Hypertension

Hypertension is a common condition that affects one in every three adults in the United States and is becoming increasingly prevalent among children. The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines define hypertension in adults as a blood pressure of ≥ 130/80 mm Hg and the Eighth Joint National Committee (JNC 8) criteria specify ≥ 140/90 mm Hg. Hypertension can be classified as either primary (essential) or secondary. Primary hypertension accounts for ∼ 90% of cases of hypertension and has no detectable cause, whereas secondary hypertension is caused by a specific underlying condition. Typical underlying conditions include renal, endocrine, and vascular diseases (e.g., renal failure, primary hyperaldosteronism, coarctation of the aorta). Clinically, hypertension is usually asymptomatic until organ damage occurs, with the brain, heart, kidneys, and/or eyes (e.g., retinopathy, myocardial infarction, stroke) most commonly affected. If present, early symptoms of hypertension may include headache, dizziness, tinnitus, and chest discomfort. Hypertension is suspected if in-office blood pressure is persistently elevated on two or more separate measurements and is confirmed with out-of-office measurement. Further diagnostic measures include assessment of cardiovascular risk, evaluation of possible target organ damage (e.g., kidney function tests), and additional tests if an underlying disease is suspected. Treatment of primary hypertension includes lifestyle changes (e.g., diet, weight loss, exercise) and pharmacotherapy. Commonly prescribed antihypertensive medications include angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), thiazide diuretics, and calcium channel blockers (CCBs); pharmacological management of pediatric and pregnant patients differs, as some of these drugs are contraindicated in these patient populations. To treat secondary hypertension, the underlying cause needs to be addressed.

See also “Hypertensive crisis.”

• Hypertension in adults
  • 2017 ACC/AHA: persistent systolic blood pressure (SBP) ≥ 130 mm Hg and/or diastolic blood pressure (DBP) ≥ 80 mm Hg ^[1]
  • 2020 International Society of Hypertension (ISH) and 2014 JNC 8: persistent SBP ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg ^[2][3]
• Hypertension in children
  • < 13 years of age: blood pressure ≥ 95^th percentile or ≥ 130/80 mm Hg, whichever is lower ^[4]
  • ≥ 13 years of age: persistent systolic blood pressure (SBP) ≥ 130 mm Hg and/or diastolic blood pressure (DBP) ≥ 80 mm Hg ^[4]
• Primary hypertension: hypertension with no identifiable cause
• Secondary hypertension: hypertension caused by an identifiable underlying condition
• Resistant hypertension: hypertension that remains uncontrolled (≥ 130/80 mm Hg) despite treatment with ≥ 3 antihypertensives OR requires ≥ 4 medications to be controlled ^[1][5][6]

• Prevalence ^[1]
  • Hypertension affects between approximately one-third and one-half of adults in the US. ^[8][9]
    • Primary hypertension: accounts for ∼ 90% of cases of hypertension in adults and prevalence is increasing in children and adolescents. ^[1][4][10]
    • Secondary hypertension: accounts for ∼ 10% of cases of hypertension in adults ^[1]
  • Prevalence increases with age: Approximately 65–75% of adults develop hypertension by 65–74 years of age. ^[11]
  • Rates are highest in African American individuals, followed by white individuals, and lowest in Asian American and Hispanic individuals. ^{[8][12][13][14]}
  • ∼ 60–87% of overweight and ∼ 73–95% of obese patients are affected. ^[15]
• Sex ^[1]
  • ♂ > ♀ below 65 years of age
  • After menopause, prevalence increases in women.

Epidemiological data refers to the US, unless otherwise specified.

Primary hypertension ^[1][8]

• Multifactorial etiology including epigenetic, genetic, and environmental factors
• Directly related to total peripheral resistance and cardiac output
• Risk factors for primary hypertension
  • Nonmodifiable risk factors
    • Positive family history
    • Race and ethnicity
    • Advanced age
  • Modifiable risk factors
    • Overweight and obesity (greatest modifiable risk factor)
    • Uncontrolled diabetes
    • Smoking
    • Excessive alcohol intake
    • Diet high in sodium and low in potassium
    • Physical inactivity
    • Psychological stress

Secondary hypertension

See “Secondary hypertension.”

• Hypertension is usually asymptomatic until:
  • Complications of end-organ damage arise (see “Complications” below)
  • Or an acute increase in blood pressure occurs (see “Hypertensive crisis”)
• Secondary hypertension usually manifests with symptoms of the underlying disease.
• Nonspecific symptoms of hypertension
  • Headaches, esp. early morning or waking headache
  • Dizziness, tinnitus, blurred vision
  • Flushed appearance
  • Epistaxis
  • Chest discomfort, palpitations
  • Strong, bounding pulse on palpation
  • Nervousness
  • Fatigue, sleep disturbances

Since hypertension is often asymptomatic, regular screening is necessary to prevent end-organ damage.

White coat and masked hypertension ^[1]

These subtypes can be distinguished either by ambulatory blood pressure measurement (ABPM) or home blood pressure monitoring (HBPM).

White coat hypertension ^[1][16]

• Definition: elevated blood pressure readings in a clinical setting (caused by anxiety) but normal readings when measured elsewhere
• Diagnostics
  • Confirm true elevation of the in-office blood pressure measurements.
    • Take different blood pressure measurements several minutes apart (after the patient has had time to relax).
    • Take blood pressure measurements on several visits (at least two).
  • Consider screening using daytime ABPM (preferable) or HBPM in patients with in-office blood pressure ≥ 130/89 mm Hg and ≤ 160/100 mm Hg after a 3-month trial of lifestyle changes.
  • Diagnosis is confirmed in patients with: ^[1]
    • In-office readings ≥ 130/89 mm Hg and ≤ 160/100 mm Hg
    • AND out-of-office readings < 130/80 mm Hg
• Management
  • Continue lifestyle changes for managing hypertension.
  • Repeat ABPM or HBPM annually to monitor for progression to sustained hypertension.

In patients with white coat hypertension, the incidence of conversion to sustained hypertension is ∼ 1–5% per year. It is unclear if the risk of ASCVD is increased; this likely depends on the presence of additional risk factors. ^[1][16]

Hypertension that is only recorded in clinical settings in patients currently on antihypertensive medication is called white coat effect.

Masked hypertension ^[1][16]

• Definition: normal blood pressure readings in a clinical setting but consistently elevated readings when measured elsewhere
• Screening: : Consider ABPM or HBPM in adults with consistent in-office SBP 120–129 mm Hg or DBP 75–79 mm Hg. ^[8]
• Management
  • Continue lifestyle changes for managing hypertension.
  • Start pharmacological treatment of hypertension.
  • Repeat ABPM or HBPM annually.

Patients with masked hypertension have a similar risk of stroke, cardiovascular disease, and all-cause mortality to those with sustained hypertension. ^[1][16]

Isolated systolic hypertension ^[17][18]

• Definition: elevated SBP (≥ 140 mm Hg) with DBP within normal limits (≤ 90 mm Hg)
• Etiology ^[17]
  • Most common: decreased arterial elasticity and compliance due to aging
  • May also be secondary to increased cardiac output due to:
    • Anemia
    • Hyperthyroidism
    • Chronic aortic regurgitation
    • AV fistula
• Clinical features
  • Often asymptomatic
  • Signs of increased pulse pressure: e.g., head pounding, rhythmic nodding, bobbing of the head in synchrony with the heartbeat
  • Symptoms of hypertension
• Diagnostics
  • Assess for secondary causes.
  • See “Diagnosis of hypertension” for details on diagnostic testing.
• Treatment
  • Recommend lifestyle changes for managing hypertension.
  • Start pharmacological treatment of hypertension.
    • First-line medication: thiazide diuretics or dihydropyridine calcium antagonists ^[18]
    • Treatment goal: SBP < 140 mm Hg

Patients with isolated systolic hypertension have a high risk of renal dysfunction and cardiovascular events, e.g., myocardial infarction, stroke.

Signs suggestive of secondary hypertension ^[1][19]

• Severe hypertension
  • Resistant hypertension
  • Target organ damage disproportionate to the degree of hypertension
  • Hypertensive emergency
• Unusual onset of hypertension
  • Abrupt onset
  • Onset at < 30 years of age
  • Onset of diastolic hypertension at > 65 years of age
  • Exacerbation of previously controlled hypertension
  • Drug-induced hypertension
• Unprovoked or significant hypokalemia

Aortic dissection is a (rare) life-threatening cause of secondary hypertension that may manifest with a blood pressure difference between the right and left arm.

Causes of secondary hypertension ^{[1][10][10][19]}

• Most common causes in adults include:
  • < 40 years of age: thyroid dysfunction, fibromuscular dysplasia, and renal parenchymal disease
  • 40–64 years of age: hyperaldosteronism, thyroid dysfunction, and obstructive sleep apnea
  • ≥ 65 years of age: renal artery stenosis
• Most common causes in children and adolescents (< 18 years of age) include renal parenchymal disease and coarctation of the aorta

Young adults (especially women < 40 years of age) with suspected secondary hypertension should be assessed for renal artery stenosis caused by fibromuscular dysplasia.

RECENT: Renal (e.g., renal artery stenosis, glomerulonephritis), Endocrine (e.g., Cushing syndrome, hyperthyroidism, Conn syndrome), Coarctation of the aorta, Estrogen (oral contraceptives), Neurological (raised intracranial pressure, psychostimulants use), and Treatment (e.g., glucocorticoids, NSAIDs) are the causes of secondary hypertension.

Renal hypertension

Any renal disease can potentially trigger hypertension.

• Renal artery stenosis (e.g., due to atherosclerosis, fibromuscular dysplasia, polyarteritis nodosa, aortic arch syndrome)
  • Potential indications for further workup
    • Resistant hypertension
    • Recurrent flash pulmonary edema
    • Abdominal bruit
    • ↑ Serum creatinine (by ≥ 50%) within 1 week of starting an ACEI or ARB ^[19]
    • Hypokalemia ^[20][21]
    • Asymmetric kidney size
  • Workup and findings: Duplex ultrasonography or MRA or CTA of the renal arteries
• Renal parenchymal disease: (e.g., due to glomerulonephritis, polycystic kidney disease, systemic lupus erythematosus, renal tumors, atrophic kidney)
  • Potential indications for further workup
    • Urinary symptoms
    • History of excessive analgesic use
    • Family history of polycystic kidney disease
    • Abdominal mass (ADPKD)
    • ↑ Serum creatinine
    • Abnormal urine analysis (e.g., hematuria, proteinuria)
  • Workup and findings: Renal ultrasound
• Chronic kidney disease

Endocrine hypertension

It is not necessary to stop a patient's antihypertensive medications prior to testing for primary hyperaldosteronism. ^[22]

Other

• Coarctation of the aorta distal to the left subclavian artery
  • Potential indications for further workup: Blood pressure difference between the upper and lower limbs
  • Workup and findings
    • Doppler echocardiography
    • X-ray chest
    • CTA or MRA chest and abdomen
• Obstructive sleep apnea
  • Pathophysiology: ↑ catecholamines during apneic phases → secondary hypertension
  • Potential indications for further workup
    • Resistant hypertension
    • Obesity, snoring, and/or daytime sleepiness
    • Nondipping pattern on 24-hour blood pressure monitoring
  • Workup and findings: sleep studies often leads to resolution of hypertension.
  • Continuous positive airway pressure (CPAP)
• Substance-related
  • Potential indications for further workup
    • Recreational drug use: amphetamines, cocaine, phencyclidine
    • Caffeine, nicotine, and/or alcohol use
    • Use of certain medications: sympathomimetic drugs (e.g., decongestants), corticosteroids, NSAIDs, oral contraceptives
  • Workup and findings
    • Urine drug screening
    • Response to withdrawal of suspected culprit

Management

• Management of secondary hypertension depends on the suspected cause; involve specialists (e.g., endocrinologist or nephrologist) early.
• See “Approach to management of hypertension.”

Approach ^[1]

• Screen patients using in-office blood pressure measurement.
• Confirm elevated values with ABPM or HBPM.
• Perform a thorough physical examination and obtain initial laboratory studies.
  • Stratify patients by cardiovascular risk (using the ASCVD risk estimator tool).
  • Evaluate for target organ damage.
• Consider diagnostic workup for secondary causes of hypertension in patients with:
  • Abnormalities identified during evaluation for newly diagnosed hypertension
  • Signs suggestive of secondary hypertension

Screening for hypertension ^[8]

• Indications
  • Annual screening ^[1]
    • Individuals > 40 years of age
    • Adults of any age with risk factors for primary hypertension
  • Screening every 3–5 years: individuals 18–39 years of age with previously normal blood pressure (< 130/85 mm Hg) and no risk factors
• Method: in-office blood pressure measurement
  • If elevated, measurements should be repeated on both arms.
  • Elevated average blood pressure on at least two readings obtained on at least two separate visits supports a diagnosis of hypertension. ^[1]

∼ 20% of individuals with high blood pressure are unaware they have hypertension. ^[23]

Diagnostic confirmation ^[1][8][24]

Out-of-office measurement is recommended in all individuals for confirmation of hypertension before initiating treatment.

• Ambulatory blood pressure measurement (ABPM): preferred method
  • A device measures blood pressure at fixed intervals (e.g., every 15–30 minutes) over 12–24 hours.
  • Takes measurements while the individual is carrying out normal activities during the day and at nighttime
• Home blood pressure monitoring (HBPM): Blood pressure is measured by the individual at periodic intervals.

Patients should be taught to measure their own blood pressure to allow for long-term monitoring and assessment of treatment.

Evaluation of patients with newly diagnosed hypertension ^[1][3][19]

The initial exam should focus on evaluation for signs indicating secondary hypertension and target organ damage, and the assessment of ASCVD risk. ^[25]

• Physical examination and patient history
  • BMI and waist circumference
  • Neurological examination ^[19][25]
  • Cardiac examination
• Routine studies
  • Fasting blood glucose
  • Serum sodium, potassium, and calcium levels
  • Renal function tests: serum creatinine and eGFR
  • CBC
  • TSH
  • Lipid profile (HDL, LDL, and triglycerides levels)
  • Urinalysis and urinary albumin-to-creatinine ratio
  • Electrocardiogram (ECG)
• Additional studies
  • Hemoglobin A1c
  • Fundoscopy
  • Liver chemistries ^[3]
  • Serum uric acid
  • Echocardiogram

The initial evaluation should include an assessment for orthostatic hypotension (by measuring blood pressure while sitting and standing), especially in older adults. All adults ≤ 30 years of age with elevated brachial blood pressure should also have their blood pressure measured in their thigh to rule out coarctation of the aorta. ^[1]

Some experts recommend that all individuals with hypertension be tested for primary hyperaldosteronism at least once because of its relatively high prevalence in patients with hypertension. ^[5][22]

Recommendations regarding indications for treatment and target blood pressure differ between clinical practice guidelines. The following recommendations are consistent with those in the 2017 ACC/AHA guidelines unless specified otherwise. ^{[1][2][3][26][27]}

Approach ^[1]

• Lifestyle changes for managing hypertension: for all patients with SBP > 120 mm Hg or DBP > 80 mm Hg
• Identify indications for antihypertensive treatment.
• Select first-line antihypertensive medication based on individual patient characteristics (see also “Antihypertensive treatment by comorbidities”)
• Titrate treatment to reach target blood pressure. ; ^[1][2][3]
  • Most adults: blood pressure < 130/80 mm Hg
  • Individualize targets based on age and comorbidities.
• Follow-up regularly: reassess indications for pharmacological treatment and tailor therapy to individual needs.

Nonpharmacological measures

• Lifestyle measures alone may be trialed for 3–6 months in patients with: ^[5]
  • Elevated blood pressure
  • Stage 1 hypertension and 10-year ASCVD risk < 10 %

Smoking cessation should be advised in all patients to reduce ASCVD risk. ^[1]

Consider possible psychosocial factors or social determinants of health that may be contributing to the patient's high blood pressure (e.g., stress, anxiety, lack of access to fresh food) and make appropriate referrals where necessary. ^[5]

Increased potassium intake should not be recommended for patients with advanced CKD. ^[29]

Indications for antihypertensive treatment ^{[1][2][3][31][32]}

The thresholds for pharmacological treatment are controversial and vary depending on age (see “Hypertension in older adults”); the following recommendations are based on the 2017 ACC/AHA guidelines.

• Adults with SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg and ≥ 1 of the following:
  • Clinical ASCVD (e.g., ischemic heart disease, peripheral artery disease, or previous stroke) or congestive heart failure (CHF)
  • 10-year ASCVD risk ≥ 10%; (based on the ACC/AHA Pooled Cohort Equations; includes age ≥ 65 years and diabetes mellitus)
• All adults with SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg

Initial medication ^[1][2][19]

Choice of initial medication should be based on the following:

• Patient's initial blood pressure ; ^[3][33]
  • SBP 130–139 mm Hg or DBP 80–89 mm Hg (stage 1 hypertension): Consider initial monotherapy.
  • SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg AND an average blood pressure > 20/10 mm Hg above target
    • Initiate combination therapy.
    • Prescribe combination pills if possible.
    • Commonly used combinations are an ACEI or ARB PLUS either a dihydropyridine CCB OR a thiazide-type diuretic.
• Additional factors to consider
  • Major comorbidities (see “Antihypertensive treatment by comorbidities”)
  • Major contraindications
  • Adverse effects that may be unacceptable to patients
  • Patient race: For Black patients (including individuals with diabetes) without CHF or CKD, initial antihypertensive therapy should include a thiazide-type diuretic or CCB. ^[12][34]

To maximize medication adherence, prescribe generic medications in dosing regimens comprising as few pills as few times a day as possible (use combination pills whenever clinically appropriate), and provide a 90-day medication supply once the dosage is stable.

First-line options

First-line medications for primary hypertension are thiazide diuretics, ACEIs, ARBs, and dihydropyridine CCBs.

Do not prescribe an ACEI and ARB together or in combination with a direct renin inhibitor. This increases the risk of hyperkalemia and renal dysfunction and does not provide additional benefit. ^[1][19]

Second-line options

Patients with CKD or baseline potassium > 5.5 mEq/L and those who take potassium supplements or potassium-sparing drugs are at higher risk of hyperkalemia as an adverse effect from pharmacological treatment for hypertension. ^[1][25][28]

Do not abruptly discontinue beta blockers or alpha-2 agonists. They must be slowly tapered to avoid triggering rebound hypertension. ^[1]

Treatment based on comorbidities

Do not use nondihydropyridine CCBs in patients with HFrEF because of their myocardial depressant effects. ^[1]

Beta blockers can mask symptoms of hypoglycemia in patients with diabetes mellitus.

General principles ^[1][2][5]

Goals include evaluating medication adherence, monitoring treatment and relevant laboratory studies, and adjusting medication.

• Patients on nonpharmacological treatment alone: Follow up after 3–6 months.
  • If blood pressure is uncontrolled: Initiate pharmacological treatment.
• Most patients initiated on pharmacological treatment: Follow up after ∼ 1 month.
  • If blood pressure is uncontrolled: Continue to escalate therapy at one-month intervals.
  • Once blood pressure is controlled: Reassess after 3–6 months and annually thereafter if blood pressure remains stable.

Laboratory studies ^[1][2][5]

• Serum electrolytes
  • For most patients, check at the one-month follow-up visit.
  • Checking after ∼ 2 weeks may be reasonable in certain patients, e.g.:
    • Patients with initial low serum sodium who were started on a thiazide diuretic ^[41]
    • Patients with CKD and initial high creatinine or high normal potassium who were started on an ACEI or ARB ^[28]
• Serum creatinine
  • Check within 2–4 weeks in patients with CKD who were started on an ACEI or ARB.
  • Discontinuation of ACEIs or ARBs is usually not necessary if creatinine increases by < 30% from baseline without concomitant hyperkalemia or fluid retention. ^[28]

Medication titration ^[1]

• Adjust medication based on adverse effects, e.g.:
  • Hyponatremia: Discontinue or avoid thiazide diuretics; consider loop diuretics if necessary.
  • Hypokalemia: Consider initiating a potassium-sparing diuretic after ruling out hyperaldosteronism.
  • Hyperkalemia: Consider restricting dietary potassium or initiating a thiazide diuretic or cation-exchange polymer after ruling out pseudohyperkalemia.
  • Cough in patients on ACEIs: Switch to an ARB.
• Adjust medication to reach optimal blood pressure control.
  • Ask about medication adherence. ^[6]
  • If indicated, adjust medications using one of the following strategies: ^[2][25][42]
    • Increasing the dose of the initial drug
    • Switching to another drug (“sequential monotherapy”) ^[43]
    • Adding a second drug (in the form of a single combination pill, if possible)
  • If the treatment goal cannot be reached with two drugs: ^[1][35]
    • Add a third drug.
    • Evaluate for secondary hypertension, if indicated.

Therapeutic inertia (failure on the part of the physician to appropriately escalate treatment when indicated) is one possible reason for poor blood pressure control. Be sure to reassess the treatment plan at each visit. ^[44]

• Rule out pseudoresistance, e.g., due to inaccurate blood pressure measurement, suboptimal medication adherence, or white coat hypertension. ^[45]
• Optimize lifestyle changes for managing hypertension.
• Discontinue or reduce medications that may contribute to hypertension if possible.
• Assess for and treat causes of secondary hypertension.
• Adjust antihypertensive medications.
  • Ensure that the prescribed diuretic is a thiazide diuretic.
  • Add an aldosterone antagonist.
  • Consider the sequential addition of second-line antihypertensives (e.g., beta blockers, direct arteriolar vasodilators, loop diuretics) in an individualized approach.
• Refer to a hypertension specialist or cardiologist if:
  • Blood pressure remains uncontrolled
  • Secondary hypertension is suspected

Resistant hypertension affects ∼ 15% of all individuals treated for hypertension in the US. ^[6]

Special considerations ^[32][46]

• Hypertension affects > 60% of individuals > 60 years of age. ^[32]
• Most older adults have isolated systolic hypertension. ^[1][47]

In older adults, isolated systolic hypertension is common because of age-related stiffening of the arteries. ^[1]

Diagnostics ^[1][3][46]

• Diagnosis of hypertension in older adults is similar to younger adults.
• Record orthostatic vital signs upon diagnosis. ^[1][3]

Treatment

Nonpharmacological management ^[32][46]

• Initiate lifestyle changes for managing hypertension.
• Optimize management of comorbid conditions and causes of secondary hypertension (e.g., obstructive sleep apnea).
• Avoid medications that can increase blood pressure, if possible.

Pharmacological therapy ^[1][3][32]

• Patients with acute severe hypertension require treatment for hypertensive crises.
• Thresholds for initiating routine treatment in older adults are controversial and vary by guideline between SBP ≥ 130 mm Hg and BP ≥ 150/90 mm Hg. ^{[1][2][3][32][48]}
  • Consider the principles of prescribing for older adults, e.g.:
    • Comorbid conditions ^[1][32]
    • Risk factors for adverse effects
    • Patient preferences and goals of care ^[46][47]
  • Utilize shared decision-making, especially for patients with multiple comorbidities and/or increased fall risk.
• Choice of antihypertensive therapy (see also “Pharmacology for older adults) ^[46]
  • First-line antihypertensive medications are the same as in younger adults.
  • If possible, avoid:
    • Beta-blockers: increased CVD risk in adults > 60 years of age ^[46]
    • Alpha-blockers and loop diuretics: risk of orthostatic hypotension and falls
  • If multiple agents are needed, consider combination pills to reduce medication regimen complexity.
• Regularly reassess functional status, renal function, electrolyte levels, and orthostatic vital signs. ^[46]

Special considerations ^[4][49]

• Most childhood and adolescent hypertension in the US is due to primary hypertension.
• Diagnosis and treatment of hypertension in children is important for reducing the risk of:
  • Hypertension and cardiovascular disease in adulthood
  • End organ damage (e.g., left ventricular hypertrophy, CKD)

Risk factors for hypertension in children ^[4]

• Risk factors for hypertension in children are similar to adults (see “Etiology of hypertension” and “Secondary hypertension”).
• Young children with the following conditions are at risk of early onset (< 3 years old) hypertension:
  • History of prematurity, very low birth weight, or neonatal complications requiring NICU admission
  • Congenital heart disease including coarctation of the aorta (even if corrected)
  • Known (or family history of) renal disease or congenital anomalies of the kidney and urinary tract
  • Recurrent UTIs
  • Malignancy
  • History of transplant (solid organ or bone marrow)
  • Certain systemic illnesses associated with elevated BP (neurofibromatosis type 1, sickle cell disease, tuberous sclerosis)
  • Elevated ICP
  • Use of medications known to elevate BP
• Children ≥ 3 years of age are additionally at elevated risk if they have:
  • Obesity
  • Diabetes
  • Sleep-disordered breathing ^[4]

Classification

Screening for hypertension in children ^[4]

• Timing
  • Individuals with risk factors for hypertension in children: at every visit
  • Children with no known risk factors: annually from 3 years of age
• Method
  • Either a manual or automatic blood pressure monitor may be used for initial screening.
  • Ensure the correct cuff size is selected and follow the recommended technique for BP measurement.
• Interpretation
  • If elevated, repeat twice within the same visit, using a manual blood pressure monitor.
  • If the average of the 3 readings is elevated, start diagnostics.

Ensure proper cuff size when measuring blood pressure; for children and adolescents with obesity, consider using an adult-sized cuff. ^[4]

Diagnostics ^[4][49]

• Asymptomatic children
  • Initiate lifestyle changes for HTN and arrange return visits to reassess BP.
  • Refer to subspecialist care and for ABPM if BP remains elevated on:
    • 3 visits if the patient has elevated BP or stage 1 HTN
    • 2 visits if the patient has stage 2 HTN
  • If ABPM confirms hypertension, children require evaluation for newly diagnosed HTN with the following modifications:
    • Obtain echocardiography to assess for LVH in children with indications for pharmacotherapy.
    • ECGs are not routinely recommended to screen for LVH because of low sensitivity in children.
    • Do not assess for microalbuminuria or elevated uric acid in children with primary hypertension. ^[4]
• Children with acute severe hypertension or symptomatic hypertension: Perform diagnostics for hypertensive crises.
• All children: Assess for causes of secondary HTN if the following indications are met. ^[4]
  • • All children < 6 years of age; or children of any age with abnormal findings on history, examination, or laboratory studies
    • Children ≥ 6 years with no family history of HTN or history of obesity
  • Recommended studies vary according to clinical suspicion but should include a renal ultrasound in all children < 6 years or in children of any age with abnormal urinalysis or renal function tests.
  • For further information, see “Secondary hypertension.”

Electrocardiography is not recommended to screen for LVH because of low sensitivity in children. ^[4]

A complete evaluation for secondary hypertension is not necessary for hypertensive children > 6 years of age who are obese, have a family history of hypertension, and have no concerning history or physical examination findings. ^[4]

Management of hypertension in children ^[4][49]

Approach

• Screen children for hypertensive crises and refer urgently to the emergency department if present. ^[4]
• Initiate lifestyle changes for managing hypertension.
• Manage the underlying cause of secondary hypertension and treat associated comorbidities (if present). ^[4][50]
• Aim for target blood pressure of < 90^th percentile or < 130/80 mm Hg for children ≥ 13 years of age.
• Assess for indications for pharmacotherapy and start if present.

Consider referral to a pediatric cardiologist or nephrologist for all children with a diagnosis of hypertension. ^[4]

Pharmacotherapy ^[4]

• Indications
  • HTN not improving with lifestyle changes
  • Stage 2 hypertension in children with BMI < 95^th percentile
  • Symptomatic HTN (e.g., headaches, altered mental status) ^[49]
  • HTN in children with CKD or diabetes
  • LVH on echocardiography ^[49]
• Principles of prescribing
  • Pharmacological management should be performed by a specialist.
  • Start medication at the lowest dose possible and titrate up every 2–4 weeks as needed.
  • Monotherapy is preferred; however, multiple agents may be necessary to control BP.
• Options
  • ACE inhibitors (e.g., benazepril, captopril) ^[4]
  • ARBs (e.g., candesartan, losartan)
  • Thiazide diuretics (e.g., chlorothiazide, hydrochlorothiazide)
  • Long-acting calcium channel blocker (e.g., amlodipine)

ACE inhibitors or ARBs are generally preferred for hypertensive children with diabetes, CKD, and/or proteinuria. ^[4]

Bbeta blockers are not recommended for the initial treatment of hypertension in children because of their potential adverse effects (metabolic effects such as impaired glucose tolerance and potential exacerbation of asthma) and lack of improved efficacy compared to other medications. ^[4]

Follow-up ^[4]

• Treatment with lifestyle modifications only: office visits every 3–6 months
• Treatment with pharmacotherapy:
  • Office visits every 4–6 weeks until blood pressure is at target, then every 3–4 months ^[4]
  • Periodic monitoring (e.g., every 6–12 months) for end-organ damage

Prevention ^[4]

• Lifestyle changes for managing hypertension will also help prevent hypertension.
• Weight management, a healthy diet, and increasing activity levels should be routinely discussed as part of preventive care.

• Arterial hypertension is the most common risk factor for cardiovascular disease
• It leads to changes in the vascular endothelium, particularly of the small vessels, and can therefore affect any organ system.
• See also “Hypertensive crisis.”

Cardiovascular system (hypertensive vascular disease) ^[51][52]

• Left ventricular hypertrophy, hypertrophic cardiomyopathy, dilated cardiomyopathy
• Congestive heart failure
• Coronary artery disease and myocardial infarction
• Atrial fibrillation
• Aortic aneurysm
• Aortic dissection
• Carotid artery stenosis
• Peripheral artery disease
• Atherosclerosis

Brain ^[51][52][53]

• Stroke , TIA
• Subcortical leukoencephalopathy
• Cognitive changes such as memory loss

Kidneys ^[52][54]

• Hypertensive nephrosclerosis: a renal vascular injury secondary to long-standing arterial hypertension
  • Pathophysiology: chronic hypertension → hypertrophy of medial and intimal layers → narrowing of afferent arterioles → ↓ glomerular blood flow → glomerular and tubular ischemia → arteriolonephrosclerosis and fibrosis (focal segmental glomerulosclerosis) → end-stage renal disease
  • Clinical findings
    • Initially microalbuminuria and microhematuria
    • ↑ BUN, Cr, and uric acid levels
    • Nephrosclerosis with proteinuria (usually < 1 g/day) and progressive renal failure occur with disease progression.
  • Diagnostics: renal biopsy shows vascular, glomerular, and tubulointerstitial changes ^[55]
    • Arterial and arteriolar medial hypertrophy, intimal thickening, and hyalinosis
    • Global glomerulosclerosis (more common) or focal segmental glomerulosclerosis
    • Tubulointerstitial fibrosis
  • Treatment: ACE-inhibitors (first-line), ARBs
• Chronic kidney disease

Eyes ^[51][52]

• Hypertensive retinopathy
  • Arteriosclerotic and hypertension-related changes of the retinal vessels
  • Initial reactive vasoconstriction (vasospasm), followed by sclerosis with breakdown of blood-retinal barrier and subsequent hemorrhage and exudation
  • Fundoscopic examination
    • Cotton wool spots
    • Retinal hemorrhages (i.e., flame-shaped hemorrhages)
    • Microaneurysms
    • Macular star (results from exudation into the macula)
    • Hard exudates
    • Arteriovenous nicking: a tapering of a retinal venule at the point where a retinal arteriole crosses the retinal venule
      • Hourglass shape on fundoscopic examination
      • Associated with advanced hypertensive retinopathy.
    • Elschnig spots: multiple, round, brown-black spots with a bright ring that are scattered throughout the retina
    • Marked swelling and prominence of the optic disk with indistinct borders due to papilledema and optic atrophy (end-stage disease)
  • The presence of papilledema in a hypertensive patient may indicate a hypertensive crisis and warrants urgent lowering of blood pressure (see “Hypertensive crisis”).

Local treatment of retinopathy is not possible, therefore, systemic reduction of blood pressure is critical.

We list the most important complications. The selection is not exhaustive.

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