Evaluation of hypertension

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Last reviewed: 3 Nov 2024

Last updated: 31 May 2024

Hypertension is a common disorder that affects a large proportion of the community. It is usually asymptomatic and is detected on routine exam or after the occurrence of a complication such as a heart attack or stroke.[1]

The 2017 ACC/AHA guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults defines hypertension as any systolic blood pressure measurement of ≥130 mmHg or any diastolic blood pressure measurement of ≥80 mmHg.[2] ACC/AHA blood pressure categories are defined as follows:

Elevated blood pressure: systolic blood pressure of 120-129 mmHg and diastolic blood pressure of <80 mmHg
Stage 1 hypertension: systolic blood pressure of 130-139 mmHg and/or diastolic blood pressure of 80-89 mmHg
Stage 2 hypertension: systolic blood pressure of ≥140 mmHg and/or diastolic blood pressure of ≥90 mmHg.

The 2017 ACC/AHA guidelines definition represents a more aggressive approach to diagnosis and treatment of hypertension compared with Joint National Committee (JNC) 7 and JNC 8 recommendations, where blood pressure in the range of 120-139 mmHg/80-89 mmHg is considered prehypertension and blood pressure >140/90 mmHg is considered elevated.[3][4]

Publication of the 2017 ACC/AHA guidelines has prompted widespread debate, and there are calls for the recommendations to be revisited. Implementing the guidelines would increase the prevalence of hypertension by 26.8% in the US. Critics are concerned that labelling more patients as hypertensive could increase psychological morbidity, as well as exposing lower-risk patients to the potential harm of antihypertensive medications.[5]

The 2017 ACC/AHA guidelines were mainly based on the results of the SPRINT trial, which investigated intensive or standard hypertension treatment in people with a systolic blood pressure of ≥130 mmHg with an increased cardiovascular risk (but without diabetes).[6] Listen to our podcast for more on the controversy. BMJ Best Practice Podcast: hypertension Opens in new window

European guidelines categorize hypertension as follows:[7]

High-normal: systolic 130-139 mmHg and/or diastolic 85-89 mmHg
Grade 1: systolic 140-159 mmHg and/or diastolic 90-99 mmHg
Grade 2: systolic 160-179 mmHg and/or diastolic 100-109 mmHg
Grade 3: systolic ≥180 mmHg and/or diastolic ≥110 mmHg.

Isolated systolic hypertension is also graded according to systolic blood pressure values in the ranges indicated, provided that diastolic values are <90 mmHg.[7]

Although different studies have used a variety of cut-off points for the diagnosis of hypertension in the community, any blood pressure >120 mmHg systolic is associated with an increased cardiovascular risk. The importance of hypertension is its relation to other cardiovascular risk factors and consequent overall cardiovascular risk.

The AHA defines resistant hypertension as:[8]

Clinic blood pressure >130/80 mmHg despite the concurrent use of at least 3 antihypertensive agents (including an ACE inhibitor or angiotensin receptor antagonist, a long-acting calcium channel blocker, and a diuretic) at maximum or maximally tolerated doses.
Patients who require 4 or more antihypertensive agents to achieve their target blood pressure are also considered to have resistant hypertension. The diagnosis requires the exclusion of white-coat hypertension and poor adherence with antihypertensive medication.

This topic addresses the evaluation of hypertension in adults.

Epidemiology

According to a global analysis of trends in hypertension, the number of adults ages 30-79 years with hypertension increased from 650 million to 1.28 billion in the period 1990-2019.[9] Based on National Health and Nutrition Survey (NHANES) data from 2017-2020, an estimated 122.4 million US adults ages ≥20 years have hypertension (defined as self-reported use of antihypertensive medication, systolic BP ≥130 mmHg or diastolic BP ≥80 mmHg).[10] During this period, the prevalence of hypertension was 28.5% among those ages 20-44 years, 58.6% among those ages 45-64 years, and 76.5% among those ages ≥65 years.[10] The prevalence may be similar or higher in Western Europe.[11][12]

Globally, the overall prevalence of hypertension in adults is 30% to 45%, according to European guidelines, with an overall higher prevalence in men than in women (24% and 20%, respectively).[7] However, prevalence by sex has been found to differ with age with prevalence higher in men than in women ages <65 years, but higher in women than in men ages ≥65 years.[10]

Hypertension is more prevalent in black people than in white people, starting in childhood, with 76% of black men and women developing hypertension by age 55 years, compared with 55% and 40% of white men and women, respectively.[13]

The exact prevalence of hypertension is difficult to assess, as it is usually asymptomatic. Prevalence is expected to rise as the "cut-off" value for hypertension is redefined at a lower level.

Approximately 15% of patients with hypertension have resistant hypertension.[8]

Complications and hypertension-mediated organ damage

Studies have shown that treatment of hypertension can reduce the incidence of future cardiovascular and cerebrovascular events.[14][15] The aim of early diagnosis and treatment of hypertension is to lower overall cardiovascular risk and prevent cerebrovascular events.

The effects of chronic hypertension on organ systems are referred to as hypertension-mediated organ damage.

Left ventricular hypertrophy, cardiovascular disease, cerebrovascular disease, hypertensive retinopathy, and nephropathy are the most common manifestations.[16] The presence of left ventricular hypertrophy is a poor prognostic sign, and regression of left ventricular hypertrophy improves prognosis.[17] Patients with resistant hypertension are at higher risk of experiencing cardiovascular and cerebrovascular events and developing chronic kidney disease.[8]

Cardiovascular risk

Guidelines on the management of hypertension emphasize the importance of calculating and managing the overall cardiovascular risk of a patient, rather than focusing only on blood pressure readings. The ACC and AHA have published an online tool to calculate patients’ 10-year and lifetime risk of atherosclerotic cardiovascular disease. ACC: ASCVD Risk Estimator Plus Opens in new window For individuals ages 40-70 years, each increment of 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure across the entire blood pressure range from 115/75 to 185/115 mmHg doubles the risk of cardiovascular disease.[18] The European Society for Cardiology has proposed that sex-specific thresholds may be appropriate as lower blood pressure levels are associated with an increased risk of cardiovascular disease in women.[19] Treating associated cardiovascular risk factors such as obesity, diabetes, hypercholesterolemia, and smoking are as important as managing hypertension in lowering overall cardiovascular risk.

Meta-analysis has confirmed that lowering blood pressure reduces cardiovascular disease and death in people with baseline systolic blood pressure of 140 mmHg or higher.[20] However, primary preventive blood pressure lowering does not benefit people with lower baseline blood pressure (except those with preexisting cardiovascular disease).[20] One Cochrane review found insufficient evidence to justify lower blood pressure targets (≤135/85 mmHg) in people with hypertension and cardiovascular disease.[21] Another Cochrane review found that, for those with moderate to high cardiovascular risk, the benefits of setting a target lower than the standard target (≤140/90 mmHg) did not outweigh the harms.[22]

Differentials

Common

Essential hypertension
Renal artery stenosis
Chronic kidney disease
Obstructive uropathy
Obstructive sleep apnea/hypopnea syndrome
Obesity hypoventilation syndrome

Full details

Uncommon

Coarctation of aorta
Preeclampsia
Glomerulonephritis
Nephrotic syndrome
Polycystic kidney disease
Pheochromocytoma
Hyperaldosteronism
Cushing disease/syndrome
Hyperthyroidism
Hypothyroidism
Hyperparathyroidism
Chronic alcohol excess
Medication
Illicit drug use
"White-coat hypertension"

Full details

Contributors

Authors

Sunil Nadar, MD, FRCP, CCT, FESC, FACC

Consultant Cardiologist

Dudley Group of hospitals NHS trust

Dudley

Disclosures

SN is an author of a number of references cited in this topic.

Gregory Y.H. Lip, MD, FRCP, DFM, FACC, FESC, FEHRA

Price-Evans Professor of Cardiovascular Medicine

University of Liverpool

Senior Investigator

National Institute for Health Research

Distinguished Professor

Faculty of Medicine

Aalborg University

Denmark

Adjunct Professor

Yonsei University

Seoul

South Korea

Disclosures

GYHL is a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, and Anthos. No fees are received personally. GYHL is an author of a number of references cited in this topic.

Peer reviewers

Rod Jackson, MD, PhD

Professor of Epidemiology

Head of the Section of Epidemiology & Biostatistics

School of Population Health

University of Auckland

Auckland

New Zealand

Disclosures

RJ declares that he has no competing interests.

Alan Wilkinson, MD, FRCP

Professor of Medicine

David Geffen School of Medicine at UCLA

Los Angeles

Disclosures

AW declares that he has no competing interests. Unfortunately we have since been made aware that Professor Wilkinson is deceased.

Michael Schachter, MB, BSc, FRCP

Department of Clinical Pharmacology

St Mary’s Hospital

Imperial College

London

Disclosures

MS declares that he has no competing interests.

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Evaluation of hypertension

Summary

Epidemiology

Complications and hypertension-mediated organ damage

Cardiovascular risk

Differentials

Common

Uncommon

Contributors

Authors

Sunil Nadar, MD, FRCP, CCT, FESC, FACC

Disclosures

Gregory Y.H. Lip, MD, FRCP, DFM, FACC, FESC, FEHRA

Disclosures

Peer reviewers

Rod Jackson, MD, PhD

Disclosures

Alan Wilkinson, MD, FRCP

Disclosures

Michael Schachter, MB, BSc, FRCP

Disclosures

Patient information

Calculators

Videos

Log in or subscribe to access all of BMJ Best Practice

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