HYPERTENSION

Hypertension is a common condition that affects one in every three adults in the United States.
The AHA/ACC guidelines define it as a blood pressure of ≥ 130/80 mm Hg and by JNC 8 criteria
as ≥ 140/90 mm Hg. Hypertension can be classified as either primary (essential) or
secondary. Primary hypertension accounts for approx. 95% of cases of hypertension and has no
detectable cause, whereas secondary hypertension is due to a specific underlying condition.
Typical underlying conditions include renal, endocrine, or vascular diseases (e.g., renal
failure, primary hyperaldosteronism, or coarctation of the aorta). Clinically, hypertension is
usually asymptomatic until organ damage occurs, which then commonly affects the
brain, heart, kidneys, or eyes (e.g., retinopathy, myocardial infarction, stroke). Common early
symptoms of hypertension include headache, dizziness, tinnitus, and chest discomfort.
Hypertension is diagnosed if blood pressure is persistently elevated on two or more separate
measurements. Further diagnostic measures include evaluation of possible 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 ACE
inhibitors, angiotensin receptor blockers, thiazide diuretics, and calcium channel blockers.
Management of pediatric patients and pregnant women differs from that of nonpregnant adults
because some of these drugs are contraindicated in these patient groups. To treat secondary
hypertension, the underlying cause needs to be addressed.

 AHA/ACC 2017 definition: persistent systolic blood pressure of ≥ 130 mm

Hg and/or diastolic blood pressure ≥ 80 mm Hg
 JNC 8 definition: persistent systolic blood pressure of ≥ 140 mm
Hg and/or diastolic blood pressure ≥ 90 mm Hg
 Definition of hypertension in children < 13 years: blood pressure ≥
95  percentile to < 95  percentile + 12 mm Hg OR systolic blood pressure ≥ 130 mm
th th

Hg and/or diastolic blood pressure ≥ 80 mm Hg (whichever is lower)  [1][2]

 Prevalence
o One in three adults in the US is affected.
o Prevalence increases with age (∼ 65% among those ≥ 60 years of age). 
o African Americans are more commonly affected than Asian American or
white individuals. 
o 60–75% of obese and overweight patients are affected.
 Sex: ♂ > ♀ below age of 45; the sex ratio is almost balanced at > 45 years of age
(i.e., after menopause)
 Most common risk factor for cardiovascular disease
References: [6][7][3][8][9][10][11][12]
 Primary (essential) hypertension
 No specific cause; multifactorial etiology including epigenetic/genetic and
environmental factors
 Accounts for 85–95% of cases of hypertension in adults
 Accounts for 15–20% of cases of hypertension in children < 12 years of age
 Age at onset: 25–55 years (prevalence is increasing in adolescents)
Risk factors
 Nonmodifiable risk factors
o Positive family history
o Ethnicity
o Advanced age
 Modifiable risk factors
o Obesity
o Diabetes 
o Smoking, excessive alcohol or caffeine intake
o Diet high in sodium, low in potassium 
o Physical inactivity
o Psychological stress

Secondary hypertension
 Caused by an identifiable underlying condition
 Accounts for 5–15% of cases of hypertension in adults
 Accounts for 70–85% of cases of hypertension in children < 12 years of age 
 Age at onset < 25 years or > 55 years
Causes
 Endocrine hypertension
o Primary hyperaldosteronism (Conn syndrome): most common cause
of secondary hypertension in adults
o Hypercortisolism (Cushing syndrome)
o Hyperthyroidism
o Pheochromocytoma
o Primary hyperparathyroidism
o Acromegaly
o Congenital adrenal hyperplasia 
 Renal hypertension 
o Renovascular hypertension (e.g., due to renal artery stenosis)
o Polycystic kidney disease (ADPKD)
o Renal failure (renal parenchymal hypertension) 
o Glomerulonephritis
o Systemic lupus erythematosus
o Renal tumors
 Coarctation of the aorta
 Obstructive sleep apnea
 Medication: sympathomimetic drugs, corticosteroids, NSAIDs, oral
contraceptives 
 Recreational drug use: amphetamines, cocaine, phencyclidine
 Isolated systolic hypertension: See “subtypes and variants” below for details.
 Hypertension is usually asymptomatic until:
o Complications of end-organ damage arise (see “Complications” below)
o Or an acute increase in blood pressure occurs (see hypertensive
crisis below)
 Secondary hypertension usually manifests with symptoms of the underlying
disease (e.g., abdominal bruit in renovascular disease, edema in CKD, daytime
sleepiness in obstructive sleep apnea).
 Nonspecific symptoms of hypertension
o Headaches, esp. early morning or waking headache 
o Dizziness, tinnitus, blurred vision
o Flushed appearance
o Epistaxis
o Chest discomfort, palpitations; strong, bounding pulse on palpation
o Nervousness
o Fatigue, sleep disturbances

White coat hypertension (white coat effect)

 Definition: arterial hypertension detected only in clinical settings or during blood
pressure measurement at a physician's practice
 Etiology: anxiety experienced by the patient
 Clinical features: consistently normal blood pressure measurements and
normalization of elevated blood pressure outside of a clinical setting
 Diagnostics: 24-hour blood pressure monitoring
 Isolated systolic hypertension (ISH)
 Definition: increase in systolic blood pressure (≥ 140 mm Hg) with diastolic BP
within normal limits (≤ 90 mm Hg)
 Etiology
o ISH in elderly: decreased arterial elasticity and increased stiffness →
decreased arterial compliance
o ISH secondary to increased cardiac output
 Anemia
 Hyperthyroidism
 Chronic aortic regurgitation
 AV fistula
 Clinical features:
o Often asymptomatic
o Signs of increased pulse pressure: e.g., head pounding, rhythmic nodding,
or bobbing of the head in synchrony with heartbeats
o Symptoms of hypertension (see “clinical features” above)
 Diagnostics: See “diagnosis of hypertension” below.
 Treatment: thiazide diuretics or dihydropyridine calcium antagonists
 Prognosis: high risk of cardiovascular events (MI, stroke, renal dysfunction)

General approach
Blood pressure monitoring
 Repeated measurements on both arms 
 : Hypertension is diagnosed if the average blood pressure on at least two
readings obtained on at least two separate visits is elevated.
 Long-term measurement of blood pressure (24 hours)
 See “Blood pressure measurement” for the basic approach to measurement.
nitial evaluation of newly diagnosed hypertensive patients
 Stratification of cardiovascular risk: fasting blood glucose, lipid profile
(HDL, LDL, and triglycerides levels)
 Evaluation of end-organ damage and underlying causes
o Complete blood count
o Renal function tests: serum creatinine and eGFR
o Serum Na , K , and Ca
+ + 2+

o Urinalysis 
 o TSH 
o Electrocardiogram (ECG) 

Approach to diagnosing secondary hypertension

 General indicators of secondary hypertension
o Young age (< 30 years) at onset of hypertension
Onset of diastolic hypertension at an older age (> 55 years)
o Abrupt onset of hypertension
o End-organ damage that is disproportionate to the degree of hypertension
o Recurrent hypertensive crises
o Resistant hypertension: hypertension that is resistant to treatment with
at least three antihypertensives of different classes including a diuretic
 Specific indicators (For details regarding individual diagnostic procedures, see
the individual articles.
 Initiation of treatment
o Number of antihypertensives
Newly diagnosed hypertension with BP < 150/90 mm Hg: Begin
therapy with one primary antihypertensive.
 Newly diagnosed hypertension with BP > 150/90 mm Hg: Begin
therapy with two primary antihypertensives.
o Choice of antihypertensive drug
 Non-African American patients (including individuals
with diabetes): thiazide-type diuretic, calcium channel
blocker (CCB), angiotensin-converting enzyme inhibitor (ACE-I),
or angiotensin receptor blocker (ARB)
 African American patients (including individuals
with diabetes): thiazide-type diuretic or CCB 
 In adults with chronic kidney disease: initial (or add-on) treatment
should include an ACE inhibitor or ARB to
improve kidney outcome. 
 Follow-up
 o Reassess within one month of initiating or changing pharmacological
therapy.
 If the treatment goal is not reached with one drug, increase the
dose of the initial drug or add a second drug.
 If the treatment goal cannot be reached with two drugs:
 Add a third drug. 
 Evaluate for secondary causes of hypertension.
 If blood pressure is controlled: Reassess after 3–6 months and
annually thereafter.

Treatment of hypertension in pregnancy

 First-line treatment: methyldopa 
, labetalol, hydralazine (vasodilator), and nifedipine (CCB)
 Second-line treatment: thiazides, clonidine (alpha-2 agonist)
 Contraindicated: furosemide, ACE-I, ARB, renin inhibitors (aliskiren) 
 For details, see treatment of gestational hypertension.

Treatment of hypertension in children

 Treat the underlying cause (e.g., surgical correction of coarctation of the aorta)
 Lifestyle changes in children with elevated BP (see nonpharmacologic measures in the
treatment section below)
 Pharmacologic management is indicated for symptomatic hypertension, diabetes
mellitus, CKD, and end-organ damage, as well as if there is an insufficient response or no
response to lifestyle changes.
o Goal: BP < 90  percentile (BP < 50  percentile in children with DM or CKD)
th th

o Drugs: ACE inhibitor, ARB, or calcium channel blocker

 In children with CKD or diabetes mellitus, ACE inhibitors or ARBs are
preferable.
 Hypertensive emergency: labetalol, nicardipine, or sodium nitroprusside

Arterial hypertension leads to changes in the vascular endothelium, particularly of the
small vessels, and can therefore affect any organ system.
 See also hypertensive crises.

Cardiovascular system
 Congestive heart failure, dilated cardiomyopathy, hypertrophic
cardiomyopathy
 Coronary artery disease and myocardial infarction
 Atrial fibrillation
 Aortic aneurysm
 Aortic dissection 
 Carotid artery stenosis
 Peripheral artery disease
 Atherosclerosis

Brain
 Stroke 
 , TIA
 Cognitive changes such as memory loss
 Kidneys
 Hypertensive nephrosclerosis 
o Pathophysiology: chronic hypertension →
narrowing of afferent arterioles and efferent arterioles →
reduction of glomerular blood flow → glomerular and tubular ischemia →
arteriolonephrosclerosis and fibrosis (focal segmental glomerulosclerosis) → end-
stage renal disease 
o Typical findings
 Initially microalbuminuria and microhematuria
 With disease progression, nephrosclerosis
with macroalbuminuria (usually < 1 g/day) and progressive renal failure occur.
 Biopsy: sclerosis in capillary tufts, arterial hyalinosis 

Eyes
 Hypertensive retinopathy
o Arteriosclerotic and hypertension-related changes of the retinal vessels 
o Fundoscopic examination:
 Cotton-wool spots
 Retinal hemorrhages (i.e., flame-shaped hemorrhages)
 Microaneurysms
 Macular star (results from exudation into the macula)
 Arteriovenous nicking 
 Marked swelling and prominence of the optic disk with indistinct
borders due to papilledema and optic atrophy (end-stage disease)
 Presence of papilledema in a hypertensive patient may indicate a hypertensive
crisis and warrants urgent lowering of the blood pressure (see hypertensive crises)