Hypertension

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Hypertension Main page
Overview
Causes
Classification Primary Hypertension Secondary Hypertension Hypertensive Emergency Hypertensive Urgency
Screening

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

Overview

Historical Perspective

• [Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
• In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
• In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].

Classification

• [Disease name] may be classified according to [classification method] into [number] subtypes/groups:

• [group1]
• [group2]
• [group3]

• Other variants of [disease name] include [disease subtype 1], [disease subtype 2], and [disease subtype 3].

Pathophysiology

• The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
• The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
• On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
• On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Causes

Disease name] may be caused by [cause1], [cause2], or [cause3].

OR

Common causes of [disease] include [cause1], [cause2], and [cause3].

OR

The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].

OR

The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click here.

Differentiating [disease name] from other Diseases

• [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as:

• [Differential dx1]
• [Differential dx2]
• [Differential dx3]

Epidemiology and Demographics

• The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
• In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

• Patients of all age groups may develop [disease name].

• [Disease name] is more commonly observed among patients aged [age range] years old.
• [Disease name] is more commonly observed among [elderly patients/young patients/children].

Gender

• [Disease name] affects men and women equally.

• [Gender 1] are more commonly affected with [disease name] than [gender 2].
• The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

Race

• There is no racial predilection for [disease name].

• [Disease name] usually affects individuals of the [race 1] race.
• [Race 2] individuals are less likely to develop [disease name].

Risk Factors

• Common risk factors in the development of [disease name] are [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

Modifiable risk factors	Fixed risk factors
Current smoker, secondhand smoking	Chronic kidney disease
Diabetes mellitus	Family history
Dyslipidemia/hypercholesterolemia	Increased age
Obesity	Low socioeconomic/educational status
Physical inactivity/low fitness	Male sex
Unhealthy diet	Obstructive sleep apnea Psychological stress

Natural History, Complications and Prognosis

• The majority of patients with [disease name] remain asymptomatic for [duration/years].
• Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
• If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
• Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
• Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

Diagnosis

Diagnostic Criteria

• The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:

• [criterion 1]
• [criterion 2]
• [criterion 3]
• [criterion 4]

History and Symptoms

• [Disease name] is usually asymptomatic.
• Symptoms of [disease name] may include the following:

• [symptom 1]
• [symptom 2]
• [symptom 3]
• [symptom 4]
• [symptom 5]
• [symptom 6]

Physical Examination

• Patients with [disease name] usually appear [general appearance].
• Physical examination may be remarkable for:

• [finding 1]
• [finding 2]
• [finding 3]
• [finding 4]
• [finding 5]
• [finding 6]

Laboratory Findings

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

• Fasting blood sugar
• Complete blood count
• Lipid profile
• Serum creatinine with eGFR
• Serum sodium, potassium, calcium
• Thyroid-stimulating hormone
• Urinalysis

• Optional laboratory test in hypertensive patients include:

• Uric acid
• Urinary albumin to creatinine ratio

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

There are no other diagnostic studies associated with [disease name].

OR

[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

• There is no treatment for [disease name]; the mainstay of therapy is supportive care.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

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	Chlorthalidone is a prolonged half-life drug and reduces cardiovascular risk Hyponatremia, hypokalemia, uric acid and calcium levels should be monitored
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	Avoidance of using in combination with ARB and direct renin inhibitor Using with caution in CKD or in patients are on K sparing agents due to the risk of hyperkalemia Avoidance in pregnancy Avoidance in patients with a history of angioedema with ACEI Avoidance in severe bilateral renal artery stenosis
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	Avoidance of using in combination with ACEI or direct renin inhibitor Using with caution in CKD or in patients are on K sparing drugs due to the risk of hyperkalemia Avoidance in pregnancy Avoidance in patients with a history of angioedema with ARB It can be used in patients with a history of angioedema with ACEI after 6 weeks of discontinuation of ACEI Avoidance in severe bilateral renal artery stenosis
CCB—dihydropyridines	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	Avoidance of using in heart failure reduced EF except amlodipine,felodipine Pedal edema is dose associated, more common in women
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)	Avoidance of using in combination with betablocker due to the risk of bradycardia Avoidance of using in heart failure reduced EF Avoidance of using diltiazem with verapamil due to drug interaction via CYP3A4
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	Preferred diuretic in symptomatic heart failure Preffered diuretic in moderate to severe CKD (GFR<30 cc/min)
Diuretics—potassium sparing	Amiloride 5–10 1-2 Triamterene 50–100 1-2	Mild antihypertensive effect Useful for treatment of hypokalemia due to thiazide monotherapy Avoidance of using in patients with significant CKD (GFR <45 mL/min).
Diuretics—aldosterone antagonists	Eplerenone 50–100 1-2 Spironolactone 25–100 1	Preferred for primary aldostronism and resistant hypertension Add-on therapy in resistant hypertension Lesser risk of gyncomasty and impotence with eplerenone Avoidance of combination therapy with K sparing agents
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	Beta-blockers are not first-line therapy of hypertension unless in the presence of IHD orheart failure Preferredbeta-blockers in bronchospastic airway disease preferred Bisoprolol, metoprolol succinate in heart failure reduced EF
Betablocker-cardioselective and vasodilatory	Nebivolol 5–40 1	Induction of nitric oxide Vasodilarory effect
Beta blockers—noncardioselective	Nadolol 40–120 1 Propranolol IR 80–160 2 Propranolol LA 80–160 1	Not recommended, especially in IHD or heart failure
Beta blockers—intrinsic sympathomimetic activity	Acebutolol 200–800 2 Penbutolol 10–40 1 Pindolol 10–60 2	Not recommended , especially in IHD or heart failure
Beta blockers—combined alpha-beta receptor	Carvedilol 12.5–50 2 Carvedilol phosphate 20–80 1 Labetalol 200–800 2	Carvedilol is preferred in heart failure reduced EF
Direct renin inhibitor	Aliskiren 150–300 1	Avoidance of using in combination with ARB or ACEI Using with caution in CKD or patients are on K sparing agents due to the risk of hyperkalemia Avoidance in pregnancy Avoidance in severe bilateral renal artery stenosis
Alpha-1 blockers	Doxazosin 1–16 1 Prazosin 2–20 2-3 Terazosin 1–20 1-2	Side-effect is orthostasis hypotension, especially in old patients Seconde line of treatment, preferred in BPH and hypertension
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	Last line of treatment due to CNS adverse effect on elderly patients Avoidance of abrupt discontinuation of clonidine because of rebound hypertension
Direct vasodilators	Hydralazine 100–200 2-3 Minoxidil 5–100 1-3	Recommended to use with betablocker and diuretic due to sodium and water retention and reflex tachycardia Side effect of hydralazine is drug-induced lupus-like syndrome at higher doses Side effect of [[minoxidil] is hirsotism,pericardial effusion

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

• There are no primary preventive measures available for [disease name].

• Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

References

Overview

Hypertension is generally defined as an elevated systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg. Hypertension can be chronic or acute. While 95% of the cases of chronic hypertension are primary, 5% of chronic hypertension is secondary to other underlying causes. Hypertensive crisis is the acute elevation of blood pressure and it can be classified into hypertensive emergency or hypertensive urgency when end organ damage is present or absent respectively.

Causes

When a full evaluation yields no clear etiology for the elevated blood pressure:

• Primary hypertension, also called essential hypertension.

Secondary hypertension can be caused by:

• Apnea
• Hyperaldosteronism
• Renal failure
• Coarctation of aorta
• Cushing's syndrome
• Drugs
• Diet
• Pheochromocytoma
• Obesity
• Hyperparathyroidism

For detailed causes of secondary hypertension, click here.

Classification

For more details about each specific type of hypertension, click on the links in blue in the algorithm below.
In order to distinguish primary hypertension from secondary hypertension, click here.

Hypertension

Chronic hypertension

Hypertensive crisis Acute elevation of blood pressure - Systolic blood pressure >180 mm Hg OR - Diastolic blood pressure >120 mm Hg

Primary hypertension (also known as essential hypertension) (95% of the cases)

Secondary hypertension (5% of the cases)

Hypertensive emergency Evidence of end organ damage

Hypertensive urgency No evidence of end organ damage

Screening

The age to begin screening for hypertension varies between 13-20 years of age, according to different authorities. Generally, hypertension is defined as SBP > 140 mmHg and/or DBP > 90 mmHg. In specific populations, however, routine follow-up target BP may be different; and initiation of treatment may be considered at even lower BP values than those considered for the normal population.