Summary
Definition
History and exam
Key diagnostic factors
- systolic blood pressure (BP) ≥130 mmHg or diastolic BP ≥80 mmHg
- retinopathy
Other diagnostic factors
- headache
- visual changes
- dyspnea
- chest pain
- sensory or motor deficit
Risk factors
- obesity
- aerobic exercise <3 times/week
- moderate/high alcohol intake
- metabolic syndrome
- diabetes mellitus
- black ancestry
- age >60 years
- family history of hypertension or chronic coronary disease
- sleep apnea
- sodium intake >1.5 g/day
- low fruit and vegetable intake
- dyslipidemia
Diagnostic tests
1st tests to order
- ECG
- fasting metabolic panel with estimated GFR
- lipid panel
- urinalysis
- Hb
- thyroid-stimulating hormone
Tests to consider
- urinary albumin to creatinine ratio
- 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
Treatment algorithm
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: stage 1 hypertension and lower CVD risk and without diabetes
without chronic renal disease or cardiovascular disease (CVD)-related comorbidity: higher CVD risk or with diabetes
concomitant chronic coronary disease without congestive heart failure
concomitant heart failure (HF)
concomitant left ventricular hypertrophy without chronic coronary 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
Contributors
Authors
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
CA
Disclosures
JB declares that he has no competing interests.
Acknowledgements
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.
Disclosures
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
Dundee
UK
Disclosures
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
Houston
TX
Disclosures
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
London
UK
Disclosures
ML is a consultant for ROX Medical. ML receives honorarium from Cardiosonic, St. Jude Medical, and institutional grant/research support from Medtronic.
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