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.
- 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
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
- Alcohol consumption
- Diet high in sodium
- Physical inactivity
- Medications (oral contraceptives, NSAIDs, antidepressants, steroids, stimulants)
- Illicit drugs
- Renal: primary kidney disease, renovascular
- Obstructive sleep apnea
- Endocrine: pheochromocytoma, primary aldosteronism, Cushing syndrome, Graves’ disease
- Coarctation of the aorta
|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|
- Most often presents with no signs or symptoms
- Can present with headache, epistaxis, tinnitus, or dizziness
- 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 (MUCH) is diagnosed in patients treated for hypertension who are normotensive in the clinic but hypertensive outside.
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, or hypertensive kidney disease).
- In cases of white-coat hypertension: ambulatory BP monitoring (ABPM) over a period of 24 hours is appropriate.
- Hb and Hct: may indicate anemia 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
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
- 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
- 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
|Pharmacologic class||Use||Avoid in|
|Thiazide diuretics||1st-line||Patients with gout, pregnancy, and electrolyte disorders|
|β-blockers||Prior MI, stable angina, chronic heart failure, atrial arrhythmias||Heart block, sick sinus syndrome, COPD, asthma, acute heart failure|
|ACEis||Heart failure, diabetes, unstable angina, MI, kidney disease||Pregnancy, renovascular hypertension, angioedema|
|ARBs||Heart failure, diabetes, kidney disease||Pregnancy, renovascular hypertension|
|Calcium channel blockers||Atrial tachyarrhythmias, Raynaud syndrome||Heart block, sick sinus syndrome, pregnancy, heart failure|
|Aldosterone receptor blockers||Prior MI, heart failure||Pregnancy, hyperkalemia|
Hypertension is a risk factor for atherosclerosis, which can lead to MI, ischemic heart disease, cerebrovascular accident, 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 and autosomal dominant.
- Glomerulonephritis: immune-mediated 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: causes increased peripheral vascular resistance because of increased calcium levels with resultant elevation in BP.
- Hyperaldosteronism: patients present with increased levels of aldosterone, which in turn increases sodium and water reabsorption, causing hypertension. In the adrenocorticotropic hormone (ACTH)–dependent form, androgens may also be increased, and women can experience hirsutism and menstrual disruptions.
- 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
- 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
- Unger, T., Borghi, C., Charchar, F., et al. (2020.) International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension 75:1334–1357.