Essential hypertension

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.[1]National Heart, Lung, and Blood Institute. The seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Aug 2004 [internet publication]. https://www.nhlbi.nih.gov/files/docs/guidelines/jnc7full.pdf [2]Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018 Sep 1;39(33):3021-104. https://academic.oup.com/eurheartj/article/39/33/3021/5079119 http://www.ncbi.nlm.nih.gov/pubmed/30165516?tool=bestpractice.com [3]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. https://jamanetwork.com/journals/jama/fullarticle/1791497 http://www.ncbi.nlm.nih.gov/pubmed/24352797?tool=bestpractice.com The main goal of treatment is to decrease the risk of mortality and of cardiovascular and renal morbidity.[4]Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet. 1998 Jun 13;351(9118):1755-62. http://www.ncbi.nlm.nih.gov/pubmed/9635947?tool=bestpractice.com

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.[3]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. https://jamanetwork.com/journals/jama/fullarticle/1791497 http://www.ncbi.nlm.nih.gov/pubmed/24352797?tool=bestpractice.com 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.[2]Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018 Sep 1;39(33):3021-104. https://academic.oup.com/eurheartj/article/39/33/3021/5079119 http://www.ncbi.nlm.nih.gov/pubmed/30165516?tool=bestpractice.com

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.[5]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. https://www.jacc.org/doi/full/10.1016/j.jacc.2017.11.006 http://www.ncbi.nlm.nih.gov/pubmed/29146535?tool=bestpractice.com  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.[6]The SPRINT Study Research Group. Systolic Blood Pressure Intervention Trial. 2016 [internet publication]. https://www.sprinttrial.org/public/dspHome.cfm [7]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. https://www.nejm.org/doi/10.1056/NEJMoa1511939 http://www.ncbi.nlm.nih.gov/pubmed/26551272?tool=bestpractice.com  Patients with diabetes or stroke were excluded from the trial.