Overview of Hypertension in Adults

7/6/2016
Overviewofhypertensioninadults
OfficialreprintfromUpToDate
www.uptodate.com2016UpToDate
Authors
JanBasile,MD
MichaelJBloch,MD,FACP,FASH,
FSVM,FNLA
SectionEditors
GeorgeLBakris,MD
NormanMKaplan,MD
DeputyEditor
JohnPForman,MD,MSc
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:May2016.|Thistopiclastupdated:Mar02,2016.
INTRODUCTIONThetreatmentofhypertensionisthemostcommonreasonforofficevisitsofnonpregnantadults
tocliniciansintheUnitedStatesandforuseofprescriptiondrugs[1].TheNationalHealthandNutritionExamination
Survey(NHANES)conductedfrom2005through2008estimatedthatapproximately29to31percentofadultsinthe
UShavehypertension[1].Extrapolatingfromthesedata,approximately76.4millionAmericansovertheageof20
yearshavehypertension[2].DatafromNHANES19992006suggestthatasmanyas8percentofUSadultshave
undiagnosedhypertension.
Thenumberofpatientswithhypertensionislikelytogrowasthepopulationagessinceeitherisolatedsystolic
hypertensionorcombinedsystolicanddiastolichypertensionoccursinthemajorityofpersonsolderthan65years
(figure1)[3].Therisingincidenceofobesitywillalsoincreasethenumberofhypertensiveindividuals[3].(See
"Treatmentofhypertensionintheelderlypatient,particularlyisolatedsystolichypertension".)
Despitetheprevalenceofhypertensionanditsassociatedcomplications,controlofthediseaseisfarfromadequate.
Althoughratesofhypertensionawareness,treatment,andcontrolhaveimprovedoverthepastfewdecades,datafrom
NHANES20052008showthatonly50.1percentofpersonswithhypertensionhavetheirbloodpressureundercontrol,
whichwasdefinedasalevelbelow140/90mmHg(table1)[4,5].
Therearenumerouspotentialreasonsforlowratesofbloodpressurecontrol,includingpooraccesstohealthcareand
medicationsaswellaslackofadherencewithlongtermtherapyforaconditionthatisusuallyasymptomatic[6].The
lattermaybeparticularlytruewhenthetherapymayinterferewiththepatient'squalityoflifeandwhenitsimmediate
benefitsmaynotbeobvioustothepatient.Therapeuticinertia,definedasthefailurebyproviderstoincreasetherapy
inthesettingofidentifiedpoorbloodpressurecontrol,isalsobecomingawellrecognizedbarriertoachievingimproved
controlrates[7].Thus,hypertensionwilllikelyremainthemostcommonriskfactorforheartattackandstroke[8].
(See"Patientadherenceandthetreatmentofhypertension".)
Thistopicprovidesabroadoverviewofthedefinitions,pathogenesis,complications,diagnosis,evaluation,and
managementofhypertension.Detaileddiscussionsofalloftheseissuesarefoundseparately.Thereaderisdirected,
whennecessary,tomoredetaileddiscussionsoftheseissuesinothertopics.
DEFINITIONS
HypertensionThefollowingdefinitionsweresuggestedin2003bytheseventhreportoftheJointNational
Committee(JNC7)andarebasedupontheaverageoftwoormoreproperlymeasured(table2)readingsateachof
twoormoreofficevisitsafteraninitialscreening[4,5]:
Normalbloodpressure:systolic<120mmHganddiastolic<80mmHg
Prehypertension:systolic120to139mmHgordiastolic80to89mmHg(see"Prehypertension")
Hypertension:
Stage1:systolic140to159mmHgordiastolic90to99mmHg
Stage2:systolic160mmHgordiastolic100mmHg
Formoststudiesandinclinicalpractice,patientswhoareactivelytakingantihypertensivemedicationsareusually
definedashavinghypertensionregardlessoftheirobservedbloodpressure.
Althoughdefinitionsofhypertension(includingstage1andstage2hypertension)andprehypertensionwerenot
specificallyaddressedinthe2014EvidencedBasedGuidelinesforManagementofHighBloodPressureinAdultsas
reportedbythepanelmembersappointedtotheeighthJointNationalCommittee(JNC8),thresholdswereadoptedfor
thetreatmentofbloodpressurethataregenerallyconsistentwiththesedefinitions[4].
Isolatedsystolichypertensionisconsideredtobepresentwhenthebloodpressureis140/<90mmHg,andisolated
http://www.uptodate.com/contents/overviewofhypertensioninadults?topicKey=NEPH%2F3852&elapsedTimeMs=1&source=search_result&searchTerm 1/41
7/6/2016
diastolichypertensionisconsideredtobepresentwhenthebloodpressureis<140/90mmHg.Patientswithblood
pressure140/90mmHgareconsideredtohavemixedsystolic/diastolichypertension.
Thesedefinitionsapplytoadultsonnoantihypertensivemedicationandwhoarenotacutelyill.Ifthereisadisparityin
categorybetweenthesystolicanddiastolicpressures,thehighervaluedeterminestheseverityofthehypertension.
Similarbutnotidenticaldefinitionsweresuggestedinthe2013EuropeanSocietiesofHypertensionandCardiology
(ESH/ESC)guidelinesforthemanagementofarterialhypertension[9].ThemajordifferenceisthattheEuropean
guidelinesdividebloodpressuresbelow140/90mmHgintothreecategories("optimal,""normal,"and"highnormal")
insteadofthetwocategories("normal"and"prehypertension")definedbyJNC7.
Theprognosticsignificanceofbloodpressureasacardiovascularriskfactorappearstobeagedependent.The
systolicpressureisthegreaterpredictorofriskinpatientsovertheageof50to60years[10].Underage50years,
diastolicbloodpressureisabetterpredictorofmortalitythansystolicreadings[11].Systolichypertensioninolder
individualsisdiscussedindetailseparately.(See"Treatmentofhypertensionintheelderlypatient,particularlyisolated
systolichypertension".)
DefinitionsbaseduponambulatoryandhomereadingsIncreasingly,thediagnosisofhypertensionismade
usingambulatorybloodpressuremonitoring(ABPM)orhomebloodpressuremonitoring.
Whilethereissomedebateaboutthemostappropriatedefinition,thefollowingdiagnosticcriteriaweresuggestedby
the2013ESH/ESCguidelinesmeetingoneormoreofthesecriteriausingABPMqualifiesashypertension[9]:
A24houraverageof130/80mmHgorabove
Daytime(awake)averageof135/85mmHgorabove
Nighttime(asleep)averageof120/70mmHgorabove
Homereadingscorrelatemorecloselywiththeresultsofdaytimeambulatorymeasurementsthanwithbloodpressure
takenintheclinician'soffice.Althoughitremainscontroversial,hypertensionmaybedefinedbyrepeatedhomeblood
pressurereadingsthataverage135/85mmHg.Theuseofambulatoryandhomebloodpressuremonitoringinadultsis
discussedindetailelsewhere.(See"Ambulatoryandhomebloodpressuremonitoringandwhitecoathypertensionin
adults"and"Bloodpressuremeasurementinthediagnosisandmanagementofhypertensioninadults",sectionon
'Ambulatorybloodpressuremonitoring'.)
Bothwhitecoathypertensionandmaskedhypertensionareconditionsthatcanbedefinedbaseduponthecomparison
ofABPMandofficebasedbloodpressuremeasurements.
WhitecoathypertensionWhitecoathypertensionisdefinedasbloodpressurethatisconsistentlyelevatedby
officereadingsbutdoesnotmeetdiagnosticcriteriaforhypertensionbaseduponoutofofficereadings.(See
"Ambulatoryandhomebloodpressuremonitoringandwhitecoathypertensioninadults",sectionon'Whitecoat
hypertension'.)
MaskedhypertensionMaskedhypertensionisdefinedasbloodpressurethatisconsistentlyelevatedbyoutof
officemeasurementsbutdoesnotmeetthecriteriaforhypertensionbaseduponofficereadings.(See"Ambulatoryand
homebloodpressuremonitoringandwhitecoathypertensioninadults",sectionon'Maskedhypertension'.)
Moderatetoseverehypertensiveretinopathy(formerlycalled"malignanthypertension")Moderatetosevere
hypertensiveretinopathy,correspondingtogradesIIIandIVhypertensiveretinopathy,referstospecific
pathophysiologicalchangesthatmaybeassociatedwithmarkedhypertension,includingretinalhemorrhages,
exudates,orpapilledema(image1)[12].Thesefindingsmaybeassociatedwithhypertensiveencephalopathyand
acutehypertensivenephrosclerosis(formerlycalled"malignantnephrosclerosis").(See"Moderatetosevere
hypertensiveretinopathyandhypertensiveencephalopathyinadults".)
Malignanthypertensionisusuallyassociatedwithdiastolicpressuresabove120mmHg.However,itcanoccurat
diastolicpressuresaslowas100mmHginpreviouslynormotensivepatientswithacutehypertensiondueto
preeclampsiaoracuteglomerulonephritis.
HypertensiveemergencySeverehypertension(usuallyadiastolicbloodpressureabove120mmHg)withevidence
ofacuteendorgandamageisdefinedasahypertensiveemergency.Ahypertensiveemergencycanbelifethreatening
andrequiresimmediatetreatment,usuallywithparenteralmedicationsinamonitoredsetting(table3).(See"Evaluation
andtreatmentofhypertensiveemergenciesinadults".)
HypertensiveurgencySeverehypertension(usuallyadiastolicbloodpressureabove120mmHg)inasymptomatic
patientsisreferredtoashypertensiveurgency.Thereisnoprovenbenefitfromrapidreductioninbloodpressurein
7/6/2016
asymptomaticpatientswhohavenoevidenceofacuteendorgandamageandareatlittleshorttermrisk[1315].(See
"Managementofsevereasymptomatichypertension(hypertensiveurgencies)inadults".)
PRIMARY(ESSENTIAL)HYPERTENSION
PathogenesisMaintenanceofarterialbloodpressureisnecessaryfororganperfusion.Ingeneral,thearterialblood
pressureisdeterminedbythefollowingequation:
BloodPressure(BP)=CardiacOutput(CO)xSystemicVascularResistance(SVR)
Bloodpressurereactstochangesintheenvironmenttomaintainorganperfusionoverawidevarietyofconditions.The
primaryfactorsdeterminingthebloodpressurearethesympatheticnervoussystem,thereninangiotensinaldosterone
system,andtheplasmavolume(largelymediatedbythekidneys).
Thepathogenesisofprimaryhypertension(formerlycalled"essential"hypertension)ispoorlyunderstoodbutismost
likelytheresultofnumerousgeneticandenvironmentalfactorsthathavemultiplecompoundingeffectson
cardiovascularandrenalstructureandfunction.Someofthesefactorsarediscussedintheensuingsection.
Riskfactorsforprimary(essential)hypertensionAlthoughtheexactetiologyofprimaryhypertensionremains
unclear,anumberofriskfactorsarestronglyandindependentlyassociatedwithitsdevelopment,including:
AgeAdvancingageisassociatedwithincreasedbloodpressure,particularlysystolicbloodpressure,andan
increasedincidenceofhypertension.
ObesityObesityandweightgainaremajorriskfactorsforhypertensionandarealsodeterminantsoftherisein
bloodpressurethatiscommonlyobservedwithaging[16,17].(See"Obesityandweightreductionin
hypertension".)
FamilyhistoryHypertensionisabouttwiceascommoninsubjectswhohaveoneortwohypertensiveparents,
andmultipleepidemiologicstudiessuggestthatgeneticfactorsaccountforapproximately30percentofthe
variationinbloodpressureinvariouspopulations[18,19].(See"Geneticfactorsinthepathogenesisof
hypertension".)
RaceHypertensiontendstobemorecommon,bemoresevere,occurearlierinlife,andbeassociatedwith
greatertargetorgandamageinblacks.(See"Hypertensivecomplicationsinblacks".)
ReducednephronnumberReducedadultnephronmassmaypredisposetohypertension,whichmayberelated
togeneticfactors,intrauterinedevelopmentaldisturbance(eg,hypoxia,drugs,nutritionaldeficiency),premature
birth,andpostnatalenvironment(eg,malnutrition,infections).(See"Possibleroleoflowbirthweightinthe
pathogenesisofprimary(essential)hypertension".)
HighsodiumdietExcesssodiumintake(eg,>3000mg/day)increasestheriskforhypertension,andsodium
restrictionlowersbloodpressure.(See"Saltintake,saltrestriction,andprimary(essential)hypertension"and
"Lowreninprimary(essential)hypertension".)
ExcessivealcoholconsumptionExcessalcoholintakeisassociatedwiththedevelopmentofhypertension.
(See"Cardiovascularbenefitsandrisksofmoderatealcoholconsumption",sectionon'Hypertension'.)
PhysicalinactivityPhysicalinactivityincreasestheriskforhypertension,andexerciseisaneffectivemeansof
loweringbloodpressure[16,20].(See"Exerciseinthetreatmentandpreventionofhypertension",sectionon
'Efficacy'.)
DiabetesanddyslipidemiaThepresenceofothercardiovascularriskfactors,includingdiabetesand
dyslipidemia,appeartobeassociatedwithanincreasedriskofdevelopinghypertension[21].
PersonalitytraitsanddepressionHypertensionmaybemorecommonamongthosewithcertainpersonality
traits,suchashostileattitudesandtimeurgency/impatience[22],aswellasamongthosewithdepression[23].
SECONDARYORCONTRIBUTINGCAUSESOFHYPERTENSIONAnumberofcommonanduncommon
medicalconditionsmayincreasebloodpressureandleadtosecondaryhypertension.Inmanycases,thesecauses
maycoexistwithriskfactorsforprimaryhypertension(formerlycalled"essential"hypertension)andaresignificant
barrierstoachievingadequatebloodpressurecontrol.(See"Evaluationofsecondaryhypertension"and"Definition,risk
factors,andevaluationofresistanthypertension",sectionon'Secondarycausesofhypertension'.)
Majorcausesofsecondaryhypertensioninclude:
7/6/2016
Prescriptionoroverthecountermedications:
Oralcontraceptives,particularlythosecontaininghigherdosesofestrogen,whichcanoftenraisetheblood
pressurewithinthenormalrangebutcanalsoinduceoverthypertension(see"Effectoforalcontraceptives
andpostmenopausalhormonetherapyonbloodpressure")
Nonsteroidalantiinflammatoryagents,particularlychronicuse(see"NSAIDsandacetaminophen:Effects
onbloodpressureandhypertension")
Antidepressants,includingtricyclicantidepressantsandselectiveserotoninreuptakeinhibitors
Glucocorticoids
Decongestants,suchaspseudoephedrine
Weightlossmedications
Erythropoietin
Cyclosporine
Stimulants,includingmethylphenidateandamphetamines
IllicitdruguseDrugssuchasmethamphetaminesandcocainecanraisebloodpressure.
PrimaryrenaldiseaseBothacuteandchronickidneydisease,particularlywithglomerularorvasculardisorders,
canleadtohypertension.(See"Overviewofhypertensioninacuteandchronickidneydisease".)
PrimaryaldosteronismThepresenceofprimarymineralocorticoidexcess,primarilyaldosterone,shouldbe
suspectedinanypatientwiththetriadofhypertension,unexplainedhypokalemia,andmetabolicalkalosis.
However,upto50percentofpatientswillhaveanormalplasmapotassiumconcentration.Thepresenceof
primaryaldosteronismshouldalsobeconsideredinpatientswithresistanthypertension.(See"Pathophysiology
andclinicalfeaturesofprimaryaldosteronism"and"Approachtothepatientwithhypertensionandhypokalemia".)
RenovascularhypertensionRenovasculardiseaseisarelativelycommondisorder.Renovascularhypertension
ismoreoftenduetofibromusculardysplasiainyoungerpatientsandmoreoftenduetoatherosclerosisinolder
patients.(See"Establishingthediagnosisofrenovascularhypertension".)
ObstructivesleepapneaDisorderedbreathingduringsleepappearstobeanindependentriskfactorfor
systemichypertension.(See"Obstructivesleepapneaandcardiovasculardisease".)
PheochromocytomaPheochromocytomaisararecauseofsecondaryhypertension.Aboutonehalfofpatients
withpheochromocytomahaveparoxysmalhypertensionmostoftheresthavewhatappearstobeprimary
hypertension.(See"Clinicalpresentationanddiagnosisofpheochromocytoma"and"Treatmentof
pheochromocytomainadults".)
Cushing'ssyndromeCushing'ssyndromeisararecauseofsecondaryhypertension,buthypertensionisa
majorcauseofmorbidityanddeathinpatientswithCushing'ssyndrome.(See"Epidemiologyandclinical
manifestationsofCushing'ssyndrome".)
OtherendocrinedisordersHypothyroidism,hyperthyroidism,andhyperparathyroidismmayalsoinduce
hypertension.(See"Cardiovasculareffectsofhypothyroidism"and"Cardiovasculareffectsofhyperthyroidism"
and"Primaryhyperparathyroidism:Clinicalmanifestations",sectionon'Cardiovascular'.)
CoarctationoftheaortaCoarctationoftheaortaisoneofthemajorcausesofsecondaryhypertensioninyoung
children,butitmayalsobediagnosedinadulthood[24].(See"Clinicalmanifestationsanddiagnosisof
coarctationoftheaorta".)
COMPLICATIONSOFHYPERTENSIONHypertensionisassociatedwithanumberofseriousadverseeffects.
Thelikelihoodofdevelopingthesecomplicationsisincreasedwithhigherlevelsofbloodpressure.Theincreaseinrisk
beginsasthebloodpressurerisesabove115/75mmHginallagegroups(figure2AB)[25].However,thisrelationship
doesnotprovecausality,whichcanonlybedemonstratedbyrandomizedtrialsshowingbenefitfrombloodpressure
reduction.
Hypertensionisquantitativelythemajormodifiableriskfactorforprematurecardiovasculardisease,beingmore
commonthancigarettesmoking,dyslipidemia,ordiabetes,whicharetheothermajorriskfactors[26].Inolder
7/6/2016
patients,systolicpressureandpulsepressurearemorepowerfuldeterminantsofriskthandiastolicpressure[10].
Importantly,theincreaseincardiovascularriskassociatedwithhypertensionisaffectedbythepresenceorabsenceof
otherriskfactors(figure3)[27].(See"Cardiovascularrisksofhypertension".)
Eachofthefollowingcomplicationsiscloselyassociatedwiththepresenceofhypertension:
Leftventricularhypertrophy(LVH)isacommonandearlyfindinginpatientswithhypertension[28].LVHis
associatedwithahigherincidenceofsubsequentheartfailure,myocardialinfarction,suddendeath,andstroke
(figure4)[29].(See"Clinicalimplicationsandtreatmentofleftventricularhypertrophyinhypertension".)
Theriskofheartfailure,bothsystolic(reducedejectionfraction)anddiastolic(preservedejectionfraction),
increaseswiththedegreeofbloodpressureelevation[30].Thepathogenesisofheartfailureinpatientswith
hypertensionisbothischemicandnonischemic.(See"Epidemiologyandcausesofheartfailure".)
Hypertensionisthemostcommonandmostimportantriskfactorforischemicstroke,theincidenceofwhichcan
bemarkedlyreducedbyeffectiveantihypertensivetherapy[31].(See"Clinicaldiagnosisofstrokesubtypes",
sectionon'Ecologyandriskfactors'.)
Hypertensionisthemostimportantriskfactorforthedevelopmentofintracerebralhemorrhage[32].(See
"Spontaneousintracerebralhemorrhage:Pathogenesis,clinicalfeatures,anddiagnosis".)
Hypertensionisaleadingriskfactorforischemicheartdisease,includingmyocardialinfarctionandcoronary
interventions[26].(See"Overviewoftheriskequivalentsandestablishedriskfactorsforcardiovascular
disease".)
Hypertensionisariskfactorforchronickidneydiseaseandendstagerenaldisease(figure5)[33,34].Itcanboth
directlycausekidneydisease,whichiscalledhypertensivenephrosclerosis,andacceleratetheprogressionofa
varietyofotherrenaldiseases.Therelationshipbetweenbloodpressureandrenaldiseaseisstrongeramong
blacks.(See"Clinicalfeatures,diagnosis,andtreatmentofhypertensivenephrosclerosis"and"Antihypertensive
therapyandprogressionofnondiabeticchronickidneydiseaseinadults".)
DIAGNOSISOFHYPERTENSIONAlladultsshouldbescreenedforhypertension.Anelevatedscreeningblood
pressure,whichistypicallyobtainedintheclinician'soffice,shouldbeconfirmedusingoutofofficemeasurements,if
possible(algorithm1).
ScreeningWeagreewiththe2015UnitedStatesPreventiveServicesTaskForce(USPSTF)guidelinesthatall
individuals18yearsoroldershouldbescreenedforelevatedbloodpressure[35].Inpractice,bloodpressure
measurementissimpleandquickandisperformedatmostofficevisits.
However,ataminimum,thefrequencyofscreeningshouldbeasfollows:
Adults40yearsoroldershouldhavetheirbloodpressuremeasuredatleastannually
Adultsbetween18and39yearsshouldalsobescreenedatleastannuallyiftheyhaveriskfactorsfor
hypertension(eg,obesity)oriftheirpreviouslymeasuredbloodpressurewas130139/8589mmHg
Adultsbetween18and39yearswhoselatestbloodpressurewas<130/80mmHgandhavenoriskfactorsfor
hypertensionshouldbescreenedatleasteverythreeyears.
DiagnosisIntheuncommonpatientwhohasaninitialscreeningbloodpressure180/110mmHgorwhopresents
withhypertensiveemergency,adiagnosisofhypertensioncanbemadewithoutfurtherconfirmation.(See"Evaluation
andtreatmentofhypertensiveemergenciesinadults".)
Inallotherpatientswhohaveanelevatedscreeningbloodpressure,thediagnosisofhypertensionshouldbeconfirmed
usingoutofofficebloodpressuremeasurement,preferablyambulatorybloodpressuremonitoring(ABPM)(algorithm
1).HomebloodpressuremonitoringisanacceptablealternativetoABPMifABPMisnotpossible.Thisapproachis
consistentwithrecommendationsfromtheUSPSTFandtheCanadianHypertensionEducationProgram(CHEP)
[35,36].
Occasionally,outofofficeconfirmationofhypertensionisnotpossiblebecauseofissueswithavailabilityof
equipment,insurance,andcost.Inthesesituations,adiagnosisofhypertensioncanbeconfirmedbyserialoffice
basedbloodpressuremeasurements,spacedoveraperiodofweekstomonths(algorithm1).Thenumberofserial
officebasedmeasurementsthatarerequiredtobeelevatedbeforeadiagnosisofhypertensioncanbeconfirmed
dependsupontheseverityofthebloodpressureelevation,thepresenceorabsenceofendorgandamage(eg,left
ventricularhypertrophy[LVH]),andthepresenceorabsenceofdiabetesorchronickidneydisease[36].
7/6/2016
BloodpressuremeasurementBloodpressuremeasurementisbrieflyreviewedhere.Detaileddiscussionson
ABPM,homebloodpressuremonitoring,andofficebasedbloodpressuremeasurementcanbefoundinothertopics.
(See"Ambulatoryandhomebloodpressuremonitoringandwhitecoathypertensioninadults"and"Bloodpressure
measurementinthediagnosisandmanagementofhypertensioninadults".)
ABPMABPMisthepreferredmethodforconfirmingthediagnosisofhypertension.Highqualitydatasuggest
thatABPMpredictstargetorgandamageandcardiovasculareventsbetterthanofficebloodpressurereadings.ABPM
recordsthebloodpressureatpresetintervals(usuallyevery15to20minutesduringthedayandevery30to60
minutesduringsleep).ABPMcanidentifywhitecoatandmaskedhypertensionandcanalsobeusedtoconfirmnormal
bloodpressurereadingsobtainedbyselfmonitoringathome.Itisalsotheonlymethodofbloodpressuremeasurement
thatcanreliablyobtainnocturnalreadings,whichmayhaveimportantprognosticimplications.
Approximately20to25percentofpatientswithstage1officehypertensionhavewhitecoatorisolatedoffice
hypertensioninthattheirbloodpressureisrepeatedlynormalwhenmeasuredathome,atwork,orbyABPM.Oneway
tominimizethewhitecoateffectistouseappropriateofficemeasurementtechniqueand,potentially,touseautomated
devicesthatsystematicallyobtainmultiplerepeatedbloodpressuremeasurementsatspecifictimeintervals[37].(See
"Ambulatoryandhomebloodpressuremonitoringandwhitecoathypertensioninadults",sectionon'Whitecoat
hypertension'.)
ABPMinlargepopulationshasrevealedasignificantnumberofpatientswhohaveelevatedoutofofficereadings
despitenormalofficereadings(ie,maskedhypertension)[38].Limiteddatasuggestthatcardiovascularriskiselevated
insuchpatientstoadegreesimilartothatofpatientswithsustainedhypertension.(See"Ambulatoryandhomeblood
pressuremonitoringandwhitecoathypertensioninadults",sectionon'Maskedhypertension'.)
Inadditiontopatientswithsuspectedwhitecoathypertension,ABPMcouldbeconsideredinthefollowing
circumstances:
Suspectedepisodichypertension(eg,pheochromocytoma)
Determiningtherapeuticresponse(ie,bloodpressurecontrol)inpatientswhoareknowntohaveasubstantial
whitecoateffect)
Hypotensivesymptomswhiletakingantihypertensivemedications
Resistanthypertension
Autonomicdysfunction
HomebloodpressuremonitoringAppropriatetrainingandequipmentisparamounttoobtainingaccurate
homebloodpressurereadings.Patientsshouldbeinstructedtouseavalidated,automatedoscillometricdevicethat
measuresbloodpressureinthebrachialartery(upperarm)andtoperformmeasurementsinaquietroomafterfive
minutesofrestintheseatedpositionwiththebackandarmsupported.Atleast12to14measurementsshouldbe
obtained,withbothmorningandeveningmeasurementstaken,overaperiodofoneweek.Moderatequalitydata
suggestthatselfrecordedbloodpressuretakenathomeorworkcorrelatemorecloselywiththeresultsof24houror
daytimeambulatorymonitoringandtargetorgandamagethanwithofficebasedmeasurements.(See"Bloodpressure
measurementinthediagnosisandmanagementofhypertensioninadults",sectionon'Homebloodpressure
monitoring'and"Ambulatoryandhomebloodpressuremonitoringandwhitecoathypertensioninadults",sectionon
'Homebloodpressuremeasurements'.)
OfficebasedbloodpressuremeasurementIfofficebasedmeasurementsareused,propertechniqueand
interpretationofthebloodpressureisessentialinthediagnosisandmanagementofhypertension.Thereareavariety
ofstepsthatmustbefollowedtoachievemaximumaccuracyinthisprocess(table2)[39].Thepreferredtechniqueis
discussedindetailseparately.(See"Bloodpressuremeasurementinthediagnosisandmanagementofhypertensionin
adults".)
Automatedoscillometricbloodpressuredevicesareusedfrequentlyinofficesettings.Someautomatedoscillometric
devicestakemultipleconsecutivereadingsintheofficewiththepatientsittingandrestingalonethistechnique,
knownasautomatedofficebloodpressure(AOBP),betterpredictstheresultsofABPMthantraditionalofficeblood
pressuremeasurementandmayreducethewhitecoateffect.Bloodpressurereadingsaretypicallylowerwith
automatedoscillometricbloodpressuredevicesthanwiththeauscultatorymethodassuch,alowerthresholdis
recommendedfordiagnosinghypertension(<135/85mmHg).(See"Bloodpressuremeasurementinthediagnosisand
managementofhypertensioninadults",sectionon'AutomatedoscillometricBPmeasurement'.)
Inadditiontoobtainingmultiplebloodpressuremeasurements,bloodpressureshouldbemeasuredinbotharms,and,
particularlyinolderindividualsorthosewithpotentialorthostaticsymptoms,posturalmeasurementsshouldbetaken:
7/6/2016
Systolicbloodpressurereadingsintheleftandrightarmsshouldberoughlyequivalent.Adiscrepancyofmore
than15mmHgmayindicatesubclavianstenosisand,hence,peripheralarterialdisease.(See"Bloodpressure
measurementinthediagnosisandmanagementofhypertensioninadults".)
Posturalhypotension,definedasa20mmHgorgreaterfallinsystolicpressureuponrisingfromsupinetoan
unassisteduprightposition,shouldbepursuedinpatientsoverage65years,thoseexperiencingdizzinessor
weaknessuponstanding,orthosewithdiabetes.(See"Mechanisms,causes,andevaluationoforthostatic
hypotension".)
EVALUATIONOnceithasbeendeterminedthatthepatienthaspersistenthypertension,anevaluationshouldbe
performedtoascertainthefollowinginformation(see"Initialevaluationofthehypertensiveadult"):
Todeterminetheextentoftargetorgandamageand/orestablishedcardiovasculardisease.
Toassessothercardiovascularriskfactors.(See"Overviewoftheriskequivalentsandestablishedriskfactors
forcardiovasculardisease".)
Toidentifylifestylefactorsthatcouldpotentiallycontributetohypertension.(See'Riskfactorsforprimary
(essential)hypertension'above.)
Toidentifyinterferingsubstances(eg,chronicuseofnonsteroidalantiinflammatorydrugs,oralcontraceptives)
andpotentiallycurablecausesofsecondaryhypertension.(See'Secondaryorcontributingcausesof
hypertension'above.)
Mostpatientswithpresumedprimaryhypertension(formerlycalled"essential"hypertension)shouldundergoa
relativelylimitedworkupforsecondarycausesutilizinginformationgainedfromthehistory,physical
examination,androutinelaboratorytests.(See'History'belowand'Physicalexamination'belowand'Laboratory
testing'below.)
However,itisimportanttobeawareoftheclinicalcluessuggestingthepossiblepresenceofoneofthecauses
ofsecondaryhypertension(table4),whichmayindicatetheneedforamoreextensiveevaluation.Theseissues
arediscussedindetailelsewhere.(See"Initialevaluationofthehypertensiveadult"and"Evaluationofsecondary
hypertension".)
HistoryThehistoryshouldsearchforthosefactsthathelptodeterminethepresenceofprecipitatingoraggravating
factors(includingprescriptionmedications,nonprescriptionnonsteroidalantiinflammatoryagents,andalcohol
consumption),thedurationofhypertension,previousattemptsattreatment,theextentoftargetorgandamage,andthe
presenceofotherknownriskfactorsforcardiovasculardisease(table5).
PhysicalexaminationThemaingoalsofthephysicalexaminationaretoevaluateforsignsofendorgandamage,
forestablishedcardiovasculardisease,andforevidenceofpotentialcausesofsecondaryhypertension.Thephysical
examinationshouldincludetheunderutilizedbutimportantfunduscopicexaminationtoevaluateforhypertensive
retinopathy(table6).
LaboratorytestingThefollowingtestsshouldbeperformedinallpatientswithnewlydiagnosedhypertension[5,40]
(see"Initialevaluationofthehypertensiveadult",sectionon'Laboratorytesting'):
Electrolytesandserumcreatinine(tocalculatetheestimatedglomerularfiltrationrate)
Fastingglucose
Urinalysis
Lipidprofile(totalandHDLcholesterol,triglycerides)
Electrocardiogram
AdditionaltestsAdditionaltestsmaybeindicatedincertainsettings:
Increasedalbuminuriaisincreasinglyrecognizedasanindependentriskfactorforcardiovasculardisease[41].A
discussionofscreeningforincreasedalbuminuriaamongnondiabeticswithhypertensionispresentedseparately.
(See"Moderatelyincreasedalbuminuria(microalbuminuria)andcardiovasculardisease"and"Epidemiologyof
chronickidneydisease".)
Echocardiographyisamoresensitivemeansofidentifyingthepresenceofleftventricularhypertrophy(LVH)than
anelectrocardiogram.Itisindicatedinpatientswithclinicallyevidentheartfailureorifleftventriculardysfunction
orcoronaryarterydiseaseissuspected[42].(See"Clinicalimplicationsandtreatmentofleftventricular
7/6/2016
hypertrophyinhypertension",sectionon'Indicationsforechocardiographyinhypertensivepatients'.)
TestingforsecondaryhypertensionSecondarycausesofhypertensionarerelativelyuncommon,andtestingfor
secondaryhypertensionmayproducefalsepositiveresults.Thus,screeningforsecondarycausesisnot
recommendedforallpatientswithprimaryhypertension.Instead,atargetedapproachisindicatedwherebyscreening
forsecondarycausesshouldbeperformedonlyinpatientswithanunusualpresentationofhypertension(newonsetat
anespeciallyyoungorespeciallyoldage,presentationwithstage2hypertension,abruptonsetofhypertensionina
patientwithpreviouslynormalbloodpressure,resistanthypertension)orinthosewithaclinicalclueforaspecific
causeofhypertension,suchasanabdominalbruit(suggestiveofrenovascularhypertension)orlowserumpotassium
(suggestiveofprimaryaldosteronism).(See"Evaluationofsecondaryhypertension".)
Thepotentialevaluationforrenovascularandothersecondarycausesofhypertensionisdiscussedseparatelyindetail.
(See"Evaluationofsecondaryhypertension".)
TREATMENT
BenefitsofbloodpressurecontrolInlargescalerandomizedtrials,antihypertensivetherapyproducesanearly50
percentrelativeriskreductionintheincidenceofheartfailure,a30to40percentrelativeriskreductioninstroke,anda
20to25percentrelativeriskreductioninmyocardialinfarction[43].
Theserelativeriskreductionscorrespondtothefollowingabsolutebenefits:antihypertensivetherapyforfourtofive
yearspreventsacoronaryeventin0.7percentofpatientsandacerebrovasculareventin1.3percentofpatientsfora
totalabsolutebenefitofapproximately2percent(figure6)[44].Thus,100patientsmustbetreatedforfourtofive
yearstopreventacomplicationintwopatients.Itispresumedthatthesestatisticsunderestimatethetruebenefitof
treatingstage1hypertensionsincethesedatawerederivedfromtrialsofrelativelyshortduration(fivetosevenyears)
thismaybeinsufficienttodeterminetheefficacyofantihypertensivetherapyonlongertermdiseasessuchas
atherosclerosisandheartfailure.(See"Hypertension:Whoshouldbetreated?".)
Equalifnotgreaterrelativeriskreductionshavebeendemonstratedwithantihypertensivetreatmentofolder
hypertensivepatients(overage65years),mostofwhomhaveisolatedsystolichypertension.Becauseadvancedage
isassociatedwithhigheroverallcardiovascularrisk,evenmodestandrelativelyshorttermreductionsinblood
pressuremayprovideabsolutebenefitsthataregreaterthanthatobservedinyoungerpatients.(See"Treatmentof
hypertensionintheelderlypatient,particularlyisolatedsystolichypertension".)
Thebenefitsofantihypertensivetherapyarelessclearandmorecontroversialinpatientswhohavemildhypertension
andnopreexistingcardiovasculardisease,andinelderlypatientswhoarefrail.(See"Hypertension:Whoshouldbe
treated?",sectionon'Lowriskpatients'and"Treatmentofhypertensionintheelderlypatient,particularlyisolated
systolichypertension",sectionon'Problemoffrailty'.)
Whoshouldbetreated?Allhypertensivepatientsshouldundergoappropriatenonpharmacologic(lifestyle)
modification(table7).(See'Nonpharmacologictherapy'below.)
Whenantihypertensivedrugsareused,weemploythefollowinggeneralapproach,whichisconsistentwiththe2014
recommendationsfrompanelmembersoftheeighthJointNationalCommittee(JNC8)andtheEuropeanSocietiesof
HypertensionandCardiology(ESH/ESC).Theseguidelinesrefertobloodpressuresmeasuredintheoffice.However,
consistentwiththerecommendationsofothers,wealsofeelthathypertensionshould,wheneverpossible,be
confirmedwithoutofofficebloodpressurereadings,usingeitherrepeatedhomemeasurementsor,preferably,
ambulatorybloodpressuremonitoring(ABPM),priortotheinitiationofantihypertensivetherapy[35,36](see
"Hypertension:Whoshouldbetreated?"and'Diagnosisofhypertension'above):
Evidencefromclinicalhypertensiontrialssuggeststhatantihypertensivemedicationsshouldgenerallybebegun
iftheofficesystolicpressureispersistently140mmHgand/ortheofficediastolicpressureispersistently90
mmHgdespiteattemptednonpharmacologictherapy[4,9].(See"Hypertension:Whoshouldbetreated?".)
Startingwithtwodrugsshouldbeconsideredinpatientswithabaselinebloodpressurethatis20/10mmHgor
moreabovegoalbloodpressure[9].Thisstrategymayincreasethelikelihoodthattargetbloodpressuresare
achievedinamorereasonabletimeperiod,butitshouldbeusedcautiouslyinpatientsatincreasedriskfor
orthostatichypotension(suchasdiabeticsandtheelderly).(See"Choiceofdrugtherapyinprimary(essential)
hypertension".)
Alowersystolicbloodpressuregoaliswarrantedinmanypatientswithestablishedatherosclerotic
cardiovasculardisease(orthoseathighrisk)andinpatientswithchronickidneydiseasecomplicatedby
proteinuria.Thesedataarepresentedseparately.(See"Whatisgoalbloodpressureinthetreatmentof
7/6/2016
hypertension?"and"Goalbloodpressureinpatientswithcardiovasculardiseaseorathighrisk",sectionon'Goal
bloodpressure'and"Antihypertensivetherapyandprogressionofnondiabeticchronickidneydiseaseinadults",
sectionon'Bloodpressuregoal'.)
Inanumberofconditions(eg,atrialfibrillation,heartfailure,postmyocardialinfarction),certainantihypertensive
drugsaregiventoimprovesurvivaloftheunderlyingdisease,andotherdrugsarecontraindicated,independentof
thebloodpressure(table8).(See"Choiceofdrugtherapyinprimary(essential)hypertension".)
Asnotedabove,thebenefitsofantihypertensivetherapyarelessclearandmorecontroversialinpatientswhohave
mildhypertensionandnopreexistingcardiovasculardisease,andinelderlypatientswhoarefrail.(See"Hypertension:
Whoshouldbetreated?",sectionon'Lowriskpatients'and"Treatmentofhypertensionintheelderlypatient,
particularlyisolatedsystolichypertension",sectionon'Problemoffrailty'.)
NonpharmacologictherapyTreatmentofhypertensionshouldinvolvenonpharmacologictherapy(alsocalled
lifestylemodification)aloneorinconcertwithantihypertensivedrugtherapy(table7)[45]:
DietarysaltrestrictionInwellcontrolledrandomizedtrials,theoverallimpactofmoderatesodiumreductionisa
fallinbloodpressureinhypertensiveandnormotensiveindividualsof4.8/2.5and1.9/1.1mmHg,respectively
(figure7)[46,47].Theeffectsofsodiumrestrictiononbloodpressure,cardiovasculardisease,andmortalityas
wellasspecificrecommendationsforsodiumintakearediscussedindetailelsewhere.(See"Saltintake,salt
restriction,andprimary(essential)hypertension".)
WeightlossWeightlossinoverweightorobeseindividualscanleadtoasignificantfallinbloodpressure
independentofexercise.Thedeclineinbloodpressureinducedbyweightlosscanalsooccurintheabsenceof
dietarysodiumrestriction[48],butevenmodestsodiumrestrictionmayproduceanadditiveantihypertensive
effect[49].Theweightlossinduceddeclineinbloodpressuregenerallyrangesfrom0.5to2mmHgforevery1
kgofweightlost,orabout1mmHgforevery1poundlost(figure8)[50].(See"Dietinthetreatmentand
preventionofhypertension"and"Obesityandweightreductioninhypertension".)
DietaryApproachestoStopHypertension(DASH)dietTheDASHdietarypatternishighinvegetables,fruits,
lowfatdairyproducts,wholegrains,poultry,fish,andnutsandlowinsweets,sugarsweetenedbeverages,and
redmeats.TheDASHdietarypatternisconsequentlyrichinpotassium,magnesium,calcium,protein,andfiber,
butlowinsaturatedfat,totalfat,andcholesterol.Atrialinwhichallfoodwassuppliedtonormotensiveormildly
hypertensiveadultsfoundthattheDASHdietarypatternreducedbloodpressureby6/4mmHgcomparedwith
typicalAmericanstyledietthatcontainedthesameamountofsodiumandthesamenumberofcalories.
CombiningtheDASHdietarypatternwithmodestsodiumrestrictionproducedanadditiveantihypertensiveeffect.
Thesetrialsandareviewofdietinthetreatmentofhypertensionarediscussedindetailelsewhere.(See"Dietin
thetreatmentandpreventionofhypertension".)
ExerciseAerobicexercise,andpossiblyresistancetraining,candecreasesystolicanddiastolicpressureby,on
average,4to6mmHgand3mmHg,respectively,independentofweightloss.Moststudiesdemonstratinga
reductioninbloodpressurehaveemployedthreetofoursessionsperweekofmoderateintensityaerobic
exerciselastingapproximately40minutesforaperiodof12weeks.(See"Exerciseinthetreatmentand
preventionofhypertension".)
LimitedalcoholintakeWomenwhoconsumetwoormorealcoholicbeveragesperdayandmenwhohavethree
ormoredrinksperdayhaveasignificantlyincreasedincidenceofhypertensioncomparedwithnondrinkers
[16,51]thiseffectisdoserelatedandismostprominentwhenintakeexceedsfivedrinksperday.Ontheother
hand,decreasingalcoholintakeinindividualswhodrinkexcessivelysignificantlylowersbloodpressure.
Moderatealcoholuse(onedrinkperdayforwomenandonetotwodrinksperdayformen)hasalimitedeffecton
bloodpressure,associatedwithamodestdecreaseincardiovascularriskascomparedwithnoalcohol
consumption.(See"Cardiovascularbenefitsandrisksofmoderatealcoholconsumption".)
ComprehensiveinterventionThebenefitsofcomprehensivelifestylemodification,includingtheDASHdietand
increasedexercise,weretestedinthePREMIERtrial[52].At18months,therewasalowerprevalenceof
hypertension(22versus32percent),andlessuseofantihypertensivemedications(10to14versus19percent),
althoughthedifferencewasnotstatisticallysignificant.(See"Dietinthetreatmentandpreventionof
hypertension",sectionon'PREMIERtrial'.)
PatienteducationPatienteducationhasbeendemonstratedtoresultinimprovedbloodpressurecontrol[53].In
additiontoeducationofpatientsbytheirclinicians,bloodpressurecontrolmaybeimprovedwhenpatientswith
hypertensionhearthepersonalstoriesoftheirpeerswithhypertension[54].
7/6/2016
Drugtreatment
GeneralefficacyMultipleguidelinesandmetaanalysesconcludethatthedegreeofbloodpressurereduction,
notthechoiceofantihypertensivemedication,isthemajordeterminantofreductionincardiovascularriskinpatients
withhypertension[9,43,55,56].Recommendationsfortheuseofspecificclassesofantihypertensivemedicationsare
baseduponclinicaltrialevidenceofdecreasedcardiovascularrisk,bloodpressureloweringefficacy,safety,and
tolerability.Mostpatientswithhypertensionwillrequiremorethanonebloodpressuremedicationtoreachgoalblood
pressure.Havingmultipleavailableclassesofbloodpressuremedicationpermitsclinicianstoindividualizetherapy
baseduponindividualpatientcharacteristicsandpreferences.
Somepatientshaveanindicationforaspecificdrugordrugsthatisunrelatedtoprimaryhypertension(formerlycalled
"essential"hypertension),whichwillinfluencethechoiceoftherapy(table8).(See"Choiceofdrugtherapyinprimary
(essential)hypertension".)
InitialmonotherapyinuncomplicatedhypertensionIntheabsenceofaspecificindication,therearefour
mainclassesofdrugsthatarerecommendedforuseasinitialmonotherapy:
Thiazidediuretics
Longactingcalciumchannelblockers(mostoftenadihydropyridinesuchasamlodipine)
Angiotensinconvertingenzyme(ACE)inhibitors
AngiotensinIIreceptorblockers(ARBs)
Mostguidelinesandrecommendations,includingthosemadebypanelmembersfromJNC8andESH/ESC,support
theuseofanyoftheseclassesasinitialtherapyinmanypatients.(See"Choiceofdrugtherapyinprimary(essential)
hypertension".)
However,athiazidediureticorlongactingcalciumchannelblockershouldbeusedasinitialmonotherapyinblack
patients,andanACEinhibitororARBshouldbeusedforinitialmonotherapyinpatientswhohavediabetic
nephropathyornondiabeticchronickidneydiseasecomplicatedbyproteinuria.(See"Treatmentofhypertensionin
blacks"and"Treatmentofhypertensioninpatientswithdiabetesmellitus"and"Antihypertensivetherapyand
progressionofnondiabeticchronickidneydiseaseinadults".)
Betablockersarenolongerrecommendedasinitialmonotherapyintheabsenceofaspecific(compelling)indication
fortheiruse,suchasischemicheartdiseaseorheartfailurewithdecreasedejectionfraction[4,57].(See"Choiceof
drugtherapyinprimary(essential)hypertension".)
CombinationtherapyInmostcases,singleagenttherapywillnotadequatelycontrolbloodpressure,
particularlyinthosewhosebloodpressureismorethan20/10mmHgabovegoal.Combinationtherapywithdrugsfrom
differentclasseshasasubstantiallygreaterbloodpressureloweringeffectthandoublingthedoseofasingleagent
[58].Whenmorethanoneagentisneededtocontrolthebloodpressure,werecommendtherapywithalongacting
ACEinhibitororARBinconcertwithalongactingdihydropyridinecalciumchannelblocker.CombinationofanACE
inhibitororARBwithathiazidediureticcanalsobeusedbutmaybelessbeneficial.ACEinhibitorsandARBsshould
notbeusedtogether.Thesupportivedatafortheserecommendationsarepresentedelsewhere.(See"Choiceofdrug
therapyinprimary(essential)hypertension",sectionon'Combinationtherapy'.)
Fixeddose,singlepillcombinationmedicationsshouldbeusedwheneverfeasibletoreducetheburdenonpatientsand
improvemedicationadherence.(See"Theprevalenceandcontrolofhypertension",sectionon'Methodstoimprove
controlrates'.)
PossiblebenefitfromnocturnaltherapyTheaveragenocturnalbloodpressureisapproximately15percent
lowerthandaytimevalues.Failureofthebloodpressuretofallbyatleast10percentduringsleepiscalled
"nondipping"andisastrongerpredictorofadversecardiovascularoutcomesthandaytimebloodpressure.(See
"Ambulatoryandhomebloodpressuremonitoringandwhitecoathypertensioninadults",sectionon'Nocturnalblood
pressureandnondippers'.)
Thereissomeevidencethat,inpatientstakingmorethanoneantihypertensivemedication,shiftingatleastonedrug
fromthemorningtotheeveningmayrestorethenormalnocturnalbloodpressuredip,reduceoverall24hourmean
bloodpressure,anddecreasetheincidenceofcardiovasculardisease.Thisisdiscussedinmoredetailelsewhere.
(See"Choiceofdrugtherapyinprimary(essential)hypertension",sectionon'Bedtimeversusmorningdosing'.)
Similarobservationshavebeenmadeinpatientswithchronickidneydisease.(See"Overviewofhypertensioninacute
andchronickidneydisease",sectionon'Possiblebenefitfromnocturnaltherapy'.)
http://www.uptodate.com/contents/overviewofhypertensioninadults?topicKey=NEPH%2F3852&elapsedTimeMs=1&source=search_result&searchTer 10/41
7/6/2016
GoalbloodpressureAfterantihypertensivetherapyisinitiated,patientsshouldbereevaluatedandtherapyshould
beincreasedeverytwotofourweeksuntiladequatebloodpressurecontrolisachieved.Oncebloodpressurecontrolis
achieved,patientsshouldbereevaluatedeverythreetosixmonthstoensuremaintenanceofcontrol.
Recommendationsaboutgoalbloodpressurevarysomewhataccordingtopatientageandcomorbidities.Theseissues
arediscussedindetailelsewhere.(See"Whatisgoalbloodpressureinthetreatmentofhypertension?"and"Goal
bloodpressureinpatientswithcardiovasculardiseaseorathighrisk"and"Antihypertensivetherapyandprogressionof
nondiabeticchronickidneydiseaseinadults"and"Treatmentofhypertensioninpatientswithdiabetesmellitus"and
"Antihypertensivetherapytopreventrecurrentstrokeortransientischemicattack".)
Fortherapidlygrowingpopulationofhypertensiveindividualsoverage65yearswithisolatedsystolichypertension(eg,
anofficediastolicbloodpressurebelow90mmHg),cautionisneedednottoreducethediastolicbloodpressuretoo
aggressively(<55to60mmHg),sincelowachieveddiastolicpressureshavebeenassociatedwithanincreasedrisk
ofmyocardialinfarctionandstroke[5961].Amoredetaileddiscussionofthetreatmentofolderpatientswithisolated
systolichypertensionispresentedelsewhere.(See"Treatmentofhypertensionintheelderlypatient,particularly
isolatedsystolichypertension"and"Overviewofsecondarypreventionofischemicstroke".)
ResistanthypertensionResistanthypertensionisdefinedas:bloodpressurethatisnotcontrolleddespite
adherencetoanappropriatethreedrugregimen(includingadiuretic)inwhichalldrugsaredosedat50percentormore
ofthemaximumrecommendedantihypertensivedoseorbloodpressurethatrequiresatleastfourmedicationsto
achievecontrol.Thedefinition,evaluation,andtreatmentofresistanthypertensionarediscussedindetailelsewhere.
(See"Definition,riskfactors,andevaluationofresistanthypertension"and"Treatmentofresistanthypertension".)
Approximately15percentofpatientsdiagnosedwithhypertensionappeartohaveresistanthypertension.However,
manypatientswhoappeartohaveresistanthypertensionactuallyhavepseudoresistanceratherthantrueresistance.
Pseudoresistanceresultsfromsomeorallofthefollowingproblems(see"Definition,riskfactors,andevaluationof
resistanthypertension",sectionon'Apparent,true,andpseudoresistanthypertension'):
Inaccuratebloodpressuremeasurement(eg,useofaninappropriatelysmallbloodpressurecuff).
Pooradherencetobloodpressuremedications.
Pooradherencetolifestyleanddietaryapproachestolowerbloodpressure.
Suboptimalantihypertensivetherapy,dueeithertoinadequatedosesorexclusionofadiureticfromthe
antihypertensiveregimen.
Whitecoatresistanceasanexample,aSpanishstudyfoundthat35percentofpatientswithapparenttreatment
resistanthypertensionactuallyhadwellcontrolledbloodpressurebyambulatorymonitoring,suggestingtheyhad
whitecoathypertensionasacauseoftheirresistance[62].
Oneormoreofthefollowingissuesmaycontributetotrueresistanthypertension(see"Definition,riskfactors,and
evaluationofresistanthypertension",sectionon'Riskfactors'):
Extracellularvolumeexpansion
Increasedsympatheticactivation
Ingestionofsubstancesthatcanelevatethebloodpressure,suchasnonsteroidalantiinflammatorydrugsor
stimulants
Secondaryorcontributingcausesofhypertension
DiscontinuingtherapySomepatientswithstage1hypertensionarewellcontrolled,oftenonasinglemedication.
Afteraperiodofyears,thequestionarisesastowhetherantihypertensivetherapycanbegraduallydiminishedoreven
discontinued.
Afterdiscontinuationoftreatment,between5and55percentofpatientsremainnormotensiveforatleastonetotwo
years[63]alargerfractionofpatientsdowellwithadecreaseinthenumberand/ordoseofmedicationstaken[64,65].
Moregradualtaperingofdrugdoseisindicatedinwellcontrolledpatientstakingmultipledrugs[66].(See"Cantherapy
bediscontinuedinwellcontrolledhypertension?".)
Abruptcessationoftherapywithashortactingbetablocker(suchaspropranolol)ortheshortactingalpha2agonist,
clonidine,canleadtoapotentiallyfatalwithdrawalsyndrome.Gradualdiscontinuationoftheseagentsoveraperiodof
weeksshouldpreventthisproblem.(See"Withdrawalsyndromeswithantihypertensivetherapy".)
7/6/2016
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"and
"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgradereading
level,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.Thesearticlesare
bestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.BeyondtheBasicspatient
educationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewrittenatthe10thto12thgrade
readinglevelandarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthesetopics
toyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon"patientinfo"
andthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Highbloodpressureinadults(TheBasics)"and"Patientinformation:
Controllingyourbloodpressurethroughlifestyle(TheBasics)"and"Patientinformation:Reducingthecostsof
medicines(TheBasics)"and"Patientinformation:Medicinesforhighbloodpressure(TheBasics)"and"Patient
information:Highbloodpressureemergencies(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Highbloodpressureinadults(BeyondtheBasics)"and
"Patientinformation:Highbloodpressuretreatmentinadults(BeyondtheBasics)"and"Patientinformation:High
bloodpressure,diet,andweight(BeyondtheBasics)"and"Patientinformation:Reducingthecostsofmedicines
(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Thefollowingdefinitionsofhypertensiondependuponthemethodofmeasurementandapplytoadultsonno
antihypertensivemedicationandwhoarenotacutelyill.Ifthereisadisparityincategorybetweenthesystolic
anddiastolicpressures,thehighervaluedeterminestheseverityofthebloodpressure(see'Definitions'above):
Hypertensionusingofficebasedbloodpressure:
Normalbloodpressure:systolic<120mmHganddiastolic<80mmHg
Prehypertension:systolic120to139mmHgordiastolic80to89mmHg
Stage1hypertension:systolic140to159mmHgordiastolic90to99mmHg
Stage2hypertension:systolic160mmHgordiastolic100mmHg
Isolatedsystolichypertension:bloodpressureof140/<90mmHg
Isolateddiastolichypertension:bloodpressure<140/90mmHg
Hypertensionusingambulatorybloodpressuremonitoring(ABPM):
Mean24hourbloodpressuresystolic>130mmHgordiastolic>80mmHg
Meandaytimebloodpressuresystolic>135mmHgordiastolic>85mmHg
Hypertensionusinghomebloodpressuremonitoring
Meanofmultiplereadingsoversevendaysofsystolic>135mmHgordiastolic>85mmHg
Moderatetoseverehypertensiveretinopathyisdefinedasseverehypertensionwithretinalhemorrhages,
exudates,orpapilledema,withorwithouthypertensiveencephalopathy.(See'Moderatetoseverehypertensive
retinopathy(formerlycalled"malignanthypertension")'above.)
Hypertensiveurgencyisdefinedasseverehypertension(diastolicpressureusually>120mmHg)in
asymptomaticpatientswithnoacutetargetorgandamage.Hypertensiveemergencyisdefinedassevere
hypertensioninpatientswithacuteongoingtargetorgandamage.(See'Hypertensiveurgency'aboveand
'Hypertensiveemergency'above.)
Resistanthypertensionisdefinedas:bloodpressurethatisnotcontrolleddespiteadherencetoanappropriate
threedrugregimen(includingadiuretic)inwhichalldrugsaredosedat50percentormoreofthemaximum
recommendedantihypertensivedoseorbloodpressurethatrequiresatleastfourmedicationstoachievecontrol.
(See'Resistanthypertension'above.)
Mostpatientswithhypertensionhaveprimaryhypertension(formerlycalled"essential"hypertension).The
pathogenesisofprimaryhypertensionisnotwellunderstoodbutismostlikelytheresultofnumerousgeneticand
environmentalfactorsthathavemultiplecompoundingeffects.Numerousriskfactorsfordevelopinghypertension
havebeenidentified,includingage,blackrace,ahistoryofhypertensioninoneorbothparents,ahighsodium
intake,excessalcoholintake,excessweight,andphysicalinactivity.(See'Primary(essential)hypertension'
7/6/2016
above.)
Identifiableorsecondaryhypertensionmayresultfromacuteorchronicrenaldisease,renovasculardisease,
sleepapnea,endocrinedisorders,orcertaindrugs.(See'Secondaryorcontributingcausesofhypertension'
above.)
Hypertensionisassociatedwithanumberofserioustargetorganeffects,includingcoronaryheartdisease,
clinicalheartfailurewitheitherpreservedorreducedejectionfraction,ischemicandhemorrhagicstroke,chronic
kidneydisease,andacutehypertensiveemergenciessuchashypertensiveencephalopathyandacuteaortic
dissection(table3).(See'Complicationsofhypertension'above.)
Ascreeningofficebloodpressureshouldbeperformedannuallyinadults40yearsorolderandinyoungeradults
withhighnormalbloodpressureorriskfactorsforhypertensionyoungeradultswithnormalbloodpressureand
noriskfactorsforhypertensioncanbescreenedeverythreeyears.(See'Screening'above.)
Intheuncommonpatientwhohasaninitialscreeningbloodpressure180/110mmHgorwhopresentswith
hypertensiveemergency,adiagnosisofhypertensioncanbemadewithoutfurtherconfirmation.Inallother
patientswhohaveanelevatedscreeningbloodpressure,thediagnosisofhypertensionshouldbeconfirmed
usingoutofofficebloodpressuremeasurement,preferablyABPM(algorithm1).Homebloodpressuremonitoring
isanacceptablealternativetoABPMifABPMisnotpossible.Occasionally,outofofficeconfirmationof
hypertensionisnotpossiblebecauseofissueswithavailabilityofequipment,insurance,andcost.Inthese
situations,adiagnosisofhypertensioncanbeconfirmedbyserialofficebasedbloodpressuremeasurements,
spacedoveraperiodofweekstomonths.(See'Diagnosis'above.)
Whitecoathypertensionispresentifapatienthaspersistentlyelevatedbloodpressurewhenmeasuredinthe
office,butrepeatedlynormalbloodpressurewhenmeasuredathome,atwork,or,preferably,byABPM.ABPM
shouldbeconsideredinpatientswithsuspectedwhitecoathypertension,episodichypertension,hypertension
resistanttoincreasingmedication,hypotensivesymptomswhiletakingantihypertensivemedications,andin
patientswithautonomicdysfunction.(See'ABPM'above.)
Oncehypertensionhasbeendiagnosed,anevaluationshouldbeperformedtodeterminetheextentoftarget
organdamageandcardiovasculardisease,toevaluateothercardiovascularriskfactors,andtodecidewhether
anevaluationforsecondarycausesofhypertensioniswarranted.Thisinitialevaluationshouldincludeacareful
history,physicalexamination,urinalysis,routinebloodchemistries,serumcreatinine,fastingglucose,lipidpanel,
andanelectrocardiogram.Inaddition,testingformoderatelyincreasedalbuminuria(formerlycalled
"microalbuminuria")shouldbeconsidered(alwaysinpatientswithdiabetes),andechocardiographycanbe
performedinselectedpatients.(See'Evaluation'above.)
Anevaluationforidentifiable(reversible)orsecondarycausesofhypertensionshouldbereservedforpatients
whohaveanunusualpresentationofhypertensionorclinicalcluesthatpointtothepresenceofaspecific
underlyingcause.(See'Testingforsecondaryhypertension'aboveand"Evaluationofsecondaryhypertension".)
Allpatientsdiagnosedwithhypertensionshouldundergoappropriatenonpharmacologic(lifestyle)modification
(table7),regardlessoftheneedforantihypertensivemedications.(See'Nonpharmacologictherapy'above.)
Afterconfirmationwithoutofofficebloodpressuremeasurementifpossible,antihypertensivemedicationsshould
generallybestartediftheofficesystolicpressureispersistently140mmHg(inpatientsyoungerthan60years)
and/ortheofficediastolicpressureispersistently90mmHgintheofficedespiteattemptednonpharmacologic
therapy.Startingwithtwodrugsshouldbeconsideredinpatientswithabaselinebloodpressurethatis20/10
mmHgormoreabovethegoal.(See'Whoshouldbetreated?'above.)
Itistheattainedbloodpressure,notthespecificdrug(s)used,whichisthemajordeterminantofoutcomein
thosewithuncomplicatedhypertension.Intheabsenceofaspecificindication,therearefourmainclassesof
drugsthatareusedforinitialmonotherapy(see'Initialmonotherapyinuncomplicatedhypertension'above):
Thiazidediuretics
Longactingcalciumchannelblockers(mostoftenadihydropyridine)
Angiotensinconvertingenzyme(ACE)inhibitors
AngiotensinIIreceptorblockers(ARBs)
Inanumberofconditions(eg,atrialfibrillation,heartfailure,postmyocardialinfarction),certainantihypertensive
drugsaregiventoimprovesurvivaloftheunderlyingdisease,andotherdrugsarecontraindicated,independentof
thebloodpressure(table8).(See'Initialmonotherapyinuncomplicatedhypertension'above.)
7/6/2016
Weandmostmajorguidelinesrecommendoneoftwobloodpressuregoalsforthemajorityofpatients(see'Goal
bloodpressure'aboveand"Whatisgoalbloodpressureinthetreatmentofhypertension?"and"Treatmentof
hypertensionintheelderlypatient,particularlyisolatedsystolichypertension"):
Goalbloodpressureis<140/90mmHgforthegeneralhypertensivepopulationundertheageof60years,
andforpatientswithdiabetesorchronickidneydisease,regardlessofage.
Goalbloodpressureis<150/90mmHgforthegeneralhypertensivepopulationaged80yearsandolder.
Goalbloodpressureis<150/90mmHgformostofthegeneralhypertensivepopulationaged60to79years,
butagoalof<140/90mmHgmaybeappropriateforsomepatients.Thechoicebetweenthesetwogoal
bloodpressuresdependsuponthepatient'sgeneralhealth,comorbidconditions,posturalbloodpressure
changes,thenumberofmedicationsneededtoreachthegoal,anduponindividualvaluesandpreferences.
Recommendationsaboutgoalbloodpressurevarysomewhataccordingtopatientageandcomorbidities.These
issuesarediscussedindetailelsewhere.(See"Whatisgoalbloodpressureinthetreatmentofhypertension?"
and"Goalbloodpressureinpatientswithcardiovasculardiseaseorathighrisk"and"Antihypertensivetherapy
andprogressionofnondiabeticchronickidneydiseaseinadults"and"Treatmentofhypertensioninpatientswith
diabetesmellitus"and"Antihypertensivetherapytopreventrecurrentstrokeortransientischemicattack".)
Fortherapidlygrowingpopulationofhypertensiveindividualsoverage65yearswithisolatedsystolic
hypertension(eg,adiastolicbloodpressurebelow90mmHg),cautionisneedednottoreducethediastolicblood
pressuretooaggressively(tobelow55to60mmHg),sincesuchlowdiastolicpressureshavebeenassociated
withanincreasedriskforcardiovascularevents.(See'Goalbloodpressure'above.)
ACKNOWLEDGMENTTheauthorsandUpToDatewouldliketothankDr.FrankDominoandDr.NormanKaplan
forauthoringandcontributingtoearlierversionsofthistopicreview.
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.EganBM,ZhaoY,AxonRN.UStrendsinprevalence,awareness,treatment,andcontrolofhypertension,1988
2008.JAMA2010303:2043.
2.WrightJD,HughesJP,OstchegaY,etal.Meansystolicanddiastolicbloodpressureinadultsaged18andover
intheUnitedStates,20012008.NatlHealthStatReport2011:1.
3.KaplanNM,VictorRG.Hypertensioninthepopulationatlarge.In:Kaplan'sClinicalHypertension,11thed,
WoltersKluwer,Philadelphia2014.p.1.
4.JamesPA,OparilS,CarterBL,etal.2014evidencebasedguidelineforthemanagementofhighbloodpressure
inadults:reportfromthepanelmembersappointedtotheEighthJointNationalCommittee(JNC8).JAMA2014
311:507.
5.ChobanianAV,BakrisGL,BlackHR,etal.TheSeventhReportoftheJointNationalCommitteeonPrevention,
Detection,Evaluation,andTreatmentofHighBloodPressure:theJNC7report.JAMA2003289:2560.
6.WangTJ,VasanRS.EpidemiologyofuncontrolledhypertensionintheUnitedStates.Circulation2005
112:1651.
7.EganBM,BandyopadhyayD,ShaftmanSR,etal.Initialmonotherapyandcombinationtherapyandhypertension
controlthefirstyear.Hypertension201259:1124.
8.GreenlandP,KnollMD,StamlerJ,etal.Majorriskfactorsasantecedentsoffatalandnonfatalcoronaryheart
diseaseevents.JAMA2003290:891.
9.ManciaG,FagardR,NarkiewiczK,etal.2013ESH/ESCGuidelinesforthemanagementofarterial
hypertension:theTaskForceforthemanagementofarterialhypertensionoftheEuropeanSocietyof
Hypertension(ESH)andoftheEuropeanSocietyofCardiology(ESC).JHypertens201331:1281.
10.FranklinSS,LarsonMG,KhanSA,etal.Doestherelationofbloodpressuretocoronaryheartdiseaserisk
changewithaging?TheFraminghamHeartStudy.Circulation2001103:1245.
11.TaylorBC,WiltTJ,WelchHG.Impactofdiastolicandsystolicbloodpressureonmortality:implicationsforthe
definitionof"normal".JGenInternMed201126:685.
12.AhmedME,WalkerJM,BeeversDG,BeeversM.Lackofdifferencebetweenmalignantandaccelerated
hypertension.BrMedJ(ClinResEd)1986292:235.
13.Severesymptomlesshypertension.Lancet19892:1369.
14.O'MailiaJJ,SanderGE,GilesTD.Nifedipineassociatedmyocardialischemiaorinfarctioninthetreatmentof
7/6/2016
hypertensiveurgencies.AnnInternMed1987107:185.
15.GrossmanE,MesserliFH,GrodzickiT,KoweyP.Shouldamoratoriumbeplacedonsublingualnifedipine
capsulesgivenforhypertensiveemergenciesandpseudoemergencies?JAMA1996276:1328.
16.FormanJP,StampferMJ,CurhanGC.Dietandlifestyleriskfactorsassociatedwithincidenthypertensionin
women.JAMA2009302:401.
17.SonneHolmS,SrensenTI,JensenG,SchnohrP.Independenteffectsofweightchangeandattainedbody
weightonprevalenceofarterialhypertensioninobeseandnonobesemen.BMJ1989299:767.
18.StaessenJA,WangJ,BianchiG,BirkenhgerWH.Essentialhypertension.Lancet2003361:1629.
19.WangNY,YoungJH,MeoniLA,etal.Bloodpressurechangeandriskofhypertensionassociatedwithparental
hypertension:theJohnsHopkinsPrecursorsStudy.ArchInternMed2008168:643.
20.CarnethonMR,EvansNS,ChurchTS,etal.Jointassociationsofphysicalactivityandaerobicfitnessonthe
developmentofincidenthypertension:coronaryarteryriskdevelopmentinyoungadults.Hypertension2010
56:49.
21.deSimoneG,DevereuxRB,ChinaliM,etal.Riskfactorsforarterialhypertensioninadultswithinitialoptimal
bloodpressure:theStrongHeartStudy.Hypertension200647:162.
22.YanLL,LiuK,MatthewsKA,etal.Psychosocialfactorsandriskofhypertension:theCoronaryArteryRisk
DevelopmentinYoungAdults(CARDIA)study.JAMA2003290:2138.
23.MengL,ChenD,YangY,etal.Depressionincreasestheriskofhypertensionincidence:ametaanalysisof
prospectivecohortstudies.JHypertens201230:842.
24.ThesixthreportoftheJointNationalCommitteeonprevention,detection,evaluation,andtreatmentofhighblood
pressure.ArchInternMed1997157:2413.
25.LewingtonS,ClarkeR,QizilbashN,etal.Agespecificrelevanceofusualbloodpressuretovascularmortality:
ametaanalysisofindividualdataforonemillionadultsin61prospectivestudies.Lancet2002360:1903.
26.WilsonPW.Establishedriskfactorsandcoronaryarterydisease:theFraminghamStudy.AmJHypertens1994
7:7S.
27.JacksonR,LawesCM,BennettDA,etal.Treatmentwithdrugstolowerbloodpressureandbloodcholesterol
basedonanindividual'sabsolutecardiovascularrisk.Lancet2005365:434.
28.LorellBH,CarabelloBA.Leftventricularhypertrophy:pathogenesis,detection,andprognosis.Circulation2000
102:470.
29.VakiliBA,OkinPM,DevereuxRB.Prognosticimplicationsofleftventricularhypertrophy.AmHeartJ2001
141:334.
30.LevyD,LarsonMG,VasanRS,etal.Theprogressionfromhypertensiontocongestiveheartfailure.JAMA
1996275:1557.
31.StaessenJA,FagardR,ThijsL,etal.Randomiseddoubleblindcomparisonofplaceboandactivetreatmentfor
olderpatientswithisolatedsystolichypertension.TheSystolicHypertensioninEurope(SystEur)Trial
Investigators.Lancet1997350:757.
32.ThriftAG,McNeilJJ,ForbesA,DonnanGA.Riskfactorsforcerebralhemorrhageintheeraofwellcontrolled
hypertension.MelbourneRiskFactorStudy(MERFS)Group.Stroke199627:2020.
33.CoreshJ,WeiGL,McQuillanG,etal.Prevalenceofhighbloodpressureandelevatedserumcreatininelevelin
theUnitedStates:findingsfromthethirdNationalHealthandNutritionExaminationSurvey(19881994).Arch
InternMed2001161:1207.
34.HsuCY,McCullochCE,DarbinianJ,etal.Elevatedbloodpressureandriskofendstagerenaldiseasein
subjectswithoutbaselinekidneydisease.ArchInternMed2005165:923.
35.SiuAL,U.S.PreventiveServicesTaskForce.Screeningforhighbloodpressureinadults:U.S.Preventive
ServicesTaskForcerecommendationstatement.AnnInternMed2015163:778.
36.DaskalopoulouSS,RabiDM,ZarnkeKB,etal.The2015CanadianHypertensionEducationProgram
recommendationsforbloodpressuremeasurement,diagnosis,assessmentofrisk,prevention,andtreatmentof
hypertension.CanJCardiol201531:549.
37.MyersMG.Aproposedalgorithmfordiagnosinghypertensionusingautomatedofficebloodpressure
measurement.JHypertens201028:703.
38.LurbeE,TorroI,AlvarezV,etal.Prevalence,persistence,andclinicalsignificanceofmaskedhypertensionin
youth.Hypertension200545:493.
39.BeeversG,LipGY,O'BrienE.ABCofhypertension:Bloodpressuremeasurement.PartIIconventional
sphygmomanometry:techniqueofauscultatorybloodpressuremeasurement.BMJ2001322:1043.
40.ManciaG,DeBackerG,DominiczakA,etal.2007GuidelinesfortheManagementofArterialHypertension:The
TaskForcefortheManagementofArterialHypertensionoftheEuropeanSocietyofHypertension(ESH)andof
theEuropeanSocietyofCardiology(ESC).JHypertens200725:1105.
41.FormanJP,BrennerBM.'Hypertension'and'microalbuminuria':thebelltollsforthee.KidneyInt200669:22.
7/6/2016
42.CuspidiC,LonatiL,MaccaG,etal.Cardiovascularriskstratificationinhypertensivepatients:impactof
echocardiographyandcarotidultrasonography.JHypertens200119:375.
43.BloodPressureLoweringTreatmentTrialists'Collaboration,TurnbullF,NealB,etal.Effectsofdifferent
regimenstolowerbloodpressureonmajorcardiovasculareventsinolderandyoungeradults:metaanalysisof
randomisedtrials.BMJ2008336:1121.
44.HebertPR,MoserM,MayerJ,etal.Recentevidenceondrugtherapyofmildtomoderatehypertensionand
decreasedriskofcoronaryheartdisease.ArchInternMed1993153:578.
45.EckelRH,JakicicJM,ArdJD,etal.2013AHA/ACCguidelineonlifestylemanagementtoreduce
cardiovascularrisk:areportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceon
PracticeGuidelines.JAmCollCardiol201463:2960.
46.HeFJ,LiJ,MacgregorGA.Effectoflongertermmodestsaltreductiononbloodpressure:Cochranesystematic
reviewandmetaanalysisofrandomisedtrials.BMJ2013346:f1325.
47.AppelLJ,BrandsMW,DanielsSR,etal.Dietaryapproachestopreventandtreathypertension:ascientific
statementfromtheAmericanHeartAssociation.Hypertension200647:296.
48.TuckML,SowersJ,DornfeldL,etal.Theeffectofweightreductiononbloodpressure,plasmareninactivity,
andplasmaaldosteronelevelsinobesepatients.NEnglJMed1981304:930.
49.WheltonPK,AppelLJ,EspelandMA,etal.Sodiumreductionandweightlossinthetreatmentofhypertensionin
olderpersons:arandomizedcontrolledtrialofnonpharmacologicinterventionsintheelderly(TONE).TONE
CollaborativeResearchGroup.JAMA1998279:839.
50.StevensVJ,CorriganSA,ObarzanekE,etal.Weightlossinterventioninphase1oftheTrialsofHypertension
Prevention.TheTOHPCollaborativeResearchGroup.ArchInternMed1993153:849.
51.AscherioA,RimmEB,GiovannucciEL,etal.Aprospectivestudyofnutritionalfactorsandhypertensionamong
USmen.Circulation199286:1475.
52.ElmerPJ,ObarzanekE,VollmerWM,etal.Effectsofcomprehensivelifestylemodificationondiet,weight,
physicalfitness,andbloodpressurecontrol:18monthresultsofarandomizedtrial.AnnInternMed2006
144:485.
53.RoumieCL,ElasyTA,GreevyR,etal.Improvingbloodpressurecontrolthroughprovidereducation,provider
alerts,andpatienteducation:aclusterrandomizedtrial.AnnInternMed2006145:165.
54.HoustonTK,AllisonJJ,SussmanM,etal.Culturallyappropriatestorytellingtoimprovebloodpressure:a
randomizedtrial.AnnInternMed2011154:77.
55.RosendorffC,BlackHR,CannonCP,etal.Treatmentofhypertensioninthepreventionandmanagementof
ischemicheartdisease:ascientificstatementfromtheAmericanHeartAssociationCouncilforHighBlood
PressureResearchandtheCouncilsonClinicalCardiologyandEpidemiologyandPrevention.Circulation2007
115:2761.
56.LawMR,MorrisJK,WaldNJ.Useofbloodpressureloweringdrugsinthepreventionofcardiovasculardisease:
metaanalysisof147randomisedtrialsinthecontextofexpectationsfromprospectiveepidemiologicalstudies.
BMJ2009338:b1665.
57.WebbAJ,FischerU,MehtaZ,RothwellPM.Effectsofantihypertensivedrugclassoninterindividualvariationin
bloodpressureandriskofstroke:asystematicreviewandmetaanalysis.Lancet2010375:906.
58.WaldDS,LawM,MorrisJK,etal.Combinationtherapyversusmonotherapyinreducingbloodpressure:meta
analysison11,000participantsfrom42trials.AmJMed2009122:290.
59.VokZ,BotsML,HofmanA,etal.Jshapedrelationbetweenbloodpressureandstrokeintreated
hypertensives.Hypertension199934:1181.
60.BangaloreS,QinJ,SloanS,etal.Whatistheoptimalbloodpressureinpatientsafteracutecoronary
syndromes?:RelationshipofbloodpressureandcardiovasculareventsinthePRavastatinORatorVastatin
EvaluationandInfectionTherapyThrombolysisInMyocardialInfarction(PROVEITTIMI)22trial.Circulation
2010122:2142.
61.SomesGW,PahorM,ShorrRI,etal.Theroleofdiastolicbloodpressurewhentreatingisolatedsystolic
hypertension.ArchInternMed1999159:2004.
62.delaSierraA,SeguraJ,BanegasJR,etal.Clinicalfeaturesof8295patientswithresistanthypertension
classifiedonthebasisofambulatorybloodpressuremonitoring.Hypertension201157:898.
63.SchmiederRE,RockstrohJK,MesserliFH.Antihypertensivetherapy.Tostopornottostop?JAMA1991
265:1566.
64.NelsonMR,ReidCM,KrumH,etal.Shorttermpredictorsofmaintenanceofnormotensionafterwithdrawalof
antihypertensivedrugsinthesecondAustralianNationalBloodPressureStudy(ANBP2).AmJHypertens2003
16:39.
65.FreisED,ThomasJR,FisherSG,etal.Effectsofreductionindrugsordosageafterlongtermcontrolof
systemichypertension.AmJCardiol198963:702.
66.FinnertyFAJr.Steppeddowntherapyversusintermittenttherapyinsystemichypertension.AmJCardiol1990
7/6/2016
66:1373.
Topic3852Version35.0
7/6/2016
GRAPHICS
PrevalenceofhypertensionintheUnitedStates
Prevalenceofhypertensioninmen(uppergraph)andwomen(lowergraph)according
toageandrace/ethnicityintheUnitedStatesfromtheNationalHealthandNutrition
ExaminationSurvey(NHANES).Hypertensionoccursearlierandmorefrequentlyin
nonHispanicblacks.
Datafrom:EganBM,ZhaoY,AxonRN.JAMA2010303:2043.
Graphic66935Version9.0
7/6/2016
Trendsintheawareness,treatment,andcontrolofhighbloodpressure
inadultsintheUnitedStates
NHANESII
19761980
NHANESIII
19881991
NHANESIII
19911994
NHANES
1999
2000
NHANES
2007
2008
Awareness
51
73
68
70
81
Treatment
31
55
54
59
72
Control*
10
29
27
34
50
Thedataareforadultswhoare18to74yearsofagewithasystolicpressure140mmHgand/or
adiastolicpressure90mmHg.
NHANES:NationalHealthandNutritionExaminationSurvey.
*Controlisdefinedasasystolicpressurebelow140mmHgandadiastolicpressurebelow90mmHg.
Adaptedfrom:TheSeventhReportoftheJointNationalCommitteeonPrevention,Detection,Evaluation,
andTreatmentofHighBloodPressure,JAMA2003289:2560,andfromUSTrendsinPrevalence,
Awareness,Treatment,andControlofHypertension19882008,JAMA2010303:2043.
7/6/2016
Guidelinesforthemeasurementofbloodpressuretodiagnoseand
treathypertension
Patientconditions
Posture
Initially,checkforposturalchangesbytakingreadingsafterfiveminutessupine,thenimmediately
andtwominutesafterstandingthisisparticularlyimportantinpatientsoverage65years,
diabetics,orthosetakingantihypertensivedrugs
Sittingpressuresarerecommendedforroutinefollowupthepatientshouldsitquietlywiththe
backsupportedforfiveminutesandthearmsupportedattheleveloftheheart
Circumstances
Nocaffeineduringthehourprecedingthereading,andnosmokingduringthepreceding30minutes
Noexogenousadrenergicstimulants,suchasphenylephrineindecongestantsoreyedropsfor
pupillarydilatation
Aquiet,warmsetting
Homereadingsshouldbetakenuponvaryingcircumstances
Equipment
Cuffsize
Thelengthofthebladdershouldbe80percent,andthewidthofthebladdershouldbeatleast40
percentofthecircumferenceoftheupperarm
Manometer
Aneroidgaugesshouldbecalibratedeverysixmonthsagainstamercurymanometer
Technique
Numberofreadings
Takeatleasttworeadingsoneachvisit,separatedbyasmuchtimeaspossibleifreadingsvaryby
morethan5mmHg,takeadditionalreadinguntiltwoconsecutivereadingsareclose
Forthediagnosisofhypertension,takethreereadingsatleastoneweekapart
Initially,takebloodpressureinbotharmsifpressuresdiffer,usethehigherarm
Ifthearmpressureiselevated,takethepressureinoneleg,particularlyinpatientsunderage30
years
Performance
Inflatethebladderquicklyto20mmHgabovethesystolicpressureasestimatedfromlossofradial
pulse
Deflatethebladder3mmHgpersecond
RecordtheKorotkoffphaseV(disappearance)asthediastolicpressureexceptinchildreninwhom
useofphaseIV(muffling)maybepreferable
IftheKorotkoffsoundsareweak,havethepatientraisethearm,openandclosethehandfiveto
tentimes,andtheninflatethebladderquickly
Recordings
Notethepressure,patientposition,arm,andcuffsize:eg,140/90,seated,rightarm,largeadultcuff
7/6/2016
Retinalfundusphotographsofhypertensiveretinopathy
Representativedigitalretinalfundusphotographsofmild(A,B),moderate(C,D),andsevere(E,F)
hypertensiveretinopathy,asgradedwiththesimplifiedclassification:
(A)Mildhypertensiveretinopathyisindicatedbythepresenceofgeneralizedarteriolarnarrowing,
arteriovenous(AV)nicking,andopacificationofthearteriolarwall("copperwiring").
(B)Mildhypertensiveretinopathywithfocalarteriolarnarrowing.
(C,D)Moderatehypertensiveretinopathywithmultipleretinalhemorrhagesandcottonwoolpatches.
(E,F)Severehypertensiveretinopathywithswellingoftheopticdisk,retinalhemorrhages,hard
exudates,andcottonwoolpatches.
From:DownieLE,HodgsonLA,DsylvaC,etal.Hypertensiveretinopathy:ComparingtheKeithWagenerBarkerto
asimplifiedclassification.JHypertens201331:960.DOI:10.1097/HJH.0b013e32835efea3.Reproducedwith
7/6/2016
permissionfromLippincottWilliams&Wilkins.Copyright2013InternationalSocietyofHypertensionand
EuropeanSocietyofHypertension.Unauthorizedreproductionofthismaterialisprohibited.
7/6/2016
Hypertensiveemergencies
GradesIIIIVhypertensiveretinopathywithseverelyelevatedbloodpressures
Cerebrovascular
Hypertensiveencephalopathy
Atherothromboticbraininfarctionwithseverehypertension
Intracerebralhemorrhage
Subarachnoidhemorrhage
Cardiac
Acuteaorticdissection
Acuteleftventricularfailure
Acuteorimpendingmyocardialinfarction
Aftercoronarybypasssurgery
Renal
Acuteglomerulonephritis
Renalcrisesfromcollagenvasculardiseases
Severehypertensionafterkidneytransplantation
Microangiopathichemolyticanemia
Excessivecirculatingcatecholamines
Pheochromocytomacrisis
Foodordruginteractionswithmonoamineoxidaseinhibitors
Sympathomimeticdruguse(cocaine)
Reboundhypertensionaftersuddencessationofantihypertensivedrugs
Eclampsia
Surgical
Severehypertensioninpatientsrequiringimmediatesurgery
Postoperativehypertension
Postoperativebleedingfromvascularsuturelines
Severebodyburns
Severeepistaxis
7/6/2016
Coronaryheartdiseasemortalityrelatedtobloodpressureand
age
Coronaryheartdisease(CHD)mortalityrate,picturedonalogscalewith95percent
confidenceintervals(CI),ineachdecadeofageinrelationtotheestimatedusual
systolicanddiastolicbloodpressureatthestartofthatdecade.CHDmortalityincreases
withbothhigherpressuresandolderages.Fordiastolicpressure,eachagespecific
regressionlineignoresthelefthandpoint(ie,atslightlylessthan75mmHg)forwhich
theriskliessignificantlyabovethefittedregressionline(asindicatedbythebrokenline
below75mmHg).
IHD:ischemicheartdisease.
Datafrom:LewingtonS,ClarkeR,QizilbashN,etal.Agespecificrelevanceofusualbloodpressure
tovascularmortality:ametaanalysisofindividualdataforonemillionadultsin61prospective
studies.Lancet2002360:1903.
7/6/2016
Strokemortalityrelatedtobloodpressureandage
Strokemortalityrate,picturedonalogscalewith95percentconfidenceintervals
(CI),ineachdecadeofageinrelationtotheestimatedusualsystolicand
diastolicbloodpressureatthestartofthatdecade.Strokemortalityincreases
withbothhigherpressuresandolderages.Fordiastolicpressure,eachage
specificregressionlineignoresthelefthandpoint(ie,atslightlylessthan75
mmHg),forwhichtheriskliessignificantlyabovethefittedregressionline(as
indicatedbythebrokenlinebelow75mmHg).
DatafromProspectiveStudiesCollaboration,Lancet2002360:1903.
7/6/2016
Additiveeffectsofriskfactorsoncardiovasculardiseaseatfive
years
CumulativeabsoluteriskofCVDatfiveyearsaccordingtosystolicbloodpressureand
specifiedlevelsofotherriskfactors.Thereferencecategoryisanondiabetic,
nonsmoking50yearoldwomanwithaserumTCof154mg/dL(4.0mmol/L)andHDL
cholesterolof62mg/dL(1.6mmol/L).TheCVDrisksaregivenforsystolicblood
pressurelevelsof110,130,150,and170mmHg.Intheothercategories,the
additionalriskfactorsareaddedconsecutively.Asanexample,thediabetescategory
isa50yearolddiabeticmanwhoisasmokerandhasaTCof270mg/dL(7mmol/L)
andHDLcholesterolof39mg/dL(1mmol/L).
BP:bloodpressureCVD:cardiovasculardiseaseTC:totalcholesterol.
Adaptedfrom:JacksonR,LawesCM,BennettDA,etal.Lancet2005365:434.
7/6/2016
CardiovascularriskwithLVHbyechocardiography
Fouryear,ageadjustedincidenceofcardiovasculareventsinmenand
womenintheFraminghamStudyaccordingtoleftventricularmass
determinedbyechocardiography.Subjectswithincreasedleft
ventricularmass(farrightpanel)hadamarkedincreasein
cardiovascularrisk.
LVH:leftventricularhypertrophyCV:cardiovascular.
Adaptedfrom:LevyD,GarrisonRJ,SavageDD,etal.Prognosticimplicationsof
echocardiographicallydeterminedleftventricularmassintheFraminghamHeart
Study.NEnglJMed1990322:1561.
7/6/2016
RelationbetweenhypertensionanddevelopmentofESRD
Cumulativeincidenceofendstagerenaldisease(ESRD),duetoanycause,accordingtobloodpressure
categoryin332,544menscreenedfortheMRFITtrial.Theadjustedrelativeriskincreasedfrom1.0inthose
withoptimalbloodpressure(<120/<80)to1.9withhighnormalbloodpressure,3.1withmildhypertension,
6.0withmoderatehypertension,and11.2withseverehypertension.Patientswithstage1hypertensionor
lowerbloodpressurewereatverylowriskofESRDat16years(0.34percent).
Redrawnfrom:KlagMJ,WheltonPK,RandallBL,etal.Bloodpressureandendstagerenaldiseaseinmen.NEnglJMed
1996334:13.
7/6/2016
Approachtothediagnosisofhypertensioninadults
7/6/2016
7/6/2016
AllbloodpressurevaluesareinmmHg.Criteriaaremetifeitherthesystolicordiastolicpressurethresholdis
met(itisnotnecessaryforbothtobemetsimultaneously).
AcceptablemethodsforambulatoryandhomebloodpressuremonitoringarediscussedintheUpToDatetopic
bloodpressuremeasurementinthediagnosisandmanagementofhypertension.Ambulatorybloodpressure
monitoringisperformedbyhavingthepatientwear,typicallyfor24hours,anelectronicbloodpressurecuff
thatautomaticallymeasuresthebloodpressure,usuallyeveryhalfhourduringthedayandhourlyatnight
meanvaluesareusedtodeterminethepresenceofhypertension.Homebloodpressuremonitoringis
performed,usuallybythepatientorafamilymember,usinganelectronicormanualbloodpressurecuff.
Automatedofficebloodpressureisperformedusingadevicethatcanautomaticallytakeandaveragemultip
consecutivemeasurementswhilethepatientisaloneinaroom.Therearemanyacceptabledevicesfor
automatedofficebloodpressuremeasurement.ExamplesincludetheBpTRU,MicrolifeWatchBPOffice,and
OmronHEM907devices.
BP:bloodpressureAOBP:automatedofficebloodpressureABPM:ambulatorybloodpressuremonitoring.OfficeBPrefers
manual(auscultatory)bloodpressurethatiscommonlyperformedinroutinepractice.
*Ifthebloodpressureisthiselevated,oriftherearesignsandsymptomsofhypertensiveemergencyatanypointlateri
thealgorithm,adiagnosisofhypertensioncanbemade.Signsandsymptomsofahypertensiveemergencyinclude
headache,alteredmentalstatus,nausea,vomiting,chestpain,amongothersdetailscanbefoundintheUpToDatetopic
evaluationandtreatmentofhypertensiveemergenciesinadults.
Avarietyofmethodsforhomebloodpressuremeasurementhavebeenused.Acommonstrategyistohavethepatient
measurehisorherbloodpressuretwicedaily(morningandevening)forsevendays.Readingsfromthefirstdayare
discarded,andtheremaining12valuesareaveraged.
Inmostinstances,homebloodpressuremeasurementshouldbepossible.Inexpensivedevicestomeasurebloodpressu
athomeareavailable.Alternatively,homebloodpressuredevicescanbeborrowed(eg,providedbytheclinic),orblood
pressurecanbemeasuredatwork.
Oncehomebloodpressureisdocumentedtobenormal,raisingsuspicionforwhitecoathypertension,insurancecoverag
forambulatorybloodpressuremonitoringmaybesimplertoacquire.Ambulatorybloodpressuremonitoringmaybeavaila
throughaspecialist,ifnotofferedbytheprimarycareprovider.
Beforerepeatingthebloodpressuremeasurementintheoffice,contributingcausesofhypertensionshouldberemoved
possible,suchasdecongestants,nonsteroidalantiinflammatorydrugs,andothersdetailscanbefoundintheUpToDate
overviewtopiconhypertensioninadults.
Targetorgandamageofhypertensionincludeshypertensiveretinopathy,leftventricularhypertension,andotherfinding
detailscanbefoundintheUpToDateoverviewtopiconhypertensioninadults.
7/6/2016
Clinicalfeaturesofthedifferentcausesofsecondaryhypertension
Disorder
General
Suggestiveclinicalfeatures
Severeorresistanthypertension
Anacuteriseinbloodpressureoverapreviouslystablevalue
Provenageofonsetbeforepuberty
Agelessthan30yearswithnofamilyhistoryofhypertensionandnoobesity
Renovascular
Anacuteelevationinserumcreatinineofatleast30%afteradministrationof
disease
angiotensinconvertingenzyme(ACE)inhibitororangiotensinIIreceptor
blocker(ARB)
Moderatetoseverehypertensioninapatientwithdiffuseatherosclerosis,a
unilateralsmallkidney,orasymmetryinrenalsizeofmorethan1.5cmthat
cannotbeexplainedbyanotherreason
Moderatetoseverehypertensioninpatientswithrecurrentepisodesofflash
pulmonaryedema
OnsetofstageIIhypertensionafterage55years
Systolicordiastolicabdominalbruit(notverysensitive)
Primaryrenal
disease
Elevatedserumcreatinineconcentration
Oralcontraceptives
Newelevationinbloodpressuretemporallyrelatedtouse
Abnormalurinalysis
NSAIDs
Stimulants(eg,
cocaine,
methylphenidate)
Calcineurin
inhibitors
Antidepressants
Pheochromocytoma
Paroxysmalelevationsinbloodpressure
Triadofheadache(usuallypounding),palpitations,andsweating
Primary
aldosteronism
Unexplainedhypokalemiawithurinarypotassiumwastinghowever,morethan
onehalfofpatientsarenormokalemic
Cushing'ssyndrome
Cushingoidfacies,centralobesity,proximalmuscleweakness,andecchymoses
Mayhaveahistoryofglucocorticoiduse
Sleepapnea
syndrome
Primarilyseeninobesemenwhosnoreloudlywhileasleep
Daytimesomnolence,fatigue,andmorningconfusion
Coarctationofthe
Hypertensioninthearmswithdiminishedordelayedfemoralpulsesandlowor
aorta
unobtainablebloodpressuresinthelegs
Leftbrachialpulseisdiminishedandequaltothefemoralpulseiforiginofthe
leftsubclavianarteryisdistaltothecoarct
Hypothyroidism
Symptomsofhypothyroidism
Elevatedserumthyroidstimulatinghormone
Primary
Elevatedserumcalcium
hyperparathyroidism
NSAID:nonsteroidalantiinflammatorydrug.
7/6/2016
7/6/2016
Importantaspectsofthehistoryinthepatientwithhypertension
Durationofhypertension
Presenceofotherriskfactors
Lastknownnormalbloodpressure
Smoking
Courseofthebloodpressure
Diabetes
Priortreatmentofhypertension
Drugs:types,doses,sideeffects
Intakeofagentsthatmaycause
hypertension
Dyslipidemia
Physicalinactivity
Dietaryhistory
Sodium
Nonsteroidalantiinflammatorydrugs
Alcohol
Estrogens
Saturatedfats
Adrenalsteroids
Psychosocialfactors
Cocaine
Familystructure
Sympathomimetics
Workstatus
Excessivesodium
Educationallevel
Familyhistory
Hypertension
Prematurecardiovasculardiseaseordeath
Familialdiseases:pheochromocytoma,renal
disease,diabetes,gout
Symptomsofsecondarycauses
Muscleweakness
Sexualfunction
Featuresofsleepapnea
Earlymorningheadaches
Daytimesomnolence
Loudsnoring
Erraticsleep
Spellsoftachycardia,sweating,tremor
Thinningoftheskin
Flankpain
Symptomsoftargetorgandamage
Headaches
Transientweaknessorblindness
Lossofvisualacuity
Chestpain
Dyspnea
Claudication
7/6/2016
Importantaspectsofthephysicalexaminationinthehypertensive
patient
Accuratemeasurementofbloodpressure
Generalappearance
Distributionofbodyfat
Skinlesions
Musclestrength
Alertness
Fundoscopy
Hemorrhage
Papilledema
Cottonwoolspots
Neck
Palpationandauscultationofcarotids
Thyroid
Heart
Size
Rhythm
Sounds
Lungs
Rhonchi
Rales
Abdomen
Renalmasses
Bruitsoveraortaorrenalarteries
Femoralpulses
Extremities
Peripheralpulses
Edema
Neurologicassessment
Visualdisturbance
Focalweakness
Confusion
7/6/2016
Cardiovascularbenefitoftreatingmildhypertension
Reducedincidenceoffatalandtotalcoronaryheartdisease(CHD)events
andstrokesfollowingantihypertensivetherapyin17controlledstudies
involvingalmost48,000patientswithmildtomoderatehypertension.The
numberofpatientshavingeachoftheseeventsisdepicted,withactive
treatmentloweringtheincidenceofcoronaryeventsby16percentand
strokeby40percent.However,theabsolutebenefitasshown,inpercent,
bythenumbersatthetopofthegraphwasmuchless.Treatmentfor
approximatelyfourtofiveyearspreventedacoronaryeventorastrokein
2percentofpatients(0.7+1.3),includingpreventionofdeathin0.8
percent.
CVA:cerebrovascularaccident(stroke).
Datafrom:HebertPR,MoserM,MayerJ,etal.Recentevidenceondrugtherapyof
mildtomoderatehypertensionanddecreasedriskofcoronaryheartdisease.Arch
InternMed1993153:578.
7/6/2016
Lifestylemodificationsinthemanagementofhypertension
Approximate
systolicBP
reduction,
range*
Modification
Recommendation
Weightreduction
Maintainnormalbodyweight(BMI,18.5to24.9kg/m 2)
5to20mmHgper10
kgweightloss
AdoptDASH
Consumeadietrichinfruits,vegetables,andlowfat
8to14mmHg
eatingplan
dairyproductswithareducedcontentofsaturatedand
totalfat
Dietarysodium
Reducedietarysodiumintaketonomorethan100
reduction
meq/day(2.4gsodiumor6gsodiumchloride)
Physicalactivity
Engageinregularaerobicphysicalactivitysuchasbrisk
2to8mmHg
4to9mmHg
walking(atleast30minutesperday,mostdaysofthe
week)
Moderationof
Limitconsumptiontonomorethan2drinksperdayin
alcohol
mostmenandnomorethan1drinkperdayinwomen
consumption
andlighterweightpersons
2to4mmHg
Foroverallcardiovascularriskreduction,stopsmoking.Theeffectsofimplementingthese
modificationsaredoseandtimedependentandcouldbehigherforsomeindividualstheyarenot
alladditive.
BMI:bodymassindexBP:bloodpressureDASH:DietaryApproachestoStopHypertension.
Reproducedfrom:TheSeventhReportoftheJointNationalCommitteeonPrevention,Detection,Evaluation,
andTreatmentofHighBloodPressure.Availableat
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.
7/6/2016
Considerationsforindividualizingantihypertensivetherapy
Indication
Antihypertensivedrugs
Compellingindications(majorimprovementinoutcomeindependentofbloodpressure)
Systolicheartfailure
ACEinhibitororARB,betablocker,diuretic,aldosterone
antagonist*
Postmyocardialinfarction
ACEinhibitor,betablocker,ARB,aldosteroneantagonist
Proteinuricchronickidney
ACEinhibitororARB
disease
Anginapectoris
Betablocker,calciumchannelblocker
Atrialfibrillationratecontrol
Betablocker,nondihydropyridinecalciumchannelblocker
Atrialflutterratecontrol
Likelytohaveafavorableeffectonsymptomsincomorbidconditions
Benignprostatichyperplasia
Alphablocker
Essentialtremor
Betablocker(noncardioselective)
Hyperthyroidism
Betablocker
Migraine
Betablocker,calciumchannelblocker
Osteoporosis
Thiazidediuretic
Raynaud'ssyndrome
Dihydropyridinecalciumchannelblocker
Contraindications
Angioedema
ACEinhibitor
Bronchospasticdisease
Betablocker
Depression
Reserpine
Liverdisease
Methyldopa
Pregnancy(oratriskfor)
ACEinhibitor,ARB,renininhibitor
Secondorthirddegreeheart
block
Mayhaveadverseeffectoncomorbidconditions
Depression
Betablocker,centralalpha2agonist
Gout
Diuretic
Hyperkalemia
Aldosteroneantagonist,ACEinhibitor,ARB,renininhibitor
Hyponatremia
Thiazidediuretic
Renovasculardisease
ACEinhibitor,ARB,orrenininhibitor
ACE:angiotensinconvertingenzymeARB:angiotensinreceptorblocker.
*AbenefitfromanaldosteroneantagonisthasbeendemonstratedinpatientswithNYHAclassIIIIVheart
failureordecreasedleftventricularejectionfractionafteramyocardialinfarction.
Adaptedfrom:TheseventhreportoftheJointNationalCommitteeonprevention,detection,evaluation,and
treatmentofhighbloodpressure.JAMA2003289:2560.
7/6/2016
Bloodpressurechangeandsodiumreduction
Pooledresultsfromallsodiumreductiontrialsconcerningthemeannetchangeinblood
pressureduetorestrictionsinsodiumintakeamongvarioussubsetsofpatients.
SBP:systolicbloodpressureDBP:diastolicbloodpressure.
*Themeanchangeiscomparedwithcontrolvalues.
Datafrom:CutlerJA,FollmannD,AllenderPS.AmJClinNutr199765:643S.
7/6/2016
Weightlossinducedreductionindiastolicblood
pressure
Relationshipbetweenthequantityofweightlostandthefallindiastolic
bloodpressurein308moderatelyobesepatientsgivenaweight
reductionregimenfor18months.Thepatientsbeganwithadiastolic
pressurebetween80and89mmHgthosewholostthemostweighthad
thelargestreductionindiastolicpressure.Thedecreasesinthesystolic
pressureweresimilar.
BP:bloodpressure.
Datafrom:StevensVJ,CorriganSA,ObarzanekE,etal.Weightlossintervention
inphase1oftheTrialsofHypertensionPrevention.TheTOHPCollaborative
ResearchGroup.ArchInternMed1993153:849.
7/6/2016
ContributorDisclosures
JanBasile,MDGrant/Research/ClinicalTrialSupport:NHLBI[Hypertension].Speaker'sBureau:Arbor
Pharmaceuticals[Hypertension(Azilsartan)]Janssen[Diabetes(Canagliflozin)].Consultant/AdvisoryBoards:Actavis
[Hypertension(Nebivolol)]Amgen[Lipidlowering(Evolocumab)]ArborPharmaceuticals[Hypertension(Azilsartan)]
Lilly[Diabetes(Dulaglutide)]Janssen[Diabetes(Canagliflozin)].MichaelJBloch,MD,FACP,FASH,FSVM,FNLA
Grant/Research/ClinicalTrialSupport:AstraZeneca[Diabetes(Dapagliflozin)].Speaker'sBureau:Jansen
[Anticoagulation(Rivaroxaban)]Amgen[Lipids(Evolucumab)]Lumbeck[Orthostaticintolerance(Droxidopa)].
Consultant/AdvisoryBoards:Amgen[Lipids(Evolucumab)]Lumbeck[Orthostaticintolerance(Droxidopa)]Takeda
[Hypertension(Azilsartan)].GeorgeLBakris,MDGrant/Research/ClinicalTrialSupport:Bayer,BoehringerIngelheim,
Relypsa,VascularDynamics,Medtronic[Diabeticneuropathy,diabetes,hypertension(Empagliflozin,patiromer)].
Consultant/AdvisoryBoards:AstraZeneca,ArborPharmaceuticals,Bayer,BoehringerIngelheim,Relypsa,Vascular
Dynamics,Medtronic[Diabeticneuropathy,diabetes,hypertension(Empagliflozin,patiromer)].NormanMKaplan,
MDNothingtodisclose.JohnPForman,MD,MScNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressed
byvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthe
content.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsof
evidence.
Conflictofinterestpolicy

Overview of Hypertension in Adults

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Overview of Hypertension in Adults

Uploaded by

Copyright:

Available Formats

7/6/2016

You might also like