Hypertension

Last updated: June 27, 2022

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Hypertension is a common condition that affects one in every three adults in the United States. The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines define it as a blood pressure of ≥ 130/80 mm Hg and the Eighth Joint National Committee (JNC 8) criteria as ≥ 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, which commonly affects the brain, heart, kidneys, and/or eyes (e.g., retinopathy, myocardial infarction, stroke). 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); management of pediatric and pregnant patients differs, as some of these drugs are contraindicated. To treat secondary hypertension, the underlying cause needs to be addressed.

See also “Hypertensive crisis.”

  • Hypertension in adults (stage 1)
    • 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) (stage 1): blood pressure ≥ 95thpercentile or ≥ 130/80 mm Hg, whichever is lower [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]
Classification of hypertension in adults
2017 ACC/AHA guideline [1] 2014 JNC 8 guideline [2][7] 2020 ISH guideline [3]
Normal blood pressure
  • SBP < 120 mm Hg
  • AND DBP < 80 mm Hg
  • SBP < 130 mm Hg
  • AND DBP < 85 mm Hg
Elevated blood pressure
  • SBP 120–129 mm Hg
  • AND DBP < 80 mm Hg
  • SBP 120–139 mm Hg
  • OR DBP 80–89 mm Hg
  • SBP 130–139 mm Hg
  • OR DBP 85–89 mm Hg
Stage 1 hypertension
  • SBP 130–139 mm Hg
  • OR DBP 80–89 mm Hg
  • SBP 140–159 mm Hg
  • OR DBP 90–99 mm Hg
Stage 2 hypertension
  • SBP ≥ 140 mm Hg
  • OR DBP ≥ 90 mm Hg
  • SBP ≥ 160 mm Hg
  • OR DBP ≥ 100 mm Hg
  • Prevalence [1]
    • Hypertension affects between approximately one-third and one-half of adults in the US. [8][9]
    • 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]

Epidemiological data refers to the US, unless otherwise specified.

Primary hypertension [1][8]

Secondary hypertension

See “Secondary hypertension.”

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).

Interpretation of blood pressure readings [1][16]
In-office blood pressure Out-of-office blood pressure

Sustained hypertension

  • Elevated
  • Elevated
White coat hypertension (isolated clinic hypertension)
  • Elevated
  • Normal
Masked hypertension (isolated ambulatory hypertension)
  • Normal
  • Elevated

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

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

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]

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]

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]

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.

Endocrine hypertension

Common causes of endocrine hypertension [1]
Potential indication for further workup Typical findings
Primary hyperaldosteronism (Conn syndrome)
Pheochromocytoma
Hypercortisolism (Cushing syndrome)
Hyperthyroidism
  • TSH, ↑ free T4
Primary hyperparathyroidism
  • Typically asymptomatic
  • ↑ Serum calcium
Congenital adrenal hyperplasia
Acromegaly

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

Other

Management

Approach [1]

Screening for hypertension [8]

  • Indications
    • Annual screening [1]
    • 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]

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]

Nonpharmacological measures

  • Lifestyle measures alone may be trialed for 3–6 months in patients with: [5]
Lifestyle changes for managing hypertension [1][5][19]
Intervention (in order of effectiveness) Target Approximate SBP reduction in hypertensive patients
Weight loss (most effective measure)
  • 1 mm Hg per kg reduction in body weight in overweight individuals
Diet DASH diet
  • Diet rich in fruits, vegetables, and whole grains [28]
  • Low in saturated and trans fats
  • 11 mm Hg
Decrease dietary sodium
  • Daily sodium intake < 1500 mg [5][25][28]
  • 5–6 mm Hg
Increase dietary potassium
  • Daily potassium intake 3.5–5 g (preferably by increasing fruit and vegetable intake) [29]
  • 4–5 mm Hg
Decrease alcohol intake
  • 4 mm Hg
Exercise Aerobic [30]
  • 90–150 minutes per week [5][28]
  • 5–8 mm Hg
Dynamic resistance (e.g., weight training)
  • 90–150 minutes per week
  • 4 mm Hg
Isometric resistance (e.g., hand grip exercise)
  • Three sessions per week
  • 5 mm Hg

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. The following recommendations are based on the 2017 ACC/AHA guidelines.

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
  • Additional factors to consider

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 antihypertensive medications [1][19][25][35]
Drug class Examples Indications
ACEIs
ARBs
Thiazide diuretics
Dihydropyridine CCBs [19]
Nondihydropyridine CCBs
  • Less commonly used

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

Second-line antihypertensive medications [1][25]
Drug class Examples Indications
Beta blockers
Loop diuretics
Potassium-sparing diuretics Aldosterone antagonists
Epithelial sodium channel blockers
Direct renin inhibitors
  • Rarely used
Alpha-1 blockers
Alpha-2 agonists
  • Rarely used
Direct arteriolar vasodilators
  • Hydralazine is a treatment option in pregnant patients.

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

Antihypertensive treatment by comorbidities [1]

Comorbidity Treatment recommendations

History of stroke or TIA [37]

  • Initial therapy
  • Treatment goal: blood pressure < 130/80 mm Hg in most patients [1]

Stable ischemic heart disease

CKD [28]
Diabetes
CHF
Asthma [40]
Osteoporosis
Gout
Migraine

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.:
  • 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]

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]

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

Treatment of hypertension in pregnancy [1]

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

Treatment of hypertension in children [4][47][48]

As in adults, beta 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 relatively lower efficacy compared to other medications.

Cardiovascular system (hypertensive vascular disease) [49][50]

Brain [49][50][51]

Kidneys [50][52]

Eyes [49][50]

Classification system according to Keith-Wagener-Barker [49]
Grade 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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