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Last updated: May 12, 2021

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Hypertension is a common condition that affects one in every three adults in the United States. The ACC/AHA 2017 guidelines define it as a blood pressure of ≥ 130/80 mm Hg and the JNC 8 criteria as ≥ 140/90 mm Hg. Hypertension can be classified as either primary (essential) or secondary. Primary hypertension accounts for approx. 95% of cases of hypertension and has no detectable cause, whereas secondary hypertension is due to a specific underlying condition. Typical underlying conditions include renal, endocrine, or vascular diseases (e.g., renal failure, primary hyperaldosteronism, or coarctation of the aorta). Clinically, hypertension is usually asymptomatic until organ damage occurs, which then commonly affects the brain, heart, kidneys, or eyes (e.g., retinopathy, myocardial infarction, stroke). Common early symptoms of hypertension include headache, dizziness, tinnitus, and chest discomfort. Hypertension is diagnosed if blood pressure is persistently elevated on two or more separate measurements. Further diagnostic measures include evaluation of possible 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 ACE inhibitors, angiotensin receptor blockers, thiazide diuretics, and calcium channel blockers. Management of pediatric patients and pregnant women differs from that of nonpregnant adults because some of these drugs are contraindicated in these patient groups. To treat secondary hypertension, the underlying cause needs to be addressed.

See also “Hypertensive crisis.”

  • Definition of hypertension in adults: persistent systolic blood pressure of ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg
  • ACC/AHA 2017 definition [1]
AHA/ACC 2017 BP categories
BP category Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg)
Normal blood pressure < 120 AND < 80
Elevated 120–129 AND < 80
Stage 1 hypertension 130–139 OR 80–89
Stage 2 hypertension ≥ 140 OR ≥ 90
  • Prevalence
    • One in three adults in the US is affected. [4]
    • Prevalence increases with age (65% of men and 75% of women develop hypertension by the age of ≥ 70 years). [5]
    • Rates are highest in African Americans and lowest in Asian Americans, with white individuals falling in the middle. [6][7]
    • 60–75% of obese and overweight patients are affected. [8]
  • Sex [9]
    • > below 45 years of age
    • The sex ratio is almost balanced at > 45 years of age (i.e., after menopause)

Epidemiological data refers to the US, unless otherwise specified.

Primary (essential) hypertension

Secondary hypertension [10][11]

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

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

White coat hypertension (white coat effect)

  • Definition: arterial hypertension detected only in clinical settings or during blood pressure measurement at a physician's practice
  • Etiology: anxiety experienced by the patient
  • Clinical features: consistently normal blood pressure measurements and normalization of elevated blood pressure outside of a clinical setting
  • Diagnostics
    • Take different blood pressure measurements several minutes apart (after the patient had time to relax)
    • Take blood pressure measurements on several visits (at least 2)

Isolated systolic hypertension (ISH) [13]

General approach [11][14][15]

Blood pressure monitoring

Initial evaluation of newly diagnosed hypertensive patients

Approach to diagnosing secondary hypertension [11][14][15]

  • General indicators of secondary hypertension
    • Young age (< 30 years) at onset of hypertension
    • Onset of diastolic hypertension at an older age (> 55 years)
    • Abrupt onset of hypertension
    • End-organ damage that is disproportionate to the degree of hypertension
    • Recurrent hypertensive crises
    • Resistant hypertension: hypertension that is resistant to treatment with at least three antihypertensives of different classes including a diuretic
  • Specific indicators (For details regarding individual diagnostic procedures, see the individual articles.)
Different diagnostics for causes of secondary hypertension
Diagnostic findings Underlying condition
Electrolyte and acid-base status
Difference in blood pressure
  • In both arms
  • Of upper and lower limbs
Sleep disorder
  • Daytime sleepiness (Epworth scale, Berlin questionnaire)
  • Nondipping in 24-hour blood pressure monitoring
Laboratory studies
  • TSH, ↑ free T4

Screening for hypertension (USPSTF recommendations) [16]

  • Individuals 18–39 years of age with normal blood pressure (< 130/85 mm Hg) and without other risk factors: Screen every 3–5 years.
  • Individuals > 40 years of age or who are at increased risk for high blood pressure : Screen every year.

Nonpharmacological measures (lifestyle changes for managing hypertension)

Intervention (in order of effectiveness) Target Approximate systolic BP reduction in hypertensive patients
Weight loss
  • 1 mm Hg per kg reduction in body weight in overweight individuals
DASH diet
  • Diet rich in fruits, vegetables, and whole grains
  • Low in saturated and trans fats
  • 11 mm Hg
Decrease dietary sodium
  • Daily sodium intake < 1500 mg/day
  • 5–6 mm Hg
Exercise Aerobic
  • 90–150 minutes per week
  • 65–75% of maximum heart rate (e.g., brisk walk)
  • 5–8 mm Hg
Dynamic resistance (e.g., weight training)
  • 50–80% of maximum strength
  • 6 exercises with 3 sets per exercise and 10 repetitions per set
  • 90–150 minutes per week
  • 4 mm Hg
Isometric resistance (e.g., handgrip exercise)
  • 30–40% of maximum strength
  • 4 repetitions/session, 3 sessions/week for 8–10 weeks
  • 5 mm Hg
Increase dietary potassium
  • Daily potassium intake 3.5–5 g
  • 4–5 mm Hg
Decreased alcohol intake
  • : ≤ 2 drink daily
  • : ≤ 1 drink daily
  • 4 mm Hg
Smoking cessation
  • Completely quit smoking
  • 3–5 mm Hg after 1 year
  • 6–7 mm Hg after 3 years [17]

Nonpharmacological measures should be pursued in any patient with a systolic BP > 130 mm Hg or a diastolic BP > 90 mm Hg.
Patients should be taught to measure their own blood pressure to allow for long-term monitoring and assessment of treatment efficiency.

Pharmacologic treatment [12][14][15][18]

Guideline Indication for pharmacological therapy Treatment goal
AHA/ACC 2017
  • Age < 65: BP < 130/80 mm Hg
  • Age ≥ 65: systolic BP < 130 mm Hg
  • For patients with significant comorbidities or limited life expectancy, the BP goal is determined based on clinical judgment and the patient's preference.
  • BP less than threshold for initiating pharmacological therapy
Overview of antihypertensive drugs
Drug class Comments Side effects
First-line drugs
ACEIs (e.g., lisinopril, captopril, enalapril)
ARBs (e.g., losartan, valsartan)
Thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone)
CCBs Dihydropyridines(e.g., nifedipine, amlodipine)
Nondihydropyridines (e.g., diltiazem, verapamil)
Second-line drugs
Beta blockers (e.g., propranolol, metoprolol, labetalol)
Loop diuretics (e.g., furosemide, torsemide)
Aldosterone antagonists (e.g., eplerenone, spironolactone)
Direct renin inhibitors (e.g., aliskiren)
  • Should not be used in combination with ACEIs or ARBs
Alpha-1 blockers (e.g., prazosin, doxazosin)
Alpha-2 agonists (e.g., clonidine)
  • Rarely used
Direct arteriolar vasodilators (e.g., hydralazine, nitroprusside)
  • Follow-up: Reassess within one month of initiating or changing pharmacological therapy.
    • If blood pressure is controlled: Reassess after 3–6 months and annually thereafter.
    • If the treatment goal is not reached with one drug, increase the dose of the initial drug or add a second drug.
    • If the treatment goal cannot be reached with two drugs:
      • Add a third drug.
      • Evaluate for secondary causes of hypertension.

Treatment according to subgroups [12][14][15][18]

Moms Love Healthy Newborns: Use Methyldopa, Labetalol, Hydralazine, or Nifedipine for hypertensive pregnant women.

Beta blockers are not recommended for initial treatment of hypertension in children due to their metabolic side effects (e.g., impaired glucose tolerance) and the fact that they exacerbate asthma!

Cardiovascular system [11][19]

Brain [11][19][20]

Kidneys [19][21]

Eyes [11][19]

Classification system according to Keith-Wagener-Barker [11]
Findings Symptoms
Grade I Vessel diameter variation: arteriolar constriction and tortuosity Usually asymptomatic
Grade II Gunn sign and marked constriction of vessels and sclerosis of arterioles
Grade III Cotton-wool exudates, hard exudates, retinal hemorrhage, retinal edema, macular star formation Decreased and/or blurred vision, headaches
Grade IV Papilledema, optic atrophy

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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