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

Hypertension is a major risk factor for cardiovascular disease and is a major public health problem. The prevalence of hypertension increased among the united states patients due to changing The previous cut-off 140/90 mmHg.

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 and requires ≥ medications.
• Refractory hypertension is explained as failing to control hypertension with at least five classes of antihypertensive drugs including [[long-acting

thiazide-type]] diuretic, such as chlorthalidone, and a mineralocorticoid receptor antagonist, such as spironolactone

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

• Common risk factors associated with resistant hypertension include:

• older age
• obesity
• CKD
• black race
• DM

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 resistant hypertension include MI, stroke, ESRD, and death.
• 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 [