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A 49-year-old African American man reports to the clinic after being told his blood pressure was “high” during a screening at a community health fair. His body mass index was calculated as 29. He has “prediabetes” from a previous examination with a current hemoglobin A1c of 6.4%. His total cholesterol is 150 mg/dL with a high-density lipoprotein cholesterol level of 30 mg/dL. His resting blood pressure was 168/96 mm Hg on the first assessment with 172/98 mm Hg 20 minutes later in the clinic. He has a family history of high blood pressure, with both parents and his sister and brother currently being treated for hypertension. He reports he tries to limit his salt intake and walks on his job as a sales associate at a hardware store. His blood pressure values are consistent with a diagnosis of high blood pressure with the questions:

  • Should there be any intervention to reduce the blood pressure?

  • How should the blood pressure be reduced and by what agent (s)?

  • How low should the blood pressure be reduced?

For the caregivers at the clinic to determine the most appropriate treatment plan for this patient, it is essential to answer these clinical questions with the highest quality evidence available.


The three questions posed in the Health Scenario are fundamental to the optimal management of patients with high blood pressure. Hypertension typically is defined as a systolic blood pressure of 140 mm Hg or greater or a diastolic blood pressure of 90 mm Hg or greater.

Hypertension is one of the most common medical conditions among adults worldwide. For example, it is estimated that one in every four adults in the United States has high blood pressure. The prevalence of hypertension rises dramatically with age—among young adults age 35 to 44 years, only about one in seven persons has high blood pressure, but among adults age 65 years or older, more than half of all persons have this condition. Overall, men tend to have a slightly higher prevalence of high blood pressure than do women. African Americans have a higher risk of developing hypertension than do either non-Hispanic whites or Mexican Americans.

In addition to these demographic patterns, a number of risk factors have been identified for high blood pressure. Physical inactivity is one such predisposing factor, as are obesity, excessive alcohol consumption, and tobacco use. A diet too high in sodium content and too low in potassium content also is associated with risk of high blood pressure in some, if not all, populations. A positive family history also increases the risk of hypertension, although the extent to which this pattern reflects genetic predisposition, shared environmental exposures, or a mixture of both is unknown.

The most common form of high blood pressure, accounting for 90% or more of all occurrences, is ...

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