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hypertension (HTN, high blood pressure, HBP)

Elevation of arterial blood pressure above normal range (> 140/90). Commonly called high blood pressure, frequently abbreviated HTN. Classification: - blood pressure (BP) classification of hypertension (adults) stage systolic (JNC8) diastolic (JNC8) AHA/ACC ESC/EACTS normal < 120 < 80 <120/80 elevated BP 120-139/70-89 prehypertension [1,2] 120-139 80-89 120-129/<80 stage I (mild) 140-159 90-99 130-139/80-89 stage II (moderate) 160-179 100-109 >140/90 stage III (severe) 180-209 110-119 not applicable stage IV (very severe) > 210 > 120 not applicable * JNC8 vs AHA/ACC * ACP (MKSAP19) uses AHA/ACC for staging, does not recognize JNC8 # elevated BP is a new class from European Society of Cardiology to capture virtually all healthy people (diastolic BP >=70 mm Hg) Diagnosis: - a blood pressure > 140/90 on 3 successive outpatient visits makes the diagnosis of hypertension - a blood pressure > 140/90 based on an average of 2 or more readings > 1 minute apart at 2 or more visits [4] - a single blood pressure reading is inadequate; multiple measurements are needed (2-5); combining home BP measurement with office-based measurements improves assessment [18] - a minimum of 5-6 BP measurements is necessary to make the diagnosis of hypertension [18] Etiology: 1) primary (essential) hypertension - risk factors - excessive dietary salt (see salt-sensitive HTN) - excessive calorie intake - stress - African-American origin - obesity - family history of hypertension (see genetics) - migraine or severe headaches (RR=1.25) [21] 2) secondary hypertension a) pharmacologic causes: - clonidine withdrawal - corticotropin (ACTH) - cyclosporin - glucocorticoids - monoamine oxidase (MAO) inhibitors with sympathomimetics - erythropoietin - birth control pills - non-steroidal anti-inflammatory action (NSAIDs) - antagonism of beta-blockers & Ca+2 channel blockers - sympathomimetics in over-the-counter cold remedies,i.e. pseudoephedrine, not significant b) endocrine - acromegaly - adrenal cortical hyperfunction - Cushing's disease - hyperaldosteronism - hyperthyroidism - pheochromocytoma - hyperparathyroidism c) renovascular disease (including renal artery stenosis) d) renal parenchymal disease (chronic kidney disease) e) coarctation of the aorta f) alcohol increases early morning blood pressure surge g) smoking increases early morning blood pressure surge h) 'white coat hypertension' i) sleep deprivation [14,16] j) sleep apnea [17] k) toxins: bisphenol A Epidemiology: 1) 10-20% of persons age 25-45 years 2) 30-40% of persons age 55-74 years 3) 60% of persons > 65 years of age 4) 40% of persons with hypertension not aware of their condition [19] 5) lower income persons with public insurance are less likely to have access to healthy food choices [24] Pathology: - renal sympathetic hyperactivity - the renin angiotensin pathway is the major system influencing blood pressure - both hypertensive crisis & chronic hypertension can result in multiple organ damage including damage to eyes, blood vessels, brain, heart & kidney Genetics: monogenic forms of hypertension - Liddle syndrome - glucocorticoid-remediable hyperaldosteronism - apparent mineralocorticoid excess - pseudohypoaldosteronism type 2 (Gordon syndrome) - mineralocorticoid receptor activation - mutations in peroxisome-activated receptor-gamma (PPAR-gamma) - hypertension & brachydactyly History: - duration, baseline blood pressure, chest or back pain, headaches, dyspnea, orthopnea, dizziness, blurred vision, nausea/vomiting, tremor, palpitations, diaphoresis, diarrhea, edema, hematuria, dysuria, polyuria, flank pain, thyroid disease, heart failure, alcohol withdrawal, non-compliance with antihypertensive agents (esp clonidine or beta-blocker) Clinical manifestations: 1) patients are generally asymptomatic 2) clinical manifestations of target organ disease a) neurologic manifestations - acute changes - altered mental status including coma - stroke - headaches, dizziness, vertigo, tremors - diplopia, diminished visual acuity - focal deficits: numbness, weakness, slurred speech, cranial nerve palsies - chronic changes - stroke b) cardiac manifestations - acute changes - chest pain, dyspnea, pulmonary edema - chronic changes - clinical or ECG evidence of CAD - LVH by ECG or echocardiogram - S3 & S4 heart sounds - lateral displacement of PMI c) vascular manifestations - decreased peripheral pulses - bruits - abdominal, femoral, carotid d) retinal manifestations - acute changes - papilledema, hemorrhages - chronic changes - thickened arterial walls, blurred disk margins, focal areas of white exudate, arterial nicking e) renal changes - acute changes - hematuria - azotemia - chronic changes - elevated serum creatinine (> 1.5 mg/dL) - proteinuria f) clinical manifestations of secondary hypertension - edema - striae - truncal obesity - hyperpigmentation - numbness of extremities - foot ulcers - muscle weakness - tachycardia Laboratory: 1) serum chemistries a) electrolytes - serum K+: hypokalemia (off diuretics) should give consideration to hyperaldosteronism & renal artery stenosis b) urea nitrogen c) serum creatinine d) serum glucose e) serum calcium, serum phosphate f) serum albumin g) serum transaminases (serum ALT, serum AST) h) serum alkaline phosphatase i) serum bilirubin j) serum cholesterol (lipid panel) k) serum uric acid l) plasma aldosterone/renin m) thyroid function tests 2) urinalysis: a) random U/A: leukocytes, protein, blood, glucose b) urine albumin/creatinine [4] c) 24 hour urine: metanephrines, cortisol 3) complete blood count (CBC) 4) captopril-renin stimulation test* 5) dexamethasone suppression test* * refractory HTN or otherwise indicated Special laboratory: - electrocardiogram: - evidence of left ventricular hypertrophy suggests chronic hypertension - ambulatory blood pressure monitor - goals: daytime systolic BP < 136 mm Hg; nighttime systolic BP < 125 mm Hg - normals: 24 hour average blood pressure < 115/75 mm Hg, daytime average blood pressure < 120/80 mm Hg, nighttime average blood pressure < 100/65 mm Hg - better predictor of cardiovascular outcomes than office-based blood pressure measurements, including left ventricular hypertrophy & cardiac death [4] - home blood pressure monitoring may be an acceptable alternative [4] - echocardiogram not routine - useful for assessing LV hypertrophy [4] Radiology: 1) renal ultrasound to evaluate kidneys 2) renal vein renin for hypertension refractory to therapy 3) renal arteriogram or magnetic resonance angiogroaphy if renovascular hypertension suspected 4) renal artery CT angiography for suspected fibromuscular dysplasia (adominal bruit in a young woman) 5) CXR: rib notching or indentation of or distal aortic arch with coarctation of the aorta Management: 1) acute treatment of hypertension a) goal is reduction of blood pressure by 25% - do not lower blood pressure rapidly to < 140/80 - adverse effect include: cerebral hypoperfusion & acute tubular necrosis (ATN) b) intravenous - sodium nitroprusside drip - esmolol drip - labetalol drip - indicated when offending agent has alpha-adrenergic receptor stimulating properties, i.e. cocaine c) oral agents - nifedipine 10 mg every hr - captopril 10 mg every hr - clonidine 0.1 mg every hr d) nitropaste e) hospitalize for: - blood pressure > 210/120 - acute manifestations f) see hospitalization for treatment of hypertension in hospitalized patients - treatment of inpatient hypertension or intensifying antihypertensives at hospital discharge is not associated with improved BP control [20] - intensive antihypertensive treatment of hospitalized older adults with elevated blood pressures is associated with a greater risk of adverse events [22] - treatment associated with higher risks of acute kidney injury & myocardial injury [20] g) an early drop in eGFR of > 15% with intensive treatment is associated with increased risk of end-stage renal disease [23] 2) chronic hypertension (see chronic hypertension) 3) screening recommended for all adults >= 18 years of age [15] Follow-up: 1) Every 2 months for blood pressure 140-160/90-100 2) Every 2 weeks for blood pressure 160-180/100-110 3) Every week for blood pressure > 180/110 4) hospitalize for blood pressure > 210/120 Also consider: 1) ambulatory blood pressure monitoring* 2) home blood pressure monitoring* * systolic BP goals of home blood pressure monitoring & of ambulatory blood pressure monitoring may differ from goals of office-based measurements

Interactions

disease interactions

Related

ambulatory blood pressure monitoring (ABPM) antihypertensive agents & diabetes risk blood pressure & hypertension in diabetes blood pressure (BP) early morning blood pressure surge (EMBPS) etiology of arterial hypertension home blood pressure monitoring hypertension clinical trials Joint National Committee on High Blood Pressure medications that may raise blood pressure poor prognostic indicators of hypertension prevention of hypertension salt-sensitive hypertension (ssHTN)

Useful

blood pressure in the very old systolic hypertension (hypertension in the elderly)

Specific

chronic hypertension hypertension during pregnancy hypertension in adolescents & children hypertensive crisis (malignant hypertension) hypertensive urgency masked hypertension secondary hypertension stage 1 hypertension stage 2 hypertension stage 3 hypertension stage 4 hypertension uncontrolled hypertension upper body hypertension white-coat hypertension

General

cardiovascular disease (CVD) sign/symptom

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39, 340-346
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 220-221
  3. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 65-84
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2021 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Prescriber's Letter 7(12):79-70 2000
  6. Journal Watch 21(3):21, 2001 Mogensen et al Randomised controlled trial of dual blockade of renin- angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study. BMJ 321:1440, 2000 PMID: 11110735
  7. Journal Watch 22(8):61, 2002 Oliveria SA et al Physician-related barriers to the effective management of uncontrolled hypertension. Arch Intern Med 162:413, 2002 PMID: 11863473
  8. Journal Watch 22(8):61, 2002 Boutitie F et al J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data. Ann Intern Med 136:438, 2002 PMID: 11900496
  9. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004
  10. Prescriber's Letter 10(1):1 2003
  11. Prescriber's Letter 10(4):19 2003
  12. Journal Watch 24(1):5, 2004 Chobanian AV et al The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 289:2560, 2003 PMID: 12748199
  13. Chobanian AV et al Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 42:1206, 2003 PMID: 14656957
  14. Cappuccio FP et al, Gender-specific associations of short sleep duration with prevalent and incident hypertension: The Whitehall II Study. Hypertension 2007, 50:693 PMID: 17785629
  15. US Preventive Services Task Force. Screening for high blood pressure: US Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2007, 147:783 PMID: 18056662 - Wolff T and Miller T Evidence for the US Preventive Services Task Force recommendation on screening for high blood pressure. Ann Intern Med 2007, 147:787 PMID: 18056663 - corresponding NGC guideline withdrawn Jan 2013
  16. Knutson KL et al Association Between Sleep and Blood Pressure in Midlife The CARDIA Sleep Study Arch Intern Med. 2009;169(11):1055-1061 PMID: 19506175
  17. O'Connor GT et al Prospective study of sleep-disordered breathing and hypertension: The Sleep Heart Health Study. Am J Respir Crit Care Med 2009, 179:1159 PMID: 19264976
  18. Powers BJ et al Measuring Blood Pressure for Decision Making and Quality Reporting: Where and How Many Measures? Annals of Internal Medicine: June 20, 2011 154(12):781-788 PMID: 21690592 http://www.annals.org/content/154/12/781.full.pdf+html - Appel LJ et al Improving the Measurement of Blood Pressure: Is It Time for Regulated Standards? Annals of Internal Medicine: June 20, 2011 154(12):838-39 PMID: 21690599 http://www.annals.org/content/154/12/838.extract
  19. Centers for Disease Control and Prevention Vital Signs: Awareness and Treatment of Uncontrolled Hypertension Among Adults - United States, 2003-2010 MMWR September 4, 2012 / 61(Early Release);1-7 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm61e0904a1.htm
  20. Rastogi R, Sheehan MM, Hu B, Shaker V, Kojima L, Rothberg MB. Treatment and outcomes of inpatient hypertension among adults with noncardiac admissions. JAMA Intern Med 2020 Dec 28; PMID: 33369614 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2774562
  21. Zhang J, Mao Y, Li Y et al Association between migraine or severe headache and hypertension among US adults: A cross-sectional study. Nut Metab Cardiovasc Dis. 2022 Nov 18;S0939-4753(22)00457-4. PMID: 36604265
  22. Anderson TS et al. Clinical outcomes of intensive inpatient blood pressure management in hospitalized older adults. JAMA Intern Med 2023 Jul; 183:715. PMID: 37252732 PMCID: PMC10230372 (available on 2024-05-30) https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2805021
  23. Ku E et al. Acute declines in estimated GFR in blood pressure target trials and risk of adverse outcomes. Am J Kidney Dis 2023 Oct; 82:454. PMID: 37269972 https://www.ajkd.org/article/S0272-6386(23)00653-4/fulltext
  24. NEJM Knowledge+
  25. McEvoy JW, McCarthy CP, Bruno RM, et al. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024 Aug 30:ehae178. PMID: 39210715 https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehae178/7741010