Hypertension is defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg.
Recent ACC/AHA guidelines suggest hypertension as ≥130/80 mmHg.
Blood Pressure Classification
|Category |Systolic (mmHg)|Diastolic (mmHg)| |———————|—————|-—————| |Normal |<120 |<80 |Pre-hypertension |120-139 |80-89 |Stage 1 Hypertension|140-159 |90-99 |Stage 2 Hypertension|≥160 |≥100 |Hypertensive Crisis |≥180 |≥120
Leading cause of disability-adjusted life years worldwide.
Primary risk factor for burden of disease and death globally.
Over 1.5 billion individuals worldwide have hypertension.
Associated with 9.4 million deaths worldwide yearly.
Accounts for 13.5% of all deaths worldwide.
United States Statistics
Estimated 30% prevalence in the US
More than 130 million adults in the US have hypertension.
Nearly 1 in 2 adults in the US has hypertension.
Only 25% control rate among treated patients.
The prevalence of blood pressure awareness, treatment, and control among adults in the US is dismal at 60%, 51%, and 21%, respectively, and these figures have failed to improve over the past several years.
In 2020, hypertension was a primary or contributing cause of 670,000+ deaths (20% of all US deaths)
Death rate has increased by>34% over the past decade.
Each 10% improvement in hypertension control could save 14,000 lives per year.
Annual cost exceeds $50 billion
Lifetime Risk
90% lifetime incidence for individuals with normal BP at age 55 – Untreated hypertension shortens life expectancy by 5 years
Pathophysiology
Hypertension results from multiple mechanisms:
Increased salt sensitivity and volume expansion Increased renin-angiotensin-aldosterone system activity Enhanced sympathetic nervous system activity Increased arterial stiffness Endothelial dysfunction Renal sympathetic nerve activation
Vascular risk starts at BP levels as low as 115/75 mmHg
Risk is continuous, consistent, and independent of other risk factors
Each 20 mmHg systolic or 10 mmHg diastolic increase doubles cardiovascular death risk.
Approximately 50% of cardiovascular risk from suboptimal systolic BP is attributed to values in the 130-150 mmHg range.
Major Complications of hypertension:
Most important risk factor for stroke Leading cause of congestive heart failure Major cause of kidney insufficiency Single most common risk factor for atrial fibrillation development Important role in atherosclerosis and coronary artery disease
>50% of adults aged >65 have hypertension
Among those ≥80 years, approximately 80% have hypertension
Pattern of hypertension changes with age: before age 50, mostly diastolic; after age 50, isolated systolic predominates
Racial and Ethnic Disparities Prevalence 1.5-2.0 times greater in African Americans than whites. 57.1% of Black individuals vs 43.6% of white individuals have hypertension. Among women: 56.7% prevalence in Black women vs 36.7% in white women
Hypertension-associated death rates in Black men are 2.5-fold higher than white men.
Only 25% of African Americans have BP under control vs 34% of whites.
Higher prevalence in men than women.
Contributes to more excess deaths in women than any other preventable factor.
Premenopausal females with isolated hypertension have relatively low absolute short-term cardiovascular risk compared to males
Secondary Hypertension
Accounts for **5-10% of cases
Results from identifiable, often correctable causes
Common causes include: Cushing’s syndrome and primary aldosteronism (<10% of cases) Renal disease Endocrine abnormalities Coarctation of the aorta
Pediatric Hypertension Estimated prevalence: 2-5% in children Correlates with family history, low birth weight, and excessive weight BP in children/adolescents increasing parallel with weight gain During childhood, represents independent risk factor for adult hypertension
Resistant Hypertension
Affects 10-20% of hypertensive patients (10-12 million persons)
Resistant Hypertension is defined as elevated BP despite concurrent use of ≥3 antihypertensive drugs of different classes, including a diuretic.
Resistant hypertension is associated with a poor prognosis with marked increase in all-cause mortality and cardiovascular events
About 64% of men and 68% of women have hypertension.
High prevalence related to age-associated arterial stiffness.
Chronic pain may increase risk of hypertension.
Systolic BP and pulse pressure are stronger risk factors than diastolic BP.
Intensive treatment may increase risk of complications with hypotension, syncope, and electrolyte abnormalities.
Hypertensive disorders of pregnancy have increased in the US.
Hypertensive disorders of pregnancy contribute to adverse maternal and child health outcomes, and can increase a woman’s lifetime cardiovascular disease risk
Benefits of Treatment of hypertension.
36% reduction in strokes 27% reduction in coronary artery disease 32% reduction in all cardiovascular disease 55% reduction in heart failure 20% reduction in total mortality
Blood Pressure Targets
General goal: <140/90 mmHg Diabetics: <130/80 mmHg Diabetics with chronic kidney disease: <125/75 mmHg <120 mmHg systolic may be optimal for high-risk patients
Only 25% of US hypertensive patients achieve BP <140/90 mmHg
Fewer than 1/3 of patients achieve recommended BP control levels 12-27% of hypertensive patients require ≥3 drugs for adequate control
High BMI and low physical activity are key modifiable risk factors.
Obesity-36-47% prevalence in obese vs 20% in normal weight individuals?
Sodium intake-Should be ≤6g sodium chloride per day
Physical fitness Decreases BP in both lean and obese subjects
DASH diet implementation recommended
Exercise 30 minutes aerobic activity most days
Medications That Increase Blood Pressure
Antidepressants (8.7% of hypertensive patients) Steroids (1.9%) Estrogens (1.7%) Other agents: acetaminophen, birth control pills, decongestants, corticosteroids
Recommended Initial Agents
Thiazide diuretics-particularly for Stage 1 hypertension
Calcium channel blockers
ACE inhibitors
Angiotensin receptor blockers (ARBs)
Beta-blockers-Not generally recommended unless ischemic heart disease or heart failure present.
Combination therapy is often required for Stage 2 hypertension.
Ambulatory BP monitoring is superior to clinic measurements in predicting cardiovascular events and mortality.
Home BP monitoring correlates better with end-organ damage than clinic measurements.
Nocturnal BP has stronger predictor of cardiovascular outcomes than daytime measurements.
Target organ assessments:
Serum creatinine determination needed in all patients.
Left ventricular hypertrophy assessment
Proteinuria evaluation
Cardiovascular risk factor assessment
Intensive BP control in elderly may increase complications
Very aggressive control may not always improve outcomes.
White coat hypertension accounts for 20% of patients with elevated readings.
Orthostatic hypotension-Risk factor for falls in elderly with uncontrolled hypertension