Hypertension, Chronic

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

Demographics

• 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 ...