History and exam

Key diagnostic factors

Key risk factors include age >65 years, moderate/high alcohol intake, lack of exercise, family history of hypertension or coronary artery disease, obesity, metabolic syndrome, diabetes mellitus, hyperuricaemia, black ancestry, and obstructive sleep apnoea.

Anaeroid, mercury, or electronic cuff. Equipment needs calibration. Auscultatory devices (e.g., mercury, aneroid) are not generally useful for home blood pressure monitoring (HBPM) because patients rarely master the required technique for blood pressure (BP) measurement using these devices.[5] White-coat hypertension is suspected when blood pressure readings in the office exceed those outside of the clinical setting. Ambulatory blood pressure monitoring (ABPM) or HBPM may be helpful in patients with suspected white-coat hypertension and is recommended routinely by some guidelines.[50] Automated office blood pressure is another option that has been designed to more accurately measure blood pressure. Multiple measurements are taken while the patient is alone in a quiet room and the mean blood pressure is calculated.[52] Masked hypertension is suspected when out-of-office BP measurements exceed those taken in the clinical setting. In adults with elevated office BP (120-129/<80 mmHg) but not meeting the ACC/AHA criteria for hypertension, screening for masked hypertension with daytime ABPM or HBPM is reasonable.[5]

Retinal vascular changes are seen commonly in longstanding hypertension.

Other diagnostic factors

Rarely a presenting symptom, unless hypertension is acute or in the setting of hypertensive urgency.

Decreased visual acuity or floaters, papilloedema (rare).

Suggests possible congestive heart failure or coronary artery disease. Dyspnoea may be an anginal equivalent, particularly in the setting of diabetes.

Suggests coronary artery disease.

Suggests cerebrovascular disease.

Risk factors

Data from the Nurses' Health Study showed that a gain of 5 kg above weight at 18 years of age was associated with 60% higher risk of development of hypertension in middle age.[33] A 4.5 mmHg increase in blood pressure has been associated with each 4.5 kg (10 lb) gain in weight.[34] One systematic review found that risk of hypertension increased continuously with increasing body mass index (BMI), waist circumference, weight gain, and waist-to-hip and waist-to-height ratio.[35]

It has been postulated that the link between obesity and hypertension is driven by increased circulating volume, leading to increased cardiac output and persistently elevated peripheral vascular resistance.[30]

Obesity is associated with the metabolic syndrome, insulin resistance, and type 2 diabetes.

Bariatric treatment of class III obesity (BMI 40 or above) can reduce or eliminate risk factors for cardiovascular disease, with an effect on hypertension, diabetes, and dyslipidaemia.[36][37]

Patients with low level of fitness had a 52% greater relative risk of hypertension at 12-year follow-up compared with those with high levels of fitness.[39]

Chronic alcohol consumption of more than 1 drink per day in women and more than 2 drinks per day in men has been shown to be associated with an increased risk of blood pressure (BP) elevation.[5][41] One Cochrane review of the effect of alcohol on BP found that high-dose alcohol (>30 g) has a biphasic effect, decreasing BP up to 12 hours after consumption and increasing BP after 13 hours.[42]

Abdominal obesity has been specifically associated with an increased risk of hypertension, as compared with generalised obesity.[43]

Insulin resistance and hyperinsulinaemia are thought to contribute to the development of hypertension through a variety of inflammatory mechanisms.[17]

Hyperglycaemia, hyperinsulinaemia, and insulin resistance lead to endothelial damage and oxidative stress, and are independently associated with the development of hypertension.[44]

Highest incidence of hypertension is seen in black non-Hispanic people, at all age levels.[4]

Incidence of hypertension increases with age in people of all ancestries and both sexes.[4]

Patient may have family history of hypertension or coronary artery disease risk factors.[2]

Obstructive sleep apnoea is a risk factor for several cardiovascular diseases, including hypertension.[5] In addition, there is a possible dose-response relationship between the severity of obstructive sleep apnoea and the risk of essential hypertension.[45]

Obstructive sleep apnoea is also associated with an increased risk of resistant hypertension.[46]

Individuals show a varied tolerance for sodium intake, and reduced sodium intake has modest effect on blood pressure (BP) lowering.[19][20] One meta-analysis has shown the amount of BP lowering achieved with sodium reduction has a dose-response relation and is greater for older populations, non-white populations, and those with higher baseline systolic BP.[38]

Modest reduction in blood pressure with 4 to 6 servings of fruits and vegetables coupled with lower sodium and fat intake (Dietary Approaches to Stop Hypertension [DASH] diet).[40]

Risk of hypertension is increased in the setting of the metabolic syndrome.

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