History
Following the documentation of hypertension, which is confirmed after an elevated blood pressure (BP) on at least three separate occasions (based on the average of 2 or more readings taken at each of ≥2 follow-up visits after initial screening), a detailed history should extract the following information:
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Extent of end-organ damage (eg, heart, brain, kidneys, eyes)
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Assessment of patients’ cardiovascular risk status
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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. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) identifies the following as targets of end-organ damage [5] :
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Heart: left ventricular hypertrophy, angina/previous myocardial infarction, previous coronary revascularization, and heart failure
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Brain: stroke or transient ischemic attack, dementia
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Chronic kidney disease
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Peripheral arterial disease
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Retinopathy
The JNC 7 identifies the following as major cardiovascular risk factors [5] :
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Hypertension: component of metabolic syndrome
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Tobacco use, particularly cigarettes, including chewing tobacco
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Elevated LDL cholesterol (or total cholesterol ≥240 mg/dL) or low HDL cholesterol: component of metabolic syndrome
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Diabetes mellitus: component of metabolic syndrome
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Obesity (BMI ≥30 kg/m2): component of metabolic syndrome
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Age greater than 55 years for men or greater than 65 years for women: increased risk begins at the respective ages; the Adult Treatment Panel III used earlier age cut points to suggest the need for earlier action
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Estimated glomerular filtration rate less than 60 mL/min
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Microalbuminuria
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Family history of premature cardiovascular disease (men < 55 years; women < 65 years)
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Lack of exercise
Obtain a history of the patient’s use of over-the-counter medications; herbal medicines such as herbal tea containing licorice (the issue is products containing licorice root; large amount of licorice in the US is licorice candy, but black licorice and over-the-counter licorice root supplements are increasingly available); ephedrine/ephedra; current and previous unsuccessful antihypertensive medication trials; oral contraceptives; ethanol; and illicit drugs such as cocaine. The patient’s lifestyle factors should also be included, such as changes in weight, dietary intake of sodium and cholesterol, exercise level, and psychosocial stressors. [7]
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.
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. [5, 7] 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. [53] "Nondipping" is the loss of the usual physiologic nocturnal drop in blood pressure and is associated with an increased cardiovascular risk.
A study by Wong and Mitchell indicated that independent of other risk factors, the presence of certain signs of hypertensive retinopathy (eg, retinal hemorrhages, microaneurysms, cotton-wool spots) is associated with an increased cardiovascular risk (eg, stroke, stroke mortality). [54] Consequently, perform a funduscopic eye evaluation to identify any signs of early or late, chronic or acute hypertensive retinopathy, such as arteriovenous nicking or vessel wall changes (eg, copper/silver wiring, hard exudates, flame-shaped hemorrhages, papilledema). Acute or chronic ocular changes can be the initial finding in asymptomatic patients that requires a primary care referral. Alternatively, 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. In addition, examine the neck for carotid bruits, distended veins, or enlarged thyroid gland. [5, 7] 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.
Hypertension and Cerebrovascular Disease
Blood pressure is a powerful determinant of risk for ischemic stroke and intracranial hemorrhage; in fact, 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 are associated with a significant incidence of strokes. The American Heart Association notes that individuals whose blood pressure level is lower than 120/80 mm Hg have about 50% the lifetime stroke risk of that of hypertensive individuals.
The main pathologic findings are in the heart, which shows an increase in mass caused principally by left ventricular hypertrophy. Histologically, the individual myocytes are enlarged and show nucleomegaly (“box car” nuclei) (see the image below). Hearts that are enlarged secondary to hypertension have an increased incidence of arrhythmia and death. 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.
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 (eg, neurologic, cardiovascular). 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, [55] as well as acute myocardial infarction. Hypertension is also one of several conditions that have been increasingly recognized as having an association with posterior reversible encephalopathy syndrome (PRES), a condition characterized by headache, altered mental status, visual disturbances, and seizures. [56]
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 black 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. Note that BNP is inversely proportional to the degree of a patient’s obesity. [57]
Hypertension in Pediatric Patients
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, although various health data showed a decreasing trend between 1963 and 1988, followed by an upward trend. Hypertension is now commonly discovered in children, and the long-term health risks to these children 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 cases of secondary hypertension are attributed to renovascular disease.
Hypertension in Pregnancy
Hypertension is the most common medical problem encountered during pregnancy, complicating 2-3% of pregnancies. [58]
A large, population-based study compared 26,651 pregnant women with hypertensive disorders to 213,397 pregnant women without hypertensive disorders to determine risk of end-stage renal disease and found that the incidence of chronic kidney disease was almost 11-fold higher in the hypertensive group. [59] This group also exhibited a 14-fold increased risk for end-stage renal disease. The risk was much greater for women with preeclampsia or eclampsia. [60]
The American College of Obstetricians and Gynecologists (ACOG) recommends that women with prior preeclampsia who have delivered preterm (< 37.5 weeks) or who have a history of recurrent preeclampsia undergo yearly assessment of blood pressure, lipid profile, plasma glucose, and body weight. [61]
Primary Aldosteronism
Mineralocorticoid excess secondary to primary hyperaldosteronism is characterized by excessive production of aldosterone. Previously considered a rare cause of hypertension, PA is now recognized to be the most common cause of secondary hypertension. Renal sodium retention, kaliuresis, hypokalemia, and hypochloremic metabolic alkalosis are the common manifestations. It should be considered in patients who have an exaggerated hypokalemic response to a thiazide diuretic or who have hypokalemia unprovoked by a diuretic. These patients develop increased intravascular volume, resulting in hypertension. Hypokalemia, however, is present in less than half of patients with PA, and thus the ratio of plasma aldosterone to renin activity should be used for screening of suspected cases. Blood pressure 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.
The incidence of primary hyperaldosteronism was 1.5% in one study. [11] However, the true incidence of primary aldosteronism has been estimated to be as high as 5-15% and is often associated with metabolic syndrome. [62] Related to this, obesity is increasingly associated with PA and treatment with aldosterone receptor antagonists have proven effective in this population.
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Hypertension. 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.
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Hypertension. 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.
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Hypertension. Electrocardiogram (ECG) from a 46-year-old man with long-standing hypertension. This ECG shows left atrial abnormality and left ventricular hypertrophy with strain.
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Hypertension. Hypertrophied cardiac myocytes with enlarged "box car" nuclei.
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Hypertension. Age-adjusted trends in hypertension and controlled hypertension among adults aged 18 and over: United States, 1999–2016. Courtesy of the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS).
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Hypertension. Prevalence of hypertension among adults aged 18 and over, by sex and age: United States, 2015–2016. Courtesy of the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS).
Tables
- Table 2. NHIS/NCHS Age-Adjusted Prevalence Estimates in Individuals Aged 18 Years and Older in 2015.
- Table 2. Identifiable Hypertension and Screening Tests
- Table 3. Hypertensive Disorders in Pregnancy
- Table 4. Guidelines for Blood Pressure Screening in Adults
- Table 5. Target Blood Pressure Recommendations
- Table 6. American Society of Hypertension/International Society of Hypertension Treatment Recommendations
- Table 7. JNC 7 Classification of Hypertensive Disorders in Pregnancy
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. |
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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. [5] * 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. |
|
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. [5] |
|
Issuing Organization |
Year |
Screening Populations |
Screening Measurement |
Screening Interval |
European Society of Cardiology/ European Society of Hypertension (ESC/ESH) [9] |
2018 |
All adults |
Office measurement |
At regular intervals on the basis of the blood pressure level:
|
US Preventive Services Task Force (USPSTF) [127] |
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) [5] |
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) [128] |
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) [129] |
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) [126] |
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 |
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) [5] |
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) [88] |
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) [126] |
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) [130] |
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) [131] |
2014 |
All adults |
< 140/90 mm Hg |
American College of Cardiology/American Heart Association (ACC/AHA) [1] |
2017 |
All adults |
< 130/80 mm Hg |
American Society of Hypertension/International Society of Hypertension (ASH/ISH) [132] |
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) [129] |
2014 |
All adults Adults with diabetes |
< 150/90 mm Hg < 150/85 mm Hg |
American Diabetes Association (ADA) [71] |
2016 |
Adults with diabetes |
< 140/90 mm Hg; < 130/80 mm Hg target may be appropriate in younger adults |
American Diabetes Association (ADA) [83] |
2017 |
Adults with diabetes |
< 140/90 mm Hg; < 130/80 mm Hg target may be appropriate for those at high risk of cardiovascular disease (if achievable without undue treatment burden) |
CAD = coronary artery disease; MI = myocardial infarction; TIA = transient ischemic attack. |
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Patients Without Other Major Medical Condition |
First-line Drugs |
Added 2nd Drug (if needed to reach BP target) |
Added 3rd Drug (if needed to reach BP target) |
African ancestry |
CCB or thiazide diuretic |
ARB or ACEI |
Combination of CCB plus ACEI or ARB plus thiazide diuretic |
White and other non-African ancestry ages < 60 years |
ARB or ACEI |
CCB or thiazide diuretic |
Combination of CCB plus ACEI or ARB plus thiazide diuretic |
White and other non-African ancestry ages ≥60 years |
CCB or thiazide diuretic; ARB or ACEI also effective |
ARB or ACEI; CCB or thiazide diuretic if ARB or ACEI used first |
Combination of CCB plus ACEI or ARB plus thiazide diuretic |
Major medical condition |
|||
Diabetes (white and other non-African ancestry) |
ARB or ACEI |
CCB or thiazide diuretic |
Alternative 2nd drug (CCB or thiazide diuretic) |
Diabetes (African ancestry) |
CCB or thiazide diuretic |
ARB or ACEI |
Alternative 1st drug (CCB or thiazide diuretic) |
Chronic kidney disease |
ARB or ACEI |
CCB or thiazide diuretic |
Alternative 2nd drug (CCB or thiazide diuretic) |
Coronary artery disease |
Beta-blocker plus ARB or ACEI |
CCB or thiazide diuretic |
Alternative 2nd drug (CCB or thiazide diuretic) |
Stroke |
ACEI or ARB |
CCB or thiazide diuretic |
Alternative 2nd drug (CCB or thiazide diuretic) |
Symptomatic heart failure |
Beta-blocker plus ARB or ACEI plus diuretic plus spironolactone regardless of BP; CCB can be added if needed for BP control |
||
ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BP = blood pressure; CCB = calcium channel blocker. |
|||
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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- Overview
- Presentation
- DDx
- Workup
- Treatment
- Approach Considerations
- Nonpharmacologic Therapy
- Pharmacologic Therapy
- Management of Diabetes and Hypertension
- Management of Hypertensive Emergencies
- Management of Hypertension in Pregnancy
- Management of Hypertension in Pediatric Patients
- Management of Hypertension in the Elderly
- Management of Hypertension in Black Patients
- Management of Ocular Hypertension
- Management of Renovascular Hypertension
- Management of Resistant Hypertension
- Management of Pseudohypertension
- Management of Pheochromocytoma
- Management of Primary Hyperaldosteronism
- Interventions for Improving Blood Pressure Control
- Prevention
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- Medication
- Medication Summary
- Diuretics, Thiazide
- Diuretic, Potassium-Sparing
- Diuretics, Loop
- ACEIs
- ARBs
- Beta-Blockers, Beta-1 Selective
- Beta-Blockers, Alpha Activity
- Beta-Blockers, Intrinsic Sympathomimetic
- Vasodilators
- Calcium Channel Blockers
- Aldosterone Antagonists, Selective
- Alpha2-agonists, Central-acting
- Renin Inhibitors/Combos
- Alpha-Blockers, Antihypertensives
- Antihypertensives, Other
- Antihypertensive Combinations
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