Evaluation of hypertension

Last reviewed: December 2018

Last updated: June 2018

Summary

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]

Hypertension has been defined in joint guidelines by American learned bodies (American College of Cardiology [ACC] and American Heart Association [AHA] among others) [2] and also by the British Society of Hypertension [3] and the European Society of Hypertension. [4] There are differences in the definition of hypertension between guidelines.

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 higher or any diastolic blood pressure measurement of 80 mmHg or higher. [2] ACC/AHA blood pressure categories are defined as follows:

Elevated blood pressure: systolic blood pressure of 120 to 129 mmHg and diastolic blood pressure of <80 mmHg
Stage 1 hypertension: systolic blood pressure of 130 to 139 mmHg and/or diastolic blood pressure of 80 to 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 to 139 mmHg/80 to 89 mmHg was considered prehypertension and blood pressure above 140/90 mmHg considered elevated. [5] [6]

Publication of the 2017 ACC/AHA guidelines has prompted widespread debate. Not everyone has fully accepted the 2017 ACC/AHA guidelines and there are calls for these recommendations to be revisited. 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). [7] Listen to our podcast for more on the controversy. BMJ Best Practice Podcast: hypertension

European guidelines categorize hypertension as follows: [4] [8]

Stage 1: systolic 140 to 159 mmHg and/or diastolic 90 to 99 mmHg

Stage 2: systolic 160 to 179 mmHg and/or diastolic 100 to 109 mmHg
Stage 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. [4]

Although different studies have used a variety of cut-off points for the diagnosis of hypertension in the community, any blood pressure over 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.

This topic addresses the evaluation of hypertension in adults.

Epidemiology

In the US, data from the National Health and Nutrition Survey (NHANES) suggest that 29% of adults (>18 years) are hypertensive (cut-off value 140/90 mmHg). This ranges from around 7% in those ages 18 to 39 years to 66% in those ages >60 years. [9] The prevalence seems to be higher in Western Europe. [10] However, as elevated blood pressure is usually asymptomatic, the exact prevalence of hypertension is difficult to assess, and is expected to rise as the "cut-off" value for hypertension is redefined at a lower level.

Complications and target organ damage

Studies have shown that treatment of hypertension can reduce the incidence of future cardiovascular and cerebrovascular events. [11] 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 target organ damage.

Left ventricular hypertrophy, cardiovascular disease, cerebrovascular disease, hypertensive retinopathy, and nephropathy are the most common manifestations. [12] The presence of left ventricular hypertrophy is a poor prognostic sign, and regression of left ventricular hypertrophy improves prognosis. [13]

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. For individuals ages 40 to 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. [14] 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. [15] However, primary preventive blood pressure lowering does not benefit people with lower baseline blood pressure (except those with preexisting cardiovascular disease). [15]

Differentials

Common

Essential hypertension
Renal artery stenosis
Chronic kidney disease
Obstructive uropathy
Obstructive sleep apnea

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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"

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Contributors

Authors VIEW ALL 

Sunil Nadar, MD, FRCP, CCT, FESC

Senior Consultant Cardiologist

Sultan Qaboos University Hospital

Muscat

Oman

Disclosures

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

Gregory Lip, MD, FRCP, FESC, FACC

Professor of Cardiovascular Medicine

University of Birmingham

Visiting Professor of Haemostasis, Thrombosis and Vascular Sciences

University of Aston

Birmingham

Disclosures

GL is a consultant for Bayer/Janssen, BMS/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife, and Daiichi-Sankyo; he is also a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche, and Daiichi-Sankyo. GL is an author of references cited in this topic.

Peer reviewers VIEW ALL 

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 target organ damage

Cardiovascular risk

Differentials

Common

Uncommon

Contributors

Authors VIEW ALL 

Sunil Nadar, MD, FRCP, CCT, FESC

Disclosures

Gregory Lip, MD, FRCP, FESC, FACC

Disclosures

Peer reviewers VIEW ALL 

Rod Jackson, MD, PhD

Disclosures

Alan Wilkinson, MD, FRCP

Disclosures

Michael Schachter, MB, BSc, FRCP

Disclosures

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