Hypertension is a common condition that affects one in every three adults in the United States. The ACC/AHA 2017 guidelines define it as a blood pressure of ≥ 130/80 mm Hg and the JNC 8 criteria as ≥ 140/90 mm Hg. Hypertension can be classified as either primary (essential) or secondary. Primary hypertension accounts for approx. 95% of cases of hypertension and has no detectable cause, whereas secondary hypertension is due to a specific underlying condition. Typical underlying conditions include renal, endocrine, or vascular diseases (e.g., renal failure, primary hyperaldosteronism, or coarctation of the aorta). Clinically, hypertension is usually asymptomatic until organ damage occurs, which then commonly affects the brain, heart, kidneys, or eyes (e.g., retinopathy, myocardial infarction, stroke). Common early symptoms of hypertension include headache, dizziness, tinnitus, and chest discomfort. Hypertension is diagnosed if blood pressure is persistently elevated on two or more separate measurements. Further diagnostic measures include evaluation of possible organ damage (e.g., kidney function tests) and additional tests if an underlying disease is suspected. Treatment of primary hypertension includes lifestyle changes (e.g., diet, weight loss, exercise) and pharmacotherapy. Commonly prescribed antihypertensive medications include ACE inhibitors, angiotensin receptor blockers, thiazide diuretics, and calcium channel blockers. Management of pediatric patients and pregnant women differs from that of nonpregnant adults because some of these drugs are contraindicated in these patient groups. To treat secondary hypertension, the underlying cause needs to be addressed.
See also “Hypertensive crisis.”
- Definition of hypertension in adults: persistent systolic blood pressure of ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg
- ACC/AHA 2017 definition 
|AHA/ACC 2017 BP categories|
|BP category||Systolic blood pressure (mm Hg)||Diastolic blood pressure (mm Hg)|
|Normal blood pressure||< 120||AND||< 80|
|Stage 1 hypertension||130–139||OR||80–89|
|Stage 2 hypertension||≥ 140||OR||≥ 90|
- JNC 8 definition: persistent systolic blood pressure of ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg
- Definition of hypertension in children < 13 years: blood pressure ≥ 95thpercentile to < 95thpercentile + 12 mm Hg OR systolic blood pressure ≥ 130 mm Hg and/or diastolic blood pressure ≥ 80 mm Hg (whichever is lower) 
- One in three adults in the US is affected. 
- Prevalence increases with age (65% of men and 75% of women develop hypertension by the age of ≥ 70 years). 
- Rates are highest in African Americans and lowest in Asian Americans, with white individuals falling in the middle. 
- 60–75% of obese and overweight patients are affected. 
- Sex 
Epidemiological data refers to the US, unless otherwise specified.
Primary (essential) hypertension
- Risk factors
Secondary hypertension 
- Accounts for 5–10% of cases of hypertension in adults 
- Accounts for 70–85% of cases of hypertension in children < 12 years of age
- Age at onset < 25 years or > 55 years
Etiology: caused by an identifiable underlying condition
- Endocrine hypertension
- Medication: , , ,
- Recreational drug use: , ,
- : See “Subtypes and variants” below.
RECENT: Renal (e.g., renal artery stenosis, glomerulonephritis), Endocrine (e.g., Cushing syndrome, hyperthyroidism, Conn syndrome), Coarctation of the aorta, Estrogen (oral contraceptives), Neurologic (raised intracranial pressure, psychostimulants use), Treatment (e.g., glucocorticoids, NSAIDs) are the causes of secondary hypertension.
Hypertension is usually asymptomatic until:
- Complications of end-organ damage arise (see “Complications” below)
- Or an acute increase in blood pressure occurs (see “”)
- Secondary hypertension usually manifests with symptoms of the underlying disease (e.g., abdominal bruit in renovascular disease, edema in CKD, daytime sleepiness in obstructive sleep apnea).
- Nonspecific symptoms of hypertension
Since hypertension is often asymptomatic, regular screening is necessary to prevent end-organ damage.
Subtypes and variants
White coat hypertension (white coat effect)
- Definition: arterial hypertension detected only in clinical settings or during blood pressure measurement at a physician's practice
- Etiology: anxiety experienced by the patient
- Clinical features: consistently normal blood pressure measurements and normalization of elevated blood pressure outside of a clinical setting
- Take different blood pressure measurements several minutes apart (after the patient had time to relax)
- Take blood pressure measurements on several visits (at least 2)
Isolated systolic hypertension (ISH) 
- Definition: increase in systolic blood pressure (≥ 140 mm Hg) with diastolic BP within normal limits (≤ 90 mm Hg)
- Often asymptomatic
- Signs of increased pulse pressure: e.g., head pounding, rhythmic nodding, bobbing of the head in synchrony with heartbeats
- Symptoms of hypertension (see “Clinical features” above)
- Diagnostics: See “Diagnosis of hypertension” below.
- Treatment: thiazide diuretics OR dihydropyridine calcium antagonists
- Prognosis: high risk of cardiovascular events (MI, stroke, renal dysfunction)
General approach 
Blood pressure monitoring
- Repeated measurements on both arms; : Hypertension is diagnosed if the average blood pressure on at least two readings obtained on at least two separate visits is elevated.
- Long-term measurement of blood pressure (24 hours)
- See “ .”
Initial evaluation of newly diagnosed hypertensive patients
- Stratification of cardiovascular risk: fasting blood glucose, lipid profile (HDL, LDL, and triglycerides levels)
- Evaluation of end-organ damage and underlying causes
Approach to diagnosing secondary hypertension 
General indicators of secondary hypertension
- Young age (< 30 years) at onset of hypertension
- Onset of diastolic hypertension at an older age (> 55 years)
- Abrupt onset of hypertension
- End-organ damage that is disproportionate to the degree of hypertension
- Resistant hypertension: hypertension that is resistant to treatment with at least three antihypertensives of different classes including a diuretic
- Specific indicators (For details regarding individual diagnostic procedures, see the individual articles.)
|Different diagnostics for causes of secondary hypertension|
|Diagnostic findings||Underlying condition|
|Electrolyte and acid-base status|
| || |
|Difference in blood pressure|| |
|Sleep disorder|| |
|Urinalysis|| || |
| || |
Screening for hypertension (USPSTF recommendations) 
- Individuals 18–39 years of age with normal blood pressure (< 130/85 mm Hg) and without other risk factors: Screen every 3–5 years.
- Individuals > 40 years of age or who are at increased risk for high blood pressure : Screen every year.
Nonpharmacological measures (lifestyle changes for managing hypertension)
|Intervention (in order of effectiveness)||Target||Approximate systolic BP reduction in hypertensive patients|
|Weight loss|| |
|DASH diet|| || |
|Decrease dietary sodium|| || |
|Exercise||Aerobic|| || |
|Dynamic resistance (e.g., weight training)|| || |
|Isometric resistance (e.g., handgrip exercise)|| || |
|Increase dietary potassium|| || |
|Decreased alcohol intake|| |
|Smoking cessation|| || |
Nonpharmacological measures should be pursued in any patient with a systolic BP > 130 mm Hg or a diastolic BP > 90 mm Hg.
Patients should be taught to measure their own blood pressure to allow for long-term monitoring and assessment of treatment efficiency.
Pharmacologic treatment 
|Guideline||Indication for pharmacological therapy||Treatment goal|
|JNC 8|| |
Initiation of treatment
Number of antihypertensives
- Newly diagnosed hypertension with BP < 150/90 mm Hg: Begin therapy with one primary antihypertensive.
- Newly diagnosed hypertension with BP > 150/90 mm Hg: Begin therapy with two primary antihypertensives.
- Choice of antihypertensive drug
- Non-African American patients (including individuals with diabetes): thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB)
- African American patients (including individuals with diabetes): thiazide-type diuretic or CCB
- In adults with chronic kidney disease: initial (or add-on) treatment should include an ACEI OR ARB to improve kidney outcome.
- Number of antihypertensives
|Overview of antihypertensive drugs|
|Drug class||Comments||Side effects|
|(e.g., lisinopril, captopril, enalapril)|
|ARBs (e.g., losartan, valsartan)|
|(e.g., hydrochlorothiazide, chlorthalidone)|| |
|Dihydropyridines(e.g., nifedipine, amlodipine)|
|Nondihydropyridines (e.g., diltiazem, verapamil)|| |
|(e.g., propranolol, metoprolol, labetalol)|| |
|furosemide, torsemide)(e.g.,|| |
|(e.g., eplerenone, spironolactone)|| |
|(e.g., prazosin, doxazosin)|
|(e.g., clonidine)|| |
|Direct arteriolar vasodilators (e.g., hydralazine, nitroprusside)|
Follow-up: Reassess within one month of initiating or changing pharmacological therapy.
- If blood pressure is controlled: Reassess after 3–6 months and annually thereafter.
If the treatment goal cannot be reached with two drugs:
- Add a third drug.
- Evaluate for secondary causes of hypertension.
- If the treatment goal is not reached with one drug, increase the dose of the initial drug or add a second drug.
Treatment according to subgroups 
- Primary hypertension: thiazide diuretics, ACEIs, ARBs, and/or dihydropyridine CCBs
- Patients with CHF
- Patients with diabetes mellitus
- Patients with asthma
- Treatment of hypertension in pregnancy
Moms Love Healthy Newborns: Use Methyldopa, Labetalol, Hydralazine, or Nifedipine for hypertensive pregnant women.
Treatment of hypertension in children 
- Treat the underlying cause (e.g., surgical correction of coarctation of the aorta)
- Lifestyle changes in children with elevated BP (see “Nonpharmacologic measures” in “Treatment” above)
- Pharmacologic management is indicated for symptomatic hypertension, diabetes mellitus, CKD, and end-organ damage, as well as if there is an insufficient response or no response to lifestyle changes.
- Hypertensive emergency: labetalol, nicardipine, or sodium nitroprusside
- Arterial hypertension is the most common risk factor for cardiovascular disease
- It leads to changes in the vascular endothelium, particularly of the small vessels, and can therefore affect any organ system.
- See also “Hypertensive crisis.”
Cardiovascular system 
Hypertensive nephrosclerosis: a renal vascular injury secondary to long-standing arterial hypertension
- Pathophysiology: chronic hypertension → narrowing of afferent arterioles → reduction of glomerular blood flow → glomerular and tubular ischemia → arteriolonephrosclerosis and fibrosis () →
- Typical findings
- Chronic kidney disease
Hypertensive retinopathy: arteriosclerotic and hypertension-related changes of the retinal vessels
- Cotton-wool spots
- Retinal hemorrhages (i.e., flame-shaped hemorrhages)
- Macular star (results from exudation into the macula)
- Arteriovenous nicking: a tapering of a retinal venule at the point where a retinal arteriole crosses the retinal venule
- Marked swelling and prominence of the optic disk with indistinct borders due to papilledema and optic atrophy (end-stage disease)
- Fundoscopic examination:
- Presence of papilledema in a hypertensive patient may indicate a hypertensive crisis and warrants urgent lowering of the blood pressure (see “ ”)
|Classification system according to Keith-Wagener-Barker |
|Grade I||Vessel diameter variation: arteriolar constriction and tortuosity||Usually asymptomatic|
|Grade II||Gunn sign and marked constriction of vessels and sclerosis of arterioles|
|Grade III||Cotton-wool exudates, hard exudates, retinal hemorrhage, retinal edema, macular star formation||Decreased and/or blurred vision, headaches|
|Grade IV||Papilledema, optic atrophy|
Local treatment of retinopathy is not possible, therefore, systemic reduction of blood pressure is critical!
We list the most important complications. The selection is not exhaustive.
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