Hypertension Differential Diagnoses

Sections

Hypertension

DDx

Diagnostic ConsiderationsAmbulatory blood pressure monitoring

In adults aged 50 years and older, the 2010 Institute for Clinical Systems Improvement (ICSI) guideline on the diagnosis and treatment of hypertension indicates that systolic blood pressure (SBP) should be the major factor to detect, evaluate, and treat hypertension.^[4]

Ambulatory blood pressure monitoring (ABPM) is used to monitor daily and nocturnal blood pressure, providing information such as the percentage of elevated BP readings, overall BP load, and extent of BP fall during sleep.^[2]In general, these readings are lower than those in a physician office setting and have a better correlation with target-organ injury. There is usually a 10-20% BP drop during the night. People who do not demonstrate such a decrease in BP are at increased risk for cardiovascular events. Patients with 24-hour BP greater than 135/85 mm Hg have been shown to have almost double the likelihood of having a cardiovascular event.^[2]

Indications for ABPM include labile BP; a discrepancy between blood pressure measurements in and outside the physician’s office; and poor BP control. Ambulatory monitoring also identifies patients who have the distinct syndrome called white-coat hypertension,^[49]in which a patient’s blood pressures reading at home and in the physician’s office vary widely.^[59]

Problems to be considered include the following:

Steroid use
Use of over-the-counter or recreational sympathomimetic drugs
Pheochromocytoma
Acute vasculitis
Serotonin syndrome
Other central nervous system pathology
Coarctation of the aorta

Differential Diagnoses

Amphetamine Toxicity
Anxiety Disorders
Apnea, Sleep
Cocaine-Related Cardiomyopathy
Heart Failure
Hyperthyroidism, Thyroid Storm, and Graves Disease
Hypertrophic Cardiomyopathy
Myocardial Infarction
Phencyclidine Toxicity
Primary Aldosteronism
Stroke, Hemorrhagic
Stroke, Ischemic

Workup

Benjamin EJ, Blaha MJ, Chiuve SE, et al, for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation. 2017 Mar 7. 135 (10):e146-e603. [Medline]. [Full Text].
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. 2003 Dec. 42(6):1206-52. [Medline].
Katakam R, Brukamp K, Townsend RR. What is the proper workup of a patient with hypertension?. Cleve Clin J Med. 2008 Sep. 75(9):663-72. [Medline].
Institute for Clinical Systems Improvement (ICSI). Hypertension diagnosis and treatment. Bloomington, Minn: Institute for Clinical Systems Improvement (ICSI); 2010.
Whelton PK, Appel LJ, Sacco RL, et al. Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation. 2012 Dec 11. 126 (24):2880-9. [Medline].
O'Riordan M. New European hypertension guidelines released: goal is less than 140 mm Hg for all. Heartwire from Medscape [serial online]. Available at http://www.medscape.com/viewarticle/806367. June 15, 2013; Accessed: June 24, 2013.
[Guideline] Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension. 23rd European Meeting on Hypertension & Cardiovascular Protection. Available at http://www.esh2013.org/wordpress/wp-content/uploads/2013/06/ESC-ESH-Guidelines-2013.pdf. Accessed: June 24, 2013.
[Guideline] James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5. 311 (5):507-20. [Medline].
Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA. 2003 Jul 9. 290(2):199-206. [Medline].
Bianchi S, Bigazzi R, Campese VM. Microalbuminuria in essential hypertension: significance, pathophysiology, and therapeutic implications. Am J Kidney Dis. 1999 Dec. 34(6):973-95. [Medline].
Shayne PH, Pitts SR. Severely increased blood pressure in the emergency department. Ann Emerg Med. 2003 Apr. 41(4):513-29. [Medline].
Rhoades R, Planzer R. Human Physiology. 3rd. Fort Worth, TX: Saunders College Publishing; 1996.
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. 2001 Jan 4. 344(1):17-22. [Medline].
Madhur MS, Lob HE, McCann LA, et al. Interleukin 17 promotes angiotensin II-induced hypertension and vascular dysfunction. Hypertension. 2010 Feb. 55 (2):500-7. [Medline].
Venegas-Pont M, Manigrasso MB, Grifoni SC, et al. Tumor necrosis factor-alpha antagonist etanercept decreases blood pressure and protects the kidney in a mouse model of systemic lupus erythematosus. Hypertension. 2010 Oct. 56 (4):643-9. [Medline].
Kirabo A, Fontana V, de Faria AP, et al. DC isoketal-modified proteins activate T cells and promote hypertension. J Clin Invest. 2014 Oct. 124 (10):4642-56. [Medline].
Harrison DG, Guzik TJ, Lob HE, et al. Inflammation, immunity, and hypertension. Hypertension. 2011 Feb. 57(2):132-40. [Medline]. [Full Text].
Guzik TJ, Hoch NE, Brown KA, et al. Role of the T cell in the genesis of angiotensin II induced hypertension and vascular dysfunction. J Exp Med. 2007 Oct 1. 204(10):2449-60. [Medline].
Madhur MS, Lob HE, McCann LA, et al. Interleukin 17 promotes angiotensin II-induced hypertension and vascular dysfunction. Hypertension. 2010 Feb. 55(2):500-7. [Medline].
Hamer M, Steptoe A. Cortisol responses to mental stress and incident hypertension in healthy men and women. J Clin Endocrinol Metab. 2012 Jan. 97(1):E29-34. [Medline].
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. 2009 Aug. 24(8):2414-20. [Medline]. [Full Text].
Jermendy G, Horvath T, Littvay L, et al. Effect of genetic and environmental influences on cardiometabolic risk factors: a twin study. Cardiovasc Diabetol. 2011 Nov 3. 10:96. [Medline]. [Full Text].
Mitchell GF, DeStefano AL, Larson MG, et al. Heritability and a genome-wide linkage scan for arterial stiffness, wave reflection, and mean arterial pressure: the Framingham Heart Study. Circulation. 2005 Jul 12. 112(2):194-9. [Medline].
Levy D, DeStefano AL, Larson MG, et al. Evidence for a gene influencing blood pressure on chromosome 17. Genome scan linkage results for longitudinal blood pressure phenotypes in subjects from the framingham heart study. Hypertension. 2000 Oct. 36(4):477-83. [Medline].
Coffman TM. Under pressure: the search for the essential mechanisms of hypertension. Nat Med. 2011 Nov 7. 17(11):1402-9. [Medline].
Millis RM. Epigenetics and hypertension. Curr Hypertens Rep. 2011 Feb. 13(1):21-8. [Medline].
Brown MJ. Hypertension and ethnic group. BMJ. 2006 Apr 8. 332(7545):833-6. [Medline]. [Full Text].
Goldblatt H, Lynch J, Hanzal RF, Summerville WW. Studies on experimental hypertension: I. The production of persistent elevation of systolic blood pressure by means of renal ischemia. J Exp Med. 1934 Feb 28. 59 (3):347-79. [Medline]. [Full Text].
Feldstein CA. Blood pressure effects of CPAP in nonresistant and resistant hypertension associated with OSA: A systematic review of randomized clinical trials. Clin Exp Hypertens. 2016. 38 (4):337-46. [Medline].
McEvoy RD, Antic NA, Heeley E, et al, for the SAVE Investigators and Coordinators. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016 Sep 8. 375 (10):919-31. [Medline].
Marik PE, Varon J. Hypertensive crises: challenges and management. Chest. 2007 Jun. 131(6):1949-62. [Medline].
Rodriguez MA, Kumar SK, De Caro M. Hypertensive crisis. Cardiol Rev. 2010 Mar-Apr. 18(2):102-7. [Medline].
Hollander JE. Cocaine intoxication and hypertension. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S18-20. [Medline].
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005 Jan 15-21. 365 (9455):217-23. [Medline].
Forouzanfar MH, Alexander L, Anderson HR, et al, for the GBD 2013 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015 Dec 5. 386 (10010):2287-323. [Medline].
GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015 Jan 10. 385 (9963):117-71. [Medline].
Harrison L. Hypertension ER visits surge 25% in five years. Heartwire from Medsape [serial online]. Available at http://www.medscape.com/viewarticle/831531. September 11, 2014; Accessed: September 12, 2014.
Mozaffarian D, Benjamin EJ, Go AS, et al, for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015 Jan 27. 131 (4):e29-322. [Medline].
Ong YT, Wong TY, Klein R, Klein BE, Mitchell P, Sharrett AR, et al. Hypertensive Retinopathy and Risk of Stroke. Hypertension. 2013 Aug 12. [Medline].
Brooks M. Hypertensive Retinopathy Linked to Increased Stroke Risk. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/809541. Accessed: August 20, 2013.
Huang Y, Cai X, Li Y, et al. Prehypertension and the risk of stroke: a meta-analysis. Neurology. 2014 Mar 12. [Medline].
Hughes S. Even prehypertension increases stroke risk: meta-analysis. Medscape Medical News. March 14, 2014. [Full Text].
Webster J, Petrie JC, Jeffers TA, Lovell HG. Accelerated hypertension--patterns of mortality and clinical factors affecting outcome in treated patients. Q J Med. 1993 Aug. 86(8):485-93. [Medline].
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. 1999 Jul 6. 131(1):7-13. [Medline].
Mortality after 10 1/2 years for hypertensive participants in the Multiple Risk Factor Intervention Trial. Circulation. 1990 Nov. 82(5):1616-28. [Medline].
Chen G, McAlister FA, Walker RL, Hemmelgarn BR, Campbell NR. Cardiovascular outcomes in framingham participants with diabetes: the importance of blood pressure. Hypertension. 2011 May. 57(5):891-7. [Medline].
Ford ES. Trends in mortality from all causes and cardiovascular disease among hypertensive and nonhypertensive adults in the United States. Circulation. 2011 Apr 26. 123(16):1737-44. [Medline].
Bombelli M, Facchetti R, Sega R, Carugo S, Fodri D, Brambilla G, et al. Impact of body mass index and waist circumference on the long-term risk of diabetes mellitus, hypertension, and cardiac organ damage. Hypertension. 2011 Dec. 58(6):1029-35. [Medline].
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. 1998 Feb. 31(2):712-8. [Medline].
Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004 Nov 25. 351(22):2310-7. [Medline].
Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P. Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension. 1996 Jan. 27(1):144-7. [Medline].
Staykov D, Schwab S. Posterior reversible encephalopathy syndrome. J Intensive Care Med. 2012 Feb. 27(1):11-24. [Medline].
McCord J, Mundy BJ, Hudson MP, Maisel AS, Hollander JE, Abraham WT. Relationship between obesity and B-type natriuretic peptide levels. Arch Intern Med. 2004 Nov 8. 164(20):2247-52. [Medline].
Mammaro A, Carrara S, Cavaliere A, et al. Hypertensive disorders of pregnancy. J Prenat Med. 2009 Jan. 3 (1):1-5. [Medline].
US Food and Drug Administration. FDA Drug Safety Communication: FDA approves label changes to include intestinal problems (sprue-like enteropathy) linked to blood pressure medicine olmesartan medoxomil. July 3, 2013. [Full Text].
Wang IK, Muo CH, Chang YC, Liang JC, Chang CT, Lin SY, et al. Association between hypertensive disorders during pregnancy and end-stage renal disease: a population-based study. CMAJ. 2013 Jan 21. [Medline].
American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013 Nov. 122 (5):1122-31. [Medline]. [Full Text].
Stowasser M, Gordon RD. Primary aldosteronism: changing definitions and new concepts of physiology and pathophysiology both inside and outside the kidney. Physiol Rev. 2016 Oct. 96 (4):1327-84. [Medline].
Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH. How common is white coat hypertension?. JAMA. 1988 Jan 8. 259(2):225-8. [Medline].
Stiles S. Framingham Criteria Predict New Hypertension Better Than Prehypertension in Young Adults. Medscape Medical News. Available at http://www.medscape.com/viewarticle/811416. Accessed: September 30, 2013.
Carson AP, Lewis CE, Jacobs DR Jr, Peralta CA, Steffen LM, Bower JK, et al. Evaluating the Framingham Hypertension Risk Prediction Model in Young Adults: The Coronary Artery Risk Development in Young Adults (CARDIA) Study. Hypertension. 2013 Sep 16. [Medline].
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. 1995 Jun 1. 122(11):833-8. [Medline].
US Food and Drug Administration. Information on gadolinium-based contrast agents. Available at http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm142882.htm. Accessed: February 22, 2012.
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. 2011 Jun. 32(12):1509-18. [Medline].
Redon J, Cifkova R, Laurent S, Nilsson P, Narkiewicz K, Erdine S, et al. Mechanisms of hypertension in the cardiometabolic syndrome. J Hypertens. 2009 Mar. 27(3):441-51. [Medline].
[Guideline] American Diabetes Association. Standards of medical care in diabetes-2016 abridged for primary care providers. Clin Diabetes. 2016 Jan. 34 (1):3-21. [Medline]. [Full Text].
Briasoulis A, Bakris GL. Current status of renal denervation in hypertension. Curr Cardiol Rep. 2016 Nov. 18 (11):107. [Medline].
Forman JP, Scheven L, de Jong PE, Bakker SJ, Curhan GC, Gansevoort RT. Association between sodium intake and change in uric acid, urine albumin excretion, and the risk of developing hypertension. Circulation. 2012 Jun 26. 125(25):3108-16. [Medline].
[Guideline] American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care. 2011 Jan. 34 Suppl 1:S11-61. [Medline]. [Full Text].
Aburto NJ, Hanson S, Gutierrez H, Hooper L, Elliott P, Cappuccio FP. Effect of increased potassium intake on cardiovascular risk factors and disease: systematic review and meta-analyses. BMJ. 2013 Apr 3. [Medline].
Ried K, Sullivan T, Fakler P, Frank OR, Stocks NP. Does chocolate reduce blood pressure? A meta-analysis. BMC Med. 2010 Jun 28. 8:39. [Medline]. [Full Text].
Fahey T, Schroeder K, Ebrahim S. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev. 2006 Apr 19. CD005182. [Medline].
Blumenthal JA, Babyak MA, Hinderliter A, 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. 2010 Jan 25. 170 (2):126-35. [Medline].
Boggs W. Benazepril plus amlodipine effective for high-risk, stage 2 hypertension. Medscape Medical News. May 3, 2013. [Full Text].
Bakris G, Briasoulis A, Dahlof B, et al, for the ACCOMPLISH Investigators. Comparison of benazepril plus amlodipine or hydrochlorothiazide in high-risk patients with hypertension and coronary artery disease. Am J Cardiol. 2013 Jul 15. 112 (2):255-9. [Medline].
[Guideline] James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2013 Dec 18. [Medline]. [Full Text].
Wood S. JNC 8 at last! Guidelines ease up on BP thresholds, drug choices. Heartwire. December 18, 2013. [Full Text].
Cushman WC, Evans GW, Byington RP, Goff DC Jr, Grimm RH Jr. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010 Apr 29. 362(17):1575-85. [Medline]. [Full Text].
Jamerson K, Weber MA, Bakris GL, Dahlöf B, Pitt B, Shi V, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. 2008 Dec 4. 359(23):2417-28. [Medline].
Ruggenenti P, Lauria G, Iliev IP, Fassi A, Ilieva AP, Rota S, et al. 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. 2011 Nov. 58(5):776-83. [Medline].
O'Riordan M. Spironolactone provides benefit in resistant hypertension, small study shows. Medscape Medical News [serial online]. Available at http://www.medscape.com/viewarticle/806388. June 17, 2013; Accessed: July 29, 2013.
Pancioli AM. Hypertension management in neurologic emergencies. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S24-7. [Medline].
Slovis CM, Reddi AS. Increased blood pressure without evidence of acute end organ damage. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S7-9. [Medline].
Blowey DL, Duda PJ, Stokes P, Hall M. Incidence and treatment of hypertension in the neonatal intensive care unit. J Am Soc Hypertens. 2011 Nov-Dec. 5(6):478-83. [Medline].
JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res. 2008 Dec. 31 (12):2115-27. [Medline].
Ogihara T, Saruta T, Rakugi H, et al, for the Valsartan in Elderly Isolated Systolic Hypertension Study Group. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension. 2010 Aug. 56 (2):196-202. [Medline].
Williamson JD, Supiano MA, Applegate WB, et al, for theSPRINT Research Group. Intensive vs standard blood pressure control and cardiovascular disease outcomes in adults aged ≥75 years: a randomized clinical trial. JAMA. 2016 Jun 28. 315 (24):2673-82. [Medline].
Kostis JB, Cabrera J, Cheng JQ, Cosgrove NM, Deng Y, Pressel SL, et al. Association between chlorthalidone treatment of systolic hypertension and long-term survival. JAMA. 2011 Dec 21. 306(23):2588-93. [Medline].
Staessen JA, Fagard R, Thijs L, Celis H, Arabidze GG, Birkenhäger WH, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet. 1997 Sep 13. 350(9080):757-64. [Medline].
Weinberger MH, Izzo JL Jr, Purkayastha D, Weitzman R, Black HR. Comparative efficacy and safety of combination aliskiren/amlodipine and amlodipine monotherapy in African Americans with stage 2 hypertension and obesity or metabolic syndrome. J Am Soc Hypertens. 2011 Nov-Dec. 5(6):489-97. [Medline].
Nishizaka MK, Zaman MA, Calhoun DA. Efficacy of low-dose spironolactone in subjects with resistant hypertension. Am J Hypertens. 2003 Nov. 16(11 Pt 1):925-30. [Medline].
de la Sierra A, Segura J, Banegas JR, Gorostidi M, de la Cruz JJ, Armario P, et al. Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Hypertension. 2011 May. 57(5):898-902. [Medline].
Townsend RR, Epstein M. Resistant hypertension: insights on evaluation and management in the post-SPRINT (Systolic Blood Pressure Intervention Trial) era. Hypertension. 2016 Nov. 68 (5):1073-1080. [Medline].
Krum H, Schlaich M, Whitbourn R, et al. Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Lancet. 2009 Apr 11. 373(9671):1275-81. [Medline].
Catheter-based renal sympathetic denervation for resistant hypertension: durability of blood pressure reduction out to 24 months. Hypertension. 2011 May. 57(5):911-7. [Medline].
Esler MD, Krum H, Sobotka PA, et al. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet. 2010 Dec 4. 376(9756):1903-9. [Medline].
Bhatt DL, Kandzari DE, O'Neill WW, et al, for the SYMPLICITY HTN-3 Investigators. A controlled trial of renal denervation for resistant hypertension. N Engl J Med. 2014 Apr 10. 370 (15):1393-401. [Medline].
Bisognano JD, Bakris G, Nadim MK, Sanchez L, Kroon AA, Schafer J, 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. 2011 Aug 9. 58(7):765-73. [Medline].
de La Sierra A, Larrousse M, Oliveras A, Armario P, Hernández-Del Rey R, Poch E, et al. Abnormalities of vascular function in resistant hypertension. Blood Press. 2012 Apr. 21(2):104-9. [Medline].
Mariampillai JE, Eskas PA, Heimark S, et al. Apparent treatment-resistant hypertension - patient-physician relationship and ethical issues. Blood Press. 2017 Jun. 26 (3):133-8. [Medline].
Kronish IM, Woodward M, Sergie Z, Ogedegbe G, Falzon L, Mann DM. Meta-analysis: impact of drug class on adherence to antihypertensives. Circulation. 2011 Apr 19. 123(15):1611-21. [Medline]. [Full Text].
Fagugli RM, Taglioni C. Changes in the perceived epidemiology of primary hyperaldosteronism. Int J Hypertens. 2011. 2011:162804. [Medline]. [Full Text].
Pedrosa RP, Drager LF, Gonzaga CC, Sousa MG, de Paula LK, Amaro AC, et al. Obstructive sleep apnea: the most common secondary cause of hypertension associated with resistant hypertension. Hypertension. 2011 Nov. 58(5):811-7. [Medline].
Martínez-Garcia MA, Capote F, Campos-Rodriguez F, et al, for the Spanish Sleep Network. Effect of CPAP on blood pressure in patients with obstructive sleep apnea and resistant hypertension: the HIPARCO randomized clinical trial. JAMA. 2013 Dec 11. 310(22):2407-15. [Medline].
O'Riordan M. CPAP reduces blood pressure in resistant hypertension. Heartwire. December 10, 2013. [Full Text].
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. 2011 Mar. 26(3):280-6. [Medline]. [Full Text].
Bosworth HB, Powers BJ, Olsen MK, McCant F, Grubber J, Smith V, et al. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Arch Intern Med. 2011 Jul 11. 171(13):1173-80. [Medline].
[Guideline] US Preventive Services Task Force (USPSTF). Final recommendation statement: high blood pressure in adults: screening. Available at http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/high-blood-pressure-in-adults-screening. November 2015; Accessed: May 14, 2016.
[Guideline] American Congress of Obstetricians and Gynecologists (ACOG). Well-woman care: assessments & recommendations. Washington, DC: American Congress of Obstetricians and Gynecologists. Available at http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations . 2013; Accessed: May 15, 2016.
[Guideline] Department of Veterans Affairs and Department of Defense (VA/DoD). Clinical practice guideline for the diagnosis and management of hypertension in the primary care setting. Version 3.0. Available at http://www.healthquality.va.gov/guidelines/CD/htn/VADoDCPGfortheManagementofHTN.pdf . 2014; Accessed: May 15, 2016.
[Guideline] Rosendorff C, Lackland DT, Allison M, Aronow WS, et al. American Heart Association, American College of Cardiology, et al. Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. Circulation. 2015 May 12. 131 (19):e435-70. [Medline]. [Full Text].
[Guideline] Go AS, Bauman M, King SM, et al. An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension. 2013 Nov 15. [Medline]. [Full Text].
[Guideline] Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens. 2014 Jan. 32 (1):3-15. [Medline]. [Full Text].
Wright JT Jr, Williamson JD, Whelton PK, et al, for the SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015 Nov 26. 373 (22):2103-16. [Medline].
Benavente OR, Coffey CS, Conwit R, et al, for the SPS3 Study Group. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet. 2013 Aug 10. 382 (9891):507-15. [Medline].
Oparil S, Lewis CE. Should patients with cardiovascular risk factors receive intensive treatment of hypertension to Circulation</i>. 2016 Nov 1. 134 (18):1308-1310. [Medline].
Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure lowering on outcome incidence in hypertension: 7. Effects of more vs. less intensive blood pressure lowering and different achieved blood pressure levels - updated overview and meta-analyses of randomized trials. J Hypertens. 2016 Apr. 34 (4):613-22. [Medline].
O'Riordan M. AHA/ACC/CDC issue 'science advisory' on treating BP. Medscape Medical News [serial online]. Available at http://www.medscape.com/viewarticle/814442. November 15, 2013; Accessed: November 16, 2013.
[Guideline] Magee LA, Pels A, Helewa M, Rey E, von Dadelszen P, Canadian Hypertensive Disorders of Pregnancy Working Group. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy: executive summary. J Obstet Gynaecol Can. 2014 May. 36 (5):416-41. [Medline]. [Full Text].
[Guideline] Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM, American College of Emergency Physicians Clinical Policies Committee. Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 2013 Jul. 62 (1):59-68. [Medline]. [Full Text].
[Guideline] National High Blood Pressure Education Program Working Group. Report of the National High Blood Pressure Education Program Working Group on high blood pressure in pregnancy. Am J Obstet Gynecol. 2000 Jul. 183 (1):S1-S22. [Medline].
[Guideline] American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013 Nov. 122 (5):1122-31. [Medline]. [Full Text].
[Guideline] Committee on Obstetric Practice. Committee opinion no. 623: emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol. 2015 Feb. 125 (2):521-5. [Medline]. [Full Text].
Leung AA, Wright A, Pazo V, Karson A, Bates DW. Risk of thiazide-induced hyponatremia in patients with hypertension. Am J Med. 2011 Nov. 124(11):1064-72. [Medline].
Harel Z, Gilbert C, Wald R, Bell C, Perl J, Juurlink D, 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. 2012 Jan 9. 344:e42. [Medline]. [Full Text].
Cummings DM, Amadio P Jr, Nelson L, Fitzgerald JM. The role of calcium channel blockers in the treatment of essential hypertension. Arch Intern Med. 1991 Feb. 151(2):250-9. [Medline].
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. 2005 Sep. 11(9):CR403-9. [Medline].
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. 1989 Apr. 149(4):780-8. [Medline].
Strong Heart Study Data Book: A Report to American Indian Communities. Bethesda, MD: National Heart, Lung, and Blood Institute, NIH; 2001.
Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005 Oct 25. 112(17):2735-52. [Medline].
Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, 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. 2011 May 17. 57(20):2037-114. [Medline].
1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension. Guidelines Subcommittee. J Hypertens. 1999 Feb. 17(2):151-83. [Medline].
Abalos E, Duley L, Steyn DW, Henderson-Smart DJ. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2007 Jan 24. CD002252. [Medline].
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. 1999 Jun. 17(6):817-24. [Medline].
Matchar DB, McCrory DC, Orlando LA, et al. Systematic review: comparative effectiveness of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for treating essential hypertension. Ann Intern Med. 2008 Jan 1. 148 (1):16-29. [Medline]. [Full Text].
American College of Radiology. Manual on Contrast Media. Vers. 7. Available at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/contrast_manual.aspx. Accessed: February 22, 2012.
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. 2010 Feb. 41(2):307-12. [Medline].
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. 2008 May. 7(5):391-9. [Medline].
Ault MJ, Ellrodt AG. Pathophysiological events leading to the end-organ effects of acute hypertension. Am J Emerg Med. 1985 Dec. 3(6 Suppl):10-5. [Medline].
Barton JR. Hypertension in pregnancy. Ann Emerg Med. 2008 Mar. 51 (3 suppl):S16-7. [Medline].
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. 2011 Jan 22. 377(9762):312-20. [Medline].
Chapman N, Huxley R, Anderson C, Bousser MG, Chalmers J, Colman S, et al. Effects of a perindopril-based blood pressure-lowering regimen on the risk of recurrent stroke according to stroke subtype and medical history: the PROGRESS Trial. Stroke. 2004 Jan. 35(1):116-21. [Medline].
Cheung AT, Hobson RW 2nd. Hypertension in vascular surgery: aortic dissection and carotid revascularization. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S28-33. [Medline].
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. 1996 Jan. 5(1):17-24; discussion 25. [Medline].
Chrysant SG, Izzo JL Jr, Kereiakes DJ, Littlejohn T 3rd, Oparil S, Melino M, et al. Efficacy and safety of triple-combination therapy with olmesartan, amlodipine, and hydrochlorothiazide in study participants with hypertension and diabetes: a subpopulation analysis of the TRINITY study. J Am Soc Hypertens. 2012 Mar-Apr. 6(2):132-41. [Medline].
Cushman WC, Bakris GL, White WB, Weber MA, Sica D, Roberts A, et al. Azilsartan medoxomil plus chlorthalidone reduces blood pressure more effectively than olmesartan plus hydrochlorothiazide in stage 2 systolic hypertension. Hypertension. 2012 Aug. 60(2):310-8. [Medline].
Daien V, Duny Y, Ribstein J, du Cailar G, Mimran A, Villain M, et al. Treatment of hypertension with renin-angiotensin system inhibitors and renal dysfunction: a systematic review and meta-analysis. Am J Hypertens. 2012 Jan. 25(1):126-32. [Medline].
Diercks DB, Ohman EM. Hypertension with acute coronary syndrome and heart failure. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S34-6. [Medline].
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. 2009 Jul. 11(1):17-26. [Medline]. [Full Text].
Epstein M. Calcium antagonists and renal disease. Kidney Int. 1998 Nov. 54(5):1771-84. [Medline].
Faselis C, Doumas M, Kokkinos JP, Panagiotakos D, Kheirbek R, Sheriff HM, et al. Exercise capacity and progression from prehypertension to hypertension. Hypertension. 2012 Aug. 60(2):333-8. [Medline].
[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. 2011 Feb. 42(2):517-84. [Medline].
Ha V, Sievenpiper JL, de Souza RJ, Chiavaroli L, Wang DD, Cozma AI, et al. Effect of fructose on blood pressure: a systematic review and meta-analysis of controlled feeding trials. Hypertension. 2012 Apr. 59(4):787-95. [Medline].
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. 2000 Jul 29. 356(9227):359-65. [Medline].
Heilpern K. Pathophysiology of hypertension. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S5-6. [Medline].
Hermida RC, Ayala DE, Mojón A, Fernández JR. Decreasing sleep-time blood pressure determined by ambulatory monitoring reduces cardiovascular risk. J Am Coll Cardiol. 2011 Sep 6. 58(11):1165-73. [Medline].
Izzo JL Jr, Weintraub HS, Duprez DA, Purkayastha D, Zappe D, Samuel R, et al. Treating systolic hypertension in the very elderly with valsartan-hydrochlorothiazide vs. either monotherapy: ValVET primary results. J Clin Hypertens (Greenwich). 2011 Oct. 13(10):722-30. [Medline].
Kandzari DE, Bhatt DL, Sobotka PA, et al. Catheter-based renal denervation for resistant hypertension: rationale and design of the SYMPLICITY HTN-3 Trial. Clin Cardiol. 2012 Sep. 35(9):528-35. [Medline].
Kaplan NM. Calcium entry blockers in the treatment of hypertension. Current status and future prospects. JAMA. 1989 Aug 11. 262(6):817-23. [Medline].
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. 2005 Jun. 21(8):657-72. [Medline].
Kitiyakara C, Guzman NJ. Malignant hypertension and hypertensive emergencies. J Am Soc Nephrol. 1998 Jan. 9(1):133-42. [Medline].
Lao D, Parasher PS, Cho KC, Yeghiazarians Y. Atherosclerotic renal artery stenosis--diagnosis and treatment. Mayo Clin Proc. 2011 Jul. 86(7):649-57. [Medline]. [Full Text].
Lloyd-Jones D, Adams RJ, Brown TM, Carnethon M, Dai S, De Simone G, et al. Heart disease and stroke statistics--2010 update: a report from the American Heart Association. Circulation. 2010 Feb 23. 121(7):e46-e215. [Medline].
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.
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. 2000 Apr 19. 283(15):1967-75. [Medline].
Narkiewicz K. Diagnosis and management of hypertension in obesity. Obes Rev. 2006 May. 7(2):155-62. [Medline].
National Institutes of Health. Your Guide to Lowering Your Blood Pressure With DASH. April 2006. 64. [Full Text].
Novartis. Novartis announces termination of ALTITUDE study with Rasilez/Tekturna in high-risk patients with diabetes and renal impairment [press release]. Available at http://www.evaluategroup.com/Universal/View.aspx?type=Story&id=270122&sectionID=&isEPVantage=no. December 20, 2011; Accessed: February 22, 2012.
O'Connor PJ, Vazquez-Benitez G, Schmittdiel JA, Parker ED, Trower NK, Desai JR, et al. Benefits of Early Hypertension Control on Cardiovascular Outcomes in Patients With Diabetes. Diabetes Care. 2012 Sep 10. [Medline].
O'Riordan M. Olmesartan label to include intestinal problems, FDA says. Medscape Medical News. July 3, 2013. [Full Text].
Pimenta E, Calhoun DA, Oparil S. Sleep apnea, aldosterone, and resistant hypertension. Prog Cardiovasc Dis. 2009 Mar-Apr. 51(5):371-80. [Medline].
Pleis JR, Lucus JW, Ward BW. Summary health statistics for US adults: National Health Interview Survey, 2008. Vital Health Stat 10. 2009. No. 242:[Full Text].
Podymow T, August P. Antihypertensive drugs in pregnancy. Semin Nephrol. 2011 Jan. 31(1):70-85. [Medline].
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. 1989 Sep 28. 321(13):868-73. [Medline].
Rastan A, Krankenberg H, Müller-Hülsbeck S, 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. 2008 Aug. 4(2):208-13. [Medline].
Roberts CL, Ford JB, Algert CS, Antonsen S, Chalmers J, Cnattingius S, et al. Population-based trends in pregnancy hypertension and pre-eclampsia: an international comparative study. BMJ Open. 2011 May 24. 1(1):e000101. [Medline]. [Full Text].
Shook RP, Lee DC, Sui X, Prasad V, Hooker SP, Church TS, et al. Cardiorespiratory fitness reduces the risk of incident hypertension associated with a parental history of hypertension. Hypertension. 2012 Jun. 59(6):1220-4. [Medline].
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. 2011 Jul 26. 343:d4366. [Medline]. [Full Text].
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. 2001 Nov. 19(11):1949-56. [Medline].
Taubert D, Roesen R, Lehmann C, Jung N, Schomig E. Effects of low habitual cocoa intake on blood pressure and bioactive nitric oxide: a randomized controlled trial. JAMA. 2007 Jul 4. 298(1):49-60. [Medline].
World Health Organization. The World Health Report 2002 - reducing risks, promoting healthy life. Geneva, Switzerland: WHO; 2002. Available at http://www.who.int/whr/2002/en/. Accessed: February 20, 2012.
Tseng CD, Yen AM, Chiu SY, Chen LS, Chen HH, Chang SH. A predictive model for risk of prehypertension and hypertension and expected benefit after population-based life-style modification (KCIS No. 24). Am J Hypertens. 2012 Feb. 25(2):171-9. [Medline].
Tymchak W, Armstrong PW, Westerhout CM, Sookram S, Brass N, Fu Y, et al. Mode of hospital presentation in patients with non-ST-elevation myocardial infarction: implications for strategic management. Am Heart J. 2011 Sep. 162(3):436-43. [Medline].
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. 1980 Oct. 46(4):559-65. [Medline].
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. 2011 Mar. 57(3):413-20. [Medline].
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. 2000 Jan. 13(1 Pt 1):103-4. [Medline].
Yakovlevitch M, Black HR. Resistant hypertension in a tertiary care clinic. Arch Intern Med. 1991 Sep. 151(9):1786-92. [Medline].
Dolan E, O'Brien E. Is it daily, monthly, or yearly blood pressure variability that enhances cardiovascular risk?. Curr Cardiol Rep. 2015 Nov. 17 (11):93. [Medline].
Cau SB, Guimaraes DA, Rizzi E, Ceron CS, Gerlach RF, Tanus-Santos JE. The nuclear factor kappaB inhibitor pyrrolidine dithiocarbamate prevents cardiac remodelling and matrix metalloproteinase-2 up-regulation in renovascular hypertension. Basic Clin Pharmacol Toxicol. 2015 Oct. 117 (4):234-41. [Medline].
Denker MG, Cohen DL, Townsend RR. Catheter-based renal artery denervation for resistant hypertension: promise unfulfilled or unsettled?. Curr Atheroscler Rep. 2015 Oct. 17 (10):535. [Medline].
Rosner B, Cook NR, Daniels S, Falkner B. Childhood blood pressure trends and risk factors for high blood pressure: the NHANES experience 1988-2008. Hypertension. 2013 Aug. 62 (2):247-54. [Medline].
Alam T, Khan S, Gaba B, Haider MF, Baboota S, Ali J. Nanocarriers as treatment modalities for hypertension. Drug Deliv. 2017 Nov. 24 (1):358-69. [Medline].
Marcuccilli M, Kendrick J, Chonchol M. Sodium and fluid management in the conservative management of chronic kidney disease. Panminerva Med. 2017 Jun. 59 (2):116-23. [Medline].

Media Gallery

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.
Hypertrophied cardiac myocytes with enlarged "box car" nuclei.
Hypertension—or high blood pressure—can happen steadily over long time periods. The cause may not be clear (ie, primary hypertension) or hypertension may be caused by an underlying condition (ie, secondary hypertension).

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Table 1. NHIS/NCHS Age-Adjusted Prevalence Estimates in Individuals Aged 18 Years and Older in 2015.

Race/Ethnic Group	Have Hypertension, %	Have Heart Disease, %	Have Coronary Heart Disease, %	Have Had a Stroke, %
White only	23.8	11.3	5.6	2.4
Black/African American	34.4	9.5	5.4	3.7
Hispanic/Latino	23.0	8.2	5.1	2.4
Asian	20.6	7.1	3.7	1.4
American Indian/Alaska Native	28.4	13.7	9.3	2.2 (this number is considered unreliable)
Source: Summary health statistics: National Health Interview Survey, 2015. Available at: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2015_SHS_Table_A-1.pdf. Accessed: November 14, 2016. NCHS = National Center for Health Statistics; NHIS = National Health Interview Survey.

Table 2. Identifiable Hypertension and Screening Tests

Condition	Screening Test
Chronic kidney disease	Estimated glomerular filtration rate
Coarctation of the aorta	Computed tomography angiography
Cushing syndrome; other states of glucocorticoid excess (eg, chronic steroid therapy	Dexamethasone suppression test
Drug-induced/drug-related hypertension^*	Drug screening
Pheochromocytoma	24-hour urinary metanephrine and normetanephrine
Primary aldosteronism, other states of mineralocorticoid excess	Plasma aldosterone to renin activity ratio (ARR). If abnormal, refer for further evaluation such as saline infusion to determine if aldosterone levels can be suppressed, 24-hour urinary aldosterone level, and specific mineralocorticoid tests
Renovascular hypertension	Doppler flow ultrasonography, magnetic resonance angiography, computed tomography angiography
Sleep apnea	Sleep study with oxygen saturation (screening would also include the Epworth Sleepiness Scale [ESS])
Thyroid/parathyroid disease	Thyroid stimulating hormone level, serum parathyroid hormone level
Adapted from: Chobanian AV, Bakris GL, Black HR, et al, and the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. Dec 2003;42(6):1206-52.^[2] ^* Some examples of agents that induce hypertension include nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors; illicit drugs; sympathomimetic agents; oral contraceptive or adrenal steroid hormones; cyclosporine and tacrolimus; licorice; erythropoietin; and certain over-the-counter dietary supplements and medicines, such as ephedra, ma huang, and bitter orange. Drug-related causes of hypertension may be due to nonadherence, inadequate doses, and inappropriate combinations.

Table 3. Hypertensive Disorders in Pregnancy

Classification	Characteristics
Chronic hypertension	Prepregnancy or before 20 weeks’ gestation; SBP =140 mm Hg or DBP 90 mm Hg that persists >12 weeks postpartum
Preeclampsia	After 20 weeks’ gestation; SBP =140 mm Hg or DBP 90 mm Hg with proteinuria (>300 mg/24 h) Can progress to eclampsia More common in nulliparous women, multiple gestation, women with hypertension =4 years, family history of preeclampsia, previous hypertension in pregnancy, and renal disease
Chronic hypertension with superimposed preeclampsia	New-onset proteinuria after 20 weeks in hypertensive woman In a woman with hypertension and proteinuria before 20 weeks’ gestation Sudden 2- to 3-fold increase in proteinuria Sudden increase in BP Thrombocytopenia Elevated AST or ALT levels
Gestational hypertension	Temporary diagnosis Hypertension without proteinuria after 20 weeks’ gestation May be a preproteinuric phase of preeclampsia or a recurrence of chronic hypertension that abated in mid-pregnancy May lead to preeclampsia Severe cases may cause higher rates of premature delivery and growth retardation relative to mild preeclampsia
Transient hypertension	Diagnosis made retrospectively BP returns to normal by 12 weeks’ postpartum May recur in subsequent pregnancies Predictive of future primary hypertension
ALT = alanine aminotransferase; AST = aspartate aminotransferase; BP = blood pressure; DBP = diastolic BP; SBP = systolic BP. Adapted from: Chobanian AV, Bakris GL, Black HR, et al, and the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. Dec 2003;42(6):1206-52.^[2]

Table 4. Guidelines for Blood Pressure Screening in Adults

Issuing Organization	Year	Screening Populations	Screening Measurement	Screening Interval
US Preventive Services Task Force (USPSTF)^[108]	2015	Adults ≥18 years without known hypertension	Measurements outside of the clinical setting should be obtained for diagnostic confirmation before starting treatment. No evidence was found for a single gold standard protocol for HBPM or ABPM. However, both may be used in conjunction with proper office measurement to make a diagnosis and guide management and treatment options.	Annually for adults age ≥40 and those at increased risk for high blood pressure including those who have high-normal blood pressure (130–139/85–89 mm Hg), are overweight or obese, or are African American. Adults ages ≥18 to <40 years with normal blood pressure (≤130/85mm Hg) with no known risk factors should be screened every 3-5 years
Seventh Report of the Prevention, Detection, Evaluation, and Treatment of the Joint National Committee on High Blood Pressure (JNC 7)^[2]	2003	Adults ages ≥18 years	Diagnosis based on average of 2 or more seated blood pressure readings on each of two or more office visits	At least once every 2 years in adults with blood pressure less than 120/80 mm Hg and every year in those with levels of 120–139/80–89 mm Hg.
American College of Obstetricians and Gynecologists (ACOG)^[109]	2013	All females ages ≥13 years	Office measurement	Annually as part of routine well-woman care
Department of Veterans Affairs/Department of Defense (VA/DoD)^[110]	2014	All adults	Office measurement; Diagnosis based on 2 readings at 2 separate visits; For patients where diagnosis remains uncertain, home blood pressure monitoring (2-3 times a day for 7 days) or 24 hour ambulatory monitoring to confirm diagnosis	Periodic, preferably annually, at time of routine preventative care or health assessment;
European Society of Hypertension /European Society of Cardiology (ESH/ESC)^[7]	2013	All adults	Office measurement; Diagnosis based on at least 2 readings at 2 separate visits; Consider home blood pressure monitoring or 24 hour ambulatory monitoring to confirm diagnosis	At time of routine preventative care or health assessment

Table 5. Target Blood Pressure Recommendations

Issuing Organization	Year	Population	Target Blood Pressure
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)^[2]	2003	All adults except those with diabetes or chronic kidney disease Adults with diabetes or chronic kidney disease	<140/90 mm Hg <130/80 mm Hg
Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8)^[76]	2014	Adults age <60 years and those >18 with diabetes or chronic kidney disease Adults age ≥60 years	<140/90 mm Hg <150/90 mm Hg
European Society of Hypertension/European Society of Cardiology (ESH/ECS)^[7]	2013	All adults except those with diabetes Adults with diabetes	140-150 mm Hg systolic; consider <140 mm Hg if the patient is fit and healthy; for ages ≥80 years, the patient's mental capacity and physical heath should also be considered if targeting to <140 mm Hg <85 mm Hg diastolic BP
American Heart Association/American College of Cardiology/American Society of Hypertension (AHA/ACC/ASH)^[111]	2015	Adults ages >80 years Adults with CAD, except as noted below Adults with MI, stroke, TIA, carotid artery disease, peripheral artery disease or abdominal aortic aneurysm	<150/90 mm Hg <140/90 mm Hg <130/80 mm Hg
American Heart Association/American College of Cardiology (ACC)/Centers for Disease Control and Prevention (AHA/ACC/CDC)^[112]	2014	All adults	<140/90 mm Hg
American Society of Hypertension/International Society of Hypertension (ASH/ISH)^[113]	2014	Adults ages 18-79 years Adults ages ≥80 years	<140/90 mm Hg; <130/80 mm Hg BP target may be considered in younger adults <150/90 mm Hg
Department of Veterans Affairs/Department of Defense (VA/DoD)^[110]	2014	All adults Adults with diabetes	<150/90 mm Hg <150/85 mm Hg
American Diabetes Association (ADA)^[66]	2016	Adults with diabetes	<140/90 mm Hg; <130/80 mm Hg target may be appropriate in younger adults

Table 6. American Society of Hypertension/International Society of Hypertension Treatment Recommendations

Patients Without Other Major Medical Condition	First-line Drugs	Added 2^nd Drug (if needed to reach BP target)	Added 3^rd Drug (if needed to reach BP target)
African ancestry	CCB or thiazide diuretic	ARB or ACE inhibitor	Combination of CCB plus ACE inhibitor or ARB plus thiazide diuretic
White and other non-African ancestry ages <60 years	ARB or ACE inhibitor	CCB or thiazide diuretic	Combination of CCB plus ACE inhibitor or ARB plus thiazide diuretic
White and other non-African ancestry ages ≥60 years	CCB or thiazide diuretic; ARB or ACE inhibitor also effective	ARB or ACE inhibitor; CCB or thiazide diuretic if ARB or ACE inhibitor used first	Combination of CCB plus ACE inhibitor or ARB plus thiazide diuretic
Major medical condition
Diabetes (white and other non-African ancestry)	ARB or ACE inhibitor	CCB or thiazide diuretic	Alternative 2^nd drug (CCB or thiazide diuretic)
Diabetes (African ancestry)	CCB or thiazide diuretic	ARB or ACE inhibitor	Alternative 1^st drug (CCB or thiazide diuretic)
Chronic kidney disease	ARB or ACE inhibitor	CCB or thiazide diuretic	Alternative 2^nd drug (CCB or thiazide diuretic)
Coronary artery disease	Beta-blocker plus ARB or ACE inhibitor	CCB or thiazide diuretic	Alternative 2^nd drug (CCB or thiazide diuretic)
Stroke	ACE inhibitor or ARB	CCB or thiazide diuretic	Alternative 2^nd drug (CCB or thiazide diuretic)
Symptomatic heart failure	Beta-blocker plus ARB or ACE inhibitor plus diuretic plus spironolactone regardless of BP; CCB can be added if needed for BP control

Table 7. JNC 7 Classification of Hypertensive Disorders in Pregnancy

Classification	Characteristics
Chronic hypertension	SBP ≥140 mm Hg or DBP ≥90 mm Hg, present pre-pregnancy or before 20 weeks’ gestation and persisting >12 weeks postpartum
Preeclampsia	SBP ≥140 mm Hg or DBP ≥90 mm Hg with proteinuria (>300 mg/24 h) that develops >20 weeks’ gestation; Can progress to eclampsia More common in nulliparous women, multiple gestation, women with hypertension ≥4 years, family history of preeclampsia, previous hypertension in pregnancy, and renal disease
Chronic hypertension with superimposed preeclampsia	New-onset proteinuria after 20 weeks’ gestation in a hypertensive woman or In a woman with hypertension and proteinuria before 20 weeks’ gestation: • Sudden 2- to 3-fold increase in proteinuria • Sudden increase in BP • Thrombocytopenia • Elevated AST or ALT levels
Gestational hypertension	Temporary diagnosis Hypertension without proteinuria after 20 weeks’ gestation May be a preproteinuric phase of preeclampsia or a recurrence of chronic hypertension that abated in mid-pregnancy May lead to preeclampsia Severe cases may cause higher rates of premature delivery and growth retardation relative to mild preeclampsia
Transient hypertension	Diagnosis made retrospectively BP returns to normal by 12 weeks postpartum May recur in subsequent pregnancies Predictive of future primary hypertension
ALT = alanine aminotransferase; AST = aspartate aminotransferase; BP = blood pressure; DBP = diastolic BP; SBP = systolic BP

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Author

Matthew R Alexander, MD, PhD Fellow, Division of Cardiovascular Medicine, Department of Internal Medicine, Physician Scientist Training Program, Vanderbilt University School of Medicine

Matthew R Alexander, MD, PhD is a member of the following medical societies: American College of Cardiology, American Heart Association

Disclosure: Nothing to disclose.

Coauthor(s)

Meena S Madhur, MD, PhD Assistant Professor, Department of Medicine, Divisions of Clinical Pharmacology and Cardiology, Vanderbilt University School of Medicine

Meena S Madhur, MD, PhD is a member of the following medical societies: American College of Cardiology, American Heart Association

Disclosure: Nothing to disclose.

David G Harrison, MD Betty and Jack Bailey Professor of Medicine and Pharmacology, Director of Clinical Pharmacology, Vanderbilt University School of Medicine

David G Harrison, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, American Physiological Society, American Society for Clinical Investigation, Association of American Physicians, Central Society for Clinical and Translational Research, American Federation for Clinical Research, Society for Vascular Medicine

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

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, Royal College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Gary Edward Sander, MD, PhD, FACC, FAHA, FACP, FASH Professor of Medicine, Director of CME Programs, Team Leader, Root Cause Analysis, Tulane University Heart and Vascular Institute; Director of In-Patient Cardiology, Tulane Service, University Hospital; Visiting Physician, Medical Center of Louisiana at New Orleans; Faculty, Pennington Biomedical Research Institute, Louisiana State University; Professor, Tulane University School of Medicine

Gary Edward Sander, MD, PhD, FACC, FAHA, FACP, FASH is a member of the following medical societies: Alpha Omega Alpha, American Chemical Society, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Federation for Clinical Research, American Federation for Medical Research, American Heart Association, American Society for Pharmacology and Experimental Therapeutics, American Society of Hypertension, American Thoracic Society, Heart Failure Society of America, National Lipid Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Chief Editor

Eric H Yang, MD Associate Professor of Medicine, Director of Cardiac Catherization Laboratory and Interventional Cardiology, Mayo Clinic Arizona

Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Acknowledgements

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