Elsevier Logo

ContenidodeClinicalKey

¿Quiere más respuestas?

¡Regístrese hoy para solicitar una prueba de ClinicalKey! Su primer paso para obtener las respuestas correctas cuando las necesite. ClinicalKey es una solución de conocimiento clínico diseñada para ayudar a los profesionales de la salud y a los estudiantes a encontrar las respuestas correctas, proporcionando conocimiento en profundidad basado en la evidencia, todo desde una única plataforma.

Jun.09.2021

Hypertension

Synopsis

Key Points

  • Hypertension is defined as blood pressure reading of 130/80 mm Hg or higher in adults r1
  • Most patients with hypertension have essential hypertension, for which there is no identifiable cause. In 10% of patientsr1, hypertension has an identifiable secondary cause, most commonly renal artery stenosis, renal parenchymal disease, endocrine abnormalities, adverse effect of a drug, or coarctation of the aorta r2
  • Initial office evaluation is focused on identification of hypertensive end-organ damage (eg, eyes, heart, kidneys) and identification of other cardiovascular risk factors. Focus search for secondary causes by clinical suspicion
  • 2017 American College of Cardiology/American Heart Association guidelines for prevention, detection, evaluation, and management of high blood pressure in adults and 2019 American College of Cardiology/American Heart Association guidelines on primary prevention of cardiovascular disease recommend a blood pressure target of less than 130/80 mm Hg for most patients r1r3
  • For Black patients, ACE inhibitors and angiotensin receptor blockers are less effective than thiazide diuretics and calcium channel blockers for lowering blood pressure. For patients of other ethnic groups, initial drug treatment should include a thiazide diuretic, a calcium channel blocker, an ACE inhibitor, or an angiotensin receptor blocker
  • Strategies for managing blood pressure that is inadequately controlled on initial medication include dose titration before addition of an additional drug or adding an additional drug without maximizing dosage of the first. Frequently readdress lifestyle factors that may affect blood pressure

Urgent Action

  • Hypertensive emergency is an acutely elevated blood pressure, usually over 120 mm Hg diastolic, accompanied by symptoms or objective signs of acute end-organ dysfunction or damage (eg, hypertensive encephalopathy, stroke, acute coronary syndromes, pulmonary edema, aortic dissection, acute kidney injury) r4
    • Quickly manage hypertensive emergencies with IV administration of carefully selected antihypertensive drugs to reduce blood pressure by no more than 25% over the first hour in most cases
    • Sodium nitroprusside, nicardipine (IV), and/or labetalol are appropriate for most hypertensive emergencies

Pitfalls c1

  • To be considered a hypertensive emergency, there must be evidence of end-organ damage; mild headache, epistaxis, and vague, non–anatomically suggestive symptoms are not diagnostic of a hypertensive emergency
  • Treatment of hypertensive emergency may be complex and must be guided by careful, individualized consideration of the type of acute end-organ dysfunction or damage. Goal blood pressure reduction may need to be modified for stroke, especially if thrombolytics are administered
  • If there is no evidence of acute end organ damage with a severely elevated blood pressure, the patient is considered to have hypertensive urgency (also known as severe asymptomatic hypertension). Acute reduction of blood pressure is not advised owing to potential adverse effects and lack of clinical benefit r5
  • Confirm isolated high blood pressure measurements on more than 1 encounter before treatment is initiated unless the initial blood pressure is very high
  • White coat hypertension may cause diagnostic confusion; ambulatory 24-hour monitoring can clarify the issue
  • Medication nonadherence is the most common cause of uncontrolled blood pressure

Terminology

Clinical Clarification

  • Hypertension is defined as systolic blood pressure 130 mm Hg or higher and diastolic blood pressure 80 mm Hg or higher in adults and r1
    • Reference range: systolic lower than 120 mm Hg and diastolic lower than 80 mm Hg
    • Elevated: systolic 120 to 129 mm Hg and diastolic lower than 80 mm Hg
    • Stage 1 hypertension: systolic 130 to 139 mm Hg or diastolic 80 to 89 mm Hg
    • Stage 2 hypertension: systolic 140 mm Hg or higher or diastolic 90 mm Hg or higher
    • Isolated diastolic hypertension: systolic lower than 130 mm Hg and diastolic 80 mm Hg or higher r6

Classification

  • Essential hypertension: not attributed to underlying, identifiable cause
  • Secondary hypertension: attributed to underlying, identifiable cause (10% of patients)
  • Other terminology
    • Resistant hypertension: blood pressure above goal despite adherence to a combination of at least 3 optimally dosed antihypertensive medications with different mechanisms of action r2r7
    • Hypertensive urgency: acute rise in blood pressure (diastolic higher than 120 mm Hg) without evidence of acute end-organ dysfunction r8r9
      • The American College of Emergency Physicians uses the synonymous term asymptomatic markedly elevated blood pressurer5
    • Hypertensive emergency: acute rise in blood pressure (diastolic higher than 120 mm Hg) accompanied by objective findings of acute end-organ dysfunction (usually of the heart, kidneys, or brain). The blood pressure threshold at which dysfunction occurs may be markedly different in individual patients r4
      • The terms hypertensive crisis and malignant hypertension are no longer recommended r8
      • Malignant hypertension is a type of hypertensive emergency characterized by severe hypertension and systemic microcirculatory damage as evidenced by advanced hypertensive retinopathy; an alternative term is acute hypertensive microangiopathyr9
    • White coat hypertension: blood pressure that is significantly higher when measured in the medical office than when measured at home or via ambulatory blood pressure monitor in patient’s usual environment r10
      • Risk factor for development of sustained essential hypertension
      • Some evidence that white coat hypertension contributes to cardiovascular mortality (to a lesser extent than essential hypertension) r10
        • Exception: if office reading is high but both home blood pressure measurement and ambulatory 24-hour measurement are within reference range, then cardiovascular risk is not higher than that of a normotensive person r11
    • Masked hypertension: blood pressure is in hypertensive range out of office but not when measured in office r12
      • Present in 15% to 30% of the general population who are normotensive during office blood pressure measurement
      • Nocturnal hypertension is a form particularly prevalent in Black patients
      • Associated with an increased risk for cardiovascular disease similar to that of sustained hypertension present in office environment
    • Isolated diastolic hypertension r6
      • May be more common in younger individuals
      • Not associated with increased risk of atherosclerotic cardiovascular disease or cardiovascular mortality

Diagnosis

Clinical Presentation

History

  • Usually asymptomatic c2
  • Mild headache, dizziness, or epistaxis are sometimes reported with elevated blood pressure, but they do not suggest end-organ dysfunction if physical examination findings are normal c3c4c5c6
  • Symptoms that suggest acute end-organ dysfunction caused by hypertensive emergency include:
    • Dyspnea c7
    • Chest pain c8
    • Severe headache c9
    • Blurry vision c10
    • Nausea and vomiting c11c12
    • Confusion c13
    • Seizures c14
    • Somnolence c15
    • Focal neurologic symptoms c16
  • Symptoms that raise suspicion of secondary hypertension include:
    • Fatigue (suggests kidney disease, hypercortisolism, thyroid disorders, or obstructive sleep apnea) c17
    • Polyuria, oliguria, edema, dysuria, and flank pain (suggests kidney disease) c18c19c20c21c22
    • Dyspnea caused by pulmonary edema (suggests renal artery stenosis) c23
    • Headache, flushing, palpitations, syncope or near syncope, visual disturbances, and excessive perspiration (suggests pheochromocytoma) c24c25c26c27c28c29c30c31
    • Change in body habitus such as weight gain with truncal obesity, buffalo hump, moon facies, or purple striae (suggests hypercortisolism) c32c33c34c35
    • Cold extremities and lower extremity claudication (suggests coarctation of the aorta) c36c37
  • Patient may report use of drugs that can elevate blood pressure, including:
    • Oral contraceptives c38
    • NSAIDs and cyclooxygenase-2 inhibitors c39c40
    • Antidepressants c41
    • Steroids c42
    • Decongestants c43c44
    • Cyclosporine c45
    • Tacrolimus c46
    • Antiretrovirals c47
    • Therapeutic stimulants c48
    • Intoxicants with stimulant properties c49c50
  • Sudden discontinuation of a centrally acting α₂-adrenergic agonist drug (eg, clonidine, methyldopa) may result in abrupt rise in blood pressure c51c52
  • Antihypertensive medication nonadherence is a common cause of acutely increased blood pressures above baseline c53

Physical examination

  • Examination findings may be normal except for blood pressure c54
  • Measure blood pressure with patient at rest; repeat later during same encounter if elevated
  • Examine for signs of hypertensive end-organ disease
    • Hypertensive retinopathy classically categorized by fundal examination findingsr14 but not necessarily clinically useful r13
      • Grade 0: normal examination findings c55
      • Grade 1: minimal arterial narrowing c56
      • Grade 2: obvious arterial narrowing with focal irregularities c57
      • Grade 3: arterial narrowing with retinal hemorrhages, exudate, or both c58c59c60
      • Grade 4: grade 3 findings plus disk swelling c61c62c63c64
      • Hard exudates are a common late finding c65
    • Signs of acute retinal injury (a hypertensive emergency)
      • Focal intraretinal periarteriolar transudates c66
      • Focal retinal pigment epithelial lesions c67
      • Macular and optic disk edema c68c69
      • Cotton-wool spots c70
    • Carotid artery bruits c71
    • If chest or back pain is present, pulse deficits and discrepancies in blood pressure between limbs suggest aortic dissection r15c72c73
    • Rales or decreased breath sounds (suggests congestive heart failure with pulmonary edema) c74c75
    • Cardiac gallops or murmurs (suggest atherosclerotic heart disease or congestive heart failure) c76c77
    • Diastolic decrescendo murmur of aortic regurgitation (suggests type A aortic dissection, but is present in only 44% of patients) r15c78
    • Dependent edema (suggests pulmonary edema or renal dysfunction) c79
    • Altered mental status with nonfocal neurologic findings (suggests hypertensive encephalopathy) c80
    • Anatomically suggestive focal deficits on neurologic examination (suggest ischemic or hemorrhagic stroke) c81
  • Signs of possible secondary cause of hypertension
    • If there is any suspicion of coarctation of the aorta as the cause of secondary hypertension, measure blood pressure in both arms and 1 thigh to look for systolic pressure differential
      • Brachial pressure differential between right and left arm of more than 30 mm Hg suggests that compromised blood flow occurs before the left subclavian artery r16c82
      • Upper extremity systolic blood pressure 20 mm Hg higher than that of the lower extremity suggests significant coarctation r17
    • Abdominal bruit that is usually high-pitched and holosystolic (suggests renal artery stenosis) c83
    • Truncal obesity, buffalo hump, moon facies, or purple striae (suggests hypercortisolism) c84c85c86c87

Causes and Risk Factors

Causes

  • Essential hypertension is considered idiopathic c88
  • Secondary hypertension occurs as a result of:
    • Hormonal and organ system abnormalities
      • Chronic kidney disease c89
      • Renal artery stenosis c90
      • Renal parenchymal disease c91
      • Cushing disease and Cushing syndrome c92c93
      • Pheochromocytoma c94
      • Hyperaldosteronism c95
      • Hyperthyroidism and untreated hypothyroidism c96c97
      • Coarctation of the aorta c98
      • Obstructive sleep apnea c99
    • Drug-induced hypertension
      • Oral contraceptives c100
      • Decongestants c101
      • Antidepressants (ie, tricyclics, selective serotonin reuptake inhibitors) c102c103c104
      • Steroids c105
      • NSAIDs c106
      • Cyclosporine c107
      • Tacrolimus c108
      • Antiretrovirals r18c109
      • Tyramine reaction with use of MAOIs c110
      • Serotonin syndrome c111
    • Intoxicant-induced hypertension
      • Cocaine c112
      • Amphetamines c113
      • Methamphetamines c114
      • Other drugs with sympathomimetic effects c115
      • Phencyclidine c116
    • Abrupt discontinuation of sympatholytic drug (eg, clonidine) may precipitate hypertension c117

Risk factors and/or associations

Age
  • Prevalence of essential hypertension increases with age c118c119c120c121c122
  • In the United States, 4.9% of children and adolescents age 8 to 17 years had hypertension as defined by 2017 guidelines from the American Academy of Pediatrics r19
  • In the United States, prevalence of hypertension was 28.2% among those age 20 to 44 years, 60.1% among those age 45 to 64 years, and 77.0% among those age 65 years or older r19c123c124
Sex r20
  • Hypertension is more common in males than females up to age 64 years; after age 65 years, the percentage of females with hypertension was higher than it was for males r19c125c126
  • In the United States, lifetime risk of hypertension (as defined by the 2017 guidelines) for those between ages 20 and 85 years was 83.8% for White male patients and 69.3% for White female patients; rates did not significantly differ among Black male patients and Black female patients r19c127
Genetics
  • Increased risk of essential hypertension with family history c128
Ethnicity/race
  • Highest prevalence of essential hypertension is in non-Hispanic Black population r19c129c130c131c132
Other risk factors/associations
  • Risk for essential hypertension
    • White coat hypertension r11c133
    • Chronic kidney disease c134
    • Obesity c135
    • High-sodium diet c136
    • Smoking c137
    • Greater risk with more than moderate alcohol consumption (ie, more than 2 drinks/day for men younger than 65 years; 1 drink/day for men aged 65 years and older; more than 1 drink/day for females at any age) r21c138
    • Psychosocial stress c139
    • Sedentary lifestyle c140
  • Exposure to ambient air pollution is associated with elevated blood pressure in children and adolescents r22c141c142

Diagnostic Procedures

Primary diagnostic tools

  • Confirm hypertension; document elevated blood pressure on at least 2 encounters using sphygmomanometry or automated blood pressure measurement r23c143
    • Proper technique when taking blood pressure is important; proper cuff size must be used because a cuff that is too small can cause a spuriously high reading
      • Seat patient with feet flat on floor, legs uncrossed, and back supported; allow patient to sit for 3 to 5 minutes without talking or moving around before recording blood pressure r12
    • Do not use blood pressure readings taken when patients are in pain or acutely ill as support for a diagnosis because they may be spuriously high
    • Home blood pressure self-monitoring or ambulatory blood pressure monitoring add additional data when white coat hypertension or masked hypertension is a consideration or office measurements are not consistent r12
    • The US Preventive Services Task Forcer24 and guidelines from Canada,r25 the United Kingdom,r14 and Europer26 recommend routine ambulatory blood pressure monitoring to confirm hypertension diagnosis after elevated office readings
  • History, physical examination (including ophthalmoscopy), ECG, and laboratory testing r23c144
    • Outpatient evaluation of hypertension: examination, ECG, and routine laboratory tests to assess for chronic end-organ damage and to identify modifiable cardiovascular risk factors c145
    • With acute elevation in blood pressure suggesting hypertensive urgency or emergency:
      • Assess for symptoms of acute end-organ damage (eg, brain, heart, kidneys, eyes)
        • For asymptomatic patients with acute rise in blood pressure (ie, hypertensive urgency)
          • Obtain creatinine level, but there is no evidence to guide other testing recommendations in hypertensive urgency r5c146
        • For symptomatic patients with acute rise in blood pressure (ie, hypertensive emergency)
          • Obtain broader laboratory testing, imaging, and ECG based on apparent end-organ damage r4
    • Evaluate for secondary causes of hypertension (with early specialist consultation to direct appropriate workup) in the following settings:
      • Any symptoms or signs suggestive of a secondary cause
      • Abrupt onset of hypertension
      • Blood pressure resistant to appropriate treatment

Laboratory

  • Routine tests at the time of hypertension diagnosis to assess for chronic end-organ damage and modifiable cardiovascular risk factors r23
    • Fasting blood glucose level and hemoglobin A1Cr14c147
    • Serum sodium, potassium, and calcium levels c148c149c150
    • Serum BUN and creatinine levels (with estimated or measured glomerular filtration rate) c151c152
    • Fasting lipid profile c153
    • Hematocrit level c154
    • Urinalysis c155
    • Measurement of urinary albumin excretion level or albumin-creatinine ratio is considered an optional baseline test unless diabetes or kidney disease is present c156c157
  • During hypertensive urgency (ie, asymptomatic patient)
    • Serum creatinine level may be useful to identify patients with occult renal dysfunction but cannot differentiate acute from chronic abnormality r5c158
  • During hypertensive emergency, evaluate for acute end-organ dysfunction r4
    • CBC c159
      • Schistocytes on manual differential suggest microangiopathic hemolytic anemia caused by renal arteriolar damage c160
    • Serum BUN and creatinine levels c161c162
      • Increased levels suggest hypertensive nephropathy
    • Urinalysis (if renal dysfunction is suspected) c163
      • Proteinuria and casts suggest hypertensive nephropathy
    • Cardiac troponin level (if chest pain or dyspnea is present) c164

Imaging

  • Imaging is not routinely recommended for adult patients with newly diagnosed hypertension unless there is clinical suspicion of secondary hypertension r23r27
    • Targeted imaging studies for suspected underlying causes are best selected with specialist consultation
  • Obtain appropriate imaging in a hypertensive emergency based on suspected end-organ dysfunction r4r9
    • Head CT or MRI scan if hypertensive encephalopathy or stroke is present c165c166
    • Chest radiography if dyspnea is present or there is concern for acute coronary syndrome c167
    • Chest radiography and CT angiography if aortic dissection is suspected c168c169
    • Renal ultrasonography to assess for postrenal obstruction and kidney size r9

Functional testing

  • ECG
    • Recommended for adults at baseline; may identify, with low sensitivity, evidence of chronic cardiac end-organ dysfunction (eg, left ventricular hypertrophy) r14r23c170
    • Indicated with complaints of dyspnea or chest pain in the setting of hypertensive emergency c171
  • Echocardiography r25
    • Not routinely recommended c172
    • May be useful in selected cases for assessment of left ventricular hypertrophy, to help define future risk of cardiovascular events c173
    • Echocardiographic assessment of left ventricular mass, as well as of systolic and diastolic left ventricular function is recommended for hypertensive patients suspected of having left ventricular dysfunction or coronary artery disease
    • Can be used in patients with hypertension and evidence of heart failure for assessment of left ventricular ejection fraction c174

Procedures

c175

Differential Diagnosis

  • Secondary hypertension occurs as a result of specific hormone and organ system abnormalities or drug use (therapeutic or recreational); suspect based on suggestive symptoms, signs, and results of baseline screening tests
    • Renal causes
      • Chronic kidney disease c176c177d1
        • Most common in middle-aged and geriatric populations and in patients with diabetes c178c179
        • Symptoms of fatigue and edema are suggestive
        • Baseline laboratory tests reveal elevated BUN and/or creatinine levels
        • Obtain renal ultrasonography; may show small, hypoechoic kidneys
      • Renal parenchymal disease c180c181
        • Common cause of secondary hypertension in preadolescent children but less common in adults c182c183c184
        • Usually caused by congenital abnormalities, glomerulonephritis, or reflux nephropathy
        • Baseline laboratory testing may reveal elevated BUN and creatinine levels; urinalysis results are typically positive for proteinuria, hematuria, and red cell casts
        • Renal ultrasonography is usually first imaging test
        • Biopsy is often required unless there is good evidence of prior bacterial infection and postinfectious glomerulonephritis is suspected
      • Renal artery stenosis c185c186
        • Most common in young women with fibromuscular dysplasia or older adults with atherosclerosis c187c188c189
        • Suspect with onset of hypertension in anyone younger than 30 years or in older adults with hypertension that is accelerating or unresponsive to therapy
        • Recurrent pulmonary edema may be present
        • Abdominal bruit may be present on examination but is not diagnostic
        • Baseline laboratory tests reveal elevated BUN and/or creatinine levels
        • If suspected, confirm with imaging studies
          • Renal artery Doppler ultrasonography, catheter-based angiographic imaging, CT angiography, or magnetic resonance angiography are diagnostic, but the preferred imaging modality is controversial and should be selected in consultation with a nephrologist
    • Endocrine causes
      • Cushing disease and Cushing syndrome c190c191c192d2
        • Most common in middle-aged adults c193c194
        • Caused by increased pituitary secretion of corticotropin (Cushing disease), increased adrenal secretion of cortisol without stimulation by corticotropin, or ectopic production of corticotropin
        • Central weight gain, striae, buffalo hump, and moon facies are common features
        • Glucose intolerance may be present
        • Diagnose in consultation with an endocrinologist
          • Determine if hypercortisolism is present with 24-hour urine collection or salivary cortisol measurement
          • Measure corticotropin levels to determine if the hypercortisolism is corticotropin-dependent or corticotropin-independent
          • Obtain imaging of adrenal glands, brain, or both, depending on results of laboratory testing and suspected source of hypercortisolism
      • Pheochromocytoma c195c196
        • Most common in middle-aged adults c197
        • Presentation may include labile blood pressure, palpitations, flushing, sweating, headaches, syncope, and near syncope
        • May result in acute sympathetic crisis with severe hypertension owing to sudden rise in serum catecholamine levels
        • Diagnose with 24-hour urine collection for metanephrines or blood specimen for plasma-free metanephrines
        • If there is biochemical confirmation of catecholamine excess, perform MRI (preferred) or CT scan of abdomen and pelvis; scintigraphy may be necessary to locate extra-adrenal pheochromocytoma
      • Hyperaldosteronism c198c199
        • Primary hyperaldosteronism is caused by oversecretion of aldosterone by adrenal glands c200
          • Usually caused by bilateral adrenal hyperplasia
          • Sometimes caused by aldosterone-secreting adenoma
        • Secondary hyperaldosteronism is caused by decreased renal perfusion, leading to increased renin and aldosterone secretion c201
          • Unexplained hypokalemia is a common feature
        • Diagnose by measuring plasma aldosterone concentration and renin activity; follow with adrenal imaging, usually with CT scan
      • Hypothyroidism or hyperthyroidism c202c203c204c205d3
        • Excess triiodothyronine raises systolic pressure in hyperthyroidism; decreased cardiac output eventually leads to increased blood pressure in untreated hypothyroidism d4
        • Temperature intolerance, weight gain or loss, and tachycardia may be present
        • Diagnose with thyroid function laboratory testing
    • Coarctation of the aorta c206c207c208
      • Most commonly diagnosed in children and young adults c209c210
      • Presentation may include delayed or decreased femoral pulses, blood pressure or pulse difference between arms depending on anatomic location, significant systolic blood pressure differential between arms and legs, and systolic or continuous cardiac murmur
      • Diagnose with echocardiography
    • Obstructive sleep apnea c211c212
      • Most common in middle-aged adults who are obese or overweight c213c214
      • Presentation may include daytime somnolence, snoring, or apneic episodes while sleeping
      • Diagnose with polysomnography
    • Acute sympathetic crisis caused by intoxicant c215
      • Paroxysmal hypertension caused by stimulants such as cocaine, amphetamines, methamphetamines, other drugs with sympathomimetic effects, and phencyclidine c216c217
      • In addition to hypertension, other prominent symptoms include tachycardia, fever, diaphoresis, dysrhythmias, chest pain, and agitation
      • If cause of intoxication is unknown, order toxicology screening of blood, urine, or gastric contents for suspected intoxicants

Treatment

Goals

  • For hypertensive emergency, rapidly lower blood pressure to minimize end-organ damage without compromising cerebral blood flow
    • For adults with a compelling condition (eg, aortic dissection, severe preeclampsia or eclampsia, pheochromocytoma crisis), reduce systolic blood pressure to less than 140 mm Hg during the first hour and to less than 120 mm Hg in aortic dissection r1
    • For adults without a compelling condition, reduce systolic blood pressure by no more than 25% within the first hour; then, if stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the 24 to 48 hours that follow r1
    • In aortic dissection, rapid lowering of systolic blood pressure is required r1r8
      • Goal systolic blood pressure of 120 mm Hg or less should be achieved within 20 minutes r1r9
    • In acute ischemic stroke, blood pressure goal depends on planned treatment (thrombolysis versus no thrombolysis) r1r8r28
      • In patients with very high blood pressure (greater than 220/120 mm Hg) who are not receiving thrombolytic therapy, it is reasonable to lower blood pressure by 15% during the first 24 hours after symptom onset r29
      • Patients who have high blood pressure and who are eligible for thrombolytic therapy should have their blood pressure lowered to less than 185/110 mm Hg before therapy and maintained at less than 180/105 mm Hg for 24 hours after therapy r29
      • No specific minimum systolic blood pressure is recommended, but systolic pressures between 141 and 150 mm Hg have been associated with optimal mortality and functional outcomes r30
    • In intracerebral hemorrhage: r1r28
      • For adults with intracerebral hemorrhage who present with systolic blood pressure greater than 220 mm Hg, it is reasonable to use continuous IV drug infusion and close blood pressure monitoring to lower systolic blood pressure
      • Immediate lowering of systolic blood pressure to less than 140 mm Hg in adults with spontaneous intracerebral hemorrhage who present within 6 hours of the acute event and have systolic blood pressure between 150 mm Hg and 220 mm Hg is not helpful in reducing death or severe disability and is potentially harmful
  • For hypertensive urgency with no evidence of acute end-organ damage, there is no specific threshold of blood pressure that must be urgently treated or specific blood pressure level that must be reached before discharge r5
    • There is no indication for referral to the emergency department, immediate reduction in blood pressure in the emergency department, or hospitalization r1
      • Acute reduction of blood pressure in the emergency department is not advised owing to potential adverse effects and lack of clinical benefit r5
    • Goal for most patients is outpatient initiation of oral antihypertensive medication by the patient's personal physician with gradual reduction of blood pressure (over a period of days) r4r5
    • Emergency department physician may initiate treatment with an oral antihypertensive if warranted by social or clinical situation (eg, patient lacks transportation, other factor that limits access to outpatient follow-up) r5
  • For newly diagnosed or chronic hypertension (non–hypertensive emergency)
    • 2019 American College of Cardiology/American Heart Association guidelines on primary prevention of cardiovascular disease recommend target blood pressure of less than 130/80 mm Hg in most cases r3
    • Blood pressure targets are generally based on degree of cardiovascular risk; more stringent blood pressure goals are recommended for patients at high risk of future cardiovascular events r1
      • High-risk factors include:
        • Established atherosclerotic cardiovascular disease (eg, coronary artery disease, ischemic stroke, peripheral vascular disease)
        • Heart failure
        • Diabetes mellitus
        • Chronic kidney disease
        • Multiple risk factors and a 10-year atherosclerotic cardiovascular disease risk of 10% or more
        • Older than 65 years
    • Blood pressure goals for specific risk groups
      • Patients with coronary artery disease
        • 2017 American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines recommend blood pressure target of less than 130/80 mm Hg for adults with confirmed hypertension and known cardiovascular disease or 10-year atherosclerotic cardiovascular disease event risk of 10% or higher r1
      • Patients with transient ischemic attack or ischemic stroke
        • American Heart Association/American Stroke Association guidelines r31
          • An office blood pressure goal of less than 130/80 mm Hg is recommended for most patients r31
        • American College of Physicians and American Academy of Family Physicians guidelines recommend: r32
          • Consider initiating or intensifying pharmacologic treatment in adults aged 60 years or older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for recurrent stroke
      • Patients with diabetes
        • 2017 American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines recommend a target of less than 130/80 mm Hg in adults r1
        • American Diabetes Association recommends individualizing blood pressure targets in all age groups
          • A blood pressure target of lower than 140/90 mm Hg is recommended in individuals who are at lower risk of cardiovascular disease (10-year atherosclerotic cardiovascular disease risk of less than 15%) r33
          • A lower blood pressure target of 130/80 mm Hg may be appropriate for individuals at high risk of cardiovascular disease (existing atherosclerotic cardiovascular disease or 10-year ASCVD risk of 15% or greater) if it can be achieved safely r33
        • American Association of Clinical Endocrinologists and American College of Endocrinology recommend an individualized target, but they state that generally blood pressure should be approximately 130/80 mm Hg in all age groups r34
      • Patients with chronic kidney disease (all ages)
        • Reduce blood pressure to lower than 130/80 mm Hg r1r35
      • Older adults
        • 2017 American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines recommend a systolic blood pressure treatment goal of less than 130 mm Hg for noninstitutionalized ambulatory community-dwelling adults aged 65 years or older r1
          • Goals need not differ even for community-dwelling patients older than 80 years
            • Treatment of hypertension significantly reduced cardiovascular mortality and morbidity in patients aged 80 years and older; relative risk reduction similar to that in patients aged 60 to 79 years r36
          • However, blood pressure targets can be individualized in patients with significant comorbidities and a limited life expectancy; less aggressive blood pressure lowering may be considered
        • Earlier American College of Physicians and American Academy of Family Physicians joint guidelines for patients aged 60 years or older recommended higher targets, which are not consistent with those of other professional organizations; they recommended: r32
          • Reducing systolic blood pressure to less than 150 mm Hg (for patients without history of stroke or transient ischemic attack and without high individual cardiovascular risk)
          • Considering 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 systolic blood pressure of less than 140 mm Hg, reducing the risk for stroke or cardiac events
        • UK guidelines recommend blood pressure treatment goal of less than 150/90 mm Hg for patients aged 80 years and older; use clinical judgement for patients who are frail or who have multiple comorbidities r14
  • For patients at low risk (none of the above comorbidities)
    • Clinical trial evidence is strongest for blood pressure target of less than 140/90 mm Hg; however, a target of less than 130/80 mm Hg may also be reasonable r1r3

Disposition

Admission criteria

Hypertensive urgency (severe asymptomatic hypertension) does not typically require acute blood pressure lowering in the emergency department or inpatient admission r1r5

Criteria for ICU admission
  • In adults with a hypertensive emergency, admission to an intensive care unit is recommended for continuous monitoring of blood pressure and target organ damage, and for parenteral administration of an appropriate agent r1r9

Recommendations for specialist referral

  • For patients discharged from the emergency department with hypertensive urgency (severe asymptomatic hypertension), refer to primary care physician for follow-up within 1 week r4
  • When goal blood pressure is not reached with multiple drugs, refer to hypertension specialist (usually cardiologist; nephrologist for patients with kidney disease)

Treatment Options

Hypertensive emergency

  • 2017 American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines provide recommendations for management of hypertensive emergencies: r1
    • For adults with a compelling condition (eg, aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma crisis), systolic blood pressure should be reduced to less than 140 mm Hg during the first hour and to less than 120 mm Hg in aortic dissection
    • For adults without a compelling condition, systolic blood pressure should be reduced by no more than 25% within the first hour; then, if stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the 24 to 48 hours that follow
    • For patients with ischemic stroke, lower blood pressure to a lesser degree, within the following parameters:
      • In patients with very high blood pressure (higher than 220/120 mm Hg) who are not receiving thrombolytic therapy, it is reasonable to lower blood pressure by 15% during the first 24 hours after symptom onset r29
      • Patients who have high blood pressure and are eligible for thrombolytic therapy should have their blood pressure lowered to less than 185/110 mm Hg before therapy and maintained at less than 180/105 mm Hg for 24 hours after therapy r29
      • No specific minimum systolic blood pressure is recommended, but systolic pressures between 141 and 150 mm Hg have been associated with optimal mortality and functional outcomes r30
    • For adults with intracerebral hemorrhage who present with systolic blood pressure higher than 220 mm Hg, it is reasonable to use continuous IV drug infusion and close blood pressure monitoring to lower systolic blood pressure
    • For patients with aortic dissection, rapid lowering of systolic blood pressure is required r1r8
      • Goal systolic blood pressure of 120 mm Hg or less should be achieved within 20 minutes r1
    • Otherwise, avoid rapid, extreme pressure reductions to prevent organ hypoperfusion r23
  • Parenteral drugs are preferred (given as titrated IV boluses or by infusion) r23
  • Sodium nitroprusside, nicardipine (IV), and/or labetalol are appropriate for most hypertensive emergencies, but initial drug of choice is based on the acute end-organ dysfunction at presentation; recommendations are consensus based r9r23
    • Sublingual or immediate-acting nifedipine is contraindicated
    • Initiate oral antihypertensives before discontinuing IV drugs
  • If acute coronary syndrome is present and there is evidence of heart failure, give nitroglycerinr23 and β-blockersr4r8
    • A fast-acting drug is preferable;r4esmolol is suggested as an agent of choicer1
    • Nitroprusside may result in coronary steal syndrome r4
  • If pulmonary edema is present, preferred drugs include sodium nitroprusside, nitroglycerin, and clevidipine r1r4r8
    • Use loop diuretics cautiously, because patients are often normovolemic or hypovolemic r4
    • β-blockers are contraindicated r1
  • If acute kidney injury is present, give calcium channel blocker (nicardipine or clevidipine) or fenoldopam r1r4r8
    • Calcium channel blockers do not affect renal perfusion; fenoldopam promotes renal excretion and is as effective as nitroprusside r4
  • If hypertensive encephalopathy (without stroke) is present, consider nitroprusside, labetalol, nicardipine, and/or enalapril r5
    • Benzodiazepines, phenytoin, and barbiturates (given for seizure control and delirium) also result in blood pressure decrease r4
  • If ischemic stroke is present, give IV nicardipine, labetalol, or clevidipine; consider IV nitroprusside if blood pressure is not controlled or diastolic pressure is greater than 140 mm Hg r29
  • If aortic dissection is present, give β-blocker to reduce shearing forces (esmolol is ideal) followed by nitroprusside or nicardipine (to provide arteriodilation) r1r4
  • If sympathetic crisis is caused by pheochromocytoma, give phentolamine, nicardipine, or clevidipine r1r8
  • If sympathetic crisis is caused by cocaine, benzodiazepines are indicated and may be sufficient to decrease blood pressure r4
    • Phentolamine or nitroprusside may be administered if benzodiazepines not successful r37
    • Do not give β-blockers owing to reflex tachycardia risk r37
  • If sympathetic crisis is caused by phencyclidine, amphetamine, tyramine reaction with use of MAOIs, or abrupt withdrawal from sympatholytic medications, give phentolamine, nitroprusside, or labetalol r4
    • Avoid β-blocker use as sole treatment owing to risk of reflex tachycardia

Hypertensive urgency

  • No evidence for a specific threshold blood pressure that must be urgently treated or a specific blood pressure level that must be reached before discharge r5
  • There is no indication for referral to the emergency department, immediate reduction in blood pressure in the emergency department, or hospitalization for such patients r1
    • No evidence that acute treatment in the emergency department results in short-term cardiovascular risk reduction r4
  • For most patients, outpatient follow-up with initiation of oral antihypertensive medications at that time is recommended unless medical follow-up is not ensured r5
  • If medical follow-up is not ensured, emergency physicians may treat markedly elevated blood pressure in the emergency department and/or initiate therapy for long-term control r5

Outpatient treatment of essential hypertension r1

  • Initiate lifestyle interventions to decrease patient's contribution to both hypertension and cardiovascular disease
    • Patients with stage 1 hypertension and an estimated 10-year atherosclerotic cardiovascular disease risk less than 10% can be treated initially with lifestyle modifications alone with repeat blood pressure evaluation within 3 to 6 months r38
    • Continue lifestyle therapy and initiate pharmacologic therapy if blood pressure remains elevated after 3 to 6 months of lifestyle interventions r38r39
  • Many patients can be started on a single agent initially, but consider starting with 2 drugs of different classes for those with stage 2 hypertension
  • Consider patient-specific factors (eg, age, concurrent medications, drug adherence, drug interactions, overall treatment regimen, out-of-pocket costs, comorbidities)
  • 2 or more antihypertensive medications are recommended to achieve a blood pressure target of less than 130/80 mm Hg in most adults with hypertension, especially in Black adults with hypertension
  • For Black patients without heart failure or chronic kidney disease, including those with diabetes, initiate treatment with 1 of the following: r1
    • Thiazide diuretic
    • Calcium channel blocker
  • For patients of other ethnic groups, including those with diabetes, initiate treatment with 1 of the following: r1
    • Thiazide diuretic
    • Calcium channel blocker
    • ACE inhibitor
    • Angiotensin receptor blocker
  • For patients with chronic kidney disease, initial or add-on therapy should include 1 of the following: r1
    • ACE inhibitor
    • Angiotensin receptor blocker, if ACE inhibitor not tolerated
  • Use of combination pills can be useful to improve adherence to antihypertensive therapy
  • In patients who do not respond to or do not tolerate treatment with 2 to 3 medications or medication combinations, team-based care may be effective, encouraging both nonpharmacologic and pharmacologic treatments
  • In general, β-blockers are not recommended for initial treatment except in patients with angina pectoris, arrhythmias, post–myocardial infarction, and heart failure; effect on cardiovascular morbidity and mortality is lower than other agents r40
  • Simultaneous use of an ACE inhibitor, angiotensin receptor blocker, and/or renin inhibitor is potentially harmful and is not recommended to treat adults with hypertension
  • A Cochrane review to compare efficacy of recommended first line drugs found that all-cause mortality is similar when ACE inhibitors or angiotensin receptor blockers are compared with other first line antihypertensive agents r41
    • ACE inhibitors and angiotensin receptor blockers are associated with decreased risk of heart failure but increased risk of stroke compared with calcium channel blockers
      • Reduction in heart failure risk was of greater significance than the increase in stroke risk
    • ACE inhibitors and angiotensin receptor blockers are associated with an increased risk of heart failure and stroke compared with thiazide diuretics
  • Another Cochrane review reported that first line low-dose thiazides reduced all morbidity and mortality outcomes in adult patients with moderate to severe primary hypertension r42
    • First line high-dose thiazides and first line β-blockers were inferior to first line low-dose thiazides

Treatment of secondary hypertension is specific to the underlying cause

  • Renal artery stenosis
    • Initial treatment is medical control of hypertension, management of hyperlipidemia, and antiplatelet therapy r43
      • Drugs that block the renin-angiotensin-aldosterone system (ACE inhibitors and angiotensin receptor blockers) improve cardiovascular outcomes based on observational studies, but they must be used with caution owing to risk of worsened renal function
    • Surgical correction may be considered for uncontrolled hypertension r43
    • A Cochrane review determined that "data are insufficient to conclude that revascularization in the form of balloon angioplasty, with or without stenting, is superior to medical therapy for the treatment of atherosclerotic renal artery stenosis in patients with hypertension. However, balloon angioplasty results in a small improvement in diastolic blood pressure and a small reduction in antihypertensive drug requirements" r44
  • Coarctation of the aorta r17
    • Requires surgical or interventional (transcatheter) catheter treatment in most cases
    • Peak-to-peak gradient of 20 mm Hg or more by cardiac catheterization is an indication for intervention
  • Endocrine conditions
    • Hypercortisolism caused by Cushing disease (pituitary cause) or Cushing syndrome (adrenal cause)
      • Transsphenoidal surgery is the treatment of choice for Cushing disease r45
      • Surgery is usually the treatment of choice for Cushing syndrome except when the tumor cannot be located r46
      • Medical management is necessary before surgery and when surgery is contraindicated r46
        • Dopamine or somatostatin agonists to modulate corticotropin release
        • Steroidogenesis inhibitors (metyrapone, ketoconazole, mitotane)
        • Glucocorticoid receptor antagonist (mifepristone)
    • Pheochromocytoma r47
      • Requires surgical resection of the tumor
      • Hypertension must be medically managed preoperatively and intraoperatively, and for inoperable disease
      • α-Blocker (phenoxybenzamine) recommended for 10 to 14 days before surgery
      • Labetalol or nitroprusside are commonly used intraoperatively
    • Hyperaldosteronism r48
      • Unilateral adrenalectomy, usually laparoscopic, is indicated in patients with an aldosterone-producing adrenal adenoma
      • Hypertension resolves within 6 months of surgery in up to 50% of patients; remainder of patients are usually less hypertensive
      • Treatment is medical with mineralocorticoid antagonists for patients with bilateral disease or for those with unilateral disease who are not surgical candidates
        • Spironolactone is the first line medical therapy; eplerenone is an alternative with fewer antiandrogenic effects
        • Amiloride may also be effective
    • Thyroid disorders
      • Treat hypothyroidism with thyroid hormone replacement
      • Hyperthyroidism may be treated medically (antithyroid drugs), with radioactive iodine, or with surgical resection r49
        • β-Blockers and calcium channel blockers (verapamil, diltiazem) may be used to reduce adrenergic manifestations of hyperthyroidism
  • Kidney disease
    • Treatment of renal parenchymal disease caused by glomerulonephritis depends on specific underlying cause r50
    • Manage chronic kidney disease according to published guidelines r51r52
      • Include an ACE inhibitor or angiotensin receptor blocker for blood pressure management r35
        • Requires careful monitoring of serum creatinine and potassium levels
      • Include diuretics in the antihypertensive regimen for most patients
  • Obstructive sleep apnea
    • Treated with nocturnal continuous positive airway pressure mask; in milder cases, a dental appliance may be effective r53
  • Drug-related causes are managed with discontinuation of the offending agent

Drug therapy

  • Oral administration (for initial and add-on therapy)
    • Thiazide diuretics c218
      • A Cochrane review compared dose-related blood pressure–lowering effect of thiazide diuretics r54
        • Hydrochlorothiazide has a dose-related blood pressure–lowering effect (mean blood pressure–lowering effect over the dose range 6.25, 12.5, 25, and 50 mg/day is 4/2, 6/3, 8/3, and 11/5 mm Hg, respectively). c219
        • No dose effect seen with other thiazide drugs, and the lowest doses studied reduced blood pressure maximally.
      • Chlorthalidone c220c221
        • Chlorthalidone Oral tablet; Adults: Initially, 25 mg PO once daily. Adjust dosage up to 100 mg PO once daily. Clinical practice guidelines recommend a dose range of 12.5 to 25 mg PO daily. A thiazide-type diuretic is recommended as an initial antihypertensive therapy in the general population without certain comorbidities. In the general black population without HF or CKD, including those with diabetes, clinical practice guidelines recommend initial antihypertensive treatment with a thiazide-type diuretic or a calcium channel blocker instead of an ACEI or ARB.
      • Hydrochlorothiazide c222c223
        • Hydrochlorothiazide Oral tablet; Adults: Initially, 12.5 to 25 mg PO once daily. Increase up to 50 mg/day PO given in 1 to 2 divided doses.
      • Metolazone c224c225
        • Metolazone Oral tablet; Adults: 2.5 to 5 mg PO once daily.
    • Calcium channel blockers
      • Amlodipine c226c227
        • Amlodipine Besylate Oral tablet; Adults: 5 mg PO once daily initially. Max: 10 mg/day.
        • Amlodipine Besylate Oral tablet; Geriatric and Debilitated patients: 2.5 mg PO once daily initially. Max: 10 mg/day.
      • Diltiazem (extended-release forms are the only form recommended for hypertension) c228c229
        • Once-daily dosage form
          • Diltiazem Hydrochloride Oral tablet, extended-release; Adults: Initially, 180 to 240 mg PO once daily. Adjust dosage to individual patient needs up to Max: 540 mg/day. Maximum antihypertensive effect usually observed by 14 days of chronic therapy; schedule dosage adjustments accordingly. Dose range: 120 to 540 mg/day.
        • Twice-daily dosage form
          • Diltiazem Hydrochloride Oral capsule, sustained release 12 hour; Adults: Initially, 60 to 120 mg PO twice daily. Usual dose: 120 to 180 mg twice daily. Max: 360 mg/day.
      • Nifedipine (extended-release forms are the only form recommended for hypertension) c230c231
        • Nifedipine Oral tablet, extended-release; Adults: Initially, 30 to 60 mg PO once daily. Max: 90 mg/day for most extended-release products; 120 mg/day for Procardia XL.
    • ACE inhibitors
      • Enalapril c232c233
        • Enalapril Maleate Oral tablet; Adults: Initially, 2.5 to 5 mg PO once daily. The usual dosage range is 10 to 40 mg/day PO, given in 1 to 2 divided doses.
      • Lisinopril c234c235
        • Lisinopril Oral tablet; Adults: Initially, 10 mg PO once daily. The usual dosage range is 20 to 40 mg PO once daily; lower doses may be necessary in patients with impaired renal function, the elderly, and in those receiving diuretics. Max: 80 mg/day.
      • Benazepril c236c237
        • Benazepril Hydrochloride Oral tablet; Adults: 10 mg PO once daily initially. If receiving diuretics, reduce to 5 mg once daily. Usual dosage 20 to 40 mg/day (1 to 2 divided doses). Max: 80 mg/day.
    • Angiotensin receptor blockers
      • Irbesartan c238c239
        • Irbesartan Oral tablet; Adults: Initially, 150 mg PO once daily unless the patient is volume-depleted. For volume-depleted patient, begin with 75 mg PO once daily. If needed, titrate up to 300 mg PO once daily. Alternatively, a small dose of a diuretic may be added.
      • Losartan c240c241
        • Losartan Potassium Oral tablet; Adults and Adolescents: Initially, 50 mg PO once daily, unless patient is volume depleted. Maintenance dosage range: 25 to 100 mg/day PO, given in 1 to 2 divided doses. Adding a diuretic has greater blood pressure reduction vs. increasing losartan dosage above 50 mg/day. When volume depletion suspected (e.g., diuretics), start at 25 mg PO once daily.
      • Valsartan c242c243
        • Valsartan Oral tablet; Adults: 80 to 160 mg PO once daily initially. Max: 320 mg/day.
  • Oral administration (for treatment of resistant hypertension [goal not reached with 3-drug regimen])
    • Aldosterone antagonists
      • Spironolactone r55c244
        • Spironolactone Oral tablet; Adults: 25 to 100 mg/day PO in single or divided doses. Dosage may be titrated at 2-week intervals. Doses greater than 100 mg/day generally do not provide additional reductions in blood pressure
      • Eplerenone r56c245
        • Eplerenone Oral tablet; Adults: 50 mg PO once daily. For inadequate response after 4 weeks, may increase dosage to 50 mg PO twice daily. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
        • Monitor serum potassium before initiation of therapy, within the first week, and at 1 month after the start of treatment or dose adjustment. Periodically assess serum potassium thereafter.
        • Advise patients not to use dietary salt substitutes that contain potassium while taking eplerenone.
    • α-Blockers
      • Doxazosin c246
        • Doxazosin Mesylate Oral tablet; Adults: Initially, 1 mg PO once daily. Max: 16 mg/day.
      • Prazosin c247
        • Prazosin Hydrochloride Oral capsule; Adults: Initially, 1 mg PO given 2 to 3 times daily. The first dose can be given at bedtime to minimize orthostatic hypotension. The average dosage is 6 to 15 mg/day PO, given in divided doses. Max: 20 mg/day PO, given in divided doses; however, some patients may need up to 40 mg/day.
        • Prazosin Hydrochloride Oral capsule; Geriatric: Initially, 1 mg PO given 1 to 2 times daily.
      • Terazosin c248
        • Terazosin Hydrochloride Oral tablet; Adults: Initially, 1 mg PO daily at bedtime. Average maintenance dose is 1—5 mg once daily. Max 20 mg/day, given in divided doses q12h.
    • β-Blockers
      • Atenolol c249
        • Atenolol Oral tablet; Adults: Initially, 25 to 50 mg PO once daily. Increase up to 100 mg/day if needed after 7 to 14 days.
        • Atenolol Oral tablet; Geriatric: Initiate at lower end of dose range (e.g., 25 to 50 mg/day PO). Titrate to attain blood pressure goal. Max: 100 mg/day.
      • Carvedilol c250
        • Twice-daily dosage form
          • Carvedilol Oral tablet; Adults: Initially, 6.25 mg PO twice daily for 7 to 14 days. If needed, increase to 12.5 mg PO twice daily for 7 to 14 days. Max 25 mg PO twice daily.
        • Once-daily dosage form
          • Carvedilol Oral capsule, extended-release; Adults: Initially, 20 mg PO daily, administer in the AM with food. After 7 to 14 days, may increase to 40 mg PO daily to attain blood pressure (BP) goals. Evaluate BP response after 7 to 14 days. If needed, may increase up to 80 mg PO daily. When converting from immediate-release carvedilol to Coreg CR capsules, clinicians may utilize the following dosage conversion information: 3.125 mg PO twice daily immediate-release = 10 mg PO once daily Coreg CR; 6.25 mg PO twice daily immediate-release = 20 mg PO once daily Coreg CR; 12.5 mg PO twice daily immediate-release = 40 mg PO once daily Coreg CR; 25 mg PO twice daily immediate-release = 80 mg PO once daily Coreg CR.
          • Carvedilol Oral capsule, extended-release; Geriatric: Consider dosage reduction (see initial adult dosage). Initially, when switching from max dose (25 mg PO twice daily immediate release), give 40 mg PO daily. If tolerated, increase to 80 mg PO daily after 2 weeks.
      • Metoprolol c251
        • Twice-daily dosage form
          • Metoprolol Tartrate Oral tablet; Adults: Initially, 100 mg/day PO, given in single or divided doses. Titrate dosage to response weekly; dose range is 100 to 450 mg/day.
        • Once-daily dosage form
          • Metoprolol Succinate Oral tablet, extended-release; Adults: Initially, 25 to 100 mg PO once daily. Titrate dosage weekly, if needed, up to 400 mg PO once daily. When switching from immediate-release metoprolol, convert to the same total daily dosage of extended-release tablets.
    • Centrally acting adrenergic agents
      • Clonidine c252
        • Oral
          • Clonidine Hydrochloride Oral tablet; Adults: Initially, 0.1 mg PO twice daily; increase by 0.1 mg/day at weekly intervals as needed. Usual range: 0.2 to 0.6 mg/day. Lower initial dose may be warranted in geriatric patients to minimize risk of side effects.
        • Transdermal c253
          • Clonidine Transdermal patch - weekly; Adults: Initially, apply one Catapres TTS-1 patch once every 7 days. Adjust dosage every 1 to 2 weeks by changing or combining dosage systems. Antihypertensive effect takes a few days to commence; reduce other antihypertensive medications gradually.
      • Guanfacine c254
        • Guanfacine Hydrochloride Oral tablet; Adults and Adolescents: Initially, 1 mg PO once daily at bedtime. May increase to 2 mg PO once daily if after 3 to 4 weeks satisfactory results have not been attained, although most of the effect of guanfacine on blood pressure is seen at 1 mg/day. Higher daily doses have been used, but adverse reactions increase significantly with doses above 3 mg/day PO. Max: 3 to 4 mg PO once daily. Do not abruptly discontinue therapy.
      • Methyldopa c255
        • Methyldopa Oral tablet; Adults and Adolescents: Initially, 250 mg PO given 2—3x/day. The usual dosage is 500—2000 mg/day PO, given in 2—4 divided doses. Max 3 g/day PO.
        • Methyldopa Oral tablet; Geriatric: Lower doses may be needed (e.g., 250—1000 mg/day PO).
    • Nonthiazide diuretics
      • Furosemide c256
        • Furosemide Oral tablet; Adults: Initially, 40 mg PO twice daily. Max: 600 mg/day.
      • Torsemide c257
        • Torsemide Oral tablet; Adults: Initially, 5 mg PO once daily. May increase to 10 mg PO once daily.
    • Renin inhibitors
      • Aliskiren c258
        • Aliskiren Hemifumarate Oral tablet; Adults: 150 mg PO once daily; depending on clinical response, may be titrated up (Max: 300 mg once daily).
    • Vasodilators
      • Hydralazine c259
        • Hydralazine Hydrochloride Oral tablet; Adults: 10 mg PO 4 times/day for the first 2—4 days, increase to 25 mg PO 4 times/day for the balance of the first week. For the second and subsequent weeks, increase to 50 mg PO 4 times/day. Max: 300 mg/day PO.
      • Minoxidil c260
        • Minoxidil Oral tablet; Adults: 5 mg PO once daily. Increase the daily dosage to 10, 20, and then 40 mg/day in single or divided doses in intervals of at least 3 days as needed. Usual effective dosage range: 10 to 40 mg/day. Max: 100 mg/day.
  • IV administration
    • Calcium channel blockers
      • Nicardipine c261
        • For short-term treatment of hypertension when oral therapy is not feasible or desirable (substituting for oral nicardipine therapy)
          • Nicardipine Hydrochloride Solution for injection; Adults: 0.5 mg/hour continuous IV infusion for 20 mg PO every 8 hours, 1.2 mg/hour continuous IV infusion for 30 mg PO every 8 hours, or 2.2 mg/hour continuous IV infusion for 40 mg PO every 8 hours.
        • For the treatment of acute hypertension, including perioperative hypertension, hypertensive urgency, and hypertensive emergency
          • Nicardipine Hydrochloride Solution for injection; Adults: 5 mg/hour continuous IV infusion, initially. Titrate by 2.5 mg/hour every 5 to 15 minutes until goal blood pressure is attained. Max: 15 mg/hour.
      • Clevidipine c262
        • Clevidipine Emulsion for injection; Adults: 1 to 2 mg/hour continuous IV infusion initially. Double dose every 90 seconds until the blood pressure approaches goal, then increase by less than double every 5 to 10 minutes as needed. Max: 32 mg/hour or 1,000 mL/24 hours due to lipid load restrictions. Max duration: 72 hours.
    • β-Blockers
      • Esmolol c263c264
        • For hypertensive emergency or hypertensive urgency.
        • Esmolol Hydrochloride Solution for injection; Adults: 500 to 1,000 mcg/kg IV over 1 minute, then 50 mcg/kg/minute continuous IV infusion, initially. Repeat bolus and titrate by 50 mcg/kg/minute until goal blood pressure is attained. Max: 200 mcg/kg/minute.
      • Labetalol c265
        • Bolus dosing
          • Labetalol Hydrochloride Solution for injection; Adults: 10 to 20 mg IV, then 20 to 80 mg IV every 10 to 30 minutes until goal blood pressure is attained. Max cumulative dose: 300 mg.
        • Continuous infusion
          • Labetalol Hydrochloride Solution for injection; Adults: 1 to 8 mg/minute continuous IV infusion until goal blood pressure is attained then transition to oral labetalol. Usual total dose: 50 to 200 mg. Max cumulative dose: 300 mg.
    • Nitrates
      • Nitroglycerin c266
        • Nitroglycerin Solution for injection; Adults: Initially, 5 mcg/minute continuous IV infusion. Titrate by 5 mcg/minute IV every 3 to 5 minutes until clinical response, or to a dose of 20 mcg/minute IV. May further increase dosage in increments of 10 mcg/minute, and if desired effect still not achieved, may increase in increments of 20 mcg/minute. Max titration: 20 mcg/minute every 3 to 5 minutes. Usual dose: 5 to 100 mcg/minute. Max: 200 mcg/minute.
    • Vasodilators
      • Fenoldopam c267
        • Fenoldopam Mesylate Solution for injection; Adults: 0.01 to 0.3 mcg/kg/minute continuous IV infusion initially. Titrate by 0.05 to 0.1 mcg/kg/minute every 15 minutes until goal blood pressure is attained. Max: 1.6 mcg/kg/minute. Max: duration: 48 hours.
      • Nitroprusside c268
        • Sodium Nitroprusside Solution for injection; Adults: 0.3 to 0.5 mcg/kg/minute continuous IV infusion, initially. Titrate by 0.5 mcg/kg/minute every 5 minutes until desired effect or blood pressure cannot be further reduced without compromising organ perfusion. Max: 10 mcg/kg/minute for 10 minutes.
        • Cyanide ions, a by-product of nitroprusside metabolism, can build up to toxic levels during nitroprusside therapy. Nitroprusside infusions of 10 mcg/kg/minute are considered maximal and this rate should not be continued for more than 10 minutes. To maintain the steady-state thiocyanate concentration below 1 mmol/L, the rate of a prolonged infusion (ie, greater than 72 hours) should not exceed 3 mcg/kg/minute (in normal patients), and 1 mcg/kg/minute in anuric patients
    • α-Blocker
      • Phentolamine c269
        • Phentolamine Mesylate Solution for injection; Adults: 5 to 15 mg IV bolus.
    • ACE inhibitor
      • Enalaprilat c270
        • Enalaprilat Solution for injection; Adults: Initially, 0.625 to 1.25 mg IV every 6 hours. Dosage may be titrated up to 5 mg IV every 6 hours.

Nondrug and supportive care

Lifestyle modifications are recommended for patients with elevated blood pressure and hypertension r3r25r57c271

  • Target weight loss based on body mass index goal of ideal body weight; aim for at least a 1-kg reduction in body weight r1c272c273
  • Participate in aerobic activity at least 90 to 150 minutes per week r1c274
  • Follow the DASH (Dietary Approaches to Stop Hypertension) eating plan, including fruits, vegetables, and low-fat dairy, with reduced fat intake r1c275
  • Sodium intake c276
    • Optimal goal is less than 1500 mg/day; aim for at least a 1000 mg/day reduction in most adults r1
    • General population-based advice is to reduce daily sodium intake to 2300 mg or less (current average daily intake in the United States is 3393 mg; ranging from about 2000 to 5000 mg/day) r58
      • Evidence confirms significant reduction in systolic blood pressure with salt restriction r59
      • Modest reduction in sodium intake decreases cardiovascular and stroke risk by 20% r59
      • Low potassium intake may worsen the effect of salt on blood pressure
    • Because salt sensitivity is on an individual continuum (30%-50% of patients are considered salt sensitive), individual effect of salt reduction may vary r60
      • Salt sensitivity is common in Black or elderly people and people with low-renin hypertension, comorbid obesity, or metabolic syndrome
      • Low intake of potassium and calcium increases the salt sensitivity of blood pressure
      • Low sodium intake may increase the risk of cardiovascular events in some patients, including those with:
        • Congestive heart failure treated with high doses of diuretics
        • Diabetes
  • Limit alcohol intake to 2 drinks per day or fewer for males (total 30 mL ethanol) and 1 drink per day or fewer for females (total 15 mL ethanol) r1r25c277
    • 1 drink is equal to 355 mL (12 oz) of beer, 148 mL (5 oz) of wine, and 44 mL (1.5 oz) of 80-proof liquor r23
  • Stop smoking to decrease overall cardiovascular risk r1d5
Procedures
c278

Comorbidities

  • Diabetes c279
    • Approximately 68% of patients with diabetes have a systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher or are taking medication for hypertension r61
    • If patient is started on an ACE inhibitor or angiotensin receptor blocker, monitor for azotemia and hyperkalemia
    • Thiazide diuretics may cause hyperglycemia; consider increased monitoring of glucose levels
  • Chronic kidney disease c280
    • Hypertension is most common cause of chronic kidney disease; conversely, chronic kidney disease can lead to or exacerbate hypertension r35
    • Target systolic blood pressure of less than 120 mm Hg is recommended r35
    • ACE inhibitor or angiotensin receptor blocker recommended for patients with high blood pressure, chronic kidney disease, and moderate or severely increased albuminuria, with or without diabetes r35
    • Treat adult kidney transplant recipients with a dihydropyridine calcium channel blocker or angiotensin receptor blocker to a target blood pressure of less than 130 mm Hg r35
    • Sodium intake should be less than 2 g/day (equivalent to 5 g of sodium chloride) for most patients r35
    • Progressive azotemia and hyperkalemia are possible; periodic laboratory monitoring is recommended

Special populations

  • Non-Hispanic Black patients
    • Risk of hypertension-related kidney failure is markedly elevated; ACE inhibitors or angiotensin receptor blockers are renoprotective but are less effective than thiazide diuretics and calcium channel blockers for lowering blood pressure r2
  • Children
    • Primary hypertension occurs mainly in children older than 13 years and is associated with family history and obesity; secondary hypertension is more common in younger children and may be caused by genetic conditions or renal, endocrine, or cardiovascular disorders r62
    • Hypertension in childhood and adolescence is associated with hypertension and cardiovascular disease in adulthood r63r64r65
    • Diagnose based on blood pressure compared with blood pressure percentile norms for age, sex, and height r25
    • Hypertension is diagnosed if systolic or diastolic blood pressure is at the 95th percentile or greater for age, sex, and height on at least 3 separate occasions, or if systolic or diastolic blood pressure is greater than 120/80 mm Hg in children age 6 to 11 years, or greater than 130/85 mm Hg in children age 12 to 17 years r25
      • Blood pressure is defined as "high normal' if systolic or diastolic blood pressure is in 90th to 95th percentile for age, sex, and height or 120/80 to 139/89 mm Hg in adolescents aged 13 years or older confirmed on 3 separate visits r66
    • Evaluate children with hypertension with serum biochemistry, lipids, glucose, urinalysis, renal ultrasound, echocardiogram, and retinal examination r25
    • Initial treatment of high normal blood pressure is aimed at lifestyle modifications of altering diet, increasing exercise, and controlling weight
    • Pharmacological therapy should be commenced in cases of symptomatic hypertension; hypertension with end-organ damage; blood pressure greater than 95th percentile plus 12 mm Hg; blood pressure in the 90th percentile or greater associated with diabetes mellitus, chronic kidney disease, or heart failure; or persistent hypertension despite a 6-month or longer trial of nonpharmacologic therapy r25
    • Goal blood pressure levels are those that are consistently below 90th percentile for age, sex, and height or below 120/80 mm Hg in adolescents aged 13 years or older r66
    • Initial pharmacologic treatment consists of monotherapy with either an ACE inhibitor, angiotensin receptor blocker, or calcium channel blocker; refer to a pediatric hypertension specialist if not controlled with monotherapy r25
  • Pregnant patients
    • Hypertension in pregnancy includes the following: r39
      • Chronic (preexisting) hypertension
        • Blood pressure higher than 140/90 mm Hg that predates the pregnancy or begins before the 20th week of gestation r67
      • Gestational hypertension
        • Blood pressure higher than 140/90 mm Hg with onset after 20 weeks of gestation in a previously normotensive woman: lasts less than 6 weeks postpartum
        • Not accompanied by proteinuria or severe features of preeclampsia (thrombocytopenia, renal insufficiency, elevated liver transaminases, pulmonary edema, cerebral or visual symptoms)
      • Preexisting hypertension with superimposed preeclampsia (gestational hypertension plus proteinuria)
      • Preeclampsia and eclampsia d6
        • Preeclampsia is defined by the presence of hypertension with proteinuria and/or new onset of signs of end-organ damage (known as severe features of preeclampsia) with onset after the 20th week of pregnancy r67
          • Severe features of preeclampsia include thrombocytopenia, renal insufficiency, elevated liver transaminases, pulmonary edema, cerebral or visual symptoms
        • Eclampsia presents as generalized, tonic-clonic seizures in patient with preeclampsia
      • Hemolysis, elevated liver enzymes, and low platelet count (HELLP syndrome) may be accompanied by severe hypertension d7
    • Maternal risks of hypertension in pregnancy include placental abruption, stroke, multiple organ failure, and disseminated vascular coagulation r39
    • Fetal risks include intrauterine growth restriction, preterm birth, intrauterine death r39
      • Increased risk of congenital defects is seen in both treated and untreated hypertension, but risk is greater for babies of treated mothers r68
    • Thresholds for pharmacologic treatment vary
      • American College of Obstetricians and Gynecologists does not recommend pharmacologic therapy for mild chronic hypertension in pregnancy (greater than 140/90 mm Hg and less than 160/110 mm Hg) and recommends considering discontinuing medication during the first trimester in women with mild hypertension who become pregnant
        • Pharmacologic therapy is recommended for pregnant patients with severe hypertension (systolic blood pressure 160 mm Hg or greater, or diastolic blood pressure 105-110 mm Hg or greater); lower threshold for treatment (150/100 mm Hg or greater) in patients with end-organ involvement r69
      • The International Society of Hypertension recommends pharmacologic treatment at blood pressure greater than 150/95 mm Hg in all pregnant patients and at blood pressure greater than 140/90 mm Hg in patients with gestational hypertension, preexisting hypertension with superimposed gestational hypertension, and hypertension with subclinical hypertension-mediated organ damage any time during pregnancy r39
      • Hypertension Canada guidelines recommend initiating antihypertensive therapy at average systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher in pregnant patients with chronic hypertension, gestational hypertension, or preeclampsia r25
    • Initial therapy consists of monotherapy with either oral labetalol, methyldopa, long-acting nifedipine, or other β-blockers r39
      • Second-line agents include clonidine, hydralazine, and thiazide diuretics
      • ACE inhibitors and angiotensin receptor blockers are contraindicated during pregnancy owing to teratogenicity and neonatal renal agenesis r25
      • Treatment with antihypertensives decreases risk of progression to severe hypertension, thrombocytopenia, and elevated liver enzymes but does not decrease risk of preeclampsia or other serious maternal complications or fetal or neonatal death or morbidity r70r71
    • Prescribe patients with chronic hypertension a daily low-dose aspirin at 12 to 28 weeks of gestation (preferably before 16 weeks) and to continue until delivery r69
    • Patients with severe hypertension (systolic at least 160-170 mm Hg and/or diastolic higher than 105-110 mm Hg) require immediate hospitalization and urgent antihypertensive therapy; considered an obstetrical emergency
      • IV labetalol and hydralazine are first line medications for the management of acute-onset, severe hypertension in pregnant patients; immediate release oral nifedipine is an alternative if IV access is not established r67
      • Magnesium sulfate is indicated for seizure prophylaxis in women with acute-onset severe hypertension during pregnancy (regardless of whether it is gestational hypertension or preeclampsia with severe features or eclampsia) r72
      • Delivery, after maternal stabilization, is recommended for patients who have a diagnosis of gestational hypertension or preeclampsia with severe features at or beyond 34 weeks of gestation r72
      • Delivery at or beyond 37 weeks of gestation is recommended in patients with gestational hypertension or preeclampsia without severe features r72

Monitoring

  • Treat adults with an elevated blood pressure or stage 1 hypertension who have an estimated 10-year atherosclerotic cardiovascular disease risk less than 10% with nonpharmacologic therapy and evaluate blood pressure again within 3 to 6 months r1c281
  • Initially treat adults with stage 1 hypertension who have an estimated 10-year atherosclerotic cardiovascular disease risk of 10% or higher with a combination of nonpharmacologic and antihypertensive drug therapy and evaluate blood pressure again in 1 month r1c282
  • Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within 1 month of the initial diagnosis, have a combination of nonpharmacologic and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have blood pressure evaluated again in 1 month r1c283c284
  • For adults with a very high average blood pressure (eg, systolic 180 mm Hg or greater, diastolic 110 mm Hg or greater), evaluation followed by prompt antihypertensive drug treatment is recommended r1c285
  • Adults initiating a new or adjusted drug regimen for hypertension should have a follow-up evaluation of adherence and response to treatment at monthly intervals until control is achieved r1c286c287
  • For adults with blood pressure within reference range, repeating evaluation every year is reasonable r1c288
  • Self-measured blood pressure monitoring is a validated approach for out-of-office blood pressure measurement and may be associated with improved blood pressure control r73
  • Laboratory monitoring
    • For all patients, monitor serum potassium and creatinine levels at least once or twice yearly r23c289c290
    • For patients taking angiotensin receptor blockers or ACE inhibitors: r74
      • Measure creatinine and potassium levels within 1 to 2 weeks of beginning therapy and 1 to 2 weeks after each dose increase; measure within 7 days if patient is at higher risk for hyperkalemia or acute kidney injury c291c292
      • If creatinine level increases by 30% over baseline after starting, discontinue drug and recheck levels in 3 days
        • If cause is temporary (eg, dehydration), patient may resume drug once resolved
        • If no cause is identified, consider renal artery stenosis or drug-induced kidney injury
      • Potassium level greater than 5.6 mEq/L generally necessitates dose reduction or discontinuation
    • For patients taking verapamil:
      • In patients taking concomitant digoxin, monitor digoxin level r75c293

Complications and Prognosis

Complications

  • Cardiovascular disease
    • Chronic hypertension is a major risk factor for cardiovascular disease and mortality, with no evidence of a threshold effect down to 115/75 mm Hg r76
    • Coronary artery disease c294
      • Diastolic blood pressure elevation is the primary predictor of risk in persons younger than 50 years r76
      • Systolic blood pressure is a more important predictor in persons older than 60 years r76
      • In adults aged 40 to 69 years, each 20-mm Hg increase in systolic blood pressure (or each 10-mm Hg increase in diastolic pressure) doubles the risk of a fatal coronary event r77
    • Stroke (including ischemic and hemorrhagic stroke) c295c296c297
      • In adults aged 40 to 69 years, each 20-mm Hg increase in systolic blood pressure (or each 10-mm Hg increase in diastolic pressure) more than doubles the risk of stroke r77
      • Similar hazard ratios for mortality for cerebral hemorrhage and ischemic stroke r76
    • Left ventricular hypertrophy and heart failure c298c299
    • Increased risk of atrial fibrillation c300
  • Hypertension is the most common cause of chronic kidney disease; conversely, chronic kidney disease can lead to or exacerbate hypertension r35c301
  • Chronic hypertensive retinopathy may cause significant vision loss over time c302
  • End-organ damage or dysfunction may also occur acutely (during hypertensive emergency), including:
    • Hypertensive encephalopathy with cerebral hyperperfusion and cerebral edema c303c304
    • Stroke, either ischemic or hemorrhagic c305c306
    • Acute coronary syndrome c307
    • Pulmonary edema caused by diastolic dysfunction or acute mitral regurgitation with left ventricular failure c308
    • Aortic dissection c309
    • Acute kidney injury c310
      • HELLP syndrome (ie, hemolysis, elevated liver enzymes, and low platelet count) may occur with very high blood pressure and microangiopathic hemolytic anemia associated with kidney injury c311c312c313
    • Acute hypertensive retinopathy with disk edema, choroidal infarction, and retinopathy c314

Prognosis

  • Essential hypertension persists for life; blood pressure tends to increase with age
  • Nearly all patients will need to continue medication throughout life
  • Untreated hypertension, especially with other cardiovascular risk factors, may lead to stroke, coronary artery disease, and heart failure

Screening and Prevention

Screening

At-risk populations

  • The US Preventive Services Task Force recommends screening for high blood pressure in all adults 18 years and older r78c315c316
    • Adults age 40 years or older and persons at increased risk for high blood pressure: screen annually
    • Adults age 18 to 39 years with no increased risk for hypertension and with prior normal blood pressure readings: screen every 3 to 5 years
  • The US Preventive Services Task Force does not recommend screening for high blood pressure in asymptomatic children and adolescents age 3 to 18 years r62
    • However, American Academy of Pediatrics, European Society of Hypertension, and Canadian hypertension guidelines do recommend regular screening blood pressure measurement in children and adolescents r25r66r79

Screening tests

  • Office measurement of blood pressure with a manual or automated sphygmomanometer r78c317
    • Use the mean of 2 measurements taken while the patient is seated
    • Multiple measurements over time have better positive predictive value than measurement on a single day
    • Ambulatory and self-measured home blood pressure monitoring can be used to confirm a diagnosis of hypertension after initial screening r73
    • Other indications for self-measured blood pressure monitoring include the diagnosing of white coat hypertension and masked hypertension and detection of morning hypertension; validated blood pressure monitoring devices that use the oscillometric method are preferred r73

Prevention

  • Risk of developing essential hypertension may be decreased by:
    • Maintenance of body weight within reference range c318
    • Regular exercise c319
    • Low-sodium diet c320
  • Calcium intake more than 1000 mg/day slightly reduces both systolic and diastolic blood pressure in normotensive people, but this finding requires confirmation r80c321
Whelton PK 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. 71(6):e13-115, 201829133356Winter KH et al: Hypertension. Prim Care. 40(1):179-94, 201323402468Arnett DK et al: 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 74(10):e177-232, 201930894318Adebayo O et al: Hypertensive emergencies in the emergency department. Emerg Med Clin North Am. 33(3):539-51, 201526226865Wolf SJ et al: Clinical policy: critical issues in the evaluation and management of adult patients in the emergency department with asymptomatic elevated blood pressure. Ann Emerg Med. 62(1):59-68, 201323842053McEvoy JW et al: Association of isolated diastolic hypertension as defined by the 2017 ACC/AHA blood pressure guideline with incident cardiovascular outcomes. JAMA. 323(4):329-38, 202031990314Carey RM et al: Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension. 72(5):e53-90, 201830354828Johnson W et al: Hypertension crisis in the emergency department. Cardiol Clin. 30(4):533-43, 201223102030van den Born BH et al: ESC Council on hypertension position document on the management of hypertensive emergencies. Eur Heart J Cardiovasc Pharmacother. 5(1):37-46, 201930165588Cuspidi C et al: White-coat hypertension, as defined by ambulatory blood pressure monitoring, and subclinical cardiac organ damage: a meta-analysis. J Hypertens. 33(1):24-32, 201525380162Mancia G et al: Long-term prognostic value of white coat hypertension: an insight from diagnostic use of both ambulatory and home blood pressure measurements. Hypertension. 62(1):168-74, 201323716584Muntner P et al: Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension. 73(5):e35-66, 201930827125Rachitskaya AV: Hypertensive retinopathy. In: Yanoff M et al, eds: Ophthalmology. 5th ed. Elsevier; 2019:516-9.e1https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323528191002966?indexOverride=GLOBAL3-s2.0-B9780323528191002966National Institute for Health and Care Excellence: Hypertension in Adults: Diagnosis and Management. NICE guideline NG136. NICE website. Published August 28, 2019. Accessed June 8, 2021. https://www.nice.org.uk/guidance/ng136https://www.nice.org.uk/guidance/ng136Hagan PG et al: The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 283(7):897-903, 200010685714Therrien J et al: Congenital heart disease in adults. In: Goldman L et al, eds: Goldman-Cecil Medicine. 26th ed. Elsevier; 2020:357-65.e4https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323532662000618?indexOverride=GLOBAL3-s2.0-B9780323532662000618Nguyen L et al: Coarctation of the aorta: strategies for improving outcomes. Cardiol Clin. 33(4):521-30, vii, 201526471817Nduka CU et al: Evidence of increased blood pressure and hypertension risk among people living with HIV on antiretroviral therapy: a systematic review with meta-analysis. J Hum Hypertens. 30(6):355-62, 201626446389Virani SS et al: Heart disease and stroke statistics--2021 update: a report from the American Heart Association. Circulation. 143(8):e254-743, 202133501848Sandberg K et al: Sex differences in primary hypertension. Biol Sex Differ. 3(1):7, 201222417477Husain K et al: Alcohol-induced hypertension: mechanism and prevention. World J Cardiol. 6(5):245-52, 201424891935Huang M et al: Effects of ambient air pollution on blood pressure among children and adolescents: a systematic review and meta-analysis. J Am Heart Assoc. 10(10):e017734, 202133942625Chobanian AV et al: Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 42(6):1206-52, 200314656957Piper MA et al: Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the US Preventive Services Task Force. Ann Intern Med. 162(3):192-204, 201525531400Rabi DM et al: Hypertension Canada's 2020 comprehensive guidelines for the prevention, diagnosis, risk assessment, and treatment of hypertension in adults and children. Can J Cardiol. 36(5):596-624, 202032389335Williams B et al: 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 39(33):3021-104, 201830165516American College of Radiology: ACR Appropriateness Criteria: Routine Chest Radiography. ACR website. Reviewed 2015. Accessed June 8, 2021. https://acsearch.acr.org/docs/69451/Narrative/https://acsearch.acr.org/docs/69451/Narrative/Gorelick PB et al: Blood pressure management in stroke. Hypertension. 76(6):1688-95, 202033040620Powers WJ et al: Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 50(12):e344-418, 201931662037Ahmed N et al: Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Stroke. 40(7):2442-9, 200919461022Kleindorfer DO et al: 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline from the American Heart Association/American Stroke Association. Stroke. STR0000000000000375, 202134024117Qaseem A et al: 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. 166(6):430-7, 201728135725American Diabetes Association: 10. Cardiovascular disease and risk management: Standards of Medical Care in Diabetes--2021. Diabetes Care. 44 (suppl 1):S125-50, 202133298421Handelsman Y et al: American Association of Clinical Endocrinologists and American College of Endocrinology--clinical practice guidelines for developing a diabetes mellitus comprehensive care plan--2015. Endocr Pract. 21 suppl 1:1-87, 201525869408Kidney Disease: KDIGO 2021 Clinical Practice Guideline on the Management of Blood Pressure in Chronic Kidney Disease. KDIGO website. Published March 2021. Accessed June 8, 2021. https://kdigo.org/guidelines/blood-pressure-in-ckd/https://kdigo.org/guidelines/blood-pressure-in-ckd/Musini VM et al: Pharmacotherapy for hypertension in adults 60 years or older. Cochrane Database Syst Rev. 6:CD000028, 201931167038McCord J et al: Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. 117(14):1897-907, 200818347214Jones DW et al: Management of stage 1 hypertension in adults with a low 10-year risk for cardiovascular disease: filling a guidance gap: a scientific statement from the American Heart Association. Hypertension. 77(6):e58-67, 202133910363Unger T et al: 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension. 75(6):1334-57, 202032370572Wiysonge CS et al: Beta-blockers for hypertension. Cochrane Database Syst Rev. 1:CD002003, 201728107561Xue H et al: First-line drugs inhibiting the renin angiotensin system versus other first-line antihypertensive drug classes for hypertension. Cochrane Database Syst Rev. 1:CD008170, 201525577154Wright JM et al: First-line drugs for hypertension. Cochrane Database Syst Rev. 4:CD001841, 201829667175Tafur-Soto JD et al: Renal artery stenosis. Cardiol Clin. 33(1):59-73, 201525439331Jenks S et al: Balloon angioplasty, with and without stenting, versus medical therapy for hypertensive patients with renal artery stenosis. Cochrane Database Syst Rev. 12:CD002944, 201425478936Fleseriu M: Medical treatment of Cushing disease: new targets, new hope. Endocrinol Metab Clin North Am. 44(1):51-70, 201525732642Sharma ST et al: Cushing's syndrome: all variants, detection, and treatment. Endocrinol Metab Clin North Am. 40(2):379-91, viii-ix, 201121565673Zuber SM et al: Hypertension in pheochromocytoma: characteristics and treatment. Endocrinol Metab Clin North Am. 40(2):295-311, vii, 201121565668Harvey AM: Hyperaldosteronism: diagnosis, lateralization, and treatment. Surg Clin North Am. 94(3):643-56, 201424857581Devereaux D et al: Hyperthyroidism and thyrotoxicosis. Emerg Med Clin North Am. 32(2):277-92, 201424766932Beck L et al: KDOQI US commentary on the 2012 KDIGO clinical practice guideline for glomerulonephritis. Am J Kidney Dis. 62(3):403-41, 201323871408Stevens PE et al: Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 158(11):825-30, 201323732715Kidney Disease: KDIGO Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. KDIGO website. Published January 2013. Accessed June 8, 2021. https://kdigo.org/guidelines/ckd-evaluation-and-management/https://kdigo.org/guidelines/ckd-evaluation-and-management/Ong JC et al: Insomnia and obstructive sleep apnea. Sleep Med Clin. 8(3):389-98, 201324015117Musini VM et al: Blood pressure-lowering efficacy of monotherapy with thiazide diuretics for primary hypertension. Cochrane Database Syst Rev. 5:CD003824, 201424869750Tataru AP et al: A systematic review of add-on pharmacologic therapy in the treatment of resistant hypertension. Am J Cardiovasc Drugs. 17(4):311-8, 201728349274Tam TS et al: Eplerenone for hypertension. Cochrane Database Syst Rev. 2:CD008996, 201728245343US Preventive Services Task Force et al: Behavioral counseling interventions to promote a healthy diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: US Preventive Services Task Force recommendation statement. JAMA. 324(20):2069-75, 202033231670US Department of Health and Human Services et al: 2020-2025 Dietary Guidelines for Americans. Health.gov website. Published December 2020. Accessed June 8, 2021. https://health.gov/our-work/food-nutrition/current-dietary-guidelineshttps://health.gov/our-work/food-nutrition/current-dietary-guidelinesHe FJ et al: Effect of longer-term modest salt reduction on blood pressure. Cochrane Database Syst Rev. 4:CD004937, 201323633321Kotchen TA et al: Salt in health and disease--a delicate balance. N Engl J Med. 368(26):2531-2, 201323802533CDC: National Diabetes Statistics Report, 2020. CDC website. Reviewed August 28, 2020. Accessed June 8, 2021. https://www.cdc.gov/diabetes/data/statistics-report/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fdiabetes%2Fdata%2Fstatistics%2Fstatistics-report.htmlhttps://www.cdc.gov/diabetes/data/statistics-report/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fdiabetes%2Fdata%2Fstatistics%2Fstatistics-report.htmlUS Preventive Services Task Force et al: Screening for high blood pressure in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 324(18):1878-83, 202033170248Hamer M et al: Blood pressure trajectories in youth and hypertension risk in adulthood: the 1970 British Cohort Study. Am J Epidemiol. 189(2):162-3, 202031742589Yang L et al: Elevated blood pressure in childhood or adolescence and cardiovascular outcomes in adulthood: a systematic review. Hypertension. 75(4):948-55, 202032114851Yano Y et al: Association of blood pressure classification in young adults using the 2017 American College of Cardiology/American Heart Association blood pressure guideline with cardiovascular events later in life. JAMA. 320(17):1774-82, 201830398601Flynn JT et al: Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 140(3):e20171904, 2017. Published corrections appear in Pediatrics. 140(6):e20173035, 2017 and Pediatrics. 142(3):e20181739, 201728827377Olson-Chen C et al: Hypertensive emergencies in pregnancy. Crit Care Clin. 32(1):29-41, 201626600442Ramakrishnan A et al: Maternal hypertension during pregnancy and the risk of congenital heart defects in offspring: a systematic review and meta-analysis. Pediatr Cardiol. 36(7):1442-51, 201525951814ACOG Practice Bulletin No. 203: Chronic hypertension in pregnancy. Obstet Gynecol. 133(1):e26-50, 201930575676Magee LA et al: Toward personalized management of chronic hypertension in pregnancy. Am J Obstet Gynecol. ePub, 202032687817Abalos E et al: Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 10:CD002252, 201830277556Gestational hypertension and preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 135(6):e237-60, 202032443079Shimbo D et al: Self-measured blood pressure monitoring at home: a joint policy statement from the American Heart Association and American Medical Association. Circulation. 142(4):e42-63, 202032567342Waked K et al: Managing hypertension in primary care. Can Fam Physician. 65(10):725-9, 201931604742Gheorghiade M et al: Digoxin in the management of cardiovascular disorders. Circulation. 109(24):2959-64, 200415210613Rosendorff C 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. J Am Soc Hypertens. 9(6):453-98, 201525840695Lewington S et al: Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 360(9349):1903-13, 200212493255US Preventive Services Task Force: Final Recommendation Statement: Hypertension in Adults: Screening. USPSTF website. Published April 27, 2021. Accessed June 8, 2021. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screeninghttps://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screeningLurbe E et al: 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 34(10):1887-920, 201627467768Cormick G et al: Calcium supplementation for prevention of primary hypertension. Cochrane Database Syst Rev. 6:CD010037, 201526126003
;