Chapter 13

• Prehypertension: systolic pressure of 120–139 mm Hg or diastolic pressure of 80–90 mm Hg.
• Stage 1 hypertension: systolic pressure of 140–159 mm Hg or diastolic pressure of 90–99 mm Hg.
• Stage 2 hypertension: systolic pressure of ≥ 160 mm Hg or diastolic pressure of ≥ 100 mm Hg.
• Measure on three separate occasions.
• In diabetic patients, diastolic pressure > 80 mm Hg, systolic pressure > 130 mm Hg, or both, on three separate occasions.

Hypertension is a major modifiable risk factor for cardiovascular disease that can, if untreated, result in serious morbidity and mortality from cardiac, cerebrovascular, vascular, and renal disease. In excess of 62 million persons in the United States are estimated to have hypertension, and only about 70% of these individuals are aware of their diagnosis. Of those, only a third are at their therapeutic goal. The potential for death and disability is therefore quite high and represents a serious public health issue. Once the diagnosis of hypertension is made and therapy instituted, elevated blood pressure can be lowered, reducing the risk of cardiovascular disease in most patients. Major antihypertensive trials, in large populations, have conclusively demonstrated that there is a direct continuous relationship between the level of blood pressure and cardiovascular morbidity and mortality. These studies have shown that treating all levels of hypertension significantly decreases fatal and nonfatal stroke, coronary events, heart failure, and chronic kidney disease and renal failure. The wide array of antihypertensive agents is very effective in reducing blood pressure. Despite similar blood pressure and overall mortality reductions, the reductions in incidence of stroke, coronary ischemic events, heart failure, and renal failure are not the same for all classes of antihypertensive agents. The reasons for these differences have not been totally explained and are the topic of much speculation.

A growing body of direct and inferential evidence suggests that reduction of blood pressure should not be the only goal of antihypertensive therapy. Therapy should also be directed toward controlling all of the patient’s modifiable cardiovascular risk factors, including dyslipidemia, smoking, obesity, physical inactivity, microalbuminuria, and diabetes mellitus.

Until recently, high blood pressure was synonymous with hypertension; now, however, data suggest that there is considerably more to hypertension than increased blood pressure. Several metabolic and functional abnormalities have even been observed in the children of hypertensive patients prior to blood pressure elevation that are similar to, but of a lesser magnitude than, those found in their parents. Hypertension is also associated with insulin resistance and glucose intolerance. Insulin levels are consistently higher in hypertensive patients than in normotensive persons. Hyperinsulinemia is worsened by thiazide diuretics, especially in the presence of β-blocker therapy. Hyperinsulinemia produces a proliferation of vascular smooth muscle and fibrous tissue and adversely affects the serum lipid profile.

Renin and angiotensin levels are also important factors in determining both the response to therapy and the prognosis. Hypertensive patients with high renin levels have a greater incidence of myocardial infarction ...

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