Hypertension Clinical Presentation

  • Author: Kamran Riaz, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN   more...
 
Updated: Jan 27, 2012
 

History

Following the documentation of hypertension, which is confirmed after an elevated blood pressure (BP) on at least 3 separate occasions (based on the average of 2 or more readings taken at each of 2 or more visits after initial screening), a detailed history should extract the following information:

  • Extent of target organ damage
  • Assessment of patients’ cardiovascular risk status
  • Exclusion of secondary causes of hypertension

Patients may have undiagnosed hypertension for years without having had their BP checked. Therefore, a careful history of end organ damage should be obtained.

A history of cardiovascular risk factors includes hypercholesterolemia, diabetes mellitus, and tobacco use (including chewing tobacco).

Obtain a history of the patient’s use of over-the-counter medications; herbal medicines such as herbal tea containing licorice; ephedrine; current and previous unsuccessful antihypertensive medication trials; oral contraceptives; ethanol; and illicit drugs such as cocaine.

The historical and physical findings that suggest the possibility of secondary hypertension are a history of known renal disease, abdominal masses, anemia, and urochrome pigmentation. A history of sweating, labile hypertension, and palpitations suggests the diagnosis of pheochromocytoma. A history of cold or heat tolerance, sweating, lack of energy, and bradycardia or tachycardia may indicate hypothyroidism or hyperthyroidism. A history of obstructive sleep apnea may be noted. A history of weakness suggests hyperaldosteronism. Kidney stones raise the possibility of hyperparathyroidism.

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Physical Examination

An accurate measurement of blood pressure is the key to diagnosis. Several determinations should be made over a period of several weeks. At any given visit, an average of 3 blood pressure readings taken 2 minutes apart using a mercury manometer is preferable. On the first visit, blood pressure should be checked in both arms and in one leg to avoid missing the diagnosis of coarctation of aorta or subclavian artery stenosis.

The patient should rest quietly for at least 5 minutes before the measurement. Blood pressure should be measured in both the supine and sitting positions, auscultating with the bell of the stethoscope. As the improper cuff size may influence blood pressure measurement, a wider cuff is preferable, particularly if the patient’s arm circumference exceeds 30 cm. Although somewhat controversial, the common practice is to document phase V (a disappearance of all sounds) of Korotkoff sounds as the diastolic pressure.

Ambulatory or home blood pressure monitoring provides a more accurate prediction of cardiovascular risk than do office blood pressure readings.[14] "Non-dipping" is the loss of the usual physiologic nocturnal drop in blood pressure and is associated with an increased cardiovascular risk.

A funduscopic evaluation of the eyes should be performed to detect any evidence of early or late, chronic or acute hypertensive retinopathy, including AV nicking or changes in the vessel wall (eg, copper wiring, silver wiring, sot, hard exudates, flame-shaped hemorrhages, papilledema). Ocular changes can be the initial finding in an asymptomatic patient necessitating a primary care referral. Both acute and chronic changes may manifest in the eyes. On the other side, a symptomatic patient may be referred to the ophthalmologist for visual changes due to hypertensive changes.

Palpation of all peripheral pulses should be performed. Absent, weak, or delayed femoral pulses suggests coarctation of the aorta or severe peripheral vascular disease.

Listen for renal artery bruit over the upper abdomen; the presence of a bruit with both a systolic and diastolic component suggests renal artery stenosis.

A careful cardiac examination is performed to evaluate signs of LVH. These include displacement of apex, a sustained and enlarged apical impulse, and the presence of an S4. Occasionally, a tambour S2 is heard with aortic root dilatation.

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Hypertension and Cerebrovascular Disease

Long-standing hypertension may manifest as hemorrhagic and atheroembolic stroke or encephalopathy. Both the high systolic and diastolic pressures are harmful; a diastolic pressure of more than 100 mm Hg and a systolic pressure of more than 160 mm Hg have led to a significant incidence of strokes. Other cerebrovascular manifestations of complicated hypertension include hypertensive hemorrhage, hypertensive encephalopathy, lacunar-type infarctions, and dementia.

Hypertensive encephalopathy is one of the clinical manifestations of cerebral edema and microhemorrhages seen with dysfunction of cerebral autoregulation and is characterized by hypertension, altered mentation, and papilledema.[15]

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Hypertensive Emergencies

The history and physical examination determine the nature, severity, and management of the hypertensive event. The history should focus on the presence of end-organ dysfunction, the circumstances surrounding the hypertension, and any identifiable etiology. The physical examination should assess whether end-organ dysfunction is present. BP should be measured in both the supine position and the standing position (assess volume depletion). BP should also be measured in both arms (a significant difference may suggest aortic dissection).

The most common clinical presentations of hypertensive emergencies are cerebral infarction (24.5%), pulmonary edema (22.5%), hypertensive encephalopathy (16.3%), and congestive heart failure (12%). Other clinical presentations associated with hypertensive emergencies include intracranial hemorrhage, aortic dissection, and eclampsia,[16] as well as acute myocardial infarction.

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Hypertensive Heart Disease

Uncontrolled and prolonged BP elevation can lead to a variety of changes in the myocardial structure, coronary vasculature, and conduction system of the heart. These changes in turn can lead to the development of left ventricular hypertrophy (LVH), coronary artery disease, various conduction system diseases, and systolic and diastolic dysfunction of the myocardium, which manifest clinically as angina or myocardial infarction, cardiac arrhythmias (especially atrial fibrillation), and congestive heart failure (CHF). Thus, hypertensive heart disease is a term applied generally to heart diseases—such as LVH, coronary artery disease, cardiac arrhythmias, and CHF—that are caused by direct or indirect effects of elevated BP. Although these diseases generally develop in response to chronically elevated BP, marked and acute elevation of BP can also lead to accentuation of an underlying predisposition to any of the symptoms traditionally associated with chronic hypertension.

In a study by Tymchak et al, patients presenting with acute heart failure as a manifestation of hypertensive emergency were more likely to be African American and have a history of heart failure; they were also more likely to have higher B-type natriuretic peptide (BNP) and creatinine levels and lower left ventricular ejection fraction.[17]

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Hypertension in Pediatric Patients

Recent advances in the ability to identify, evaluate, and care for infants with hypertension, coupled with advances in the practice of neonatology in general, have led to an increased awareness of hypertension in modern neonatal ICUs (NICUs) since its first description in the 1970s.

The true incidence of hypertension in the pediatric population is not known. Hypertension is now commonly discovered in children. The long-term health risks to these children with hypertension may be substantial.

Systemic hypertension is less common in children than in adults, but the incidence of hypertension in children is approximately 1-5%. The presence of hypertension in younger children is usually indicative of an underlying disease process (secondary hypertension). In children, approximately 5-25% of secondary hypertension is attributed to renovascular disease.

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Hypertension in Pregnancy

Hypertension is the most common medical problem encountered during pregnancy, complicating 2-3% of pregnancies. Hypertensive disorders during pregnancy are classified into the 4 following categories, as recommended by the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy:

  • Chronic hypertension
  • Preeclampsia-eclampsia
  • Preeclampsia superimposed on chronic hypertension
  • Gestational hypertension (transient hypertension of pregnancy or chronic hypertension identified in the latter half of pregnancy); this terminology is preferred over the older but widely used term pregnancy-induced hypertension (PIH) because it is more precise.
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Primary Aldosteronism

Mineralocorticoid excess secondary to primary hyperaldosteronism is infrequently observed and is characterized by excessive production of aldosterone. Renal sodium retention, kaliuresis, hypokalemia, and hypochloremic metabolic alkalosis are the common manifestations. These patients develop increased intravascular volume, resulting in hypertension. The BP increase may vary from mild hypertension to marked elevation in primary hyperaldosteronism. Patients may have underlying adenoma or hyperplasia of the adrenal gland and rarely have an extra-adrenal source for aldosterone.

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Contributor Information and Disclosures
Author

Kamran Riaz, MD  Clinical Assistant Professor, Department of Internal Medicine, Section of Cardiology, Wright State University, Boonshoft School of Medicine

Kamran Riaz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Society of Echocardiography, Ohio State Medical Association, and Royal College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Albert W Dreisbach, MD  Associate Professor of Medicine, Division of Nephrology, University of Mississippi Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

Additional Contributors

George R Aronoff, MD Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Pamela L Dyne, MD Professor of Clinical Medicine/Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mert Erogul, MD Assistant Professor of Emergency Medicine, University Hospital of Brooklyn: Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Mert Erogul, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Allysia M Guy, MD Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Dawn C Jung, MD Staff Physician, Department of Emergency Medicine, Suny Downstate Medical Center, Kings County Hospital Center

Dawn C Jung, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Claude Kortas, MD, MEd, FRCP(C) Program Director, Associate Professor, Department of Medicine, University of Western Ontario, Canada

Claude Kortas, MD, Med, FRCP(C) is a member of the following medical societies: American Society of Nephrology, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Stephen C Morris, MD Resident, Section of Emergency Medicine, Department of Surgery, Yale New Haven Hospital

Stephen C Morris, MD is a member of the following medical societies: American College of Emergency Physicians and American Medical Association

Disclosure: Nothing to disclose.

L Michael Prisant, MD, FACC, FAHA Cardiologist, Emeritus Professor of Medicine, Medical College of Georgia

L Michael Prisant, MD, FACC, FAHA is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Clinical Pharmacology, American College of Forensic Examiners, American College of Physicians, American Heart Association, and American Medical Association

Disclosure: Boehringer-Ingelheim Honoraria Speaking and teaching

Assaad J Sayah, MD Chief, Department of Emergency Medicine, Cambridge Health Alliance

Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians

Disclosure: Nothing to disclose.

Zina Semenovskaya, MD Resident Physician, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center College of Medicine

Disclosure: Nothing to disclose.

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association

Disclosure: Nothing to disclose.

Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

References

  1. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. Dec 2003;42(6):1206-52. [Medline].

  2. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA. Jul 9 2003;290(2):199-206. [Medline].

  3. Bianchi S, Bigazzi R, Campese VM. Microalbuminuria in essential hypertension: significance, pathophysiology, and therapeutic implications. Am J Kidney Dis. Dec 1999;34(6):973-95. [Medline].

  4. Shayne PH, Pitts SR. Severely increased blood pressure in the emergency department. Ann Emerg Med. Apr 2003;41(4):513-29. [Medline].

  5. Rhoades R, Planzer R. Human Physiology. 3rd. Fort Worth, TX: Saunders College Publishing; 1996.

  6. Dungan JR, Conley YP, Langaee TY, Johnson JA, Kneipp SM, Hess PJ, et al. Altered beta-2 adrenergic receptor gene expression in human clinical hypertension. Biol Res Nurs. Jul 2009;11(1):17-26. [Medline]. [Full Text].

  7. Rule AD, Fridley BL, Hunt SC, Asmann Y, Boerwinkle E, Pankow JS, et al. Genome-wide linkage analysis for uric acid in families enriched for hypertension. Nephrol Dial Transplant. Aug 2009;24(8):2414-20. [Medline]. [Full Text].

  8. Qureshi AI, Suri MF, Kirmani JF, Divani AA. Prevalence and trends of prehypertension and hypertension in United States: National Health and Nutrition Examination Surveys 1976 to 2000. Med Sci Monit. Sep 2005;11(9):CR403-9. [Medline].

  9. Webster J, Petrie JC, Jeffers TA, Lovell HG. Accelerated hypertension--patterns of mortality and clinical factors affecting outcome in treated patients. Q J Med. Aug 1993;86(8):485-93. [Medline].

  10. Culleton BF, Larson MG, Kannel WB, Levy D. Serum uric acid and risk for cardiovascular disease and death: the Framingham Heart Study. Ann Intern Med. Jul 6 1999;131(1):7-13. [Medline].

  11. Mortality after 10 1/2 years for hypertensive participants in the Multiple Risk Factor Intervention Trial. Circulation. Nov 1990;82(5):1616-28. [Medline].

  12. Chen G, McAlister FA, Walker RL, Hemmelgarn BR, Campbell NR. Cardiovascular outcomes in framingham participants with diabetes: the importance of blood pressure. Hypertension. May 2011;57(5):891-7. [Medline].

  13. Ford ES. Trends in mortality from all causes and cardiovascular disease among hypertensive and nonhypertensive adults in the United States. Circulation. Apr 26 2011;123(16):1737-44. [Medline].

  14. Redon J, Campos C, Narciso ML, Rodicio JL, Pascual JM, Ruilope LM. Prognostic value of ambulatory blood pressure monitoring in refractory hypertension: a prospective study. Hypertension. Feb 1998;31(2):712-8. [Medline].

  15. Heilpern K. Pathophysiology of hypertension. Ann Emerg Med. Mar 2008;51(3 Suppl):S5-6. [Medline].

  16. Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P. Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension. Jan 1996;27(1):144-7. [Medline].

  17. Tymchak W, Armstrong PW, Westerhout CM, et al. Mode of hospital presentation in patients with non-ST-elevation myocardial infarction: implications for strategic management. Am Heart J. Sep 2011;162(3):436-43. [Medline].

  18. Abergel E, Chatellier G, Battaglia C, Menard J. Can echocardiography identify mildly hypertensive patients at high risk, left untreated based on current guidelines?. J Hypertens. Jun 1999;17(6):817-24. [Medline].

  19. Cortigiani L, Bigi R, Landi P, Bovenzi F, Picano E, Sicari R. Prognostic implication of stress echocardiography in 6214 hypertensive and 5328 normotensive patients. Eur Heart J. Jun 2011;32(12):1509-18. [Medline].

  20. Olin JW, Piedmonte MR, Young JR, DeAnna S, Grubb M, Childs MB. The utility of duplex ultrasound scanning of the renal arteries for diagnosing significant renal artery stenosis. Ann Intern Med. Jun 1 1995;122(11):833-8. [Medline].

  21. Hermida RC, Ayala DE, Mojón A, Fernández JR. Decreasing sleep-time blood pressure determined by ambulatory monitoring reduces cardiovascular risk. J Am Coll Cardiol. Sep 6 2011;58(11):1165-73. [Medline].

  22. [Guideline] American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care. Jan 2011;34 Suppl 1:S11-61. [Medline]. [Full Text].

  23. Svetkey LP, Moore TJ, Simons-Morton DG, Appel LJ, Bray GA, Sacks FM, et al. Angiotensinogen genotype and blood pressure response in the Dietary Approaches to Stop Hypertension (DASH) study. J Hypertens. Nov 2001;19(11):1949-56. [Medline].

  24. Your Guide to Lowering Your Blood Pressure With DASH. National Institutes of Health; April 2006. 64. [Full Text].

  25. [Guideline] Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the Primary Prevention of Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. Dec 6 2010;[Medline].

  26. Slagman MC, Waanders F, Hemmelder MH, Woittiez AJ, Janssen WM, Lambers Heerspink HJ, et al. Moderate dietary sodium restriction added to angiotensin converting enzyme inhibition compared with dual blockade in lowering proteinuria and blood pressure: randomised controlled trial. BMJ. Jul 26 2011;343:d4366. [Medline].

  27. [Best Evidence] Blumenthal JA, Babyak MA, Hinderliter A, Watkins LL, Craighead L, Lin PH, et al. Effects of the DASH diet alone and in combination with exercise and weight loss on blood pressure and cardiovascular biomarkers in men and women with high blood pressure: the ENCORE study. Arch Intern Med. Jan 25 2010;170(2):126-35. [Medline].

  28. Leung AA, Wright A, Pazo V, Karson A, Bates DW. Risk of Thiazide-induced Hyponatremia in Patients with Hypertension. Am J Med. Nov 2011;124(11):1064-72. [Medline].

  29. Brown MJ, McInnes GT, Papst CC, Zhang J, MacDonald TM. Aliskiren and the calcium channel blocker amlodipine combination as an initial treatment strategy for hypertension control (ACCELERATE): a randomised, parallel-group trial. Lancet. Jan 22 2011;377(9762):312-20. [Medline].

  30. Ruggenenti P, Lauria G, Iliev IP, et al, for the DEMAND Study Investigators. Effects of manidipine and delapril in hypertensive patients with type 2 diabetes mellitus: The Delapril and Manidipine for Nephroprotection in Diabetes (DEMAND) Randomized Clinical Trial. Hypertension. Nov 2011;58(5):776-83. [Medline].

  31. Isom HC, DeMoss RD. Structural role of pyridoxal 5'-phosphate, pyridoxal 5'-phosphate analogs, and other agents in the association of subunits of Bacillus alvei apotryptophanase. Biochemistry. Sep 23 1975;14(19):4298-304. [Medline].

  32. Slovis CM, Reddi AS. Increased blood pressure without evidence of acute end organ damage. Ann Emerg Med. Mar 2008;51(3 Suppl):S7-9. [Medline].

  33. Abalos E, Duley L, Steyn DW, Henderson-Smart DJ. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. Jan 24 2007;CD002252. [Medline].

  34. Magee LA, Helewa M, Moutquin J-M et al. Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy. Journal of Obstetrics and Gynaecology Canada. March 2008;30:S1-S48. [Full Text].

  35. Hansson L, Hedner T, Lund-Johansen P, Kjeldsen SE, Lindholm LH, Syvertsen JO, et al. Randomised trial of effects of calcium antagonists compared with diuretics and beta-blockers on cardiovascular morbidity and mortality in hypertension: the Nordic Diltiazem (NORDIL) study. Lancet. Jul 29 2000;356(9227):359-65. [Medline].

  36. Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents Developed in Collaboration With the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Coll Cardiol. May 17 2011;57(20):2037-114. [Medline]. [Full Text].

  37. Kostis JB, Cabrera J, Cheng JQ, et al. Association between chlorthalidone treatment of systolic hypertension and long-term survival. JAMA. Dec 21 2011;306(23):2588-93. [Medline].

  38. Lao D, Parasher PS, Cho KC, Yeghiazarians Y. Atherosclerotic renal artery stenosis--diagnosis and treatment. Mayo Clin Proc. Jul 2011;86(7):649-57. [Medline]. [Full Text].

  39. Rastan A, Krankenberg H, Müller-Hülsbeck S, Sixt S, Tübler T, Müller C, et al. Improved renal function and blood pressure control following renal artery angioplasty: the renal artery angioplasty in patients with renal insufficiency and hypertension using a dedicated renal stent device study (PRECISION). EuroIntervention. Aug 2008;4(2):208-13. [Medline].

  40. Epstein M. Calcium antagonists and renal disease. Kidney Int. Nov 1998;54(5):1771-84.

  41. Yakovlevitch M, Black HR. Resistant hypertension in a tertiary care clinic. Arch Intern Med. Sep 1991;151(9):1786-92. [Medline].

  42. de la Sierra A, Segura J, Banegas JR, et al. Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Hypertension. May 2011;57(5):898-902. [Medline].

  43. Catheter-based renal sympathetic denervation for resistant hypertension: durability of blood pressure reduction out to 24 months. Hypertension. May 2011;57(5):911-7. [Medline].

  44. Bisognano JD, Bakris G, Nadim MK, et al. Baroreflex activation therapy lowers blood pressure in patients with resistant hypertension results from the double-blind, randomized, placebo-controlled rheos pivotal trial. J Am Coll Cardiol. Aug 9 2011;58(7):765-73. [Medline].

  45. Kronish IM, Woodward M, Sergie Z, Ogedegbe G, Falzon L, Mann DM. Meta-analysis: impact of drug class on adherence to antihypertensives. Circulation. Apr 19 2011;123(15):1611-21. [Medline].

  46. Pimenta E, Calhoun DA, Oparil S. Sleep apnea, aldosterone, and resistant hypertension. Prog Cardiovasc Dis. Mar-Apr 2009;51(5):371-80. [Medline].

  47. Pedrosa RP, Drager LF, Gonzaga CC, et al. Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertension. Hypertension. Nov 2011;58(5):811-7. [Medline].

  48. Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH. How common is white coat hypertension?. JAMA. Jan 8 1988;259(2):225-8. [Medline].

  49. Fahey T, Schroeder K, Ebrahim S. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev. Apr 19 2006;CD005182. [Medline].

  50. Pezzin LE, Feldman PH, Mongoven JM, McDonald MV, Gerber LM, Peng TR. Improving Blood Pressure Control: Results of Home-based Post-acute Care Interventions. J Gen Intern Med. Mar 2011;26(3):280-6. [Medline].

  51. Bosworth HB, Powers BJ, Olsen MK, et al. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Arch Intern Med. Jul 11 2011;171(13):1173-80. [Medline].

  52. Narkiewicz K. Diagnosis and management of hypertension in obesity. Obes Rev. May 2006;7(2):155-62. [Medline].

  53. Cummings DM, Amadio P Jr, Nelson L, Fitzgerald JM. The role of calcium channel blockers in the treatment of essential hypertension. Arch Intern Med. Feb 1991;151(2):250-9. [Medline].

  54. White WB, Weber MA, Sica D, Bakris GL, Perez A, Cao C, et al. Effects of the Angiotensin receptor blocker azilsartan medoxomil versus olmesartan and valsartan on ambulatory and clinic blood pressure in patients with stages 1 and 2 hypertension. Hypertension. Mar 2011;57(3):413-20. [Medline].

  55. Harel Z, Gilbert C, Wald R, et al. The effect of combination treatment with aliskiren and blockers of the renin-angiotensin system on hyperkalaemia and acute kidney injury: systematic review and meta-analysis. BMJ. Jan 9 2012;344:e42. [Medline]. [Full Text].

  56. 1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension. Guidelines Subcommittee. J Hypertens. Feb 1999;17(2):151-83. [Medline].

  57. AHRQ: Agency for Healthcare Research and Quality. Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin II Receptor Antagonists (ARBs) for Treating Essential Hypertension. Agency for Healthcare Research and Quality. Available at http://effectivehealthcare.ahrq.gov/healthInfo.cfm?infotype=rr&ProcessID=12 &DocID=48. Accessed May 14, 2009.

  58. Anderson CS, Huang Y, Arima H, Heeley E, Skulina C, Parsons MW, et al. Effects of early intensive blood pressure-lowering treatment on the growth of hematoma and perihematomal edema in acute intracerebral hemorrhage: the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT). Stroke. Feb 2010;41(2):307-12. [Medline].

  59. Anderson CS, Huang Y, Wang JG, Arima H, Neal B, Peng B, et al. Intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. May 2008;7(5):391-9. [Medline].

  60. Ault MJ, Ellrodt AG. Pathophysiological events leading to the end-organ effects of acute hypertension. Am J Emerg Med. Dec 1985;3(6 Suppl):10-5. [Medline].

  61. Barton JR. Hypertension in pregnancy. Ann Emerg Med. Mar 2008;51(3 Suppl):S16-7. [Medline].

  62. Brown MJ. Hypertension and ethnic group. BMJ. Apr 8 2006;332(7545):833-6. [Medline]. [Full Text].

  63. Cheung AT, Hobson RW 2nd. Hypertension in vascular surgery: aortic dissection and carotid revascularization. Ann Emerg Med. Mar 2008;51(3 Suppl):S28-33. [Medline].

  64. Chrysant SG, Fagan T, Glazer R, Kriegman A. Effects of benazepril and hydrochlorothiazide, given alone and in low- and high-dose combinations, on blood pressure in patients with hypertension. Arch Fam Med. Jan 1996;5(1):17-24; discussion 25. [Medline].

  65. Cornoni-Huntley J, LaCroix AZ, Havlik RJ. Race and sex differentials in the impact of hypertension in the United States. The National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study. Arch Intern Med. Apr 1989;149(4):780-8. [Medline].

  66. Diercks DB, Ohman EM. Hypertension with acute coronary syndrome and heart failure. Ann Emerg Med. Mar 2008;51(3 Suppl):S34-6. [Medline].

  67. Gandhi SK, Powers JC, Nomeir AM, Fowle K, Kitzman DW, Rankin KM, et al. The pathogenesis of acute pulmonary edema associated with hypertension. N Engl J Med. Jan 4 2001;344(1):17-22. [Medline].

  68. Grundy SM, Cleeman JI, Daniels SR, Donato KA, Eckel RH, Franklin BA, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. Oct 25 2005;112(17):2735-52. [Medline].

  69. Hollander JE. Cocaine intoxication and hypertension. Ann Emerg Med. Mar 2008;51(3 Suppl):S18-20. [Medline].

  70. Kaplan NM. Calcium entry blockers in the treatment of hypertension. Current status and future prospects. JAMA. Aug 11 1989;262(6):817-23. [Medline].

  71. Khan NA, McAlister FA, Lewanczuk RZ, Touyz RM, Padwal R, Rabkin SW, et al. The 2005 Canadian Hypertension Education Program recommendations for the management of hypertension: part II - therapy. Can J Cardiol. Jun 2005;21(8):657-72. [Medline].

  72. Kitiyakara C, Guzman NJ. Malignant hypertension and hypertensive emergencies. J Am Soc Nephrol. Jan 1998;9(1):133-42. [Medline].

  73. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. JAMA. Apr 19 2000;283(15):1967-75. [Medline].

  74. Marik PE, Varon J. Hypertensive crises: challenges and management. Chest. Jun 2007;131(6):1949-62. [Medline].

  75. Pancioli AM. Hypertension management in neurologic emergencies. Ann Emerg Med. Mar 2008;51(3 Suppl):S24-7. [Medline].

  76. Pollare T, Lithell H, Berne C. A comparison of the effects of hydrochlorothiazide and captopril on glucose and lipid metabolism in patients with hypertension. N Engl J Med. Sep 28 1989;321(13):868-73. [Medline].

  77. Redon J, Cifkova R, Laurent S, Nilsson P, Narkiewicz K, Erdine S, et al. Mechanisms of hypertension in the cardiometabolic syndrome. J Hypertens. Mar 2009;27(3):441-51. [Medline].

  78. Rodriguez MA, Kumar SK, De Caro M. Hypertensive crisis. Cardiol Rev. Mar-Apr 2010;18(2):102-7. [Medline].

  79. Strong Heart Study Data Book: A Report to American Indian Communities. Bethesda, MD: National Heart, Lung, and Blood Institute, NIH; 2001.

  80. The World Health Report 2002-Reducing Risks, Promoting Healthy Life. Geneva, Switzerland: World Health Organization; 2002. [Full Text].

  81. Wallach R, Karp RB, Reves JG, Oparil S, Smith LR, James TN. Pathogenesis of paroxysmal hypertension developing during and after coronary bypass surgery: a study of hemodynamic and humoral factors. Am J Cardiol. Oct 1980;46(4):559-65. [Medline].

  82. Wolz M, Cutler J, Roccella EJ, Rohde F, Thom T, Burt V. Statement from the National High Blood Pressure Education Program: prevalence of hypertension. Am J Hypertens. Jan 2000;13(1 Pt 1):103-4. [Medline].

 
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Anteroposterior x-ray from a 28-year old woman who presented with congestive heart failure secondary to her chronic hypertension, or high blood pressure. The enlarged cardiac silhouette on this image is due to congestive heart failure due to the effects of chronic high blood pressure on the left ventricle. The heart then becomes enlarged, and fluid accumulates in the lungs, known as pulmonary congestion.
Electrocardiogram (ECG) from a 47-year-old man with a long-standing history of uncontrolled hypertension. This image shows left atrial enlargement and left ventricular hypertrophy.
Electrocardiogram (ECG) from a 46-year-old man with long-standing hypertension. This ECG shows left atrial abnormality and left ventricular hypertrophy with strain.
Histologic section of an autopsy myocardial specimen from a patient with long-standing hypertension and associated coronary artery disease. This slide shows myocardial hypertrophy, contraction bands (typical of left ventricular hypertrophy), and "box car" nuclei.
Hypertrophied cardiac myocytes with enlarged "box car" nuclei.
 
 
 
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