Hypertension

Hypertension Main page
Overview
Causes
Classification Primary Hypertension Secondary Hypertension Hypertensive Emergency Hypertensive Urgency
Screening

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Overview

Historical Perspective

• [Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
• In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
• In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].

Classification

Hypertension may be classified according to the underlying disorder into two groups:

• Primary hypertension

• Gradually rising in blood pressure
• History of environmental exposure (weight gain, high-sodium diet, decreased physical activity, job change leading increased travel, excessive consumption of alcohol
• Family history of hypertension

• Secondary hypertension

• BP lability, suddenly rising BP with pallor and dizziness (pheochromocytoma)
• Snoring, hypersomnolence (obstructive sleep apnea)
• Prostatism (chronic kidney disease due to post-renal urinary tract obstruction)
• Muscle cramps, weakness (hypokalemia from primary aldosteronism or secondary aldosteronism due to renovascular disease)
• Weight loss, palpitations, heat intolerance (hyperthyroidism)
• Edema, fatigue, frequent urination (kidney disease or failure)
• History of coarctation repair (residual hypertension associated with coarctation)
• Central obesity, facial rounding, easy bruisability (Cushing syndrome)
• Medication or substance use(alcohol, NSAIDS, cocaine, amphetamines
• Absence of family history of hypertension

• Resistant hypertension is defined as a higher level of BP above the goal in spite of concurrent use of three antihypertensive drugs including a long-acting calcium channel blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a diuretic.

Hypertension Guidline	ACC/AHA	ESC/ESH
Definition of hypertension (mmHg)	≥130/80	≥140/90
Normal blood pressure range (mmHg)	Normal: <120/80 Elevated:120-129/<80	Optimal:<120/80 Normal:120-129/80-84 High normal:130-139/85-89
Hypertension stage (mmHg)	Stage1:130-139/80-89 Stage2: ≥140/90	Grade1:140-159/90-99 Grade2:160-179/100-109 Grade3: ≥180/110
Age specific blood pressure targets(9mmHg)	<65 years:<130/80 ≥65 years:<130/80	<65years:<120-129/70-79 >65 years:<130-139/70-79

Blood pressure category	Systolic blood pressure	Diastolic blood pressure
Normal	<120/80 mmHg	<80 mmHg
Elevated	120-129 mmHg	<80 mmHg
Stage 1 hypertension	130–139 mm Hg	80–89 mm Hg
Stage 2 hypertension	≥140 mm Hg	≥90 mm Hg

Pathophysiology

• The pathogenesis of [disease name] is characterized by [feature1], [feature2], and [feature3].
• The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
• On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
• On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Causes

Common causes of hypertension include:

• Genetic susceptibility

• Hypertension is a Polygenic disorder
• Findings of 25 rare mutations,120 single-nucleotide polymorphisms in hypertensive patients
• Monogenic forms of hypertension: glucocorticoid-remediable aldosteronism, Liddle syndrome, Gordon’s syndrome
• Association between high blood pressure with age and increased defects in the gene

Environmental exposure

• Overweight, obesity

• Direct relationship between body mass index and BP
• Strong relationship between waist-to hip ratio, distribution of central fat and BP
• Relation between Obesity at a young age with further hypertension

• Sodium intake

• Association between sodium intake and BP in migrants
• Triat of salt sensitivity in blacks, older adults, patients with higher level of BP, CKD, DM, metabolic syndrome

• Potassium

• Inverse relation with BP
• Inverse relation with stroke
• Higher level of [[potassium] may reduce the effect of sodium on BP

• Physical fitness

• Inverse relation between physical fitness and physical activity with BP
• Modest exercise activity reduces the risk of BP

• Alcohol

Pharmacological causes of hypertension	Management:
Alcohol	Limiting alcohol to ≤1 drink daily for women and ≤2 drinks for men
Amphetamines ( amphetamine, methylphenidate, dextroamphetamine)	Discontinue or decrease dose Behavior therapy for ADHD
Antidepressants (MAOI, SNRI, TCA)	Using alternative agents such as SSRI Avoidance of taking tyramine-containing foods with MAOI
Atypical antipsychotics (clozapine, olanzapine)	Discontinue or decrease the dose Using alternative agents such as aripiprazole, ziprasidone with a lower risk of weight gain, diabetes mellitus, dyslipidemia
Caffeine	Limiting caffeine intake to <300 mg/day in uncontrolled hypertension cause of increasing blood pressure in hypertensive patients No relationship between longterm use of [[coffeine] and hypertension or cardiovascular disease
Decongestants (phenylephrine, pseudoephedrine)	Avoidance in severe uncontrolled hypertension Using shortest duration types Using alternative agents such as nasal saline, intranasal corticosteroids, antihistamines
Herbal supplements such as Ma Huang ephedra, St. John’s wort (with MAO inhibitors, yohimbine)	Avoid use
Immunosuppressants (cyclosporine)	Using alternative agent such as tacrolimus with less effect on blood pressure
Oral contraceptives	Avoidance in uncontrolled hypertension Using progestin only form Using low dose 20-30 mcg ethinyl estradiol agents Alternative agents (barrier, abstinence, IUD)
NSAIDs	Using alternative agents such as acetaminophen, tramadol, topical NSAIDs
Recreational drugs (bath salts MDPV, cocaine, methamphetamine	Avoide use
Systemic corticosteroids ( dexamethasone, fludrocortisone, methylprednisolone, prednisone, prednisolone)	Using alternative agents ( inhaled, topical)

Differentiating [disease name] from other Diseases

• [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as:

• [Differential dx1]
• [Differential dx2]
• [Differential dx3]

Epidemiology and Demographics

• The prevalence of [disease name] is approximately [number or range] per 100,000 individuals worldwide.
• In [year], the incidence of [disease name] was estimated to be [number or range] cases per 100,000 individuals in [location].

Age

• Patients of all age groups may develop [disease name].

• [Disease name] is more commonly observed among patients aged [age range] years old.
• [Disease name] is more commonly observed among [elderly patients/young patients/children].

Gender

• [Disease name] affects men and women equally.

• [Gender 1] are more commonly affected with [disease name] than [gender 2].
• The [gender 1] to [Gender 2] ratio is approximately [number > 1] to 1.

Race

• There is no racial predilection for [disease name].

• [Disease name] usually affects individuals of the [race 1] race.
• [Race 2] individuals are less likely to develop [disease name].

Risk Factors

• Common risk factors in the development of hypertension are Diabetes mellitus Family history of hypertension, Dyslipidemia, Increased age, Obesity, Low socioeconomic state, Physical inactivity/low fitness, Male sex, Unhealthy diet, Obstructive sleep apnea, Psychological stress.

Modifiable risk factors	Fixed risk factors
Current smoker, secondhand smoking	Chronic kidney disease
Diabetes mellitus	Family history
Dyslipidemia/hypercholesterolemia	Increased age
Obesity	Low socioeconomic/educational status
Physical inactivity/low fitness	Male sex
Unhealthy diet	Obstructive sleep apnea Psychological stress

Natural History, Complications and Prognosis

• The majority of patients with [disease name] remain asymptomatic for [duration/years].
• Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
• If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
• Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
• Prognosis is generally [excellent/good/poor], and the [1/5/10­year mortality/survival rate] of patients with [disease name] is approximately [#%].

New onset or uncontrolled hypertension in adult

* Drug resistance hypertension Abrupt onset of hypertension Onset of hypertension before 30 years old Worsening of previous controlled hypertension Target organ damage Accelerated, malignant hypertension Onset of diastolic hypertension ≥ 65 years old Unprovoked hypokalemia

Yes

No

Screening for secondary hypertension

No need for screening

Conditions	Clinical features
Renal parenchymal disease	Urinary tract infection Urinary tract obstruction Hematuria Urinary frequency, nocturia Analgesic abuse Family history of polycystic kidney disease Increased serum creatinine Abnormal urinalysis
Renovascular disease	Resistant hypertension Abrupt onset of hypertension or sustained hypertension worsening or difficult to control Flash pulmonary edema Early-onset hypertension, especially in women (fibromuscular hyperplasia)
Primary aldosteronism	Resistant hypertension Hypertension with hypokalemia (spontaneous or diuretic-induced) Hypertension and muscle cramps or weakness Hypertension and incidentally discovered [[adrenal mass] Hypertension and obstructive sleep apnea Hypertension and family history of early-onset hypertension or stroke
Obstructive sleep apnea	Resistant hypertension Snoring Breathing pauses during sleep Daytime sleepiness
Drug or alcohol induced	Sodium-containing antacids Caffeine Nicotine (smoking) Alcohol NSAIDs Oral contraceptives Cyclosporine or tacrolimus Sympathomimetics (decongestants, anorectics) Cocaine Amphetamines Neuropsychiatric agents Erythropoiesis-stimulating agents Clonidine withdrawal Herbal agents (Ma Huang, ephedra)
Pheochromocytoma/paraganglioma	Resistant hypertension Paroxysmal hypertension Hypertension crisis superimposed on sustained hypertension(Spell) Blood pressure lability Headache, sweating, palpitations, pallor Family historyof pheochromocytoma/paraganglioma Adrenal incidentaloma
Cushing syndrome	Rapid weight gain, especially with central distribution Proximal muscle weakness Depression Hyperglycemia
Hypothyroidism	Dry skin Cold intolerance Constipation Hoarseness Weight gain
Hypethyroidism	Warm, moist skin Heat intolerance nervousness Tremulousness Insomnia Weight loss Diarrhea Proximal muscle weakness
Coarctation of aorta	Hypertension before 30 years old
Primary hyperparathyroidism	Hypercalcemia
Congenital adrenal hyperplasia	Hypertension and hypokalemia Virilization (11-beta-hydroxylase deficiency Masculinization in males and Primary amenorrhea in females (17-alpha-hydroxylase deficiency|)
Mineralocorticoid excess syndromes other than primary aldosteronism	Early-onset hypertension Resistant hypertension hypokalemia or hyperkalemia
Acromegaly	Acral features Enlarging shoe, glove, or hat size Headache Visual disturbances Diabetes mellitus

Diagnosis

Diagnostic Criteria

• The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:

• [criterion 1]
• [criterion 2]
• [criterion 3]
• [criterion 4]

Blood pressure measurement	Definition
Systolic blood pressure (SBP)	First Korotkoff sound
Diastolic blood pressure(DBP)	Fifth Korotkoff sound
Pulse pressure	SBP minus DBP
Mean arterial pressure	DBP plus one third pulse pressure
Mid- blood pressure	(SBP+DBP) divided by 2

Key steps for accurate blood pressure measurement	Educations
Properly prepare the patient	Have the patient relax, sitting on a chair, feet on the floor, back supported for more than 5 minutes Avoidance of coffeine, smoking, exercise for at least 30 minutes before measurement Emptying bladder before measurement No talk during measurement Removing all clothing covered the cuff location
Using proper technique	cuff size 80 % of arm
Taking proper measurement	Recording blood pressure in both arms at the first visit Using the arm with higher blood pressure for the latter measurement 1-2 minutes between two measurements Cuff inflation 20-30 mmHg above the palpable radial pulse and deflation with the speed of 2 mmHg/seconds
Documentation of reading blood pressure	[[ Systolic blood pressure] is the onset of the first Korotkoff sound and [[diastolic blood pressure] is the disappearance of all Korotkoff sounds
Average the reading	using ≥2 readings obtained on ≥2 occasions for determination the level of blood pressure
Providing blood pressure reading to patient	Providing patients the SBP/DBP readings both verbally and in writing

Arm circumference	cuff size
22-26 cm	Small adult
27-34 cm	Adult
35-44 cm	Large adult
45-52 cm	Adult thigh

Office BP≥130/80 mm Hg, but < 160/100 mmHg after 3 months of life style modification, suspected white coat hypertension

Daytime ABPM or HBPM, BP<130/80 mmHg

Yes White coat hypertension Annual ABPM or HBPM for detection of progression (class 2a)

NO Hypertension Life style modification and starting antihypertensive drug therapy (class 2a)

Office BP: 120-129/<80 mmHg after 3 months of lifestyle modification, suspected masked hypertension

Daytime ABPM or HBPM, BP≥130/80 mm Hg

Yes Masked hypertension Lifestyle modification, antihypertensive therapy (class 2a)

NO Elevated BP Lifestyle modification Annual ABPM or HBPM (class2a)

2017 ACC/AHA Guideline	Screening for Primary adlostronism:
Class of recommendation:I Level of evidence:C	Resistant hypertension, Hypokalemia ( diuretic-induced), Incidentally discovered adrenal mass Family history of early-onset hypertension or stroke at a young age (<40 years)

History and Symptoms

• [Disease name] is usually asymptomatic.
• Symptoms of [disease name] may include the following:

• [symptom 1]
• [symptom 2]
• [symptom 3]
• [symptom 4]
• [symptom 5]
• [symptom 6]

Physical Examination

• Patients with [disease name] usually appear [general appearance].
• Physical examination may be remarkable for:

• [finding 1]
• [finding 2]
• [finding 3]
• [finding 4]
• [finding 5]
• [finding 6]

Conditions	Physical examination
Renal parenchymal disease	Abdominal mass (polycystic kidney disease) Skin pallor
Renovascular disease	Abdominal systolic or diastolic bruit Femoral or carotid arteried bruits
Primary aldosteronism	Arrhythmias with hypokalemia Atrial fibrillation
Obstructive sleep apnea	Overweight Short, thick neck loss of normal nocturnal blood pressure fall
Drug or alcohol induced	Fine tremor, Tachycardia, Sweating (cocaine, ephedrine, MAO inhibitors) Acute abdominal pain (cocaine)
Pheochromocytoma/paraganglioma	Skin stigmata of neurofibromatosis (cafe-au-lait spots, neurofibromas) Orthostatic hypotension
Cushing syndrome	Central obesity Moon face Dorsal and supraclavicular fat pads, Violaceous striae Hirsutism
Hypothyroidism	Delayed ankle reflex Periorbital puffiness Coarse skin Cold skin Slow movement Goiter
Hyperthyroidism	Lid lag Fine tremor Warm, moist skin
Coarctation of aorta	Blood pressure higher in upper extremities than in lower extremities Absent femoral pulses continuous murmur over patient’s back, chest Abdominal bruit
Congenital adrenal hyperplasia	Signs of virilization (11-beta-OH) or incomplete masculinization (17-alpha-OH)
Acromegaly	Acral features Large hands and feet Frontal bossing

Laboratory Findings

• Basic laboratory test should be taken in patients with the diagnosis of hypertension include:

• Fasting blood sugar
• Complete blood count
• Lipid profile
• Serum creatinine with eGFR
• Serum sodium, potassium, calcium
• Thyroid-stimulating hormone
• Urinalysis

• Optional laboratory test in hypertensive patients include:

• Uric acid
• Urinary albumin to creatinine ratio

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

There are no other diagnostic studies associated with [disease name].

OR

[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

• There is no treatment for [disease name]; the mainstay of therapy is supportive care.

• The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Treatment strategy

Nomal BP (BP<120/80 mmHg)

Elevated BP(BP120-129/<80mmHg

Stage1 hypertension(BP 130-139/80-89mmHg

Stage 2 hypertension (BP≥ 140/90

Life style modifications

Nonpharmocological therapy(class1)

10 years CVD risk≥ 10%

Non pharmacological therapy and BPlowering medication

Reevaulation in 1 year (class 2a)

Reevaulation in 3-6 months(class 1)

Nonpharmocological therapy(class1)

Non pharmacological therapy and BPlowering medication

Reevaulation in 3-6 months(class 1)

Reevaulation in 1 months(class 1)

BPgoal reached

NO, Evaluation and optimization the adherence to medical therapy

Yes,Reevaulation in 3-6 months(class 1)

Intensification of medical therapy

First line of treatment	Drug_ Dosage(mg/day)_ Frequency	Comments
Thiazide or thiazidetype diuretics	Chlorthalidone 12.5–25 1 Hydrochlorothiazide 25–50 1 Indapamide 1.25–2.5 1 Metolazone 2.5–5 1	Chlorthalidone is a prolonged half-life drug and reduces cardiovascular risk Hyponatremia, hypokalemia, uric acid and calcium levels should be monitored
ACE inhibitors	Benazepril 10–40 1-2 Captopril 12.2-150 2-3 Enalapril 5-40 1-2 Fosinopril 10–40 1 Lisinopril 10-40 1 Moexipril 7.5–30 1-2 Perindopril 4-16 1 Quinapril 10-80 1-2 Ramipril 2.5-20 1-2 Trandolapril 1-4 1	Avoidance of using in combination with ARB and direct renin inhibitor Using with caution in CKD or in patients are on K sparing agents due to the risk of hyperkalemia Avoidance in pregnancy Avoidance in patients with a history of angioedema with ACEI Avoidance in severe bilateral renal artery stenosis
ARB	Azilsartan 40-80 1 Candesartan 8–32 1 Eprosartan 600-800 1-2 Irbesartan 150-300 1 Losartan 50-100 1-2 Olmesartan 20-40 1 Telmisartan 20-80 1 Valsartan 80-320 1	Avoidance of using in combination with ACEI or direct renin inhibitor Using with caution in CKD or in patients are on K sparing drugs due to the risk of hyperkalemia Avoidance in pregnancy Avoidance in patients with a history of angioedema with ARB It can be used in patients with a history of angioedema with ACEI after 6 weeks of discontinuation of ACEI Avoidance in severe bilateral renal artery stenosis
CCB—dihydropyridines	Amlodipine 2.5–10 1 Felodipine 2.5–10 1 Isradipine 5–10 2 Nicardipine SR 60–120 2 Nifedipine LA 30–90 1 Nisoldipine 17–34 1	Avoidance of using in heart failure reduced EF except amlodipine,felodipine Pedal edema is dose associated, more common in women
CCB—nondihydropyridines	Diltiazem ER 120–360 1 Verapamil IR 120–360 3 Verapamil SR 120–360 1-2 Verapamil-delayed onset ER 100–300 1 (in the evening)	Avoidance of using in combination with betablocker due to the risk of bradycardia Avoidance of using in heart failure reduced EF Avoidance of using diltiazem with verapamil due to drug interaction via CYP3A4
Second line of treatment	Drug_ Dosage(mg/day)_ Frequency	Comments
Diuretics—loop	Bumetanide 0.5–2 2 Furosemide 20–80 2 Torsemide 5–10 1	Preferred diuretic in symptomatic heart failure Preffered diuretic in moderate to severe CKD (GFR<30 cc/min)
Diuretics—potassium sparing	Amiloride 5–10 1-2 Triamterene 50–100 1-2	Mild antihypertensive effect Useful for treatment of hypokalemia due to thiazide monotherapy Avoidance of using in patients with significant CKD (GFR <45 mL/min).
Diuretics—aldosterone antagonists	Eplerenone 50–100 1-2 Spironolactone 25–100 1	Preferred for primary aldostronism and resistant hypertension Add-on therapy in resistant hypertension Lesser risk of gyncomasty and impotence with eplerenone Avoidance of combination therapy with K sparing agents
Betablocker-cardioselective	Atenolol 25–100 2 Betaxolol 5–20 1 Bisoprolol 2.5–10 1 Metoprolol tartrate 100–200 2 Metoprolol succinate 50–200 1	Beta-blockers are not first-line therapy of hypertension unless in the presence of IHD orheart failure Preferredbeta-blockers in bronchospastic airway disease preferred Bisoprolol, metoprolol succinate in heart failure reduced EF
Betablocker-cardioselective and vasodilatory	Nebivolol 5–40 1	Induction of nitric oxide Vasodilarory effect
Beta blockers—noncardioselective	Nadolol 40–120 1 Propranolol IR 80–160 2 Propranolol LA 80–160 1	Not recommended, especially in IHD or heart failure
Beta blockers—intrinsic sympathomimetic activity	Acebutolol 200–800 2 Penbutolol 10–40 1 Pindolol 10–60 2	Not recommended , especially in IHD or heart failure
Beta blockers—combined alpha-beta receptor	Carvedilol 12.5–50 2 Carvedilol phosphate 20–80 1 Labetalol 200–800 2	Carvedilol is preferred in heart failure reduced EF
Direct renin inhibitor	Aliskiren 150–300 1	Avoidance of using in combination with ARB or ACEI Using with caution in CKD or patients are on K sparing agents due to the risk of hyperkalemia Avoidance in pregnancy Avoidance in severe bilateral renal artery stenosis
Alpha-1 blockers	Doxazosin 1–16 1 Prazosin 2–20 2-3 Terazosin 1–20 1-2	Side-effect is orthostasis hypotension, especially in old patients Seconde line of treatment, preferred in BPH and hypertension
Central alpha2-agonist and other centrally acting drugs	Clonidine oral 0.1–0.8 2 Clonidine patch 0.1–0.3 1 weekly Methyldopa 250–1000 2 Guanfacine 0.5–2 1	Last line of treatment due to CNS adverse effect on elderly patients Avoidance of abrupt discontinuation of clonidine because of rebound hypertension
Direct vasodilators	Hydralazine 100–200 2-3 Minoxidil 5–100 1-3	Recommended to use with betablocker and diuretic due to sodium and water retention and reflex tachycardia Side effect of hydralazine is drug-induced lupus-like syndrome at higher doses Side effect of [[minoxidil] is hirsotism,pericardial effusion

Class I, Level of evidence:A

In patients with atherosclerotic renal artery stenosis, medical therapy is recommended

Class IIb, Level of evidence:C

Revascularization (percutaneous renal artery angioplasty and/ or stent placement) indicates in patients with refractory hypertension, worsening renal function, intractable heart failure, nonatherosclerotic disease (fibromuscular dysplasia)

Class IIb, Level of evidence:B

The effectiveness of continuous positive airway pressure (CPAP) to decrease blood pressure in patients with obstructive sleep apnea and hypertension is not verified

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

• There are no primary preventive measures available for [disease name].

• Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].

Recommendations for masked hypertension and white coated hypertension : (Class IIa, Level of Evidence B)

❑ Screening white coated hypertension in patients with systolic blood pressure 130-160 mmHg and diastolic blood pressure 80=-110 mmHg by using ABPM or HBPM before diagnosis of hypertension

(Class IIa, Level of Evidence C)

❑ Periodic monitoring blood pressure with ABPM or HBPM for detection of transient or sustained hypertension in white coated hypertension

(Class IIa, Level of Evidence C)

❑ Finding white coated hypertension by HBPM and ABPM in high office blood pressure inspite of receiving treatment,is recommended

(Class IIa, Level of Evidence B)

❑ Finding mask hypertension by HBPM or ABPM in office blood pressure 120-129 /75-79 mmHg

(Class IIb, Level of Evidence C)

❑ Finding white coated hypertension by HBPM or ABPM if office blood pressure 10 mmHg higher than normal in spite of receiving multiple medications ❑ Finding masked hypertension by HBPM in patients with end organ damage or high cardiovascular risk but office reading blood pressure at goal ❑ Finding masked hypertension by ABPM in patients with high HBPM inspite of receiving medications

References

Overview

Hypertension is generally defined as an elevated systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg. Hypertension can be chronic or acute. While 95% of the cases of chronic hypertension are primary, 5% of chronic hypertension is secondary to other underlying causes. Hypertensive crisis is the acute elevation of blood pressure and it can be classified into hypertensive emergency or hypertensive urgency when end organ damage is present or absent respectively.

Causes

When a full evaluation yields no clear etiology for the elevated blood pressure:

• Primary hypertension, also called essential hypertension.

Secondary hypertension can be caused by:

• Apnea
• Hyperaldosteronism
• Renal failure
• Coarctation of aorta
• Cushing's syndrome
• Drugs
• Diet
• Pheochromocytoma
• Obesity
• Hyperparathyroidism

For detailed causes of secondary hypertension, click here.

Classification

For more details about each specific type of hypertension, click on the links in blue in the algorithm below.
In order to distinguish primary hypertension from secondary hypertension, click here.

Hypertension

Chronic hypertension

Hypertensive crisis Acute elevation of blood pressure - Systolic blood pressure >180 mm Hg OR - Diastolic blood pressure >120 mm Hg

Primary hypertension (also known as essential hypertension) (95% of the cases)

Secondary hypertension (5% of the cases)

Hypertensive emergency Evidence of end organ damage

Hypertensive urgency No evidence of end organ damage

Screening

The age to begin screening for hypertension varies between 13-20 years of age, according to different authorities. Generally, hypertension is defined as SBP > 140 mmHg and/or DBP > 90 mmHg. In specific populations, however, routine follow-up target BP may be different; and initiation of treatment may be considered at even lower BP values than those considered for the normal population.