Overview of hypertension in adults
- Jan Basile, MD
Jan Basile, MD
- Professor of Medicine, Medical University of South Carolina
- Ralph H Johnson VA Medical Center, Charleston, SC
- Michael J Bloch, MD, FACP, FASH, FVM, FNLA
Michael J Bloch, MD, FACP, FASH, FVM, FNLA
- Associate Professor, University of Nevada School of Medicine
- Medical Director, Vascular Care, Renown Regional Medical Center
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
The treatment of hypertension is the most common reason for office visits of nonpregnant adults to clinicians in the United States and for use of prescription drugs . The National Health and Nutrition Examination Survey (NHANES) conducted from 2005 through 2008 estimated that approximately 29 to 31 percent of adults in the US have hypertension . Extrapolating from these data, approximately 76.4 million Americans over the age of 20 years have hypertension . Data from NHANES 1999-2006 suggest that as many as 8 percent of US adults have undiagnosed hypertension.
The number of patients with hypertension is likely to grow as the population ages since either isolated systolic hypertension or combined systolic and diastolic hypertension occurs in the majority of persons older than 65 years (figure 1) . The rising incidence of obesity will also increase the number of hypertensive individuals . (See "Treatment of hypertension in the elderly patient, particularly isolated systolic hypertension".)
Despite the prevalence of hypertension and its associated complications, control of the disease is far from adequate. Although rates of hypertension awareness, treatment, and control have improved over the past few decades, data from the 2005-2008 NHANES survey show that only 50.1 percent of persons with hypertension have their blood pressure under control, defined as a level below 140/90 mmHg (table 1) [4,5].
There are numerous potential reasons for low rates of blood pressure control, including poor access to health care and medications as well as lack of adherence with long-term therapy for a condition that is usually asymptomatic . The latter may be particularly true when the therapy may interfere with the patient's quality of life and when its immediate benefits may not be obvious to the patient. Therapeutic inertia, defined as the failure by providers to increase therapy in the setting of identified poor blood pressure control, is also becoming a well-recognized barrier to achieving improved control rates . Thus, hypertension will likely remain the most common risk factor for heart attack and stroke . (See "Patient adherence and the treatment of hypertension".)
This topic provides a broad overview of the definitions, pathogenesis, complications, diagnosis, evaluation, and management of hypertension. Detailed discussions of all of these issues are found separately. The reader is directed, when necessary, to more detailed discussions of these issues in other topics.
- Egan BM, Zhao Y, Axon RN. US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. JAMA 2010; 303:2043.
- Wright JD, Hughes JP, Ostchega Y, et al. Mean systolic and diastolic blood pressure in adults aged 18 and over in the United States, 2001-2008. Natl Health Stat Report 2011; :1.
- Kaplan NM, Victor RG. Hypertension in the population at large. In: Kaplan's Clinical Hypertension, 11th ed, Wolters Kluwer, Philadelphia 2014. p.1.
- James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507.
- Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003; 289:2560.
- Wang TJ, Vasan RS. Epidemiology of uncontrolled hypertension in the United States. Circulation 2005; 112:1651.
- Egan BM, Bandyopadhyay D, Shaftman SR, et al. Initial monotherapy and combination therapy and hypertension control the first year. Hypertension 2012; 59:1124.
- Greenland P, Knoll MD, Stamler J, et al. Major risk factors as antecedents of fatal and nonfatal coronary heart disease events. JAMA 2003; 290:891.
- Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013; 31:1281.
- Franklin SS, Larson MG, Khan SA, et al. Does the relation of blood pressure to coronary heart disease risk change with aging? The Framingham Heart Study. Circulation 2001; 103:1245.
- Taylor BC, Wilt TJ, Welch HG. Impact of diastolic and systolic blood pressure on mortality: implications for the definition of "normal". J Gen Intern Med 2011; 26:685.
- Ahmed ME, Walker JM, Beevers DG, Beevers M. Lack of difference between malignant and accelerated hypertension. Br Med J (Clin Res Ed) 1986; 292:235.
- Severe symptomless hypertension. Lancet 1989; 2:1369.
- O'Mailia JJ, Sander GE, Giles TD. Nifedipine-associated myocardial ischemia or infarction in the treatment of hypertensive urgencies. Ann Intern Med 1987; 107:185.
- Grossman E, Messerli FH, Grodzicki T, Kowey P. Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies? JAMA 1996; 276:1328.
- Forman JP, Stampfer MJ, Curhan GC. Diet and lifestyle risk factors associated with incident hypertension in women. JAMA 2009; 302:401.
- Sonne-Holm S, Sørensen TI, Jensen G, Schnohr P. Independent effects of weight change and attained body weight on prevalence of arterial hypertension in obese and non-obese men. BMJ 1989; 299:767.
- Staessen JA, Wang J, Bianchi G, Birkenhäger WH. Essential hypertension. Lancet 2003; 361:1629.
- Wang NY, Young JH, Meoni LA, et al. Blood pressure change and risk of hypertension associated with parental hypertension: the Johns Hopkins Precursors Study. Arch Intern Med 2008; 168:643.
- Carnethon MR, Evans NS, Church TS, et al. Joint associations of physical activity and aerobic fitness on the development of incident hypertension: coronary artery risk development in young adults. Hypertension 2010; 56:49.
- de Simone G, Devereux RB, Chinali M, et al. Risk factors for arterial hypertension in adults with initial optimal blood pressure: the Strong Heart Study. Hypertension 2006; 47:162.
- Yan LL, Liu K, Matthews KA, et al. Psychosocial factors and risk of hypertension: the Coronary Artery Risk Development in Young Adults (CARDIA) study. JAMA 2003; 290:2138.
- Meng L, Chen D, Yang Y, et al. Depression increases the risk of hypertension incidence: a meta-analysis of prospective cohort studies. J Hypertens 2012; 30:842.
- Burgaz A, Orsini N, Larsson SC, Wolk A. Blood 25-hydroxyvitamin D concentration and hypertension: a meta-analysis. J Hypertens 2011; 29:636.
- The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med 1997; 157:2413.
- Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360:1903.
- Wilson PW. Established risk factors and coronary artery disease: the Framingham Study. Am J Hypertens 1994; 7:7S.
- Jackson R, Lawes CM, Bennett DA, et al. Treatment with drugs to lower blood pressure and blood cholesterol based on an individual's absolute cardiovascular risk. Lancet 2005; 365:434.
- Lorell BH, Carabello BA. Left ventricular hypertrophy: pathogenesis, detection, and prognosis. Circulation 2000; 102:470.
- Vakili BA, Okin PM, Devereux RB. Prognostic implications of left ventricular hypertrophy. Am Heart J 2001; 141:334.
- Levy D, Larson MG, Vasan RS, et al. The progression from hypertension to congestive heart failure. JAMA 1996; 275:1557.
- Staessen JA, Fagard R, Thijs L, et al. Randomised double-blind comparison of placebo and active treatment for older patients with isolated systolic hypertension. The Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. Lancet 1997; 350:757.
- Thrift AG, McNeil JJ, Forbes A, Donnan GA. Risk factors for cerebral hemorrhage in the era of well-controlled hypertension. Melbourne Risk Factor Study (MERFS) Group. Stroke 1996; 27:2020.
- Coresh J, Wei GL, McQuillan G, et al. Prevalence of high blood pressure and elevated serum creatinine level in the United States: findings from the third National Health and Nutrition Examination Survey (1988-1994). Arch Intern Med 2001; 161:1207.
- Hsu CY, McCulloch CE, Darbinian J, et al. Elevated blood pressure and risk of end-stage renal disease in subjects without baseline kidney disease. Arch Intern Med 2005; 165:923.
- U.S. Preventive Services Task Force. Screening for high blood pressure: U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2007; 147:783.
- Beevers G, Lip GY, O'Brien E. ABC of hypertension: Blood pressure measurement. Part II-conventional sphygmomanometry: technique of auscultatory blood pressure measurement. BMJ 2001; 322:1043.
- Myers MG. A proposed algorithm for diagnosing hypertension using automated office blood pressure measurement. J Hypertens 2010; 28:703.
- Lurbe E, Torro I, Alvarez V, et al. Prevalence, persistence, and clinical significance of masked hypertension in youth. Hypertension 2005; 45:493.
- Mancia G, De Backer G, Dominiczak A, et al. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2007; 25:1105.
- Forman JP, Brenner BM. 'Hypertension' and 'microalbuminuria': the bell tolls for thee. Kidney Int 2006; 69:22.
- Cuspidi C, Lonati L, Macca G, et al. Cardiovascular risk stratification in hypertensive patients: impact of echocardiography and carotid ultrasonography. J Hypertens 2001; 19:375.
- Blood Pressure Lowering Treatment Trialists' Collaboration, Turnbull F, Neal B, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ 2008; 336:1121.
- Hebert PR, Moser M, Mayer J, et al. Recent evidence on drug therapy of mild to moderate hypertension and decreased risk of coronary heart disease. Arch Intern Med 1993; 153:578.
- Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:2960.
- He FJ, Li J, Macgregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ 2013; 346:f1325.
- Appel LJ, Brands MW, Daniels SR, et al. Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension 2006; 47:296.
- Tuck ML, Sowers J, Dornfeld L, et al. The effect of weight reduction on blood pressure, plasma renin activity, and plasma aldosterone levels in obese patients. N Engl J Med 1981; 304:930.
- Whelton PK, Appel LJ, Espeland MA, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA 1998; 279:839.
- Stevens VJ, Corrigan SA, Obarzanek E, et al. Weight loss intervention in phase 1 of the Trials of Hypertension Prevention. The TOHP Collaborative Research Group. Arch Intern Med 1993; 153:849.
- Ascherio A, Rimm EB, Giovannucci EL, et al. A prospective study of nutritional factors and hypertension among US men. Circulation 1992; 86:1475.
- Elmer PJ, Obarzanek E, Vollmer WM, et al. Effects of comprehensive lifestyle modification on diet, weight, physical fitness, and blood pressure control: 18-month results of a randomized trial. Ann Intern Med 2006; 144:485.
- Roumie CL, Elasy TA, Greevy R, et al. Improving blood pressure control through provider education, provider alerts, and patient education: a cluster randomized trial. Ann Intern Med 2006; 145:165.
- Houston TK, Allison JJ, Sussman M, et al. Culturally appropriate storytelling to improve blood pressure: a randomized trial. Ann Intern Med 2011; 154:77.
- Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation 2007; 115:2761.
- Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 2009; 338:b1665.
- Webb AJ, Fischer U, Mehta Z, Rothwell PM. Effects of antihypertensive-drug class on interindividual variation in blood pressure and risk of stroke: a systematic review and meta-analysis. Lancet 2010; 375:906.
- Wald DS, Law M, Morris JK, et al. Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11,000 participants from 42 trials. Am J Med 2009; 122:290.
- Vokó Z, Bots ML, Hofman A, et al. J-shaped relation between blood pressure and stroke in treated hypertensives. Hypertension 1999; 34:1181.
- Bangalore S, Qin J, Sloan S, et al. What is the optimal blood pressure in patients after acute coronary syndromes?: Relationship of blood pressure and cardiovascular events in the PRavastatin OR atorVastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction (PROVE IT-TIMI) 22 trial. Circulation 2010; 122:2142.
- Somes GW, Pahor M, Shorr RI, et al. The role of diastolic blood pressure when treating isolated systolic hypertension. Arch Intern Med 1999; 159:2004.
- de la Sierra A, Segura J, Banegas JR, et al. Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. Hypertension 2011; 57:898.
- Schmieder RE, Rockstroh JK, Messerli FH. Antihypertensive therapy. To stop or not to stop? JAMA 1991; 265:1566.
- Nelson MR, Reid CM, Krum H, et al. Short-term predictors of maintenance of normotension after withdrawal of antihypertensive drugs in the second Australian National Blood Pressure Study (ANBP2). Am J Hypertens 2003; 16:39.
- Freis ED, Thomas JR, Fisher SG, et al. Effects of reduction in drugs or dosage after long-term control of systemic hypertension. Am J Cardiol 1989; 63:702.
- Finnerty FA Jr. Stepped-down therapy versus intermittent therapy in systemic hypertension. Am J Cardiol 1990; 66:1373.
- Definitions based upon ambulatory and home readings
- White coat hypertension
- Masked hypertension
- Moderate to severe hypertensive retinopathy (formerly called "malignant hypertension")
- Hypertensive emergency
- Hypertensive urgency
- PRIMARY (ESSENTIAL) HYPERTENSION
- Risk factors for primary (essential) hypertension
- SECONDARY OR CONTRIBUTING CAUSES OF HYPERTENSION
- COMPLICATIONS OF HYPERTENSION
- DIAGNOSIS OF HYPERTENSION
- Uses of and indications for ambulatory monitoring
- - Indications for ABPM
- Physical examination
- Laboratory testing
- Additional tests
- Testing for secondary hypertension
- Benefits of blood pressure control
- Who should be treated?
- Nonpharmacologic therapy
- Drug treatment
- - General efficacy
- - Initial monotherapy in uncomplicated hypertension
- - Combination therapy
- Possible benefit from nocturnal therapy
- Goal blood pressure
- Resistant hypertension
- Discontinuing therapy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS