Hypertension: Who should be treated?
- Johannes FE Mann, MD
Johannes FE Mann, MD
- Professor of Medicine
- Friedrich Alexander University of Erlangen-Nürnberg
- International Scholar, Population Health Research Institute, McMaster University, Canada
- Karl F Hilgers, MD
Karl F Hilgers, MD
- Professor of Internal Medicine and Hypertension Research
- Friedrich-Alexander University, Erlangen-Nuremberg
- Vice Chair, Department of Nephrology and Hypertension
- Erlangen University Hospital
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
Treatment of hypertension generally begins with nonpharmacologic therapy, including moderate dietary sodium restriction, weight reduction in the obese, avoidance of excess alcohol intake, and regular aerobic exercise (table 1) [1,2]. Institution of these modalities involves little or no risk and they all may be beneficial from a general health viewpoint even in normotensive subjects. (See "Diet in the treatment and prevention of hypertension".)
Drug therapy, in comparison, may be expensive and is often associated with side effects, some of which (hypokalemia and hyperlipidemia) may actually increase coronary risk. (See "Causes of hypokalemia in adults", section on 'Diuretics' and "Antihypertensive drugs and lipids".)
Thus, there should be clear evidence of likely benefit before antihypertensive drugs are begun. Such evidence is available for most degrees of hypertension [1,3,4].
The evidence that treating different degrees of hypertension is beneficial will be reviewed here, with recommendations for who should be treated. An overview of the treatment of hypertension, the choice of antihypertensive drug as initial therapy, and goal blood pressure are discussed separately. (See "Overview of hypertension in adults", section on 'Treatment' and "Choice of drug therapy in primary (essential) hypertension" and "What is goal blood pressure in the treatment of hypertension?".)
Major societies have published definitions of hypertension [5-7]. In general, hypertension was defined as a blood pressure ≥140/≥90 mmHg. However, subsequent trials have identified groups of patients at higher risk in whom goal blood pressures below this value may be associated with improved outcomes. (See 'Goal blood pressure' below.)
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- Strandberg TE, Salomaa VV, Vanhanen HT, et al. Isolated diastolic hypertension, pulse pressure, and mean arterial pressure as predictors of mortality during a follow-up of up to 32 years. J Hypertens 2002; 20:399.
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- Franklin SS, Jacobs MJ, Wong ND, et al. Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives: analysis based on National Health and Nutrition Examination Survey (NHANES) III. Hypertension 2001; 37:869.
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- Kannel WB, Higgins M. Smoking and hypertension as predictors of cardiovascular risk in population studies. J Hypertens Suppl 1990; 8:S3.
- WHAT LEVEL OF BP INCREASES RISK?
- Epidemiologic studies
- Decreased cardiovascular risk with therapy
- - Systolic and diastolic hypertension
- Low-risk patients
- - Isolated systolic hypertension
- - Isolated diastolic hypertension
- - Increased pulse pressure
- Goal blood pressure
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- INFORMATION FOR PATIENTS