Sections

Hypertension

Guidelines

Guidelines Summary

Screening

Guidelines on screening for hypertension have been issued by the following organizations:

United States Preventive Services Task Force (USPSTF)
Joint National Committee (JNC)
American College of Obstetricians and Gynecologists (ACOG)
Department of Veterans Affairs (VA)/Department of Defense (DoD)
European Society of Hypertension (ESH)/European Society of Cardiology (ESC)

The 2013 joint European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) guidelines recommend that ambulatory blood-pressure monitoring (ABPM) be incorporated into the assessment of cardiovascular risk factors and hypertension.^{[125, 126]}

A comparison of the recommendations for blood pressure screening is provided in Table 4 below.

Table 4. Guidelines for Blood Pressure Screening in Adults (Open Table in a new window)

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: Healthy people with optimal office blood pressure (< 120/80 mm Hg): Every 5 years; remeasure if seen sooner. Patients with normal blood pressure (120-129/80-84 mm Hg): Minimum of every 3 years. Patients with high-normal blood pressure (130–139/85–89 mm Hg): Annually.
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

Hypertension Classification

In the United States, the most widely used classification of blood pressure for adults aged 18 years or older is from the 2003 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), as follows^[5]:

Normal: Systolic lower than 120 mm Hg, diastolic lower than 80 mm Hg
Prehypertension: Systolic 120-139 mm Hg, diastolic 80-89 mm Hg
Stage 1: Systolic 140-159 mm Hg, diastolic 90-99 mm Hg
Stage 2: Systolic 160 mm Hg or greater, diastolic 100 mm Hg or greater

However, the 2017, the American College of Cardiology/American Heart Association (ACC/AHA) updated their guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults by eliminating the classification of prehypertension and dividing it into two levels^{[1, 2]}:

Elevated blood pressure with a systolic pressure between 120 and 129 mm Hg and diastolic pressure less than 80 mm Hg
Stage 1 hypertension, with a systolic pressure of 130 to 139 mm Hg or a diastolic pressure of 80 to 89 mm Hg

The 2013 and 2018 ESH/ESC guidelines utilize the following classification system, which was first introduced in its 2002 guidelines^{[9, 126]}:

Optimal: Systolic lower than 120 mm Hg and diastolic lower than 80 mm Hg
Normal: Systolic 120-129 mm Hg and/or diastolic 80-84 mm Hg
High normal: Systolic 130-139 mm Hg and/or diastolic 85-89 mm Hg
Grade 1: Systolic 140-159 mm Hg and/or diastolic 90-99 mm Hg
Grade 2: Systolic 160-179 mm Hg or greater and/or diastolic 100-109 mm Hg
Grade 3: Systolic 180 mm Hg or greater and/or diastolic 110 mm Hg or greater
Isolated systolic hypertension: 140 mm Hg or greater and diastolic lower than 90 mm Hg

Both the classifications above are based on the average of two or more readings taken at each of two or more visits after initial screening.^{[5, 126]}

Target Blood Pressure

Target blood pressures have been provided in guidelines from the following organizations:

Joint National Committee (JNC)
European Society of Hypertension (ESH)/European Society of Cardiology (ESC)
American Heart Association/American College of Cardiology/American Society of Hypertension (AHA/ACC/ASH)
American Heart Association/American College of Cardiology (ACC)/Centers for Disease Control and Prevention (AHA/ACC/CDC)
American Society of Hypertension/International Society of Hypertension (ASH/ISH)
Department of Veterans Affairs (VA)/Department of Defense (DoD)
American Diabetes Association (ADA)
American College of Cardiology/American Heart Association (ACC/AHA)

A group was empaneled to write the Eighth Joint National Committee (JNC8) guideline, but this effort was discontinued by the National Heart, Lung, and Blood Institute (NHLBI). A paper was published in The Journal of the American Medical Association in 2014 that is generally referred to as 'JNC 8' but officially, there are no JNC 8 guidelines sanctioned by the NHLBI, nor has JNC 8 been endorsed by the AHA, ACC, or many other organizations that endorsed JNC7.

A comparison of the target blood pressure recommendations for the guidelines issued by various organizations is provided in Table 5, below.

Table 5. Target Blood Pressure Recommendations (Open Table in a new window)

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.

SPRINT Trial

It should be noted that, aside from the ADA guidelines, existing guideline recommendations on target BP goals were developed prior to the Systolic Blood Pressure Intervention Trial (SPRINT) study, an NIH sponsored trial that demonstrated a 25% decrease in cardiovascular events or death with targeting a systolic BP less than 120 mm Hg versus 140 mm Hg in patients at increased cardiovascular risk.^[133]These intriguing results suggest a benefit from more-intensive BP targets than are recommended in existing guidelines. However, the generalizability of the SPRINT results remain unclear. Importantly, the SPRINT trial excluded patients with diabetes mellitus or prior cerebrovascular accident. These populations have been studied previously in the ACCORD and SPS3 trials, respectively, which failed to demonstrate significant benefits to stringent BP targets of below 120-130 mm Hg.^{[90, 134]}

It is also important to recognize that the SPRINT trial utilized an automatic oscillometric office BP method without human participation, which typically yields a systolic BP that is 7-10 mm Hg lower than the standard office-based BP used in most studies.^[109]This suggests that the lower systolic BP target in the SPRINT trial may be closer to more moderate targets in other studies, and that stringent systolic BP targeting of 120 mm Hg in standard clinical practice may increase the rate of adverse events such as hypotension, electrolyte abnormalities, and acute kidney injury.^{[133, 135]}

A large meta-analysis of hypertension studies that tested systolic BP targets (including the SPRINT trial) demonstrated a reduction in cardiovascular outcomes and overall mortality with a systolic BP target below 130 mm Hg, although the magnitude of the benefit decreased with BP goals progressively below 150 mm Hg.^[136]Future guidelines will likely incorporate the results of the SPRINT trial into target BP recommendations, which may result in lower target BPs, at least for patients with high cardiovascular risk but without diabetes or prior cerebrovascular accidents.

Management

Many guidelines exist for the management of hypertension. Two of the most widely used recommendations are the 2003 Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)^[5]and annually updated guidelines from the American Diabetes Association (ADA).^[71]

In 2013, both the JNC 8 and the updated joint guidelines from the European Society of Hypertension/European Society of Cardiology (ESH/ESC) were released. In 2014 and 2015, guidelines were issued by the following organizations:

American Heart Association/American College of Cardiology/American Society of Hypertension (AHA/ACC/ASH) ^[130]
American Society of Hypertension/International Society of Hypertension (ASH/ISH) ^[132]
Department of Veterans Affairs/Department of Defense (VA/DoD) ^[129]

In 2017, the ACC/AHA as well as the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) released guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults^[1] and the elderly,^[72]respectively.

JNC 7

Key messages of the JNC 7 were as follows^[5]:

The goals of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality, with the focus on controlling the systolic BP, as most patients will achieve diastolic BP control when the systolic BP is achieved
Prehypertension (systolic 120-139 mm Hg, diastolic 80-89 mm Hg) requires health-promoting lifestyle modifications to prevent the progressive rise in BP and cardiovascular disease
In uncomplicated hypertension, a thiazide diuretic, either alone or combined with drugs from other classes, should be used for the pharmacologic treatment of most cases
In specific high-risk conditions, there are compelling indications for the use of other antihypertensive drug classes (eg, angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], beta blockers, calcium channel blockers)
Two or more antihypertensive medications will be required to achieve goal BP (< 140/90 mm Hg or < 130/80 mm Hg) for patients with diabetes and chronic kidney disease
For patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using 2 agents, one of which usually will be a thiazide diuretic, should be considered
Regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan

ADA 2016 Standard of Medical Care

In its 2016 Standards of Medical Care in Diabetes, the ADA makes the following recommendations for the control of high blood pressure ^[71]:

Initiation of pharmacotherapy is recommended for all diabetic patients with confirmed office-based blood pressure >140/90 mm Hg
Treat with a regimen that includes either an ACEI or an ARB; if one class is not tolerated, the other can be substituted
Multiple-drug therapy (including a thiazide diuretic and ACEI/ARB, at maximal doses) is generally required to achieve blood pressure targets
Serum creatinine/estimated glomerular filtration rate (eGFR) and serum potassium levels should be monitored in patients receiving ACEIs, ARBs, or diuretics

2017 ADA guidelines

The ADA released updated guidelines for patients with hypertension and diabetes in 2017, as follows^[83]:

Blood pressure should be measured at every routine clinical care visit. Patients found to have an elevated blood pressure (≥140/90 mm Hg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension.

All hypertensive patients with diabetes should have home blood pressure monitored to identify white coat hypertension.

Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed.

Most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of < 140 mm Hg and a diastolic blood pressure goal of < 90 mm Hg.

Lower systolic and diastolic blood pressure targets, such as < 130/80 mm Hg, may be appropriate for individuals at high risk of cardiovascular disease if they can be achieved without undue treatment burden.

For patients with systolic blood pressure >120 mm Hg or diastolic blood pressure >80 mm Hg, lifestyle intervention consists of weight loss if overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern, including reduced sodium and increased potassium intake; increased fruit and vegetable consumption; moderation of alcohol intake; and increased physical activity.

Patients with confirmed office-based blood pressure ≥140/90 mm Hg should, in addition to lifestyle therapy, have timely titration of pharmacologic therapy to achieve blood pressure goals.

Patients with confirmed office-based blood pressure ≥160/100 mm Hg should, in addition to lifestyle therapy, have prompt initiation and timely titration of 2 drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes.

Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes: ACEIs, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers. Multiple-drug therapy is generally required to achieve blood pressure targets (but not a combination of ACEIs and ARBs).

An ACEI or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urine albumin-to-creatinine ratio ≥300 mg/g creatinine or 30–299 mg/g creatinine. If one class is not tolerated, the other should be substituted.

For patients treated with an ACEI, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored.

Pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with systolic blood pressure < 160 mm Hg, diastolic blood pressure < 105 mm Hg, and no evidence of end-organ damage do not need to be treated with pharmacologic antihypertensive therapy.

In pregnant patients with diabetes and preexisting hypertension who are treated with antihypertensive therapy, systolic or diastolic blood pressure targets of 120–160/80–105 mm Hg are suggested in the interest of optimizing long-term maternal health and fetal growth.

2017 ACC/AHA guidelines

The 2017 ACC/AHA guidelines eliminate the classification of prehypertension and divides it into two levels^{[1, 2]}: (1) elevated BP, with a systolic pressure (SBP) between 120 and 129 mm Hg and diastolic pressure (DBP) less than 80 mm Hg, and (2) stage 1 hypertension, with an SBP of 130 to 139 mm Hg or a DBP of 80 to 89 mm Hg.

In adults at increased risk of heart failure (HF), the optimal BP in those with hypertension should be less than 130/80 mm Hg.

Adults with HFrEF (HF with reduced ejection fraction) and hypertension should be prescribed GDMT (guideline-directed management and therapy) titrated to attain a BP of less than 130/80 mm Hg.

Nondihydropyridine calcium channel blockers (CCBs) are not recommended in the treatment of hypertension in adults with HFrEF.

Adults with hypertension and chronic kidney disease (CKD) should be treated to a BP goal of less than 130/80 mm Hg.

After kidney transplantation, it is reasonable to treat patients with hypertension to a BP goal of less than 130/80 mm Hg. After kidney transplantation, it is reasonable to treat patients with hypertension with a calcium antagonist on the basis of improved glomerular filtration rate (GFR) and kidney survival.

Immediate lowering of SBP to lower than 140 mm Hg in adults with spontaneous intracerebral hemorrhage (ICH) who present within 6 hours of the acute event and have an SBP between 150 mm Hg and 220 mm Hg is not of benefit to reduce death or severe disability and can be potentially harmful.

Adults with acute ischemic stroke and elevated BP who are eligible for treatment with intravenous (IV) tissue plasminogen activator (tPA) should have their BP slowly lowered to below 185/110 mm Hg before thrombolytic therapy is initiated.

In adults with an acute ischemic stroke, BP should be less than 185/110 mm Hg before administration of IV tPA and should be maintained below 180/105 mm Hg for at least the first 24 hours after initiating drug therapy.

For adults who experience a stroke or transient ischemic attack (TIA), treatment with a thiazide diuretic, ACEI, or angiotensin receptor blocker (ARB), or combination treatment consisting of a thiazide diuretic plus ACEI, is useful.

In adults with an untreated SBP greater than 130 mm Hg but less than 160 mm Hg or a DBP greater than 80 mm Hg but less than 100 mm Hg, it is reasonable to screen for the presence of white coat hypertension by using either daytime ABPM (ambulatory BP monitoring) or HBPM (home BPM) before diagnosis of hypertension.

In adults with untreated office BPs that are consistently between 120 mm Hg and 129 mm Hg for SBP or between 75 mm Hg and 79 mm Hg for DBP, screening for masked hypertension with home BPM (or ABPM) is reasonable.

In adults with hypertension, screening for primary aldosteronism is recommended in the presence of any of the following concurrent conditions: resistant hypertension, hypokalemia (spontaneous or substantial, if diuretic induced), incidentally discovered adrenal mass, family history of early-onset hypertension, or stroke at a young age (< 40 years).

Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no more than two and one standard drinks per day, respectively.

Two or more antihypertensive medications are recommended to achieve a BP target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension.

Women with hypertension who become pregnant should not be treated with ACEIs, ARBs, or direct renin inhibitors.

Use of BP-lowering medications is recommended for secondary prevention of recurrent cardiovascular disease (CVD) events in patients with clinical CVD and an average SBP of 130 mm Hg or higher or an average DBP of 80 mm Hg or higher, and for primary prevention in adults with an estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk of 10% or higher and an average SBP of 130 mm Hg or higher or an average DBP of 80 mm Hg or higher.

Use of BP-lowering medication is recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk below 10% and an SBP of 140 mm Hg or higher or a DBP of 90 mm Hg or higher.

Adults with an elevated BP or stage 1 hypertension who have an estimated 10-year ASCVD risk below 10% should be managed with nonpharmacologic therapy and have a repeat BP evaluation within 3 to 6 months.

Adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of 10% or higher should be managed initially with a combination of nonpharmacologic and antihypertensive drug therapy and have a repeat BP evaluation in 1 month.

For adults with a very high average BP (eg, SBP ≥180 mm Hg or DBP ≥110 mm Hg), evaluation followed by prompt antihypertensive drug treatment is recommended.

Simultaneous use of an ACE, ARB, and/or renin inhibitor is potentially harmful and is not recommended to treat adults with hypertension.

2017 ACP/AAFP guidelines

The American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) released their guidelines regarding hypertension in adults aged 60 years, including the following^[72]:

Clinicians should initiate treatment in patients aged 60 years or older who have persistent SBP at or above 150 mm Hg to achieve a target of less than 150 mm Hg to reduce the risk for stroke, cardiac events, and death.
If patients 60 years or older have a history of stroke or transient ischemic attack or have high cardiovascular risk, physicians should consider starting or increasing drug therapy to achieve an SBP of less than 140 mm Hg to reduce the risk for stroke and cardiac events.
Consider initiating or intensifying pharmacologic treatment in some adults aged 60 years or older at high cardiovascular risk based on individualized assessment, to achieve a target SBP of less than 140 mm Hg to reduce the risk for stroke and cardiac events. Factors include comorbidity, medication burden, risk of adverse events, and cost. Generally, increased cardiovascular risk includes known cardiovascular disease, diabetes, or chronic kidney disease with a glomerular filtration rate of less than 45 mL/min/1.73 m ².

Collaborative AHA/ACC/CDC advisory recommendations

A science advisory on the treatment of hypertension, issued in November 2013 via a collaborative effort by the American Heart Association (AHA), the American College of Cardiology (ACC), and the Centers for Disease Control and Prevention (CDC), describes criteria for successful hypertension management algorithms and advocates the creation of algorithms that can be incorporated into a system-level approach to high BP, as well as modified to accommodate different practice settings and patient populations.^{[131, 137]}

A joint AHA/ACC/CDC algorithm in the report includes the following recommendations^{[131, 137]}:

BP: Recommended goal of 139/89 mm Hg or less
Stage 1 hypertension (systolic BP 140-159 mm Hg or diastolic BP 90-99 mm Hg): Can be treated with lifestyle modifications and, if needed, a thiazide diuretic
Stage 2 hypertension (systolic BP >160 mm Hg or diastolic BP >100 mm Hg): Can be treated with a combination of a thiazide diuretic and an ACEI, an angiotensin receptor blocker, or a calcium channel blocker
Patients who fail to achieve BP goals: Medication doses can be increased and/or a drug from a different class can be added to treatment

Joint ESH and ESC guidelines

In June 2013, the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) released new guidelines for the management of hypertension, recommending that all patients, except special populations such as patients with diabetes and the elderly, be treated to below 140 mm Hg systolic BP.^{[125, 126]} The guidelines advise that physicians should make decisions on treatment strategies based on the patient's overall level of cardiovascular risk.

Recommendations of the new ESH and ESC guidelines include^{[125, 126]}:

In patients younger than 80 years, the systolic BP target should be 140 to 150 mm Hg, but physicians can go lower than 140 mm Hg if the patient is fit and healthy; the same advice applies to octogenarians—however, the patient's mental capacity and physical heath should also be considered if targeting to less than 140 mm Hg
Patients with diabetes should be treated to below 85 mm Hg diastolic BP
Salt intake should be limited to approximately 5 to 6 g per day
Body-mass index (BMI) should be reduced to 25 kg/m² and waist circumferences should be reduced to less than 102 cm in men and less than 88 cm in women
Ambulatory BP monitoring (ABPM) should be incorporated into the assessment of risk
Effective combination therapies include thiazide diuretics with ARBs, calcium-channel antagonists, or ACEIs; or, calcium-channel antagonists with ARBs or ACEIs
Dual renin-angiotensin system blockade (ie, ARBs, ACEIs, and direct renin inhibitors) is not recommended because of the risks of hyperkalemia, low BP, and kidney failure

American Society of Hypertension/International Society of Hypertension

Joint guidelines were issued in 2013 by the American Society of Hypertension and the International Society of Hypertension (ASH/ISH) with the intent of providing an international primer with general information, especially for communities and countries with low resources. On their website, the ASH cautions that “these guidelines should be considered more as ‘an expert opinion piece,’ given that they are not systematically evidence-based and were not developed using guideline development protocol stipulated by the Institute of Medicine (IOM).”^[132]

Treatment recommendations are given for hypertensive patients with or without another major medical condition are provided in Table 6, below.^[138]

Table 6. American Society of Hypertension/International Society of Hypertension Treatment Recommendations (Open Table in a new window)

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 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 2^nd drug (CCB or thiazide diuretic)
Diabetes (African ancestry)	CCB or thiazide diuretic	ARB or ACEI	Alternative 1^st drug (CCB or thiazide diuretic)
Chronic kidney disease	ARB or ACEI	CCB or thiazide diuretic	Alternative 2^nd drug (CCB or thiazide diuretic)
Coronary artery disease	Beta-blocker plus ARB or ACEI	CCB or thiazide diuretic	Alternative 2^nd drug (CCB or thiazide diuretic)
Stroke	ACEI or ARB	CCB or thiazide diuretic	Alternative 2^nd 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.

Department of Veterans Affairs/Department of Defense

In 2014, the Department of Veteran’s Affairs/Department of Defense (VA/DoD) released an update of their 2004 guidelines for diagnosis and management of hypertension in primary care settings. Initiation of pharmacotherapy is recommended for all adults with either systolic BP ≥160 mm Hg or diastolic BP ≥90 mm Hg and for adults with a history of stroke, transient ischemic attack, or asymptomatic carotid artery disease and systolic BP ≥140 mm Hg.^[129]

Treatment may also be considered for adults ages ≥60 years with systolic BP < 160 mm Hg. Combination therapy should be initiated for adults with systolic BP >20 mm Hg or diastolic BP >10 mm Hg above the target goal. Additional recommendations include the following^[129]:

Thiazide-type diuretic as first-line therapy either as monotherapy or in combination with other drugs
Chlorthalidone or indapamide is preferred over hydrochlorothiazide
For patients who cannot tolerate thiazide-type diuretics, or as supplementary therapies for patients who do not reach their hypertensive goals with thiazide-type diuretics, or for those starting on combination therapy: ACEIs or ARBs (but not both together); long-acting dihydropyridine calcium channel blockers
For patients with chronic kidney disease, ACEIs or ARBs for improving kidney outcomes
In African Americans, recommend against ACEIs or ARBs as monotherapy
In African Americans with stage 1-3 chronic kidney disease, the combination of a thiazide-type diuretic (for cardiovascular protection) with either an ACEI or an ARB (for renal protection)

Lifestyle modifications

JNC 7 and AHA-ASA lifestyle modification recommendations

The Seventh Report of the Joint National Committee of Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommendations to lower blood pressure (BP) and decrease cardiovascular disease risk include the following, with greater results achieved when 2 or more lifestyle modifications are combined^[5]:

Weight loss helps to prevent hypertension (range of approximate systolic BP reduction [SBP], 5-20 mm Hg per 10 kg); recommendations include the DASH (Dietary Approaches to Stop Hypertension) diet (range of approximate SBP reduction, 8-14 mm Hg), which is rich in fruits and vegetables and encourages the use of fat-free or low-fat milk and milk products
Limit alcohol intake to no more than 1 oz (30 mL) of ethanol per day for men (ie, 24 oz [720 mL] of beer, 10 oz [300 mL] of wine, 2 oz [60 mL] of 100-proof whiskey) or 0.5 oz (15 mL) of ethanol per day for women and people of lighter weight (range of approximate SBP reduction, 2-4 mm Hg)
Reduce sodium intake to no more than 100 mmol/d (2.4 g sodium or 6 g sodium chloride; range of approximate SBP reduction, 2-8 mm Hg)^[8]
Maintain adequate intake of dietary potassium (approximately 90 mmol/d)
Maintain adequate intake of dietary calcium and magnesium for general health
Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health
Engage in aerobic exercise at least 30 minutes daily for most days (range of approximate SBP reduction, 4-9 mm Hg)

The 2010 American Heart Association-American Stroke Association (AHA-ASA) guidelines for the primary prevention of stroke makes the following recommendations^[139]:

Hypertension: the AHA-ASA guidelines recommend regular blood pressure screening, lifestyle modification, and drug therapy; lower risk of stroke and cardiovascular events are seen when systolic blood pressure levels are lower than 140 mm Hg and diastolic blood pressure levels are less than 90 mm Hg
In patients who have hypertension with diabetes or renal disease, the BP goal is lower than 130/80 mm Hg
Diet and nutrition: a diet that is low in sodium and high in potassium is recommended to reduce BP; diets that promote the consumption of fruits, vegetables, and low-fat dairy products, such as the DASH-style diet, help lower BP and may lower the risk of stroke
Physical inactivity: increasing physical activity is associated with a reduction in the risk of stroke; the goal is to engage in 30 minutes or more of moderate intensity activity on a daily basis
Obesity and body fat distribution: weight reduction in overweight and obese persons is recommended to reduce BP and the risk of stroke

Hypertensive Emergencies

In the 2013, the American College of Emergency Physicians (ACEP) released an update of its 2006 guidelines for hypertension in the emergency department (ED), which are focused on treating hypertensive urgency. The recommendations include the following^[140]:

In ED patients with asymptomatic markedly elevated blood pressure, routine screening for acute target organ injury (eg, serum creatinine, urinalysis, electrocardiogram [ECG]) is not required.
In select patient populations (eg, those with poor follow-up), screening for an elevated serum creatinine level may identify kidney injury that affects disposition (eg, hospital admission)
In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required
In select patient populations (eg, poor follow-up available), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control (Consensus recommendation)
Patients with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up (Consensus recommendation)

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommendations for hypertensive crises and emergencies include the following^[1]:

Admit adults with a hypertensive emergency to an ICU for continuous monitoring of BP and target organ damage, as well as for parenteral administration of an appropriate medication.
For adults with a compelling condition (ie, aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma crisis), lower SBP to below 140 mm Hg during the first hour and to below 120 mm Hg in aortic dissection.
For adults without a compelling condition, reduce the SBP to a maximum of 25% within the first hour; then, if the patient is clinically stable, lower the BP to 160/100 -110 mm Hg over the next 2-6 hours, and then cautiously to normal over the following 24-48 hours.

Hypertension in Pregnancy

Hypertensive disorders during pregnancy are classified into the four following categories, as recommended by the 2000 National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy^[141]:

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.

However, the JNC 7 categorizes hypertensive disorders during pregnancy as follows (see Table 7, below)^[5]:

Chronic hypertension
Preeclampsia
Chronic hypertension with superimposed preeclampsia
Gestational hypertension
Transient hypertension

The 2013 American College of Obstetricians and Gynecologists (ACOG) uses a classification system similar to that of JNC 7.^[142]

In 2014, the Society of Obstetricians and Gynecologists of Canada (SOGC) released revised guidelines that classify hypertension in pregnancy as follows^[138]:

Preexisting hypertension
Gestational hypertension
Preeclampsia
Other hypertensive effects (transient hypertensive effect, white-coat hypertensive effect, masked hypertensive effect)

Table 7. JNC 7 Classification of Hypertensive Disorders in Pregnancy (Open Table in a new window)

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

Specific guidelines for the management of hypertension during pregnancy have been issued by the American College of Obstetricians and Gynecologists (ACOG), Society of Obstetricians and Gynecologists of Canada (SOGC). In addition, recommendations for managing hypertension in pregnancy are included in broader hypertension management guidelines from the following organizations:

Joint National Committee (JNC)
European Society of Hypertension (ESH)/European Society of Cardiology (ESC)
American Diabetes Association (ADA)

JNC 7 recommends treating women with chronic (preexisting) hypertension and no evidence of end-organ damage whose blood pressure is 150-160 mm Hg systolic or 100-110 mm Hg diastolic^[5]

The ESH/ESC guidelines recommend considering treatment for pregnant women with chronic hypertension and BP ≥150/95 mm Hg; or in those women with BP ≥140/90 mm Hg who have gestational hypertension, subclinical organ damage, or symptoms.^[126]

The 2013 ACOG guidelines recommend that in pregnant women with chronic hypertension treated with antihypertensive medication, BP levels should be maintained between 120/80 mm Hg and 160/105 mm Hg.^[142]

Although reducing maternal risk is the goal of treating chronic hypertension in pregnancy, fetal safety largely directs the choice of antihypertensive agent. Methyldopa is generally the preferred first-line agent because of its safety profile.^{[5, 126, 142]}Other drugs that may be considered include labetalol, beta-blockers, and diuretics.^[6]ACOG does not recommend the use of any of the following^[142]:

ACEIs
ARBs
Renin inhibitors
Mineralocorticoid receptor antagonists

Severe hypertension

There is consensus across guidelines (JNC 7, ESH/ESC, ACOG, SOGC) for the need to acutely manage severe hypertension, defined as systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg or both, with the goal of preventing maternal stroke and avoiding intrauterine growth restriction (IUGR).^{[5, 126, 138, 142]}

In 2015, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice issued updated guidelines regarding the emergency treatment of acute-onset severe hypertension during pregnancy, including the following^[143]:

Acute-onset, severe hypertension that is accurately measured using standard techniques and is persistent for 15 minutes or longer is considered a hypertensive emergency
Intravenous (IV) labetalol and hydralazine have long been considered first-line medications for the management of acute-onset, severe hypertension in pregnant and post-partum women; available evidence suggests that oral nifedipine also may be considered as a first-line therapy
Parenteral labetalol should be avoided in women with asthma, heart disease, or congestive heart failure
When urgent treatment is needed before the establishment of IV access, the oral nifedipine algorithm can be initiated as IV access is being obtained, or a 200-mg dose of labetalol can be administered orally; the latter can be repeated in 30 minutes if appropriate improvement is not observed
Magnesium sulfate is not recommended as an antihypertensive agent, but it remains the drug of choice for seizure prophylaxis in severe preeclampsia and for controlling seizures in eclampsia
Sodium nitroprusside should be reserved for extreme emergencies and used for the shortest amount of time possible because of concerns about cyanide and thiocyanate toxicity in the mother and fetus or newborn, and increased intracranial pressure with potential worsening of cerebral edema in the mother
Adoption of standardized, evidence-based clinical guidelines for managing patients with preeclampsia is needed; individuals and institutions should have mechanisms in place for prompt initiation of medication when a patient presents with a hypertensive emergency

Hypertension and diabetes in pregnancy

In pregnant patients with diabetes and chronic hypertension, the ADA 2016 Standards of Medical Care in Diabetes recommends blood pressure targets of 110–129/65–79 mm Hg in the interest of optimizing long-term maternal health and minimizing impairment of fetal growth. ACEIs and ARBs are contraindicated during pregnancy.^[143]

The 2017 ADA position statement on diabetes and hypertension indicates no antihypertensive pharmacotherapy is necessary for pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with an SBP below 160 mm Hg and a DBP below 105 mm Hg, and no evidence of end organ damage.^[83]For pregnant women with diabetes and preexisting hypertension on antihypertensive therapy, suggested BP targets are an SBP of 120-160 mm Hg and a DBP target of 80-105 mm Hg.

Medication

[Guideline] Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018 Jun. 71(6):e13-e115. [QxMD MEDLINE Link]. [Full Text].
Jeffrey S. New ACC/AHA hypertension guidelines make 130 the new 140. Medscape Medical News. Available at https://www.medscape.com/viewarticle/888560. November 13, 2017; Accessed: November 18, 2017.
Rivera SL, Martin J, Landry J. Acute and chronic hypertension: what clinicians need to know for diagnosis and management. Crit Care Nurs Clin North Am. 2019 Mar. 31 (1):97-108. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Chobanian AV, Bakris GL, Black HR, 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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[Guideline] Williams B, Mancia G, Spiering W, et al, for the ESC Scientific Document Group. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018 Sep 1. 39 (33):3021-104. [QxMD MEDLINE Link]. [Full Text].
[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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Shayne PH, Pitts SR. Severely increased blood pressure in the emergency department. Ann Emerg Med. 2003 Apr. 41(4):513-29. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Harrison DG, Guzik TJ, Lob HE, et al. Inflammation, immunity, and hypertension. Hypertension. 2011 Feb. 57(2):132-40. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Coffman TM. Under pressure: the search for the essential mechanisms of hypertension. Nat Med. 2011 Nov 7. 17(11):1402-9. [QxMD MEDLINE Link].
Millis RM. Epigenetics and hypertension. Curr Hypertens Rep. 2011 Feb. 13(1):21-8. [QxMD MEDLINE Link].
Brown MJ. Hypertension and ethnic group. BMJ. 2006 Apr 8. 332(7545):833-6. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Marik PE, Varon J. Hypertensive crises: challenges and management. Chest. 2007 Jun. 131(6):1949-62. [QxMD MEDLINE Link].
Rodriguez MA, Kumar SK, De Caro M. Hypertensive crisis. Cardiol Rev. 2010 Mar-Apr. 18(2):102-7. [QxMD MEDLINE Link].
Hollander JE. Cocaine intoxication and hypertension. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S18-20. [QxMD MEDLINE Link].
Fryar CD, Ostchega Y, Hales CM, Zhang G, Kruszon-Moran D. Hypertension prevalence and control among adults: United States, 2015-2016. NCHS Data Brief. 2017 Oct. 1-8. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[Guideline] Carey RM, Calhoun DA, et al. Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension. 2018 Nov. 72 (5):e53-e90. [QxMD MEDLINE Link]. [Full Text].
Ong YT, Wong TY, Klein R, Klein BE, Mitchell P, Sharrett AR, et al. Hypertensive Retinopathy and Risk of Stroke. Hypertension. 2013 Aug 12. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Mortality after 10 1/2 years for hypertensive participants in the Multiple Risk Factor Intervention Trial. Circulation. 1990 Nov. 82(5):1616-28. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med. 2004 Nov 25. 351(22):2310-7. [QxMD MEDLINE Link].
Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P. Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension. 1996 Jan. 27(1):144-7. [QxMD MEDLINE Link].
Staykov D, Schwab S. Posterior reversible encephalopathy syndrome. J Intensive Care Med. 2012 Feb. 27(1):11-24. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Mammaro A, Carrara S, Cavaliere A, et al. Hypertensive disorders of pregnancy. J Prenat Med. 2009 Jan. 3 (1):1-5. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Koivistoinen T, Lyytikainen LP, Aatola H, et al. Pulse wave velocity predicts the progression of blood pressure and development of hypertension in young adults. Hypertension. 2018 Mar. 71 (3):451-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[Guideline] American Diabetes Association. Standards of medical care in diabetes-2016 abridged for primary care providers. Clin Diabetes. 2016 Jan. 34 (1):3-21. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Qaseem A, Wilt TJ, Rich R, et al, for the Clinical Guidelines Committee of the American College of Physicians and the Commission on Health of the Public and Science of the American Academy of Family Physicians. Pharmacologic treatment of hypertension in adults aged 60 years or older to higher versus lower blood pressure targets: A clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017 Mar 21. 166 (6):430-7. [QxMD MEDLINE Link].
Stiles S. New AHA/ACC cholesterol treatment guideline expands role of LDL targets. Medscape Medical News. Available at https://www.medscape.com/viewarticle/904736. November 10, 2018; Accessed: December 1, 2018.
[Guideline] Grundy SM, Stone NJ, Bailey AL, et al. AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018 Nov 8. [QxMD MEDLINE Link]. [Full Text].
Jellinger PS, Handelsman Y, Rosenblit PD, et al. American Association of Clinical Endocrinologists and American College of Endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease. Endocr Pract. 2017 Apr. 23 (suppl 2):1-87. [QxMD MEDLINE Link].
Briasoulis A, Bakris GL. Current status of renal denervation in hypertension. Curr Cardiol Rep. 2016 Nov. 18 (11):107. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[Guideline] American Diabetes Association. Standards of medical care in diabetes--2011. Diabetes Care. 2011 Jan. 34 Suppl 1:S11-61. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[Guideline] de Boer IH, Bangalore S, Benetos A, et al. Diabetes and hypertension: a position statement by the American Diabetes Association. Diabetes Care. 2017 Sep. 40 (9):1273-84. [QxMD MEDLINE Link]. [Full Text].
Piercy KL, Troiano RP, Ballard RM, et al. The physical activity guidelines for Americans. JAMA. 2018 Nov 20. 320 (19):2020-8. [QxMD MEDLINE Link].
2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Washington, DC: US Department of Health and Human Services; November 2018. [Full Text].
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. [QxMD MEDLINE Link].
[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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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.
Tsimihodimos V, Gonzalez-Villalpando C, Meigs JB, Ferrannini E. Hypertension and diabetes mellitus: coprediction and time trajectories. Hypertension. 2018 Mar. 71 (3):422-8. [QxMD MEDLINE Link].
Pancioli AM. Hypertension management in neurologic emergencies. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S24-7. [QxMD MEDLINE Link].
Slovis CM, Reddi AS. Increased blood pressure without evidence of acute end organ damage. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S7-9. [QxMD MEDLINE Link].
[Guideline] Flynn JT, Kaelber DC, Baker-Smith CM, et al, for the Subcommittee on Screening and management of high blood pressure in children and adolescents. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017 Sep. 140(3):[QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Frellick M. Updated hypertension guidelines released by ACP, AAFP. Medscape Medical News. Available at https://www.medscape.com/viewarticle/874494. January 17, 2017; Accessed: November 18, 2017.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Calhoun DA. Advances in resistant hypertension. Ann Transl Med. 2018 Aug. 6 (15):294. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Orciari Herman A, Sadoughi S. Heart group updates guidelines on resistant hypertension. NEJM Journal Watch. Available at https://www.jwatch.org/fw114569/2018/09/13/heart-group-updates-guidelines-resistant-hypertension. September 13, 2018; Accessed: October 2, 2018.
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. [QxMD MEDLINE Link].
Catheter-based renal sympathetic denervation for resistant hypertension: durability of blood pressure reduction out to 24 months. Hypertension. 2011 May. 57(5):911-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Fagugli RM, Taglioni C. Changes in the perceived epidemiology of primary hyperaldosteronism. Int J Hypertens. 2011. 2011:162804. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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] 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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
[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. [QxMD MEDLINE Link].
[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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
[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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
1999 World Health Organization-International Society of Hypertension Guidelines for the Management of Hypertension. Guidelines Subcommittee. J Hypertens. 1999 Feb. 17(2):151-83. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Barton JR. Hypertension in pregnancy. Ann Emerg Med. 2008 Mar. 51 (3 suppl):S16-7. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Cheung AT, Hobson RW 2nd. Hypertension in vascular surgery: aortic dissection and carotid revascularization. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S28-33. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Diercks DB, Ohman EM. Hypertension with acute coronary syndrome and heart failure. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S34-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Epstein M. Calcium antagonists and renal disease. Kidney Int. 1998 Nov. 54(5):1771-84. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Heilpern K. Pathophysiology of hypertension. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S5-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Kaplan NM. Calcium entry blockers in the treatment of hypertension. Current status and future prospects. JAMA. 1989 Aug 11. 262(6):817-23. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Kitiyakara C, Guzman NJ. Malignant hypertension and hypertensive emergencies. J Am Soc Nephrol. 1998 Jan. 9(1):133-42. [QxMD MEDLINE Link].
Lao D, Parasher PS, Cho KC, Yeghiazarians Y. Atherosclerotic renal artery stenosis--diagnosis and treatment. Mayo Clin Proc. 2011 Jul. 86(7):649-57. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
Magee LA, Helewa M, Rey E, Hypertension Guidelines Committee, Strategic Training Initiative in Research in the Reproductive Health Sciences (STIRRHS) Scholars. Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy. J Obstet Gynaecol Can. 2008 Mar. 30(3 Suppl):S1-S2. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Narkiewicz K. Diagnosis and management of hypertension in obesity. Obes Rev. 2006 May. 7(2):155-62. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Pleis JR, Lucas JW, Ward BW. Summary health statistics for U.S. adults: National Health Interview Survey, 2008. Vital Health Stat 10. 2009 Dec. No. 242:1-157. [QxMD MEDLINE Link]. [Full Text].
Podymow T, August P. Antihypertensive drugs in pregnancy. Semin Nephrol. 2011 Jan. 31(1):70-85. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Rastan A, Krankenberg H, Muller-Hulsbeck 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. [QxMD MEDLINE Link].
Roberts CL, Ford JB, Algert CS, et al. Population-based trends in pregnancy hypertension and pre-eclampsia: an international comparative study. BMJ Open. 2011 May 24. 1(1):e000101. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
Slagman MC, Waanders F, Hemmelder MH, 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. [QxMD MEDLINE Link]. [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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Yakovlevitch M, Black HR. Resistant hypertension in a tertiary care clinic. Arch Intern Med. 1991 Sep. 151(9):1786-92. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Clinical implications: hypertension. Hypertension. 2018 Feb 7. 71(3):367. [Full Text].
Osborn JW, Banek CT. Catheter-based renal nerve ablation as a novel hypertension therapy: lost, and then found, in translation. Hypertension. 2018 Mar. 71 (3):383-88. [QxMD MEDLINE Link].
Itoh H, Hayashi K, Miyashita K. Pre-emptive medicine for hypertension and its prospects. Hypertens Res. 2019 Mar. 42 (3):301-5. [QxMD MEDLINE Link].

Media Gallery

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.
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.
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.
Hypertension. Hypertrophied cardiac myocytes with enlarged "box car" nuclei.
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).
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).

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Table 2. 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.^[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.

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.^[5]

Table 4. Guidelines for Blood Pressure Screening in Adults

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: Healthy people with optimal office blood pressure (< 120/80 mm Hg): Every 5 years; remeasure if seen sooner. Patients with normal blood pressure (120-129/80-84 mm Hg): Minimum of every 3 years. Patients with high-normal blood pressure (130–139/85–89 mm Hg): Annually.
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

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)^[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.

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 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 2^nd drug (CCB or thiazide diuretic)
Diabetes (African ancestry)	CCB or thiazide diuretic	ARB or ACEI	Alternative 1^st drug (CCB or thiazide diuretic)
Chronic kidney disease	ARB or ACEI	CCB or thiazide diuretic	Alternative 2^nd drug (CCB or thiazide diuretic)
Coronary artery disease	Beta-blocker plus ARB or ACEI	CCB or thiazide diuretic	Alternative 2^nd drug (CCB or thiazide diuretic)
Stroke	ACEI or ARB	CCB or thiazide diuretic	Alternative 2^nd 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.

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 Assistant Professor of Medicine, Department of Medicine, Division of Clinical Pharmacology, Division of Cardiovascular Medicine, Vanderbilt University School of Medicine; Assistant Professor of Molecular Physiology and Biophysics, Vanderbilt University

Matthew R Alexander, MD, PhD is a member of the following medical societies: American Association of Immunologists, American Heart Association, American Physiological Society, Federation of Clinical Immunology Societies, Vanderbilt Institute for Infection, Immunology, and Inflammation

Disclosure: Nothing to disclose.

Coauthor(s)

Meena S Madhur, MD, PhD, FACC, FAHA Associate Professor with Tenure, Division Chief of Clinical Pharmacology, Department of Medicine, Division of Clinical Pharmacology and Division of Cardiology, Adjunct Associate Professor of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine; Adjunct Associate Professor of Medicine, Vanderbilt University School of Medicine

Meena S Madhur, MD, PhD, FACC, FAHA is a member of the following medical societies: American College of Cardiology, American Heart Association, American Physiological Society, American Society for Clinical Investigation

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