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 blood pressure (BP) ≥140/90 mmHg, with no secondary cause identified. The main goal of treatment is to decrease the risk of mortality and of cardiovascular and renal morbidity.
The Eighth Joint National Committee (JNC 8) guideline recommends starting pharmacologic treatment in patients with chronic kidney disease and diabetes if BP ≥140/90 mmHg. In the general population aged ≥60 years, treatment to lower blood pressure should begin when BP ≥150/90 mmHg. The latter recommendation was not agreed upon by all panel members because of the risk of cardiovascular events associated with BP ≥140/90 mmHg.
In the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) guidelines, hypertension is defined as office systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, which is equivalent to a 24-hour ambulatory blood pressure measurement average of ≥130/80 mmHg, or a home blood pressure measurement average of ≥135/85 mmHg.
Blood pressure goals and recommendations continue to evolve in line with new evidence.
The 2017 American College of Cardiology/American Heart Association guideline defines hypertension as any systolic blood pressure measurement of ≥130 mmHg or any diastolic BP measurement of ≥80 mmHg. This definition differs from the JNC 8, ESC, and ESH guidelines.
The SPRINT trial (Systolic Blood Pressure Intervention Trial) found that a lower systolic target of 120 mmHg (as measured by automated office blood pressure) reduced cardiovascular complications and deaths in people aged over 50 years with high blood pressure and at least one additional risk factor for heart disease. Patients with diabetes or stroke were excluded from the trial.
History and exam
Key diagnostic factors
- blood pressure ≥140/90 mmHg
Other diagnostic factors
- visual changes
- chest pain
- sensory or motor deficit
- 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
- sleep apnea
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 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
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.
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
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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