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For further information, see CMDT Part 11: Systemic Hypertension

Key Features

Essentials of Diagnosis

  • For conventional office-based blood pressure (BP) measurement, the American College of Cardiology and American Heart Association (ACC/AHA) suggest that

    • Normal BP be defined as < 120/80 mm Hg

    • Elevated BP, as 120–129/< 80 mm Hg

    • Stage 1 hypertension, as 130–139/80–89 mm Hg

    • Stage 2 hypertension, as ≥ 140/ ≥ 90 mm Hg

  • Usually asymptomatic

  • Severe hypertension: occipital headache at awakening, blurry vision

General Considerations

  • Mild to moderate hypertension nearly always asymptomatic

  • Severe hypertension usually due to

    • Parenchymal renal disease

    • Endocrine abnormalities

    • Renal artery stenosis

    • Drug use

    • Abrupt cessation of antihypertensive medications

  • Resistant hypertension is defined as failure to reach blood pressure (BP) control in patients adherent to full doses of a three-drug regimen (including a diuretic)

  • Table 11–14 summarizes reasons for failure to reach BP control

Table 11–14.Causes of resistant hypertension.


  • Hypertension is uncontrolled in about half of affected people

  • 64% are aware of their condition

  • 60% of those treated have BP under control

  • Incidence of hypertension increases with age

  • More men than women in early life

  • More women than men later in life

  • More common in Black Americans (up to 25–30%)

Clinical Findings

Symptoms and Signs

  • Usually asymptomatic

  • Headaches are most frequent symptom but are nonspecific

  • Elevated BP

  • Loud A2 on cardiac examination

  • Retinal arteriolar narrowing with "silver-wiring," arteriovenous nicking

  • Flame-shaped hemorrhages

  • Laboratory findings usually normal

Differential Diagnosis

Primary (essential) hypertension

  • "White-coat" hypertension

  • BP cuff too small

Secondary hypertension

  • Adrenal

    • Primary hyperaldosteronism

    • Cushing syndrome

    • Pheochromocytoma

  • Renal

    • Chronic kidney disease

    • Renal artery stenosis (atherosclerotic or fibromuscular dysplasia)

  • Other

    • Oral contraceptives

    • Alcohol

    • Nonsteroidal anti-inflammatory drugs

    • Pregnancy associated

    • Hypercalcemia

    • Hyperthyroidism

    • Obstructive sleep apnea

    • Obesity

    • Coarctation of the aorta

    • Acromegaly

    • Increased intracranial pressure

    • Cocaine or amphetamine use

    • Over-the-counter products (eg, dietary supplements containing yohimbine, an α2-antagonist, can produce severe rebound hypertension in patients taking ...

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