Essential hypertension

Last reviewed: 28 Dec 2022
Last updated: 04 Feb 2022



History and exam

Key diagnostic factors

  • blood pressure ≥140/90 mmHg
  • retinopathy
More key diagnostic factors

Other diagnostic factors

  • headache
  • visual changes
  • dyspnea
  • chest pain
  • sensory or motor deficit
Other diagnostic factors

Risk factors

  • obesity
  • sodium intake >1.5 g/day
  • aerobic exercise <3 times/week
  • low fruit and vegetable intake
  • moderate/high alcohol intake
  • metabolic syndrome
  • diabetes mellitus
  • black ancestry
  • age >60 years
  • family history of hypertension or coronary artery disease
  • dyslipidemia
  • sleep apnea
More risk factors

Diagnostic investigations

1st investigations to order

  • ECG
  • fasting metabolic panel with estimated GFR
  • lipid panel
  • urinalysis
  • Hb
  • thyroid-stimulating hormone
More 1st investigations to order

Investigations to consider

  • plasma renin activity
  • plasma aldosterone
  • renal duplex ultrasound/MRA renal arteries/CT angiography
  • 24-hour urine pheochromocytoma screen
  • plasma fractionated metanephrines
  • 24-hour urine free cortisol
  • sleep study
  • echocardiography
More investigations to consider

Treatment algorithm


without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: lower CVD risk and without diabetes

without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes

concomitant coronary artery disease without congestive heart failure

concomitant heart failure with reduced ejection fraction (<40%)

concomitant heart failure with preserved ejection fraction (>45%)

concomitant left ventricular hypertrophy without coronary artery disease

concomitant chronic renal disease without cardiovascular disease

concomitant atrial fibrillation without other comorbidity


refractory/resistant to optimized triple therapy at any stage: without congestive heart failure



Jeffrey Brettler, MD, FASH

Internal Medicine

Regional Hypertension Co-lead, Kaiser Permanente Southern California, Los Angeles

Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena



JB is a consultant for the Pan American Health Organization, helping implement hypertension programs in the Americas.


Dr Jeffrey Brettler would like to gratefully acknowledge Dr Joel Handler, Dr Jonathan N. Bella, Dr Moustapha Atoui, Dr Liran Blum, and Dr Michael A. Spinelli, previous contributors to this topic.


JH, JNB, MA, LB, and MAS declare that they have no competing interests.

Peer reviewers

Isla Mackenzie, MBChB, PhD, FRCP

Clinical Senior Lecturer in Clinical Pharmacology and Honorary Consultant Physician

University of Dundee




IM is an elected member of the British Hypertension Society Executive Committee.

Syed Wamique Yusuf, MRCPI, FACC

Associate Professor

Department of Cardiology

University of Texas MD Anderson Cancer Center




SWY declares that he has no competing interests.

Melvin Lobo, MBChB, PhD, MRCP

Director Barts Blood Pressure Centre of Excellence

NHS Reader in Cardiovascular Medicine

Department of Clinical Pharmacology

William Harvey Heart Centre




ML is a consultant for ROX Medical. ML receives honorarium from Cardiosonic, St. Jude Medical, and institutional grant/research support from Medtronic.

  • Differentials

    • Drug-induced
    • Chronic kidney disease
    • Renal artery stenosis
    More Differentials
  • Guidelines

    • Standards of medical care in diabetes - 2022
    • Screening for hypertension in adults
    More Guidelines
  • Patient leaflets

    High blood pressure

    High blood pressure: questions to ask your doctor

    More Patient leaflets
  • Videos

    How to perform an ECG: animated demonstration

    More videos
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer