e935135, 2022. doi:10.12659/MSM.935135

Only about 50% of patients in the United States with hypertension receive treatment, and about one quarter of those patients have adequate blood pressure (BP) control.

Most hypertension is primary; only 5 to 15% is secondary to another disorder (eg, primary aldosteronism, renal parenchymal disease).

Severe or prolonged hypertension damages the cardiovascular system, brain, and kidneys, increasing risk of myocardial infarction, stroke, and chronic kidney disease.

Hypertension is usually asymptomatic until complications develop in target organs.

When hypertension is newly diagnosed, do a urinalysis, spot urine albumin :creatinine ratio, blood tests (creatinine, potassium, sodium, calcium, fasting plasma glucose, lipid panel, and often thyroid-stimulating hormone), and ECG.

Reduce BP to < 130/80 mm Hg for everyone up to age 80 years, including those with a kidney disorder or diabetes.

Treatment involves lifestyle changes, especially a low-sodium and higher potassium diet, management of secondary causes of hypertension, and medications (including thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and dihydropyridine calcium channel blockers).

More Information

The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.

2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.

Carey RM, Calhoun DA, Bakris GL, et al : Resistant hypertension: Detection, evaluation, and management: A Scientific Statement From the American Heart Association. Hypertension 72:e53–e90, 2018. doi: 10.1161/HYP.0000000000000084

Williams B, Mancia G, Spiering W, et al : 2018 Practice Guidelines for the management of arterial hypertension of the European Society of Hypertension and the European Society of Cardiology: ESH/ESC Task Force for the Management of Arterial Hypertension [published correction appears in J Hypertens 2019 Feb;37(2):456]. J Hypertens 2018;36(12):2284-2309. doi:10.1097/HJH.0000000000001961

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Initial evaluation of adults with hypertension - UpToDate
Most patients with hypertension initially present with a modest elevation in blood pressure and no clinical cardiovascular disease or signs of hypertension-related target-organ damage.
Hypertension in adults: diagnosis and management
This guideline covers identifying and treating primary hypertension (high blood pressure) in people aged 18 and over, including people with type 2 diabetes. It aims to reduce the risk of cardiovascular problems such as heart attacks and strokes by helping healthcare professionals to diagnose hypertension accurately and treat it effectively.
Essential Hypertension - StatPearls - NCBI Bookshelf
This activity reviews the etiology, presentation, evaluation, and management of essential hypertension and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition. Objectives: Describe the criteria for normotensive, pre-hypertensive, and hypertensive blood pressure.
Overview of hypertension in adults - UpToDate
This topic provides a broad overview of the definitions, pathogenesis, complications, diagnosis, evaluation, and management of hypertension. Detailed discussions of all these issues are found separately. The reader is directed, when necessary, to more detailed discussions of these issues in other topics.
Hypertension: New Guidelines from the International Society ...
• Initial assessment in a patient who is hypertensive should evaluate for cardiovascular risk and any hypertension-mediated organ damage. • Consider lifestyle interventions for three to six...
Hypertension in Adults: Initial Evaluation and Management
Hypertension is the persistent elevation of systolic and/or diastolic blood pressure and a leading modifiable risk factor for cardiovascular disease; it is the most common chronic condition seen...
High blood pressure (hypertension) - Mayo Clinic
High blood pressure (hypertension) is diagnosed if the blood pressure reading is equal to or greater than 130/80 millimeters of mercury (mm Hg). A diagnosis of high blood pressure is usually based on the average of two or more readings taken on separate occasions.
2017 Guideline for the Prevention, Detection, Evaluation, and ...
The ACC and AHA convened this writing committee to address the prevention, detection, evaluation, and management of high blood pressure in adults. The first comprehensive guideline for detection, evaluation, and management of high BP was published in 1977, under the sponsorship of the NHLBI. In subsequent years, a series of Joint National ...
High blood pressure (hypertension) - Mayo Clinic
In general, hypertension is a blood pressure reading of 130/80 millimeters of mercury (mm Hg) or higher. The American College of Cardiology and the American Heart Association divide blood pressure into four general categories. Ideal blood pressure is categorized as normal. Normal blood pressure.
Hypertension - Hypertension - MSD Manual Professional Edition
Hypertension is defined as a systolic blood pressure (BP) ≥ 130 mm Hg or a diastolic blood pressure ≥ 80 mm Hg or taking medication for hypertension. Nearly half of adults in the United States have hypertension. Many of these people are not aware that they have hypertension.

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Hypertension

Classification of Blood Pressure in Adults*

General references

Etiology of Hypertension

Primary hypertension

Secondary hypertension

Etiology reference

Pathophysiology of Hypertension

Abnormal sodium transport

Sympathetic nervous system

Renin-angiotensin-aldosterone system

Vasodilator deficiency

Pathology and complications

Pathophysiology references

Symptoms and Signs of Hypertension

Diagnosis of Hypertension

Blood pressure measurement

Physical examination

Diagnosis references

Treatment of Hypertension

Lifestyle modifications

Medications

Initial Approach to Management of High Blood Pressure

Initial Choice of Antihypertensive Medication Class

Antihypertensives for Patients With Comorbidities

Devices and physical interventions

Treatment references

Prognosis for Hypertension

Prognosis references

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