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Essential hypertension

Last reviewed: 9 Apr 2025
Last updated: 08 Jan 2025

Summary

Definition

History and exam

Key diagnostic factors

  • systolic blood pressure (BP) ≥130 mmHg or diastolic BP ≥80 mmHg
  • retinopathy
Full details

Other diagnostic factors

  • headache
  • visual changes
  • dyspnea
  • chest pain
  • sensory or motor deficit
Full details

Risk factors

  • obesity
  • aerobic exercise <3 times/week
  • moderate/high alcohol intake
  • metabolic syndrome or cardiovascular-kidney-metabolic (CKM) 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
  • smoking
Full details

Diagnostic tests

1st tests to order

  • urinary albumin-to-creatinine ratio (UACR)
  • ECG
  • fasting metabolic panel with estimated GFR
  • lipid panel
  • urinalysis
  • hemoglobin
  • thyroid-stimulating hormone
Full details

Tests 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
Full details

Treatment algorithm

ACUTE

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

ONGOING

refractory/resistant to optimized triple therapy at any stage

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.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

McEvoy JW, McCarthy CP, Bruno RM, et al. 2024 ESC guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024 Oct 7;45(38):3912-4018.Full text  Abstract

Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 May 15;71(19):e127-248.Full text  Abstract

Rabi DM, McBrien KA, Sapir-Pichhadze R, et al. Hypertension Canada's 2020 comprehensive guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children. Can J Cardiol. 2020 May;36(5):596-624.Full text  Abstract

Wright JT Jr, Williamson JD, Whelton PK, et al; SPRINT Research Group. A randomized trial of intensive versus standard blood pressure control. N Engl J Med. 2015 Nov 26;373(22):2103-16.Full text  Abstract

Williams B, MacDonald TM, Morant S, et al; British Hypertension Society's PATHWAY Studies Group. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015 Nov 21;386(10008):2059-68.Full text  Abstract

Rosendorff C, Lackland DT, Allison M, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. Hypertension. 2015 Jun;65(6):1372-407.Full text  Abstract

James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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