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Essential hypertension

Last reviewed: 4 Sep 2023
Last updated: 04 Apr 2023



History and exam

Key diagnostic factors

  • systolic blood pressure (BP) ≥130 mmHg or diastolic BP ≥80 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
  • aerobic exercise <3 times/week
  • moderate/high alcohol intake
  • metabolic syndrome
  • diabetes mellitus
  • black ancestry
  • age >60 years
  • family history of hypertension or coronary artery disease
  • sleep apnea
  • sodium intake >1.5 g/day
  • low fruit and vegetable intake
  • dyslipidemia
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 (HF)

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.

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