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BASICS

Description

  • Primary (essential) hypertension: elevated blood pressure (BP) without an identifiable secondary cause.
  • Diagnostic thresholds:
  • JNC 8 & International Society of Hypertension:
    • Age <60 years: SBP β‰₯140 and/or DBP β‰₯90 mm Hg on β‰₯2 visits
    • Age β‰₯60 years: SBP β‰₯150 and/or DBP β‰₯90 mm Hg on β‰₯2 visits
    • With diabetes or CKD: SBP β‰₯140 and/or DBP β‰₯90 mm Hg
  • ACC/AHA defines stage 1 hypertension as SBP β‰₯130 and/or DBP β‰₯80 mm Hg, recommending lifestyle changes and selective pharmacotherapy based on risk.

Geriatric Considerations

  • Isolated systolic hypertension common.
  • Treatment reduces stroke, CV morbidity, and mortality.
  • Higher target SBP (~150 mm Hg) advised for elderly.
  • Thiazide diuretics show strong evidence for benefit in older adults.
  • Increased risk of medication side effects, especially in very old.

Pediatric Considerations

  • Hypertension defined as BP β‰₯95th percentile on repeated measures.
  • Measure BP routinely starting age 3.
  • Prehypertension: 90th to 95th percentile.

Pregnancy Considerations

  • Elevated BP may be chronic HTN, pregnancy-induced HTN, or preeclampsia.
  • Preferred antihypertensives: labetalol, nifedipine, methyldopa, hydralazine.
  • ACE inhibitors and ARBs contraindicated in pregnancy.
  • Treating severe hypertension reduces maternal and fetal mortality.

EPIDEMIOLOGY

  • 32–46% of U.S. adults have hypertension.
  • Higher prevalence and incidence in men.

ETIOLOGY AND PATHOPHYSIOLOGY

  • 90% cases have no identifiable cause (essential hypertension).

  • Secondary causes covered separately.

RISK FACTORS

  • Family history
  • Obesity
  • Excess dietary sodium
  • Alcohol use
  • Physical inactivity
  • Tobacco use
  • Insulin resistance
  • Obstructive sleep apnea and other sleep disorders
  • Stress

DIAGNOSIS

History

  • Usually asymptomatic except in severe cases or after CV complications.
  • Headache (especially occipital and on awakening) may occur at higher BP.

Physical Exam

  • Accurate BP measurement is essential.
  • Measure in both arms.
  • Evaluate cardiac and peripheral pulses (e.g., for coarctation).
  • Funduscopic exam: look for arteriolar narrowing, AV nicking, hemorrhages, exudates, papilledema.

Differential Diagnosis

  • Secondary hypertension when indicated by history or poor response.
  • White coat hypertension: elevated BP in clinic but normal outside.

Diagnostic Tests

  • Avoid caffeine, exercise, smoking >30 min before BP.
  • Patient seated quietly for 5 min; arm supported at heart level.
  • Use correct cuff size.
  • Average β‰₯2 readings.
  • Home BP monitoring (HBPM) and ambulatory BP monitoring (ABPM) preferred for diagnosis confirmation.
  • Labs: CBC, electrolytes, creatinine, urinalysis, lipids, fasting glucose/HbA1c.
  • ECG: evaluate LVH, arrhythmias.
  • Calculate 10-year ASCVD risk; consider sleep apnea.

TREATMENT

General Measures

  • Based on JNC 8 recommendations; shared decision-making emphasized.
  • BP goals:
  • <60 years: <140/90 mm Hg (HBPM <135/85)
  • β‰₯60 years: <150/90 mm Hg (HBPM <140/90)
  • β‰₯60 years with CKD or diabetes: <140/90 mm Hg (HBPM <135/85)
  • More aggressive treatment may be individualized for high-risk patients (SPRINT criteria).
  • Address lifestyle: diet, exercise, tobacco/alcohol cessation.
  • Medication benefit in low-risk patients with mild HTN uncertain; individualize therapy.

Medication

First-Line

  • ACE inhibitors (e.g., lisinopril, enalapril, ramipril)
  • Angiotensin receptor blockers (ARBs) (e.g., losartan, valsartan)
  • Dihydropyridine calcium channel blockers (DHP-CCBs) (e.g., amlodipine, nifedipine)
  • Thiazide diuretics (chlorthalidone preferred)

Second-Line

  • Review adherence before escalating.
  • Combine medications with complementary mechanisms (avoid ACEI + ARB).
  • Spironolactone/eplerenone for resistant hypertension.
  • Ξ²-Blockers for ischemic heart disease, arrhythmias, heart failure, migraine.
  • Centrally acting Ξ±2 agonists (clonidine, guanfacine, methyldopa).
  • Ξ±-Adrenergic antagonists for BPH.
  • Vasodilators (hydralazine, minoxidil) rarely used due to side effects.
  • Loop diuretics and metolazone in advanced renal disease.

Complementary and Alternative

  • Biofeedback and relaxation exercises.

ONGOING CARE

Follow-Up

  • Recheck electrolytes, BUN, creatinine 3-6 weeks after initiating ACEI, ARB, or thiazide.
  • Monitor every 3-6 months until stable, then every 6-12 months.
  • Encourage home BP monitoring.
  • Monitor for sexual dysfunction and quality-of-life issues.
  • Annual creatinine and potassium in patients on diuretics, ACEI, ARBs.

Diet

COMPLICATIONS

  • Heart failure, renal failure
  • Left ventricular hypertrophy
  • Myocardial infarction
  • Retinal hemorrhage
  • Stroke
  • Dementia and cognitive decline
  • Medication side effects
  • Erectile dysfunction
  • Increased mortality

REFERENCES

  1. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520.
  2. Qaseem A, Wilt TJ, Rich R, et al. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017;166(6):430-437.
  3. Krist AH, Davidson KW, Mangione CM, et al; for US Preventive Services Task Force. Screening for hypertension in adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2021;325(16):1650-1656.

Clinical Pearls

  • Number needed to treat (NNT) to prevent major CV events varies widely by baseline BP severity.
  • Measure BP outside the clinic to avoid white coat effect.
  • Avoid overly aggressive BP lowering, especially in elderly.
  • Many patients respond variably to medications; try sequential monotherapy before combination therapy when near target.