Hypertension (HTN) is a common condition that affects one in every three adults in the United States and is becoming increasingly prevalent among children. The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines define hypertension in adults as a blood pressure of ≥ 130/80 mm Hg and the Eighth Joint National Committee (JNC 8) criteria specify ≥ 140/90 mm Hg. Hypertension can be classified as either primary (essential) or secondary. Primary hypertension accounts for ∼ 90% of cases of hypertension and has no detectable cause, whereas secondary hypertension is caused by a specific underlying condition. Typical underlying conditions include renal, endocrine, and vascular diseases (e.g., renal failure, primary hyperaldosteronism, coarctation of the aorta). Clinically, hypertension is usually asymptomatic until organ damage occurs, with the brain, heart, kidneys, and/or eyes (e.g., retinopathy, myocardial infarction, stroke) most commonly affected. If present, early symptoms of hypertension may include headache, dizziness, tinnitus, and chest discomfort. Hypertension is suspected if in-office blood pressure is persistently elevated on two or more separate measurements and is confirmed with out-of-office measurement. Further diagnostic measures include assessment of cardiovascular risk, evaluation of possible target 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 angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), thiazide diuretics, and calcium channel blockers (CCBs); pharmacological management of pediatric and pregnant patients differs, as some of these drugs are contraindicated in these patient populations. To treat secondary hypertension, the underlying cause needs to be addressed.
See also “Hypertensive crisis.”
- Hypertension in adults
- Hypertension in children
- Primary hypertension: hypertension with no identifiable cause
- Secondary hypertension: hypertension caused by an identifiable underlying condition
- Resistant hypertension: hypertension that remains uncontrolled (≥ 130/80 mm Hg) despite treatment with ≥ 3 antihypertensives OR requires ≥ 4 medications to be controlled 
|Classification of hypertension in adults|
|2017 ACC/AHA guideline ||2014 JNC 8 guideline ||2020 ISH guideline |
|Normal blood pressure|
|Elevated blood pressure|
|Stage 1 hypertension|
|Stage 2 hypertension|
- Hypertension affects between approximately one-third and one-half of adults in the US. 
- Prevalence increases with age: Approximately 65–75% of adults develop hypertension by 65–74 years of age. 
- Rates are highest in African American individuals, followed by white individuals, and lowest in Asian American and Hispanic individuals. 
- ∼ 60–87% of overweight and ∼ 73–95% of obese patients are affected. 
- Sex 
Epidemiological data refers to the US, unless otherwise specified.
Primary hypertension 
- Multifactorial etiology including epigenetic, genetic, and environmental factors
- Directly related to total peripheral resistance and cardiac output
Risk factors for primary hypertension
Nonmodifiable risk factors
- Positive family history
- Race and ethnicity
- Advanced age
- Modifiable risk factors
- Nonmodifiable risk factors
See “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.
- Nonspecific symptoms of hypertension
Since hypertension is often asymptomatic, regular screening is necessary to prevent end-organ damage.
Subtypes and variants
White coat and masked hypertension 
|Interpretation of blood pressure readings |
|In-office blood pressure||Out-of-office blood pressure|
| || |
|White coat hypertension (isolated clinic hypertension)|| || |
|Masked hypertension (isolated ambulatory hypertension)|| || |
White coat hypertension 
- Definition: elevated blood pressure readings in a clinical setting (caused by anxiety) but normal readings when measured elsewhere
- Confirm true elevation of the in-office blood pressure measurements.
- Take different blood pressure measurements several minutes apart (after the patient has had time to relax).
- Take blood pressure measurements on several visits (at least two).
- Consider screening using daytime ABPM (preferable) or HBPM in patients with in-office blood pressure ≥ 130/89 mm Hg and ≤ 160/100 mm Hg after a 3-month trial of lifestyle changes.
- Diagnosis is confirmed in patients with: 
- In-office readings ≥ 130/89 mm Hg and ≤ 160/100 mm Hg
- AND out-of-office readings < 130/80 mm Hg
- Confirm true elevation of the in-office blood pressure measurements.
In patients with white coat hypertension, the incidence of conversion to sustained hypertension is ∼ 1–5% per year. It is unclear if the risk of ASCVD is increased; this likely depends on the presence of additional risk factors. 
Hypertension that is only recorded in clinical settings in patients currently on antihypertensive medication is called white coat effect.
Masked hypertension 
- Definition: normal blood pressure readings in a clinical setting but consistently elevated readings when measured elsewhere
- Screening: : Consider ABPM or HBPM in adults with consistent in-office SBP 120–129 mm Hg or DBP 75–79 mm Hg. 
Isolated systolic hypertension 
- Definition: elevated SBP (≥ 140 mm Hg) with DBP within normal limits (≤ 90 mm Hg)
- Etiology 
- Clinical features
- Assess for secondary causes.
- See “ ” for details on diagnostic testing.
Signs suggestive of secondary hypertension 
- Severe hypertension
- Unusual onset of hypertension
- Abrupt onset
- Onset at < 30 years of age 
- Onset of diastolic hypertension at > 65 years of age
- Exacerbation of previously controlled hypertension
- Drug-induced hypertension
- Unprovoked or significant hypokalemia
Causes of secondary hypertension 
- Most common causes in adults include:
- Most common causes in children and adolescents (< 18 years of age) include renal parenchymal disease and coarctation of the aorta.
RECENT: Renal (e.g., renal artery stenosis, glomerulonephritis), Endocrine (e.g., Cushing syndrome, hyperthyroidism, Conn syndrome), Coarctation of the aorta, Estrogen (oral contraceptives), Neurological (raised intracranial pressure, psychostimulants use), and Treatment (e.g., glucocorticoids, NSAIDs) are the causes of secondary hypertension.
Any renal disease can potentially trigger hypertension.
(e.g., due to atherosclerosis, , , )
- Potential indications for further workup
- Workup and findings: Duplex ultrasonography or MRA or CTA of the renal arteries
- Renal parenchymal disease: (e.g., due to , , , renal tumors, atrophic kidney)
- Chronic kidney disease
|Common causes of endocrine hypertension |
|Potential indication for further workup||Typical findings|
It is not necessary to stop a patient's antihypertensive medications prior to testing for primary hyperaldosteronism. 
- distal to the left subclavian artery
- Pathophysiology: ↑ catecholamines during apneic phases → secondary hypertension
- Potential indications for further workup
- Workup and findings: sleep studies often leads to resolution of hypertension.
- Continuous positive airway pressure (CPAP)
- Screen patients using in-office .
- Confirm elevated values with ABPM or HBPM.
- Perform a thorough physical examination and obtain initial laboratory studies.
Consider diagnostic workup for secondary causes of hypertension in patients with:
- Abnormalities identified during evaluation for newly diagnosed hypertension
Screening for hypertension 
- If elevated, measurements should be repeated on both arms.
- Elevated average blood pressure on at least two readings obtained on at least two separate visits supports a diagnosis of hypertension. 
∼ 20% of individuals with high blood pressure are unaware they have hypertension. 
Diagnostic confirmation 
Out-of-office measurement is recommended in all individuals for confirmation of hypertension before initiating treatment.
Ambulatory blood pressure measurement (ABPM): preferred method
- A device measures blood pressure at fixed intervals (e.g., every 15–30 minutes) over 12–24 hours.
- Takes measurements while the individual is carrying out normal activities during the day and at nighttime
- Home blood pressure monitoring (HBPM): Blood pressure is measured by the individual at periodic intervals.
Patients should be taught to measure their own blood pressure to allow for long-term monitoring and assessment of treatment.
Evaluation of patients with newly diagnosed hypertension 
- Physical examination and patient history
- Routine studies
- Additional studies
The initial evaluation should include an assessment for orthostatic hypotension (by measuring blood pressure while sitting and standing), especially in older adults. All adults ≤ 30 years of age with elevated brachial blood pressure should also have their blood pressure measured in their thigh to rule out coarctation of the aorta. 
Recommendations regarding indications for treatment and target blood pressure differ between clinical practice guidelines. The following recommendations are consistent with those in the 2017 ACC/AHA guidelines unless specified otherwise. 
- Lifestyle changes for managing hypertension: for all patients with SBP > 120 mm Hg or DBP > 80 mm Hg
- Identify indications for antihypertensive treatment.
- Select Antihypertensive treatment by comorbidities”) based on individual patient characteristics (see also “
Titrate treatment to reach target blood pressure. ; 
- Most adults: blood pressure < 130/80 mm Hg
- Individualize targets based on age and comorbidities.
- Follow-up regularly: reassess indications for pharmacological treatment and tailor therapy to individual needs.
- Lifestyle measures alone may be trialed for 3–6 months in patients with: 
- Elevated blood pressure
- Stage 1 hypertension and 10-year ASCVD risk < 10 %
|Lifestyle changes for managing hypertension |
|Intervention (in order of effectiveness)||Target||Approximate SBP reduction in hypertensive patients|
|Weight loss (most effective measure)|| |
|Diet||DASH diet|| || |
|Decrease dietary sodium|| || |
|Increase dietary potassium|| || |
|Decrease alcohol intake|| |
|Exercise||Aerobic || || |
|Dynamic resistance (e.g., weight training)|| || |
|Isometric resistance (e.g., hand grip exercise)|| || |
Consider possible psychosocial factors or anxiety, lack of access to fresh food) and make appropriate referrals where necessary.  that may be contributing to the patient's high blood pressure (e.g., stress,
Indications for antihypertensive treatment 
The thresholds for pharmacological treatment are controversial and vary depending on age (see “Hypertension in older adults”); the following recommendations are based on the 2017 ACC/AHA guidelines.
- Adults with SBP ≥ 130 mm Hg or DBP ≥ 80 mm Hg and ≥ 1 of the following:
- All adults with SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg
Initial medication 
Choice of initial medication should be based on the following:
Patient's initial blood pressure ; 
- SBP 130–139 mm Hg or DBP 80–89 mm Hg (stage 1 hypertension): Consider initial monotherapy.
- SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg AND an average blood pressure > 20/10 mm Hg above target
Additional factors to consider
- Major comorbidities (see “Antihypertensive treatment by comorbidities”)
- Major contraindications
- Adverse effects that may be unacceptable to patients
- Patient race: For Black patients (including individuals with diabetes) without CHF or CKD, initial antihypertensive therapy should include a thiazide-type diuretic or CCB. 
To maximize medication adherence, prescribe generic medications in dosing regimens comprising as few pills as few times a day as possible (use combination pills whenever clinically appropriate), and provide a 90-day medication supply once the dosage is stable.
|First-line antihypertensive medications |
Do not prescribe an ACEI and ARB together or in combination with a direct renin inhibitor. This increases the risk of hyperkalemia and renal dysfunction and does not provide additional benefit. 
|Second-line antihypertensive medications |
|Direct arteriolar vasodilators|| |
Patients with CKD or baseline potassium > 5.5 mEq/L and those who take potassium supplements or potassium-sparing drugs are at higher risk of hyperkalemia as an adverse effect from pharmacological treatment for hypertension. 
Treatment based on comorbidities
Antihypertensive treatment by comorbidities 
|Asthma || |
Long-term management and follow-up
General principles 
- Patients on nonpharmacological treatment alone: Follow up after 3–6 months.
- If blood pressure is uncontrolled: Initiate pharmacological treatment.
- Most patients initiated on pharmacological treatment: Follow up after ∼ 1 month.
- If blood pressure is uncontrolled: Continue to escalate therapy at one-month intervals.
- Once blood pressure is controlled: Reassess after 3–6 months and annually thereafter if blood pressure remains stable.
Laboratory studies 
- For most patients, check at the one-month follow-up visit.
- Checking after ∼ 2 weeks may be reasonable in certain patients, e.g.:
- Serum creatinine
Medication titration 
Adjust medication based on adverse effects, e.g.:
- Hyponatremia: Discontinue or avoid thiazide diuretics; consider loop diuretics if necessary.
- Hypokalemia: Consider initiating a potassium-sparing diuretic after ruling out hyperaldosteronism.
- Hyperkalemia: Consider restricting dietary potassium or initiating a thiazide diuretic or after ruling out pseudohyperkalemia.
- Cough in patients on ACEIs: Switch to an ARB.
Adjust medication to reach optimal blood pressure control.
- Ask about medication adherence. 
- If indicated, adjust medications using one of the following strategies: 
- Increasing the dose of the initial drug
- Switching to another drug (“sequential monotherapy”) 
- Adding a second drug (in the form of a single combination pill, if possible)
If the treatment goal cannot be reached with two drugs: 
- Add a third drug.
- Evaluate for , if indicated.
Therapeutic inertia (failure on the part of the physician to appropriately escalate treatment when indicated) is one possible reason for poor blood pressure control. Be sure to reassess the treatment plan at each visit. 
- Rule out pseudoresistance, e.g., due to inaccurate white coat hypertension.  , suboptimal , or
- Optimize .
- Discontinue or reduce medications that may contribute to hypertension if possible.
- Assess for and treat .
- Adjust antihypertensive medications.
- Refer to a hypertension specialist or cardiologist if:
- Blood pressure remains uncontrolled
- Secondary hypertension is suspected
Resistant hypertension affects ∼ 15% of all individuals treated for hypertension in the US. 
Special patient groups
Hypertension in older adults
Special considerations 
- Hypertension affects > 60% of individuals > 60 years of age. 
- Most older adults have isolated systolic hypertension. 
- Diagnosis of hypertension in older adults is similar to younger adults.
- Record upon diagnosis. 
Nonpharmacological management 
- Initiate .
- Optimize management of comorbid conditions and causes of secondary hypertension (e.g., obstructive sleep apnea).
- Avoid medications that can increase blood pressure, if possible.
Pharmacological therapy 
- Patients with require .
- Thresholds for initiating routine treatment in older adults are controversial and vary by guideline between SBP ≥ 130 mm Hg and BP ≥ 150/90 mm Hg. 
- Choice of antihypertensive therapy (see also “Pharmacology for older adults) 
- Regularly reassess functional status, renal function, electrolyte levels, and orthostatic vital signs. 
Hypertension in children
Special considerations 
- Most childhood and adolescent hypertension in the US is due to primary hypertension.
- Diagnosis and treatment of hypertension in children is important for reducing the risk of:
Risk factors for hypertension in children 
- Risk factors for hypertension in children are similar to adults (see “Etiology of hypertension” and “Secondary hypertension”).
- Young children with the following conditions are at risk of early onset (< 3 years old) hypertension:
- History of prematurity, very low birth weight, or neonatal complications requiring NICU admission
- Congenital heart disease including coarctation of the aorta (even if corrected)
- Known (or family history of) renal disease or congenital anomalies of the kidney and urinary tract
- Recurrent UTIs
- History of transplant (solid organ or bone marrow)
- Certain systemic illnesses associated with elevated BP (neurofibromatosis type 1, sickle cell disease, tuberous sclerosis)
- Elevated ICP
- Use of medications known to elevate BP
- Children ≥ 3 years of age are additionally at elevated risk if they have:
|Classification of hypertension in children |
|Age < 13 years ||Age ≥ 13 years |
|Normal blood pressure|| |
|Elevated blood pressure|
|Stage 1 HTN|
|Stage 2 HTN|
|Acute severe hypertension|| |
Screening for hypertension in children 
- Either a manual or automatic blood pressure monitor may be used for initial screening.
- Ensure the correct cuff size is selected and follow the recommended .
- If elevated, repeat twice within the same visit, using a manual blood pressure monitor.
- If the average of the 3 readings is elevated, start diagnostics.
Diagnostics for hypertension in children 
- Initiate and arrange return visits to reassess BP.
- Refer to subspecialist care and for ABPM if BP remains elevated on:
- 3 visits if the patient has elevated BP or stage 1 HTN
- 2 visits if the patient has stage 2 HTN
- If ABPM confirms hypertension, children require with the following modifications:
- Children with acute severe hypertension or symptomatic hypertension: Perform .
All children: Assess for causes of secondary HTN if the following indications are met. 
- Recommended studies vary according to clinical suspicion but should include a renal ultrasound in all children < 6 years or in children of any age with abnormal urinalysis or renal function tests.
- For further information, see “Secondary hypertension.”
A complete evaluation for secondary hypertension is not necessary for hypertensive children > 6 years of age who are obese, have a family history of hypertension, and have no concerning history or physical examination findings. 
Management of hypertension in children 
- Screen children for hypertensive crises and refer urgently to the emergency department if present. 
- Initiate .
- Manage the underlying cause of secondary hypertension and treat associated comorbidities (if present). 
- Aim for target blood pressure of < 90th percentile or < 130/80 mm Hg for children ≥ 13 years of age.
- Assess for indications for pharmacotherapy and start if present.
Principles of prescribing
- Pharmacological management should be performed by a specialist.
- Start medication at the lowest dose possible and titrate up every 2–4 weeks as needed.
- Monotherapy is preferred; however, multiple agents may be necessary to control BP.
Beta blockers are not recommended for the initial treatment of hypertension in children because of their potential adverse effects (metabolic effects such as impaired glucose tolerance and potential exacerbation of asthma) and lack of improved efficacy compared to other medications. 
- Treatment with lifestyle modifications only: office visits every 3–6 months
- Treatment with pharmacotherapy:
- Office visits every 4–6 weeks until blood pressure is at target, then every 3–4 months 
- Periodic monitoring (e.g., every 6–12 months) for end-organ damage
- will also help prevent hypertension.
- Weight management, a healthy diet, and increasing activity levels should be routinely discussed as part of preventive care.
- 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 vascular disease) 
Hypertensive nephrosclerosis: a renal vascular injury secondary to long-standing arterial hypertension
- Pathophysiology: chronic hypertension → hypertrophy of medial and intimal layers → narrowing of afferent arterioles → ↓ glomerular blood flow → glomerular and tubular ischemia → arteriolonephrosclerosis and fibrosis () →
- Clinical findings
- Diagnostics: renal biopsy shows vascular, glomerular, and tubulointerstitial changes 
- Treatment: ACE-inhibitors (first-line), ARBs
- Chronic kidney disease
- Arteriosclerotic and hypertension-related changes of the retinal vessels
- Initial reactive vasoconstriction (vasospasm), followed by sclerosis with breakdown of blood-retinal barrier and subsequent hemorrhage and exudation
- Cotton wool spots
- Retinal hemorrhages (i.e., flame-shaped hemorrhages)
- Macular star (results from exudation into the macula)
- Hard exudates
- Arteriovenous nicking: a tapering of a retinal venule at the point where a retinal arteriole crosses the retinal venule
- Elschnig spots: multiple, round, brown-black spots with a bright ring that are scattered throughout the retina
- Marked swelling and prominence of the optic disk with indistinct borders due to papilledema and optic atrophy (end-stage disease)
- The presence of papilledema in a hypertensive patient may indicate a hypertensive crisis and warrants urgent lowering of 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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