Hypertension

Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. The disorder can usually be managed with lifestyle modification and medications, but occasionally, vascular intervention or surgery are required. Age, sex, smoking, obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity, and diet are contributing factors to hypertension, which can lead to heart attack, stroke, congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure, and CKD CKD Chronic kidney disease (CKD) is kidney impairment that lasts for ≥ 3 months, implying that it is irreversible. Hypertension and diabetes are the most common causes; however, there are a multitude of other etiologies. In the early to moderate stages, CKD is usually asymptomatic and is primarily diagnosed by laboratory abnormalities. Chronic Kidney Disease if not managed properly. Many individuals with hypertension are undiagnosed or undertreated.

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Overview

Definition

Hypertension is defined as a BP > 130/80 mm Hg.

  • Primary (essential) hypertension is the most common type of hypertension; it has no known cause.
  • Secondary hypertension is due to another medical condition or to medications.

Epidemiology

  • Prevalence depends on the definition of hypertension.
  • In 2017, the American College of Cardiology/American Heart Association (ACC/AHA) lowered the threshold for the definition of hypertension, with prevalence now 43%–50% in adults. 
  • More common in older adults, men, and Black patients

Etiology

Primary hypertension:

The pathogenesis of primary hypertension is poorly understood but is most likely the result of numerous genetic and environmental factors affecting cardiovascular and kidney structure and function. Risk factors:

  • Male sex
  • Advanced age
  • Family history
  • Race
  • Smoking
  • Alcohol consumption
  • Obesity
  • Diet high in sodium
  • Physical inactivity

Secondary hypertension:

  • Medications (oral contraceptives, NSAIDs, antidepressants, steroids, stimulants Stimulants Stimulants are used by the general public to increase alertness and energy, decrease fatigue, and promote mental focus. Stimulants have medical uses for individuals with ADHD and sleep disorders, and are also used in combination with analgesics in pain management. Stimulants)
  • Illicit drugs
  • Renal: primary kidney disease, renovascular
  • Obstructive sleep apnea Obstructive sleep apnea Obstructive sleep apnea (OSA) is a disorder characterized by recurrent obstruction of the upper airway during sleep, causing hypoxia and fragmented sleep. Obstructive sleep apnea is due to a partial or complete collapse of the upper airway and is associated with snoring, restlessness, sleep interruption, and daytime somnolence. Obstructive Sleep Apnea
  • Endocrine: pheochromocytoma Pheochromocytoma Pheochromocytoma is a catecholamine-secreting tumor derived from chromaffin cells. The majority of tumors originate in the adrenal medulla, but they may also arise from sympathetic ganglia (also referred to as paraganglioma). Symptoms are associated with excessive catecholamine production and commonly include hypertension, tachycardia, headache, and sweating. Pheochromocytoma, primary aldosteronism, Cushing syndrome, Graves’ disease
  • Coarctation of the aorta Coarctation of the aorta Coarctation of the aorta is a narrowing of the aorta between the aortic arch and the iliac bifurcation commonly around the point of insertion of the ductus arteriosus. Coarctation of the aorta is typically congenital and the clinical presentation depends on the age of the patient. Coarctation of the Aorta

Classification

Table: Classification of hypertension (2017 JNC 8 guidelines)
BP category Systolic BP (mm Hg) Diastolic BP (mm Hg)
Normal BP < 120 mm Hg AND < 80 mm Hg
Elevated BP 120–129 mm Hg OR < 80 mm Hg
Stage 1 hypertension 130–139 mm Hg OR 80–89 mm Hg
Stage 2 hypertension ≥ 140 mm Hg OR ≥ 90 mm Hg
JNC 8: Eighth Joint National Committee

Clinical Presentation

General features

  • Most often presents with no signs or symptoms
  • Can present with headache, epistaxis, tinnitus, or dizziness

Subtypes

  • Isolated office hypertension (“white-coat hypertension“): characterized by measurements ≥ 130/80 mm Hg in the physician’s office, while measurements taken at home and during BP monitoring are normal
  • Isolated ambulatory hypertension (“masked hypertension”):
    • Increased systolic BP (≥ 140 mm Hg) with diastolic BP within normal limits (≤ 90 mm Hg)
    • Masked uncontrolled hypertension Uncontrolled hypertension Although hypertension is defined as a blood pressure of > 130/80 mm Hg, individuals can present with comorbidities of severe asymptomatic or "uncontrolled" hypertension (≥ 180 mm Hg systolic and/or ≥ 120 mm Hg diastolic) that carries with it a significant risk of morbidity and mortality. Uncontrolled Hypertension (MUCH) is diagnosed in patients treated for hypertension who are normotensive in the clinic but hypertensive outside.

Diagnosis

Medical history and physical examination

  • Prior to diagnosing hypertension, it is important to use an average based on ≥ 2 readings obtained on ≥ 2 occasions.
  • Diagnosis of hypertension should be confirmed using out-of-office BP measurement whenever possible.
  • In uncommon scenarios, diagnosis can be made if a patient presents with hypertensive urgency, ≥ 180 mm Hg systolic or ≥ 120 mm Hg diastolic, or an initial screening BP ≥ 160 mm Hg systolic or ≥ 100 Hg diastolic and known target end-organ damage (e.g., left ventricular hypertrophy, hypertensive retinopathy Hypertensive retinopathy Hypertension has many adverse effects on the eye, of which retinopathy is the most common presentation. Hypertensive retinopathy consists of retinal vascular changes that develop as a direct effect of elevated blood pressure. In acute increases of blood pressure, autoregulation results in retinal arteriolar narrowing. Hypertensive Retinopathy, or hypertensive kidney disease).
  • In cases of white-coat hypertension: ambulatory BP monitoring (ABPM) over a period of 24 hours is appropriate.

Laboratory

  • Hb and Hct: may indicate anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview due to underlying renal disease
  • Creatinine and eGFR levels: to evaluate renal function
  • Potassium levels: useful when Conn’s syndrome suspected
  • T3, T4, thyroid-stimulating hormone (TSH), aldosterone, and renin: to evaluate for the presence of endocrine hypertension
  • Urinalysis: Microalbuminuria may be an early indicator of renal damage, especially in diabetic patients.
  • 24-hour urine for catecholamines/metanephrines: if diastolic BP > 110 mm Hg, levels 2× upper limit of normal indicate pheochromocytoma Pheochromocytoma Pheochromocytoma is a catecholamine-secreting tumor derived from chromaffin cells. The majority of tumors originate in the adrenal medulla, but they may also arise from sympathetic ganglia (also referred to as paraganglioma). Symptoms are associated with excessive catecholamine production and commonly include hypertension, tachycardia, headache, and sweating. Pheochromocytoma

Electrocardiography

Evaluates for left ventricular hypertrophy (LVH): strain pattern often seen with hypertensive heart disease

  • Increased R-wave amplitude in V5, V6, I, and aVL
  • Increased S-wave amplitude in V1 and V2
  • Compensatory ST-segment and T-wave changes
Ste secondary to left ventricular hypertrophy

ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) showing left ventricular hypertrophy (LVH):
Note exaggerated amplitude of the QRS complexes and abnormal repolarization pattern typical of LVH.

Image: “STE secondary to left ventricular hypertrophy” by Department of Medicine, Baylor College of Medicine, Houston, Texas 77030, USA. License: CC BY 3.0

Imaging

  • Chest X-ray: useful to determine the presence of cardiomegaly, aortic coarctation
  • Echocardiography: evaluate for LVH, impaired systolic and/or diastolic function, valvular dysfunction/deformity
  • Renal duplex ultrasound: if renovascular hypertension suspected

Management

Nonpharmacologic measures

  • Weight reduction: ideally, BMI ≤ 25
  • Low-sodium diet: ≤ 2300 mg/day
  • Mediterranean diet: rich in fruits, vegetables, whole grains, low-fat dairy foods, and olive oil
  • Smoking cessation
  • Limit consumption of alcohol and coffee to 2 per day.
  • Regular physical activity: 30 minutes 5 days a week

Medical management

Table: Pharmacologic management of hypertension
Pharmacologic class Use Avoid in
Thiazide diuretics Thiazide diuretics Thiazide and thiazide-like diuretics make up a group of highly important antihypertensive agents, with some drugs being 1st-line agents. The class includes hydrochlorothiazide, chlorothiazide, chlorthalidone, indapamide, and metolazone. Thiazide Diuretics 1st-line Patients with gout Gout Gout is a heterogeneous metabolic disease associated with elevated serum uric acid levels (> 6.8 mg/dL) and abnormal deposits of monosodium urate in tissues. The condition is often familial and is initially characterized by painful, recurring, and usually monoarticular acute arthritis, or "gout flare," followed later by chronic deforming arthritis. Gout, pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, and electrolyte disorders
β-blockers Prior MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction, stable angina, chronic heart failure, atrial arrhythmias Heart block, sick sinus syndrome Sick Sinus Syndrome Sick sinus syndrome (SSS), also known as sinus node dysfunction, is characterized by degeneration of the sinoatrial (SA) node, the heart's primary pacemaker. Patients with SSS may be asymptomatic or may present with tachycardia or bradycardia. Sick Sinus Syndrome, COPD COPD Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by progressive, largely irreversible airflow obstruction. The condition usually presents in middle-aged or elderly persons with a history of cigarette smoking. Signs and symptoms include prolonged expiration, wheezing, diminished breath sounds, progressive dyspnea, and chronic cough. Chronic Obstructive Pulmonary Disease (COPD), asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma, acute heart failure
ACEis Heart failure, diabetes, unstable angina, MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction, kidney disease Pregnancy, angioedema Angioedema Angioedema is a localized, self-limited (but potentially life-threatening), nonpitting, asymmetrical edema occurring in the deep layers of the skin and mucosal tissue. The common underlying pathophysiology involves inflammatory mediators triggering significant vasodilation and increased capillary permeability. Angioedema
ARBs Heart failure, diabetes, kidney disease Pregnancy
Calcium channel blockers Calcium Channel Blockers Calcium channel blockers (CCBs) are a class of medications that inhibit voltage-dependent L-type calcium channels of cardiac and vascular smooth muscle cells. The inhibition of these channels produces vasodilation and myocardial depression. There are 2 major classes of CCBs: dihydropyridines and non-dihydropyridines. Class 4 Antiarrhythmic Drugs (Calcium Channel Blockers) Atrial tachyarrhythmias, Raynaud syndrome Heart block, sick sinus syndrome Sick Sinus Syndrome Sick sinus syndrome (SSS), also known as sinus node dysfunction, is characterized by degeneration of the sinoatrial (SA) node, the heart's primary pacemaker. Patients with SSS may be asymptomatic or may present with tachycardia or bradycardia. Sick Sinus Syndrome, pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, heart failure
Aldosterone receptor blockers Prior MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction, heart failure Pregnancy, hyperkalemia Hyperkalemia Hyperkalemia is defined as a serum potassium (K+) concentration >5.2 mEq/L. Homeostatic mechanisms maintain the serum K+ concentration between 3.5 and 5.2 mEq/L, despite marked variation in dietary intake. Hyperkalemia can be due to a variety of causes, which include transcellular shifts, tissue breakdown, inadequate renal excretion, and drugs. Hyperkalemia
COPD COPD Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by progressive, largely irreversible airflow obstruction. The condition usually presents in middle-aged or elderly persons with a history of cigarette smoking. Signs and symptoms include prolonged expiration, wheezing, diminished breath sounds, progressive dyspnea, and chronic cough. Chronic Obstructive Pulmonary Disease (COPD): chronic obstructive pulmonary disease Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD) is a lung disease characterized by progressive, largely irreversible airflow obstruction. The condition usually presents in middle-aged or elderly persons with a history of cigarette smoking. Signs and symptoms include prolonged expiration, wheezing, diminished breath sounds, progressive dyspnea, and chronic cough. Chronic Obstructive Pulmonary Disease (COPD)

Clinical Relevance

Hypertension is a risk factor for atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis, which can lead to MI MI MI is ischemia and death of an area of myocardial tissue due to insufficient blood flow and oxygenation, usually from thrombus formation on a ruptured atherosclerotic plaque in the epicardial arteries. Clinical presentation is most commonly with chest pain, but women and patients with diabetes may have atypical symptoms. Myocardial Infarction, ischemic heart disease Ischemic heart disease Coronary heart disease (CHD), or ischemic heart disease, describes a situation in which an inadequate supply of blood to the myocardium exists due to a stenosis of the coronary arteries, typically from atherosclerosis. Coronary Heart Disease, cerebrovascular accident Cerebrovascular accident An ischemic stroke (also known as cerebrovascular accident) is an acute neurologic injury that occurs as a result of brain ischemia; this condition may be due to cerebral blood vessel occlusion by thrombosis or embolism, or rarely due to systemic hypoperfusion. Ischemic Stroke, and peripheral ischemia.

Other conditions associated with hypertension include: 

  • Polycystic kidney disease (PKD): can be diagnosed in adults and pediatric patients. Polycystic kidney disease is an inherited disease that involves bilateral renal cysts without dysplasia. There are 2 forms: autosomal recessive Autosomal recessive Autosomal inheritance, both dominant and recessive, refers to the transmission of genes from the 22 autosomal chromosomes. Autosomal recessive diseases are only expressed when 2 copies of the recessive allele are inherited. Autosomal Recessive and Autosomal Dominant Inheritanceand autosomal dominant Autosomal dominant Autosomal inheritance, both dominant and recessive, refers to the transmission of genes from the 22 autosomal chromosomes. Autosomal dominant diseases are expressed when only 1 copy of the dominant allele is inherited. Autosomal Recessive and Autosomal Dominant Inheritance.
  • Glomerulonephritis: immune-mediated inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the renal glomeruli. Glomerulonephritis can be primary or secondary (due to other diseases). Patients with glomerulonephritis will present with various symptoms, depending on the pathology, but this disorder is commonly associated with hypertension.
  • Hyperparathyroidism Hyperparathyroidism Hyperparathyroidism is a condition associated with elevated blood levels of parathyroid hormone (PTH). Depending on the pathogenesis of this condition, hyperparathyroidism can be defined as primary, secondary or tertiary. Hyperparathyroidism: causes increased peripheral vascular resistance because of increased calcium levels with resultant elevation in BP.
  • Hyperaldosteronism Hyperaldosteronism Hyperaldosteronism is defined as the increased secretion of aldosterone from the zona glomerulosa of the adrenal cortex. Hyperaldosteronism may be primary (resulting from autonomous secretion), or secondary (resulting from physiological secretion due to stimulation of the RAAS). Classically, hyperaldosteronism presents with hypertension, hypokalemia, and metabolic alkalosis. Hyperaldosteronismpatients present with increased levels of aldosterone, which in turn increases sodium and water reabsorption, causing hypertension. In the adrenocorticotropic hormone (ACTH)–dependent form, androgens Androgens Androgens are naturally occurring steroid hormones responsible for development and maintenance of the male sex characteristics, including penile, scrotal, and clitoral growth, development of sexual hair, deepening of the voice, and musculoskeletal growth. Androgens and Antiandrogens may also be increased, and women can experience hirsutism and menstrual disruptions.

References

  1. Basile, J., Block, J. (2021). Overview of hypertension in adults. UpToDate. Retrieved March 18, 2021, from https://www.uptodate.com/contents/overview-of-hypertension-in-adults
  2. Whelton, P.K., Carey, R.M. 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. https://www.jacc.org/doi/full/10.1016/j.jacc.2017.11.006?_ga=2.178229602.677038771.1616197579-1081973158.1616197579
  3. Unger, T., Borghi, C., Charchar, F., et al. (2020.) International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension 75:1334–1357.

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