History and exam

Key diagnostic factors

common

presence of risk 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.

systolic blood pressure (BP) ≥130 mmHg or diastolic BP ≥80 mmHg

The American College of Cardiology (ACC)/American Heart Association (AHA) guideline defines hypertension as systolic BP measurement of ≥130 mmHg or diastolic BP measurement of ≥80 mmHg.[2] The European Society of Cardiology (ESC) and European Society of Hypertension (ESH) guidelines define hypertension as office (clinic) systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg.[1][64]​​

retinopathy

Retinal vascular changes are seen commonly in long-standing hypertension.

Other diagnostic factors

uncommon

headache

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

visual changes

Decreased visual acuity or floaters, papilloedema (rare).

dyspnoea

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

chest pain

Suggests chronic coronary disease.

sensory or motor deficit

Suggests cerebrovascular disease.

Risk factors

strong

obesity

Obesity is strongly associated with hypertension. 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.[30] A 4.5 mmHg increase in blood pressure has been associated with each 4.5 kg (10 lb) gain in weight.[31] 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.[32]​ One study found that younger age at onset of overweight across adulthood was associated with significantly increased risk of hypertension, with the highest relative risk with onset of overweight at 18-39 years of age.[33]

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.[34]

Obesity is associated with metabolic syndrome, insulin resistance, and type 2 diabetes. Abdominal obesity has been specifically associated with an increased risk of hypertension, compared with generalised obesity.[35]

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][38]

aerobic exercise <3 times/week

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]

moderate/high alcohol intake

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.[2][40]​ 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.[41]​ Another systematic review and meta-analysis in healthy adults found a direct linear relationship between alcohol consumption and BP, with no suggestion of a threshold, particularly for systolic BP.[42]

metabolic syndrome or cardiovascular-kidney-metabolic (CKM) syndrome

Metabolic syndrome is a cluster of common conditions, including insulin resistance, impaired glucose tolerance, abdominal obesity, reduced high-density lipoprotein-cholesterol levels, elevated triglycerides, and hypertension; there are multiple varying sets of criteria for diagnosis and not all components need to be present for a diagnosis to be made. See Metabolic syndrome​.

CKM syndrome is a disorder defined by the American Heart Association (AHA) to reflect the connections between metabolic disease (obesity, diabetes, metabolic syndrome), kidney disease, and cardiovascular disease (CVD).[43]​ It includes both individuals at risk for CVD (due to the presence of metabolic risk factors, chronic kidney disease, or both) and individuals with existing CVD. Poor cardiovascular-kidney metabolic health affects nearly all organ systems and is associated with cardiovascular morbidity and mortality. The AHA has proposed a CKM syndrome staging system based on patient risk factors and opportunities for prevention and care. The AHA recommends that these patients are managed by an interdisciplinary team with targeted referral of high-risk CKM patients to appropriate subspecialists.[44]

Abdominal obesity has been specifically associated with an increased risk of hypertension, compared with generalised obesity.[35]​ Insulin resistance and hyperinsulinaemia are thought to contribute to the development of hypertension through a variety of inflammatory mechanisms.[24][25][26][43]​ Risk of hypertension is increased in the presence of dyslipidaemia and abdominal obesity.[45]

diabetes mellitus

Hyperglycaemia, hyperinsulinaemia, and insulin resistance lead to endothelial damage and oxidative stress, and are independently associated with the development of hypertension.[46]

black ancestry

Highest incidence of hypertension is seen in black non-Hispanic people, at all age levels.[3]

age >60 years

Incidence of hypertension increases with age in people of all ancestries and both sexes.[3]

family history of hypertension or chronic coronary disease

Patient may have family history of hypertension or chronic coronary disease risk factors.[1]

sleep apnoea

Obstructive sleep apnoea (OSA) is a risk factor for several cardiovascular diseases, including hypertension.[2][47]​ OSA and hypertension also have risk factors in common, such as obesity and alcohol use, and frequently co-exist.​​ In addition, there is a possible dose-response relationship between the severity of OSA and the risk of essential hypertension.[48]

OSA is also associated with an increased risk of resistant hypertension.[49]​ Successful treatment of OSA has been shown to improve BP.[50]

weak

sodium intake >1.5 g/day

Individuals show a varied tolerance for sodium intake, and reduced sodium intake has modest effect on blood pressure (BP) lowering.[13][14]​ Meta-analyses have 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.[51][52]

low fruit and vegetable intake

A diet rich in fruits and vegetables and low-fat dairy products (Dietary Approaches to Stop Hypertension [DASH] diet) has been associated with a significantly lower systolic blood pressure (BP).[53]​ A higher vegetable nitrate intake has been associated with a lower baseline systolic and diastolic BP.[54]

dyslipidaemia

Hypertension often co-exists with dyslipidaemia. Risk of hypertension is increased in the presence of dyslipidaemia and abdominal obesity.[45]

smoking

Cigarette smoking acutely raises BP, mainly through the stimulation of the sympathetic nervous system; however, the chronic effect of smoking on hypertension is uncertain.[55]

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