Essential hypertension is typically diagnosed by screening of an asymptomatic individual.
Treatment of uncontrolled hypertension reduces the risks of mortality and of cardiac, vascular, renal, and cerebrovascular complications.
Lifestyle changes are recommended for all patients: weight loss, exercise, decreased sodium intake, Dietary Approaches to Stop Hypertension (DASH) diet, and moderation of alcohol consumption.
Choice of drug therapy is often driven by considerations related to comorbid disease, but achievement of blood pressure goal may be accomplished with a variety of therapeutic agent(s).
Essential hypertension is defined as persistently raised blood pressure (BP) with no secondary cause identified. The main goal of treatment is to decrease the risk of mortality and of cardiovascular and renal morbidity.
The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline defines hypertension as systolic BP measurement of ≥130 mmHg or diastolic BP measurement of ≥80 mmHg.
The 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) guideline defines hypertension as office systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg, which is equivalent to a 24-hour ambulatory BP measurement average of ≥130/80 mmHg, or a home BP measurement average of ≥135/85 mmHg.
The World Health Organization (WHO) recommends starting pharmacologic antihypertensive treatment in patients with a confirmed diagnosis of hypertension and systolic BP of ≥140 mmHg or diastolic BP of ≥90 mmHg.
BP goals and recommendations continue to evolve in line with new evidence.
History and exam
Key diagnostic factors
- systolic blood pressure (BP) ≥130 mmHg or diastolic BP ≥80 mmHg
Other diagnostic factors
- visual changes
- chest pain
- sensory or motor deficit
- 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
1st investigations to order
- fasting metabolic panel with estimated GFR
- lipid panel
- thyroid-stimulating hormone
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
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
- Drug-induced hypertension
- Chronic kidney disease
- Renal artery stenosis
- Standards of care in diabetes - 2023
- 2022 ESC guidelines on cardio-oncology
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