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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Usama Talib, BSc, MD [3]

Synonyms and Keywords: Blood pressure; hypertension; high blood pressure; systolic blood pressure; essential hypertension

Overview

Hypertension is a major risk factor for cardiovascular disease and a major public health problem. The prevalence of hypertension increased among the united states due to changing The previous cut-off 140/90 mmHg (the previous 2003 threshold from the Joint National Committee (JNC) 7 guideline 3) to a lower threshold of greater than or equal to 130/80 mmHg. Hypertension is a leading cause of mortality worldwide. More than half of hypertensive patients are not aware of the disorder and some diagnosed patients do not take the medication. The new guideline recommends considering the average of reading BP≥ 2 visits office. Home blood pressure monitoring (HBPM) and ambulatory blood pressure monitoring (ABPM) are better than clinic or home blood pressure readings to determine masked hypertension or white coat hypertension out of the office[1].

Historical Perspective

Classification

Hypertension classified based on presence of underlying disorders into two groups:[2][3]

Comparison between two guidelines of hypertension

Hypertension Guidline 2017 ACC/AHA 2018 ESC/ESH
Definition of hypertension (mmHg) ≥130/80 ≥140/90
Normal blood pressure range (mmHg)
  • Normal: <120/80
  • Elevated:120-129/<80
  • Optimal:<120/80
  • Normal:120-129/80-84
  • High normal:130-139/85-89
Hypertension stage (mmHg)
  • Stage1:130-139/80-89
  • Stage2: ≥140/90
  • Grade1:140-159/90-99
  • Grade2:160-179/100-109
  • Grade3: ≥180/110
Age specific blood pressure targets(9mmHg)
  • <65 years:<130/80
  • ≥65 years:<130/80
  • <65years:<120-129/70-79
  • >65 years:<130-139/70-79

2017/ACC/AHA Guideline of hypertension

  • Hypertension can be classified based on the guideline into 2 stages:
Blood pressure category Systolic blood pressure Diastolic blood pressure
Normal <120/80 mmHg <80 mmHg
Elevated 120-129 mmHg <80 mmHg
Stage 1 hypertension 130–139 mm Hg 80–89 mm Hg
Stage 2 hypertension ≥140 mm Hg ≥90 mm Hg

Pathophysiology

Causes

Common causes of hypertension include:[2]

Environmental exposure


Pharmacological causes of hypertension

Management:

  • Limiting alcohol to ≤1 drink daily for women and ≤2 drinks for men
  • Discontinue or decrease the dose
  • Behavior therapy for ADHD
  • Avoid use
  • Avoidance in uncontrolled hypertension
  • Using progestin-only form
  • Using low dose 20-30 mcg Ethinyl estradiol agents
  • Alternative agents (barrier, abstinence, IUD)
  • Avoide use
  • Using alternative agents (inhaled, topical)

Differentiating hypertension from other Diseases

  • Differential diagnosis of hypertension includes:[6]

[7][8][9]



Differentiating hypertension Explanation
Isolated systolic hypertension
  • More common in older patients, SBP ≥130 mmHg, DBP<80 mmHg
Isolated diastolic hypertension
Masked hypertension
  • Out-of-office daytime BP ≥135/85 mmHg, nighttime BP ≥120/70 mmHg, 24 h average BP ≥130/80 mmHg, normal BP in office
White coat hypertension
Severe hypertension
Malignant hypertension (emergency hypertension)

Epidemiology and Demographics

  • The prevalence of hypertension is approximately 45,600 per 100,000 individuals worldwide.
  • Between the years 2000-2002, the incidence of hypertension was estimated to be 5680 for whites, 8490 for African-Americans, 6570 for Hispanics, and 5220 for Chinese cases per 100,000 individuals in United States.[10]

Age

Gender

  • Males are more commonly affected with hypertension than females.

Race

Risk Factors

  • Common risk factors in the development of hypertension are:


Modifiable risk factors Fixed risk factors


Natural History, Complications and Prognosis

  • If hypertension left untreated, 33% of patients with hypertension may progress to developheart attack and stroke.[12]



Conditions Clinical features
Renal parenchymal disease
Renovascular disease
Primary aldosteronism
Obstructive sleep apnea
Drug or alcohol induced
Pheochromocytoma/paraganglioma
Cushing syndrome
Hypothyroidism
Hyperthyroidism
Coarctation of aorta
  • Hypertension before 30 years old
Primary hyperparathyroidism
Congenital adrenal hyperplasia
Mineralocorticoid excess syndromes other than primary aldosteronism
Acromegaly

Diagnosis

Diagnostic Criteria

  • The diagnosis of hypertension is made when at least three of the following diagnostic criteria are met:[2]

Abbreviations: SBP: Systolic blood pressure; DBP: Diastolic blood pressure; BP: Blood pressure

Blood pressure measurement Definition
Systolic blood pressure (SBP) First Korotkoff sound
Diastolic blood pressure(DBP) Fifth Korotkoff sound
Pulse pressure SBP minus DBP
Mean arterial pressure DBP plus one third pulse pressure
Mid- blood pressure (SBP+DBP) divided by 2
Arm circumference cuff size
22-26 cm Small adult
27-34 cm Adult
35-44 cm Large adult
45-52 cm Adult thigh
Key steps for accurate blood pressure measurement Educations
Properly prepare the patient
  • Have the patient relax, sitting on a chair, feet on the floor, back supported for more than 5 minutes
  • Avoidance of caffeine, smoking, exercise for at least 30 minutes before measurement
  • Emptying bladder before measurement
  • No talk during measurement
  • Removing all clothing covered the cuff location
Using proper technique
  • Cuff size 80% of arm
Taking proper measurement
  • Recording blood pressure in both arms at the first visit
  • Using the arm with higher blood pressure for the latter measurement
  • 1-2 minutes between two measurements
  • Cuff inflation 20-30 mmHg above the palpable radial pulse and deflation with the speed of 2 mmHg/seconds
Documentation of reading blood pressure
Average the reading
  • Using ≥2 readings obtained on ≥2 occasions for determination the level of blood pressure
Providing blood pressure reading to patient



 
 
 
 
 
 
 
 
 
New onset or uncontrolled hypertension in adult
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
* Drug resistance hypertension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Screening for secondary hypertension
 
 
 
 
 
 
 
 
 
 
 
 
No need for screening




Abbreviations: ABPM: Ambulatory blood pressure monitoring; HBPM: Home blood pressure monitoring; BP: Blood pressure

 
 
 
Office BP≥130/80 mm Hg, but < 160/100 mmHg after 3 months of life style modification, suspected white coat hypertension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Daytime ABPM or HBPM, BP<130/80 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
NO
  • Hypertension
  • Life style modification and starting antihypertensive drug therapy (class 2a)

  • Abbreviations: ABPM: Ambulatory blood pressure monitoring; HBPM: Home blood pressure monitoring; BP: Blood pressure

     
     
     
    Office BP: 120-129/<80 mmHg after 3 months of lifestyle modification, suspected masked hypertension
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Daytime ABPM or HBPM, BP≥130/80 mm Hg
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
    NO
  • Elevated BP
  • Lifestyle modification
  • Annual ABPM or HBPM (class2a)
  • Abbreviations: ABPM: Ambulatory blood pressure monitoring; HBPM: Home blood pressure monitoring; BP: Blood pressure

    Recommendations for masked hypertension and white coat hypertension : (Class IIa, Level of Evidence B)

    ❑ Screening for white-coat hypertension in patients with systolic blood pressure 130-160 mmHg and diastolic blood pressure 80-110 mmHg by using ABPM or HBPM before the diagnosis of hypertension

    (Class IIa, Level of Evidence C)

    ❑ Periodic monitoring of blood pressure with ABPM or HBPM for detection of transient or sustained hypertension inwhite coat hypertension

    (Class IIa, Level of Evidence C)

    ❑ Finding of white coat hypertension by HBPM and ABPM in high office blood pressure in spite of receiving treatment, is recommended

    (Class IIa, Level of Evidence B)

    ❑ Finding of mask hypertension by HBPM or ABPM in-office blood pressure 120-129 /75-79 mmHg

    (Class IIb, Level of Evidence C)

    ❑ Finding of white coat hypertension by HBPM or ABPM if office blood pressure is 10 mmHg higher than normal in spite of receiving multiple medications
    ❑ Finding of masked hypertension by HBPM in patients with end-organ damage or high cardiovascular risk but office reading blood pressure is at goal
    ❑ Finding of masked hypertension by ABPM in patients with high HBPM in spite of receiving medications

    2017 ACC/AHA Guideline

    Screening for Primary adlostronism:

    • Class of recommendation:I
    • Level of evidence:C

    History and Symptoms

    Physical Examination


    Conditions Physical examination
    Renal parenchymal disease
    Renovascular disease
    Primary aldosteronism
    Obstructive sleep apnea
    Drug or alcohol induced
    Pheochromocytoma/paraganglioma
    Cushing syndrome
    Hypothyroidism
     Hyperthyroidism
    Coarctation of aorta
    Congenital adrenal hyperplasia
    Acromegaly

    Laboratory Findings

    • Basic laboratory test should be taken in patients with the diagnosis of hypertension include:
    • Optional laboratory test in hypertensive patients include:

    Electrocardiogram

    Chest X-ray

    Echocardiography or Ultrasound

    Echocardiography may be helpful in the diagnosis of complications of hypertension, which include left ventricular hypertrophy (LVH), left ventricular (LV) diastolic dysfunction and left atrial dilation.

    CT scan

    MRI

    Other Imaging Findings

    • There are no other imaging findings associated with hypertension.

    Other Diagnostic Studies

    • There are no other diagnostic studies associated with hypertension.

    Treatment

    Medical Therapy

    • The mainstay of treatment for hypertension is: Initiation of treatment with one or more of three classes of first-line BP lowering agents:[2]
     
     
     
     
     
     
     
     
    Treatment strategy
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Nomal BP (BP<120/80 mmHg)
     
     
    Elevated BP (BP120-129/<80mmHg)
     
     
     
     
    Stage1 hypertension(BP 130-139/80-89mmHg
     
     
     
    Stage 2 hypertension (BP≥ 140/90
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Life style modifications
     
     
    Nonpharmocological therapy (class1)
     
     
     
     
    10 years cardiovascular disease (CVD) risk≥ 10%
     
     
     
    Non pharmacological therapy and BPlowering medication
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Reevaulation in 1 year (class 2a)
     
     
    Reevaulation in 3-6 months (class 1)
     
     
    NO, nonpharmocological therapy (class1)
     
    Yes,non pharmacological therapy and BP lowering medication
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Reevaulation in 3-6 months(class 1)
     
    Reevaulation in 1 months(class 1)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    BPgoal reached
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO, evaluation and optimization the adherence to medical therapy
     
     
    Yes,Reevaulation in 3-6 months(class 1)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Intensification of medical therapy
     
     
     
     
     
     



    First line of treatment Drug_ Dosage(mg/day)_ Frequency Comments
    Thiazide or thiazidetype diuretics
    Chlorthalidone 12.5–25 1
    Hydrochlorothiazide 25–50 1
    Indapamide 1.25–2.5 1
    Metolazone 2.5–5 1
    ACE inhibitors
    Benazepril 10–40 1-2
    Captopril 12.2-150 2-3
    Enalapril 5-40 1-2
    Fosinopril 10–40 1
    Lisinopril 10-40 1
    Moexipril 7.5–30 1-2
    Perindopril 4-16 1
    Quinapril 10-80 1-2
    Ramipril 2.5-20 1-2
    Trandolapril 1-4 1
    ARB
    Azilsartan 40-80 1
    Candesartan 8–32 1
    Eprosartan 600-800 1-2
    Irbesartan 150-300 1
    Losartan 50-100 1-2
    Olmesartan 20-40 1
    Telmisartan 20-80 1
    Valsartan 80-320 1
    CCBdihydropyridines
    Amlodipine 2.5–10 1
    Felodipine 2.5–10 1
    Isradipine 5–10 2
    Nicardipine SR 60–120 2
    Nifedipine LA 30–90 1
    Nisoldipine 17–34 1
    CCB—nondihydropyridines
    Diltiazem ER 120–360 1
    Verapamil IR 120–360 3
    Verapamil SR 120–360 1-2
    Verapamil-delayed onset ER 100–300 1 (in the evening)
    Second line of treatment Drug_ Dosage(mg/day)_ Frequency Comments
    Diuretics—loop
    Bumetanide 0.5–2 2
    Furosemide 20–80 2
    Torsemide 5–10 1
    Diuretics—potassium sparing
    Amiloride 5–10 1-2
    Triamterene 50–100 1-2
    Diuretics—aldosterone antagonists
    Eplerenone 50–100 1-2
    Spironolactone 25–100 1
    Betablocker-cardioselective
    Atenolol 25–100 2
    Betaxolol 5–20 1
    Bisoprolol 2.5–10 1
    Metoprolol tartrate 100–200 2
    Metoprolol succinate 50–200 1
    Betablocker-cardioselective and vasodilatory
    Nebivolol 5–40 1
    Beta blockers—noncardioselective
    Nadolol 40–120 1
    Propranolol IR 80–160 2
    Propranolol LA 80–160 1
    Beta blockers—intrinsic sympathomimetic activity
    Acebutolol 200–800 2
    Penbutolol 10–40 1
    Pindolol 10–60 2
    Beta blockers—combined alpha-beta receptor
    Carvedilol 12.5–50 2
    Carvedilol phosphate 20–80 1
    Labetalol 200–800 2
    Direct renin inhibitor
    Aliskiren 150–300 1
    Alpha-1 blockers
    Doxazosin 1–16 1
    Prazosin 2–20 2-3
    Terazosin 1–20 1-2
    Central alpha2-agonist and other centrally acting drugs
    Clonidine oral 0.1–0.8 2
    Clonidine patch 0.1–0.3 1 weekly
    Methyldopa 250–1000 2
    Guanfacine 0.5–2 1
    Direct vasodilators
    Hydralazine 100–200 2-3
    Minoxidil 5–100 1-3


    Class I, Level of evidence:A
    In patients with atherosclerotic renal artery stenosis, medical therapy is recommended
    Class IIb, Level of evidence:C
    Revascularization (percutaneous renal artery angioplasty and/ or stent placement) indicates in patients with refractory hypertension, worsening

    renal function, intractable heart failure, nonatherosclerotic disease (fibromuscular dysplasia)

    Class IIb, Level of evidence:B
    The effectiveness of continuous positive airway pressure (CPAP) to decrease blood pressure in patients with obstructive sleep apnea and hypertension is not verified

    Surgery

    Prevention

    • Once diagnosed and treated, patients with hypertension are followed-up every month for evaluation of medication adherence and response to treatment.

    References

    1. Karnjanapiboonwong A, Anothaisintawee T, Chaikledkaew U, Dejthevaporn C, Attia J, Thakkinstian A (2020). "Diagnostic performance of clinic and home blood pressure measurements compared with ambulatory blood pressure: a systematic review and meta-analysis". BMC Cardiovasc Disord. 20 (1): 491. doi:10.1186/s12872-020-01736-2. PMC 7681982 Check |pmc= value (help). PMID 33225900 Check |pmid= value (help).
    2. 2.0 2.1 2.2 2.3 2.4 2.5 Whelton, Paul K.; Carey, Robert M.; Aronow, Wilbert S.; Casey, Donald E.; Collins, Karen J.; Dennison Himmelfarb, Cheryl; DePalma, Sondra M.; Gidding, Samuel; Jamerson, Kenneth A.; Jones, Daniel W.; MacLaughlin, Eric J.; Muntner, Paul; Ovbiagele, Bruce; Smith, Sidney C.; Spencer, Crystal C.; Stafford, Randall S.; Taler, Sandra J.; Thomas, Randal J.; Williams, Kim A.; Williamson, Jeff D.; Wright, Jackson T. (2018). "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". Hypertension. 71 (6). doi:10.1161/HYP.0000000000000065. ISSN 0194-911X.
    3. Aronow, Wilbert S. (2017). "Drug-induced causes of secondary hypertension". Annals of Translational Medicine. 5 (17): 349–349. doi:10.21037/atm.2017.06.16. ISSN 2305-5839.
    4. Carey, Robert M.; Calhoun, David A.; Bakris, George L.; Brook, Robert D.; Daugherty, Stacie L.; Dennison-Himmelfarb, Cheryl R.; Egan, Brent M.; Flack, John M.; Gidding, Samuel S.; Judd, Eric; Lackland, Daniel T.; Laffer, Cheryl L.; Newton-Cheh, Christopher; Smith, Steven M.; Taler, Sandra J.; Textor, Stephen C.; Turan, Tanya N.; White, William B. (2018). "Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association". Hypertension. 72 (5). doi:10.1161/HYP.0000000000000084. ISSN 0194-911X.
    5. Oparil S, Acelajado MC, Bakris GL, Berlowitz DR, Cífková R, Dominiczak AF, Grassi G, Jordan J, Poulter NR, Rodgers A, Whelton PK (March 2018). "Hypertension". Nat Rev Dis Primers. 4: 18014. doi:10.1038/nrdp.2018.14. PMC 6477925. PMID 29565029.
    6. McEvoy, John W.; Daya, Natalie; Rahman, Faisal; Hoogeveen, Ron C.; Blumenthal, Roger S.; Shah, Amil M.; Ballantyne, Christie M.; Coresh, Josef; Selvin, Elizabeth (2020). "Association of Isolated Diastolic Hypertension as Defined by the 2017 ACC/AHA Blood Pressure Guideline With Incident Cardiovascular Outcomes". JAMA. 323 (4): 329. doi:10.1001/jama.2019.21402. ISSN 0098-7484.
    7. Franklin, Stanley S.; O’Brien, Eoin; Staessen, Jan A. (2016). "Masked hypertension: understanding its complexity". European Heart Journal: ehw502. doi:10.1093/eurheartj/ehw502. ISSN 0195-668X.
    8. Franklin, Stanley S.; Thijs, Lutgarde; Hansen, Tine W.; O’Brien, Eoin; Staessen, Jan A. (2013). "White-Coat Hypertension". Hypertension. 62 (6): 982–987. doi:10.1161/HYPERTENSIONAHA.113.01275. ISSN 0194-911X.
    9. Rubin, Sébastien; Cremer, Antoine; Boulestreau, Romain; Rigothier, Claire; Kuntz, Sophie; Gosse, Philippe (2019). "Malignant hypertension". Journal of Hypertension. 37 (2): 316–324. doi:10.1097/HJH.0000000000001913. ISSN 0263-6352.
    10. Carson AP, Howard G, Burke GL, Shea S, Levitan EB, Muntner P (June 2011). "Ethnic differences in hypertension incidence among middle-aged and older adults: the multi-ethnic study of atherosclerosis". Hypertension. 57 (6): 1101–7. doi:10.1161/HYPERTENSIONAHA.110.168005. PMID 21502561.
    11. 11.0 11.1 Siddiqui, Mohammed Azfar; Mittal, Pardeep K.; Little, Brent P.; Miller, Frank H.; Akduman, Ece Isin; Ali, Kamran; Sartaj, Sara; Moreno, Courtney C. (2019). "Secondary Hypertension and Complications: Diagnosis and Role of Imaging". RadioGraphics. 39 (4): 1036–1055. doi:10.1148/rg.2019180184. ISSN 0271-5333.
    12. Fihaya, Faris Yuflih; Sofiatin, Yulia; Ong, Paulus Anam; Sukandar, Hadyana; Roesli, Rully M.A. (2015). "Prevalence of Hypertension and Its Complications in Jatinangor 2014". Journal of Hypertension. 33: e35. doi:10.1097/01.hjh.0000469851.39188.36. ISSN 0263-6352.
    13. Rayner, B (2004). "The chest radiographA useful investigation in the evaluation of hypertensive patients". American Journal of Hypertension. 17 (6): 507–510. doi:10.1016/j.amjhyper.2004.02.012. ISSN 0895-7061.
    14. Mavrogeni, Sophie; Katsi, Vasiliki; Vartela, Vasiliki; Noutsias, Michel; Markousis-Mavrogenis, George; Kolovou, Genovefa; Manolis, Athanasios (2017). "The emerging role of Cardiovascular Magnetic Resonance in the evaluation of hypertensive heart disease". BMC Cardiovascular Disorders. 17 (1). doi:10.1186/s12872-017-0556-8. ISSN 1471-2261.