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Synonyms and Keywords: Blood pressure; hypertension; high blood pressure; systolic blood pressure; essential hypertension
Hypertension is a major risk factor for cardiovascular disease and a major public health problem. The prevalence of hypertension increased among the united states due to changing The previous cut-off 140/90 mmHg (the previous 2003 threshold from the Joint National Committee (JNC) 7 guideline 3) to a lower threshold of greater than or equal to 130/80 mmHg. Hypertension is a leading cause of mortality worldwide. More than half of hypertensive patients are not aware of the disorder and some diagnosed patients do not take the medication. The new guideline recommends considering the average of reading BP≥ 2 visits office. Home blood pressure monitoring (HBPM) and ambulatory blood pressure monitoring (ABPM) are better than clinic or home blood pressure readings to determine masked hypertension or white coat hypertension out of the office.
- Hypertension was first discovered by Scipione Riva-Rocci, an Italian physician, in 1896 following the invention of the cuff-based mercury sphygmomanometer and measurement of the peak systolic blood pressure by noting the cuff pressure at which the radial pulse was no longer palpable.
- In 1905, the sound after cuff deflation of sphygmomanometer was first identified by Russian physician Nikolai.
- Between 1910 and 1914, essential hypertension and malignant hypertension were described.
- Secondary hypertension, (5%), due to underlying disorder
- 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 kidney 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.
Comparison between two guidelines of hypertension
|Hypertension Guidline||2017 ACC/AHA||2018 ESC/ESH|
|Definition of hypertension (mmHg)||≥130/80||≥140/90|
|Normal blood pressure range (mmHg)||
|Hypertension stage (mmHg)||
|Age specific blood pressure targets(9mmHg)||
2017/ACC/AHA Guideline of hypertension
- Hypertension can be classified based on the guideline into 2 stages:
|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|
- The pathogenesis of hypertension is characterized by a malfunction in the renin-angiotensin-aldosterone system (RAAS), natriuretic peptides ,endothelium, sympathetic nervous system (SNS),immune system.
- Allelic variants of several genes have been associated with the development of primary hypertension.
- Endothelial dysfunction and increased TGF-B was shown in salt sensitivity patients lead to increased systolic blood pressure 10 mmHg following ingestion of 5 gr salt.
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
- Sodium intake
|Pharmacological causes of hypertension||
Differentiating hypertension from other Diseases
- Differential diagnosis of hypertension includes:
|Isolated systolic hypertension|
|Isolated diastolic hypertension|
|White coat hypertension|
|Malignant hypertension (emergency hypertension)|
Epidemiology and Demographics
- The prevalence of hypertension is approximately 45,600 per 100,000 individuals worldwide.
- Between the years 2000-2002, the incidence of hypertension was estimated to be 5680 for whites, 8490 for African-Americans, 6570 for Hispanics, and 5220 for Chinese cases per 100,000 individuals in United States.
- Hypertension is more commonly observed among elderly patients
- Common risk factors in the development of hypertension are:
- Common risk factors associated with resistant hypertension include:
|Modifiable risk factors||Fixed risk factors|
Natural History, Complications and Prognosis
- The clinical features of secondary hypertension dependent on the characteristics of an underlying disorder.
- If hypertension left untreated, 33% of patients with hypertension may progress to developheart attack and stroke.
- Common complications of resistant hypertension include MI, stroke, ESRD, and death that are 2-7 times higher compared with patients without resistant hypertension.
- Prognosis is generally poor without treatment, and the 10 year mortality rate of patients with hypertension is approximately 11%.
|Renal parenchymal disease|
|Obstructive sleep apnea|
|Drug or alcohol induced|
|Coarctation of aorta||
|Congenital adrenal hyperplasia|
|Mineralocorticoid excess syndromes other than primary aldosteronism|
- The diagnosis of hypertension is made when at least three of the following diagnostic criteria are met:
|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|
|Arm circumference||cuff size|
|22-26 cm||Small adult|
|35-44 cm||Large adult|
|45-52 cm||Adult thigh|
|Key steps for accurate blood pressure measurement||Educations|
|Properly prepare the patient|
|Using proper technique||
|Taking proper measurement|
|Documentation of reading blood pressure|
|Average the reading||
|Providing blood pressure reading to patient|
|New onset or uncontrolled hypertension in adult|
|* Drug resistance hypertension|
|Screening for secondary hypertension||No need for screening|
|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|
|Office BP: 120-129/<80 mmHg after 3 months of lifestyle modification, suspected masked hypertension|
|Daytime ABPM or HBPM, BP≥130/80 mm Hg|
|Recommendations for masked hypertension and white coat hypertension : (Class IIa, Level of Evidence B)|
|(Class IIa, Level of Evidence C)|
|(Class IIa, Level of Evidence C)|
|(Class IIa, Level of Evidence B)|
❑ Finding of mask hypertension by HBPM or ABPM in-office blood pressure 120-129 /75-79 mmHg
|(Class IIb, Level of Evidence C)|
❑ Finding of white coat hypertension by HBPM or ABPM if office blood pressure is 10 mmHg higher than normal in spite of receiving multiple medications
|2017 ACC/AHA Guideline||
Screening for Primary adlostronism:
History and Symptoms
- Primary hypertensive patients are usually asymptomatic.
- Symptoms related to underlying causes of secondary hypertension may include the following:
- Patients with primary hypertension usually are asymptomatic.
- In secondary hypertension physical examination may be remarkable for :
- Arterial bruit
- Irregular pulses, Tachycardia, Absent femoral pulses
- Fine tremor
- Acute abdominal pain, abdominal mass
- Skin stigmata, Violaceous striae
- Warm skin, moist skin, Skin pallor
- Central obesity
- Moon face
- Dorsal and supraclavicular fat pads
- Loss of normal nocturnal blood pressure fall
- Orthostatic hypotension
- Periorbital puffiness,Coarse skin, Cold skin, Slow movement,Goiter
- continuous murmur over back or chest
- Abdominal bruit
- 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
- Optional laboratory test in hypertensive patients include:
- An ECG may be helpful in the diagnosis of left ventricular hypertrophy associated hypertension. Findings on an ECG suggestive of left ventricular hypertrophy include
- Cornell criteria: R wave in aVL + S wave in V3> 28 millimeters in males or greater than 20 mm in females
- Modified Cornell Criteria: R wave in aVL> 12 mm
- Sokolow-Lyon Criteria: S wave in V1 + R wave in V5 or V6> 35mm
- Romhilt-Estes: If the score equals 4, LVH is present with 30% to 54% sensitivity. If the score is greater than 5, LVH is present with 83% to 97% specificity.
- The amplitude of the largest R or S in limb leads ≥ 20 mm = 3 points
- The amplitude of S in V1 or V2 ≥ 30 mm = 3 points
- The amplitude of R in V5 or V6 ≥ 30 mm = 3 points
- ST and T wave changes opposite QRS without digoxin = 3 points
- ST and T wave changes opposite QRS with digoxin = 1 point
- Left Atrial Enlargement = 3 points
- Left Axis Deviation = 2 points
- QRS duration ≥ 90 ms = 1 point
- Intrinsicoid deflection in V5 or V6 > 50 ms = 1 point
- Finding on a chest x-ray associated target organ damage in hypertension include widening aortic knob.
- Ascending aorta dilation and increased cardiothoracic ratio may be associated with hypertension.
Echocardiography or Ultrasound
Echocardiography may be helpful in the diagnosis of complications of hypertension, which include left ventricular hypertrophy (LVH), left ventricular (LV) diastolic dysfunction and left atrial dilation.
- CT scan may be helpful in the diagnosis of underlying causes of secondary hypertension such as hyperaldosteronism, pheochromocytoma, hyperparathyroidism, aortic coarctation.
- Cardiac MRI is a reliable tool in the diagnosis of hypertensive heart disease by evaluation of left ventricular hypertrophy, left ventricular mass, biventricular function, valvular disease, inflammation and stress myocardial perfusion-fibrosis.
Other Imaging Findings
- There are no other imaging findings associated with hypertension.
Other Diagnostic Studies
- There are no other diagnostic studies associated with hypertension.
- The mainstay of treatment for hypertension is: Initiation of treatment with one or more of three classes of first-line BP lowering agents:
- Calcium channel blocker (CCB)
- Renin-angiotensin-convertng enzyme inhibitors (ACEI or ARB)
- Thiazide-like diuretic
- The mainstay of therapy for resistant hypertension is:
|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 cardiovascular disease (CVD) risk≥ 10%||Non pharmacological therapy and BPlowering medication|
|Reevaulation in 1 year (class 2a)||Reevaulation in 3-6 months (class 1)||NO, nonpharmocological therapy(class1)||Yes,non pharmacological therapy and BPlowering medication|
|Reevaulation in 3-6 months(class 1)||Reevaulation in 1 months(class 1)|
|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||
|Second line of treatment||Drug_ Dosage(mg/day)_ Frequency||Comments|
|Betablocker-cardioselective and vasodilatory||
|Beta blockers—intrinsic sympathomimetic activity||
|Beta blockers—combined alpha-beta receptor||
|Direct renin inhibitor||
|Central alpha2-agonist and other centrally acting drugs||
|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|
|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|
- Surgical procedure may be performed for patients with secondary hypertension such as coarctation of aorta, primary aldosteronism.
- Weight loss: Reduction 1 mmHg in blood pressure for every one kilogram weight reduction
- Healthy diet: A diet rich in fruits, vegetables, whole grains, low-fat dairy products, reduced content of saturated and total fat
- Reduced intake of dietary sodium: Less than 1000-15000 mg/day
- Enhanced intake of dietarypotassium:3500–5000 mg/d by intaking rich diet with potassium
- Physical activity: Aerobic ( 90–150 min/week), dynamic resistance (90–150 min/week), Isometric resistance (4 × 2 min handgrip, 1 min rest between exercises, 3 sessions per week)
- Reduced alcohol intake: Men ≤2 drinks daily, Women ≤1 drink daily
- Once diagnosed and treated, patients with hypertension are followed-up every month for evaluation of medication adherence and response to treatment.
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