(See also 2017 ACC/AHA Hypertension Guidelines.)
In the US, about 75 million people have hypertension. About 81% of these people are aware that they have hypertension, only 75% are being treated, and only 51% have adequately controlled blood pressure (BP). In adults, hypertension occurs more often in blacks (41%) than in whites (28%) or Mexican Americans (28%), and morbidity and mortality are greater in blacks.
Blood pressure increases with age. About two thirds of people > 65 have hypertension, and people with a normal BP at age 55 have a 90% lifetime risk of developing hypertension. 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 that is present before pregnancy or that develops during pregnancy has special considerations (see Hypertension in Pregnancy Hypertension in Pregnancy Recommendations regarding classification, diagnosis, and management of hypertensive disorders (including preeclampsia) are available from the American College of Obstetricians and Gynecologists... read more and Preeclampsia and Eclampsia Preeclampsia and Eclampsia Preeclampsia is new-onset or worsening of existing hypertension with proteinuria after 20 weeks gestation. Eclampsia is unexplained generalized seizures in patients with preeclampsia. Diagnosis... read more ).
BP in adults is classified as normal, elevated BP, stage 1 (mild) or stage 2 hypertension (see table Classification of Blood Pressure in Adults Classification of Blood Pressure in Adults* ). Normal blood pressure in infants and adolescents Blood pressure Well-child visits aim to do the following: Promote health Prevent disease through routine vaccinations and education Detect and treat disease early Guide parents to optimize the child’s emotional... read more is much lower ( 1 General reference 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... read more ).
1. 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.
Etiology of Hypertension
Hypertension may be
Primary (85% of cases)
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 genetically susceptible people at younger ages; however, in patients > 65, high sodium intake is more likely to precipitate hypertension.
Common causes include
Renal parenchymal disease (eg, chronic glomerulonephritis or pyelonephritis Chronic Pyelonephritis Chronic pyelonephritis is continuing pyogenic infection of the kidney that occurs almost exclusively in patients with major anatomic abnormalities. Symptoms may be absent or may include fever... read more , polycystic renal disease, connective tissue disorders, obstructive uropathy Obstructive Uropathy Obstructive uropathy is structural or functional hindrance of normal urine flow, sometimes leading to renal dysfunction (obstructive nephropathy). Symptoms, less likely in chronic obstruction... read more )
Other, much rarer, causes include pheochromocytoma Pheochromocytoma A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells typically located in the adrenals. It causes persistent or paroxysmal hypertension. Diagnosis is by measuring catecholamine... read more , Cushing syndrome Cushing Syndrome Cushing syndrome is a constellation of clinical abnormalities caused by chronic high blood levels of cortisol or related corticosteroids. Cushing disease is Cushing syndrome that results from... read more , congenital adrenal hyperplasia Overview of Congenital Adrenal Hyperplasia Congenital adrenal hyperplasia is a group of genetic disorders, each characterized by inadequate synthesis of cortisol, aldosterone, or both. In the most common forms, accumulated hormone precursors... read more , hyperthyroidism Hyperthyroidism Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free thyroid hormones. Symptoms are many and include tachycardia, fatigue, weight loss, nervousness, and tremor... read more , hypothyroidism Hypothyroidism Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features such as a typical facial appearance, hoarse slow speech, and dry skin and by low levels of thyroid hormones... read more (myxedema), primary hyperparathyroidism Hyperparathyroidism Hyperparathyroidism occurs when one or more of the parathyroid glands become overactive, causing elevated serum levels of parathyroid hormone and leading to hypercalcemia. Patients may be asymptomatic... read more , acromegaly Gigantism and Acromegaly Gigantism and acromegaly are syndromes of excessive secretion of growth hormone (hypersomatotropism) that are nearly always due to a pituitary adenoma. Before closure of the epiphyses, the result... read more , coarctation of the aorta Coarctation of the Aorta Coarctation of the aorta is a localized narrowing of the aortic lumen that results in upper-extremity hypertension, left ventricular hypertrophy, and malperfusion of the abdominal organs and... read more , and mineralocorticoid excess syndromes other than primary aldosteronism. Excessive alcohol intake and use of oral contraceptives are common causes of curable hypertension. Use of sympathomimetics, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, cocaine, or licorice commonly contributes to worsening of blood pressure control.
Hypertension is defined as resistant when BP remains above goal despite use of 3 different antihypertensive drugs. Patients with resistant hypertension have higher cardiovascular morbidity and mortality ( 1 Etiology reference 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... read more ).
1. 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
Pathophysiology of Hypertension
Because blood pressure equals cardiac output (CO) × total peripheral vascular resistance (TPR), pathogenic mechanisms must involve
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 (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 normotensive children of hypertensive parents.
Sympathetic nervous system
Sympathetic stimulation increases blood pressure, usually more in patients with elevated BP and hypertension than in normotensive patients. 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 hypertensive patients, circulating plasma catecholamine levels during rest are higher than normal.
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 [< 3.5 mmol/L]) increases vasoconstriction through closure of potassium channels. Angiotensin III, present in the circulation, stimulates aldosterone release as actively as angiotensin II but has much less pressor activity. Because chymase enzymes also convert angiotensin I to angiotensin II, drugs 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 Renovascular Hypertension Renovascular hypertension is blood pressure elevation due to partial or complete occlusion of one or more renal arteries or their branches. It is usually asymptomatic unless long-standing. A... read more , at least in the early phase, but the role of the renin-angiotensin-aldosterone system in primary hypertension is not established. However, in black and older patients with hypertension, renin levels tend to be low. 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.
Deficiency of a vasodilator (eg, bradykinin, nitric oxide) rather than excess of a vasoconstrictor (eg, angiotensin, norepinephrine) may cause hypertension.
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 meal of Chinese food).
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 Overview of Coronary Artery Disease Coronary artery disease (CAD) involves impairment of blood flow through the coronary arteries, most commonly by atheromas. Clinical presentations include silent ischemia, angina pectoris, acute... read more (CAD) and myocardial infarction Overview of Acute Coronary Syndromes (ACS) Acute coronary syndromes result from acute obstruction of a coronary artery. Consequences depend on degree and location of obstruction and range from unstable angina to non–ST-segment elevation... read more (MI)
The mechanism involves development of generalized arteriolosclerosis Atherosclerosis Atherosclerosis is characterized by patchy intimal plaques (atheromas) that encroach on the lumen of medium-sized and large arteries. The plaques contain lipids, inflammatory cells, smooth muscle... read more 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.
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 ( hypertensive emergencies Hypertensive Emergencies A hypertensive emergency is severe hypertension with signs of damage to target organs (primarily the brain, cardiovascular system, and kidneys). Diagnosis is by blood pressure (BP) measurement... read more ) can cause severe cardiovascular, neurologic, renal, and retinal symptoms (eg, symptomatic coronary atherosclerosis, heart failure, hypertensive encephalopathy, renal failure).
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 Hypertensive Retinopathy Hypertensive retinopathy is retinal vascular damage caused by hypertension. Signs usually develop late in the disease. Funduscopic examination shows arteriolar constriction, arteriovenous nicking... read more ). 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
Urinalysis and urinary albumin:creatinine ratio; if abnormal, consider renal ultrasonography
Blood tests: Fasting lipids, creatinine, potassium
Renal ultrasonography if creatinine increased
Evaluate for aldosteronism if potassium decreased
ECG: If left ventricular hypertrophy, consider echocardiography
Sometimes thyroid-stimulating hormone measurement
Evaluate for pheochromocytoma or a sleep disorder if BP elevation sudden and labile or severe
Hypertension is diagnosed and classified 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 2 or 3 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 and 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, obese patients require large cuffs. The health care practitioner 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 Diagnosis reference 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... read more ).
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 Coarctation of the Aorta Coarctation of the aorta is a localized narrowing of the aortic lumen that results in upper-extremity hypertension, left ventricular hypertrophy, and malperfusion of the abdominal organs and... read more , 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. However, extreme BP elevation alternating with normal readings is unusual and possibly suggests pheochromocytoma Pheochromocytoma A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells typically located in the adrenals. It causes persistent or paroxysmal hypertension. Diagnosis is by measuring catecholamine... read more , a sleep disorder such as sleep apnea Obstructive Sleep Apnea Obstructive sleep apnea (OSA) consists of episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of apnea or... read more , or unacknowledged drug use.
The history includes the known duration of hypertension and previously recorded BP levels; any history or symptoms of coronary artery disease Overview of Coronary Artery Disease Coronary artery disease (CAD) involves impairment of blood flow through the coronary arteries, most commonly by atheromas. Clinical presentations include silent ischemia, angina pectoris, acute... read more , heart failure Heart Failure (HF) Heart failure (HF) is a syndrome of ventricular dysfunction. Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid... read more , sleep apnea or loud snoring; history or symptoms of other relevant coexisting disorders (eg, stroke Overview of Stroke Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Strokes can be Ischemic (80%), typically resulting... read more , renal dysfunction, peripheral arterial disease Peripheral Arterial Disease Peripheral arterial disease (PAD) is atherosclerosis of the extremities (virtually always lower) causing ischemia. Mild PAD may be asymptomatic or cause intermittent claudication; severe PAD... read more , dyslipidemia Dyslipidemia Dyslipidemia is elevation of plasma cholesterol, triglycerides (TGs), or both, or a low high-density lipoprotein cholesterol level that contributes to the development of atherosclerosis... read more , diabetes Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more , gout Gout Gout is a disorder caused by hyperuricemia (serum urate > 6.8 mg/dL [> 0.4 mmol/L]) that results in the precipitation of monosodium urate crystals in and around joints, most often causing recurrent... read more ); and a family history of any of these disorders.
Social history includes exercise levels and use of tobacco, alcohol, and stimulant drugs (prescribed and illicit). A dietary history focuses on intake of salt and stimulants (eg, tea, coffee, caffeine-containing sodas, energy drinks).
The physical examination includes measurement of height, weight, and waist circumference; funduscopic examination for retinopathy Symptoms and Signs Hypertensive retinopathy is retinal vascular damage caused by hypertension. Signs usually develop late in the disease. Funduscopic examination shows arteriolar constriction, arteriovenous nicking... read more ; 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. A unilateral renal artery bruit may be heard in slim patients with renovascular hypertension Renovascular Hypertension Renovascular hypertension is blood pressure elevation due to partial or complete occlusion of one or more renal arteries or their branches. It is usually asymptomatic unless long-standing. A... read more .
The more severe the hypertension and the younger the patient, the more extensive is the evaluation. Generally, when hypertension is newly diagnosed, routine testing is done to
Detect target-organ damage
Identify cardiovascular risk factors
Urinalysis and spot urine albumin:creatinine ratio
Blood tests (creatinine, potassium, sodium, fasting plasma glucose, lipid profile, and often thyroid-stimulating hormone)
Ambulatory blood pressure monitoring, renal radionuclide imaging, chest x-ray, screening tests for pheochromocytoma, and renin-sodium profiling are not routinely necessary.
However, home or ambulatory BP monitoring Holter monitor The standard electrocardiogram (ECG) provides 12 different vector views of the heart’s electrical activity as reflected by electrical potential differences between positive and negative electrodes... read more 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.
Peripheral plasma renin activity is not helpful in diagnosis or drug selection.
Depending on results of initial tests and examination, other tests may be needed. If urinalysis detects albuminuria (proteinuria), cylindruria, or microhematuria, or if serum creatinine is elevated (≥ 1.4 mg/dL [124 micromole/L] in men; ≥ 1.2 mg/dL [106 micromole/L] in women), renal ultrasonography to evaluate kidney size may provide useful information. Patients with hypokalemia unrelated to diuretic use are evaluated for primary aldosteronism Primary Aldosteronism Primary aldosteronism is aldosteronism caused by autonomous production of aldosterone by the adrenal cortex (due to hyperplasia, adenoma, or carcinoma). Symptoms and signs include episodic weakness... read more and high salt intake.
On ECG, a broad, notched P-wave indicates atrial hypertrophy and, although nonspecific, may be one of the earliest signs of hypertensive heart disease. Left ventricular hypertrophy, indicated by a sustained apical thrust and elevated QRS voltage with or without evidence of ischemia, may occur later. If either of these findings is present, echocardiography is often done. In patients with an abnormal lipid profile or symptoms of coronary artery disease, tests for other cardiovascular risk factors (eg, C-reactive protein) may be useful.
If coarctation of the aorta Coarctation of the Aorta Coarctation of the aorta is a localized narrowing of the aortic lumen that results in upper-extremity hypertension, left ventricular hypertrophy, and malperfusion of the abdominal organs and... read more is suspected, chest x-ray, 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 Diagnosis A pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells typically located in the adrenals. It causes persistent or paroxysmal hypertension. Diagnosis is by measuring catecholamine... read more (eg, by measuring plasma free metanephrines). A sleep study should also be strongly considered in these patients and those whose history suggests sleep apnea.
Patients with symptoms suggesting Cushing syndrome Cushing Syndrome Cushing syndrome is a constellation of clinical abnormalities caused by chronic high blood levels of cortisol or related corticosteroids. Cushing disease is Cushing syndrome that results from... read more , a connective tissue disorder, eclampsia Preeclampsia and Eclampsia Preeclampsia is new-onset or worsening of existing hypertension with proteinuria after 20 weeks gestation. Eclampsia is unexplained generalized seizures in patients with preeclampsia. Diagnosis... read more , acute porphyria Acute Porphyrias Acute porphyrias result from deficiency of certain enzymes in the heme biosynthetic pathway, resulting in accumulation of heme precursors that cause intermittent attacks of abdominal pain and... read more , hyperthyroidism Hyperthyroidism Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free thyroid hormones. Symptoms are many and include tachycardia, fatigue, weight loss, nervousness, and tremor... read more , myxedema Hypothyroidism Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features such as a typical facial appearance, hoarse slow speech, and dry skin and by low levels of thyroid hormones... read more , acromegaly Gigantism and Acromegaly Gigantism and acromegaly are syndromes of excessive secretion of growth hormone (hypersomatotropism) that are nearly always due to a pituitary adenoma. Before closure of the epiphyses, the result... read more , or central nervous system (CNS) disorders are evaluated.
Prognosis for Hypertension
The higher the blood pressure and the more severe the retinal changes and other evidence of target-organ involvement, the worse is the prognosis. Systolic BP predicts fatal and nonfatal cardiovascular events better than diastolic BP. 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). 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.
Treatment of Hypertension
Weight loss and exercise
Diet: Increased fruits and vegetables, decreased salt, limited alcohol
Drugs: 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. Despite the theoretical efficacy of treatment, BP is lowered to the desired level in only one third of hypertensive patients in the US.
Treatment targets for the general population, including patients with a kidney disorder or diabetes:
BP < 130/80 mm Hg regardless of age up to age 80
Lowering BP below 130/80 mm Hg appears to continue to reduce the risk of vascular complications. However, it also increases the risk of adverse drug 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.
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. 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.
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 with a structured exercise program
Weight loss if overweight or obese
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 drugs 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)
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.
(See also Drugs for Hypertension Drugs for Hypertension A number of drug classes are effective for initial and subsequent management of hypertension: Adrenergic modifiers Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers... read more .)
The decision to use drug treatment 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 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 target BP, clinicians should strive to optimize adherence before switching or adding drugs.
Drug selection is based on several factors. When one drug is given initially, for non-black patients, including those with diabetes, initial treatment may be with either an ACE inhibitor, angiotensin II receptor blocker, calcium channel blocker, or a thiazide-type diuretic (chlorthalidone or indapamide). For black patients, including those with diabetes, a calcium channel blocker or a thiazide-type diuretic is recommended initially unless patients also have stage 3 or higher chronic kidney disease. In black patients with stage 3 chronic kidney disease, an ACE inhibitor or angiotensin II receptor blocker is appropriate.
When 2 drugs are given initially, a single-pill combination with either an ACE inhibitor or angiotensin II receptor blocker and either a diuretic or a calcium channel blocker.
Signs of hypertensive emergencies Hypertensive Emergencies A hypertensive emergency is severe hypertension with signs of damage to target organs (primarily the brain, cardiovascular system, and kidneys). Diagnosis is by blood pressure (BP) measurement... read more require immediate blood pressure reduction with parenteral antihypertensives.
Some antihypertensives are contraindicated in certain disorders (eg, beta-blockers in asthma Asthma Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible bronchoconstriction. Symptoms and signs include dyspnea... read more ) or are indicated particularly for hypertensive patients with certain disorders (eg, calcium channel blockers for angina pectoris Angina Pectoris Angina pectoris is a clinical syndrome of precordial discomfort or pressure due to transient myocardial ischemia without infarction. It is typically precipitated by exertion or psychologic stress... read more , ACE inhibitors or angiotensin II receptor blockers for diabetes with proteinuria Diabetic Nephropathy In patients with diabetes mellitus, years of poorly controlled hyperglycemia lead to multiple, primarily vascular, complications that affect small vessels (microvascular), large vessels (macrovascular)... read more —see tables Initial Choice of Antihypertensive Drug Class Initial Choice of Antihypertensive Drug Class and Antihypertensives for Patients With Co-existing Conditions Antihypertensives for Patients With Co-existing Conditions ).
If the target BP is not achieved in 1 month, assess adherence and reinforce the importance of following treatment. If patients are adherent, the dose of the initial drug can be increased or a second drug added (selected from the drugs recommended for initial treatment). Note that an ACE inhibitor and an angiotensin II receptor blocker should not be used together. Therapy is titrated frequently. If target BP cannot be achieved with 2 drugs, a third drug from the initial group is added. If such a third drug is not available (eg, for black patients) or tolerated, a drug from another class (eg, beta-blocker, aldosterone antagonist) can be used. Patients with such difficult to control BP may benefit from consultation with a hypertension specialist.
If initial systolic BP is > 160 mm Hg, 2 drugs should be initiated regardless of lifestyle. An appropriate combination and dose are determined; many drug combinations are available as single tablets, which improve compliance and are preferred. For resistant hypertension (BP remains above goal despite use of 3 different antihypertensive drugs), 4 or more drugs are commonly needed.
Achieving adequate control often requires several evaluations and changes in drug therapy. Reluctance to titrate or add drugs to control BP must be overcome. Lack of patient adherence, particularly because lifelong treatment is required, can interfere with adequate BP control. Education, with empathy and support, is essential for success.
Devices and physical interventions
Percutaneous catheter-based radiofrequency ablation of the sympathetic nerves in the renal artery is approved in Europe and Australia for resistant hypertension. Although initial studies appeared promising, a recent large, double-blind study was done ( 1 Treatment references 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... read more ). This study for the first time incorporated a sham ablation procedure in the control arm and failed to show a benefit from radiofrequency ablation. Thus, sympathetic ablation should still be considered experimental and is done only in European or Australian centers with extensive experience.
A second physical intervention 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 used to stimulate the baroreceptor and, in a dose-dependent manner, lower BP. A long-term analysis of a statistically powered study showed that baroreflex activation therapy maintained its efficacy for persistent reduction of office BP in patients with resistant hypertension without major safety issues ( 2 Treatment references 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... read more ). 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 ( 3 Treatment references 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... read more ).
1. Bhatt DL, Kandzari DE, O'Neill WW, et al, for the SYMPLICITY HTN-3 Investigators: A controlled trial of renal denervation for resistant hypertension. N Engl J Med 370:1393–1401, 2014. DOI: 10.1056/NEJMoa1402670.
2. 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.
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: 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
Only about three quarters of patients in the US with hypertension are being treated, and only half have adequate blood pressure (BP) control.
Most hypertension is primary; only 5 to 15% is secondary to another disorder (eg, renal parenchymal or vascular disease, sleep apnea, pheochromocytoma, Cushing syndrome, congenital adrenal hyperplasia, hyperthyroidism).
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 urinalysis, spot urine albumin:creatinine ratio, blood tests (creatinine, potassium, sodium, fasting plasma glucose, lipid profile, and often thyroid-stimulating hormone), and ECG.
Reduce BP to < 130/80 mm Hg for everyone up to age 80, 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 drugs (including diuretics, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and calcium channel blockers).
The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
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