Hypertension, the number one cause of disability adjusted life years worldwide, and the world’s leading risk factor for burden of disease and death.
Hypertension is the most important risk factor for stroke, CHF, a major cause of kidney insufficiency, and has an important role in cardiovascular diseases, including atherosclerosis and coronary artery disease.
Normal blood pressure less than 120/80 mm Hg.

Pre-hypertension-systolic blood pressure between 120 and 139 mm Hg and diastolic between 80 and 89 mm Hg.

Defined as a systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure 90 mm Hg or higher.

Recent ACC/AHA hypertension guidelines suggest hypertension is anything equal or greater than 130/80 mmHg, greatly increasing the number of patients as having a diagnosis of hypertension.

Mortality due to hypertension has increased by more than 30% since the 1990s and the prevalence in low to middle income countries continues to rise.

Hypertension is adequately controlled in fewer than 25% of treated patients.

Goals of the American College of cardiology/American heart Association of 2017 systolic blood pressure guidelines would reduce the incidence of cardiovascular disease by 610,000 events annually and reduce deaths among US adults older than 40 years by 310,000 people every year.

In an analysis of the new blood pressure criteria of the 2017 ACC/AHA guideline-isolated diastolic hypertension was not significantly associated with increased risk for cardiovascular outcomes (McEvoy JW).

Most common problem for which patients visit physicians.

Estimated prevalence of 30% in the US.

More than 130 million adults in the US have hypertension.

Almost one in two adult patients in the US has hypertension, and an estimate rate of control blood pressure of only 25%.

Over 1.5 billion individuals worldwide have hypertension.
Untreated hypertension shortens life expectancy by five years.
BP elevations above 115/75 mmHg are associated in a continuous fashion with the risk of fatal stroke, ischemic heart disease, and non-cardiac vascular disease, and each increase of 20 mmHg systolic blood pressure or 10 mm diastolic blood pressure, doubles the risk of a fatal cardiovascular event.
Relative incidence rates of hypertension range between 3% and 18% of the population, depending on the age, gender, ethnicity, and body size.

Currently, hypertension is thought to affect roughly 50 million people in the U.S. and approximately 1.5 billion worldwide.

The highest prevalence of hypertension in Eastern Europe and the Latin American/Caribbean region.

The relationship between BP and risk of cardiovascular disease (CVD) events is continuous, consistent, and independent of other risk factors.

In 2020, hypertension was a primary or a contributing cause of more than 670,000 deaths, or 20% of all deaths in the United States.

The death rate attributable to Hypertension has increased by greater than 34% over the past decade.

Approximately 10%-20% of persons with hypertension, 10 to 12,000,000 persons, have treatment resistant hypertension, defined as elevated blood pressure despite concurrent use of at least three antihypertensive drugs of different classes, including a diuretic.

Vascular risk starts at measures as low as 115 mmHg for systolic and 75 mmHg for diastolic blood pressure and is consistent across sexes, age groups, race/ethnic categories, and countries.

It is estimated that about half the risk of cardiovascular disease that is associated with sub optimal systolic blood pressure is attributed to values in the 130 to 150 mmHg range.

In 2019 the sequelae from hypertension resulted in more than 800,000 deaths from heart disease and stroke, the first and fifth leading causes of mortality in the US, respectively.

One of the most common chronic health conditions worldwide.

Renal sympathetic nerves, which lie within and adjacent to the renal artery, are essential for initiating and maintaining systemic hypertension.

Sympathetic outflow to the kidneys is higher in patients with essential hypertension.

NHANES 2011-2012 study estimated 1 of 3 US adults have hypertension and 48.2% do not have their blood pressure under control, and 36.2% are not aware they have high blood pressure.

About 20-30% of adults have hypertension.

Lifetime incidence is 90%.

Leading cause of cardiovascular disease and deaths globally.

In individuals aged 40-70 years each increment of systolic blood pressure of 20 mmHg or 10 mmHg of diastolic blood pressure is associated with more than twice the risk of cardiovascular disease across the blood pressure range from 115/75 to 185/115 mm Hg (Lewington S et al).

The relationship between blood pressure and cardiovascular disease is continuous.

Older patients with systolic hypertension and high pulse pressure versus older patients without such changes have a greater cardiovascular morbidity and mortality and a higher prevalence of other age related diseases, loss of autonomy, and shorter life expectancy.

In patients age 50 or years or older, lowering blood pressure by 10 mmHg diastolic or 20 mm Hg systolic roughly half the incidence of stroke.

Its prevalence is higher in men than women, among Black adults than  White, or Asian adults, and among persons in the southeast US than among those in the rest of the country.

Associated with at least 9.4 million deaths worldwide yearly.

Accounts for 13.5% of all deaths worldwide.

Approximately 73 million adults in the U.S, and approximately 1 billion adults worldwide suffer with this entity.

Estimated annual cost exceeds $50 billion.

Approximately half of 80 million US adults with hypertension remain uncontrolled.

Nearly one in every three young black adults and one in every five young Mexican Americans adults have hypertension: Control of hypertension among these individuals is approximately one in 10 young adults.
Hypertension associated death rates in black men are more than 2.5 fold higher than in white men,  and  almost 1.5 fold higher than nonblack women.
An estimated 57.1% of black individuals in the US have hypertension versus 43.6% of white individuals.
Among women,black women have an estimated 56.7% prevalence of hypertension and 36.7% among white women.

Improve cardiovascular outcomes in black men are associated with a combination of angiotensin converting enzyme inhibitors/angiotensin receptor blocker and either a calcium channel blocker or a long acting thiazide diuretic on black men.

Framingham study: 90% of individuals with normal blood pressure at age 55 years eventually developed hypertension.

Prevalence of hypertension increased from 25% in 1988 to 27.7% among those 18 years of age or older with increased body mass index responsible for most of the increase.

People who are normotensive at age 55 have a 90% chance of developing hypertension in their lifetime.

Prevalence increasing during the last 20 years concurrent with increasing rates of obesity and sedentary lifestyle.

Prevalence of hypertension is 36-47% in the obese population, compared with 20% normal weight individuals.

Increased body weight is a determinant of blood pressure elevation and new onset hypertension.

Fat accumulation increases total blood volume, stroke volume, cardiac output, and obesity markedly increases prevalence of hypertension and strains the left and right sides of the heart increasing prevalence of heart failure.

More than 50% of all adults older than age 65 have hypertension.

The risk of cardiovascular death doubles with each 20/10 mm Hg increment beginning with a BP 115/75 mmHg.

There is a continuous linear increase in systolic blood pressure with advancing age.

For chronic uncontrolled hypertension every 20 mmHg increase in systolic blood pressure or 20 mmHg increase in diastolic blood pressure is associated with a doubling of vascular mortality.

There are four stages blood pressure classification-normal, prehypertension, stage 1, and stage 2 hypertension.

Hypertension single most common risk factor for the development of atrial fibrillation..

Stroke, heart failure are common complications of AF, are both related to hypertension.

Blood pressure levels are on average higher among individuals with diabetes, and increased BP is an established risk factor for diabetics.

High BMI and low aerobic capacity in adolescence is associated with a high risk of hypertension in adulthood.

In patients with type two diabetes blood pressure lowering improves mortality and clinical outcomes among those with baseline blood pressure 140 mmHg and greater, supporting the use of medications for hypertension.

High body mass index and low aerobic capacity in young men associated with a 3.5 fold increase risk of hypertension in adulthood.

Contributes to more excess deaths in women than any other preventable factor.

The higher and individual’s systolic or diastolic pressure, the higher their risk of cardiovascular morbidity and mortality ( National High Blood Pressure Education Program Working Group).

Hypertension staging:

Systolic Pressure (mm Hg) Diastolic Pressure (mm Hg)

Normal < 120 < 80

Pre-hypertension 120-139 80-89

Hypertension stage 1 140-159 90-99

Hypertension stage 2 ? 160 ? 100

Hypertensive crisis – emergency ? 180 ? 120

Excessive alcohol intake and alcohol abstinence, use of nonnarcotic analgesics and low folic acid intake are independent and modifiable risk factors in women for the development of high blood pressure.

The prevalence of hypertension in American female minority population of African-American and Hispanic women approach is 50%.

Hypertension accounts for approximately one in five deaths of American women and confers risk for ischemic stroke, intracranial hemorrhage , and heart failure among women compared with men.

Blood pressure level related to risk of stroke, coronary artery disease, congestive heart failure, and death from cardiovascular disease in a continuous manner for values as low as 115/75 mm Hg.

Multiple Risk Factor Interventional trial involving 347,978 men, the risk of fatal stroke for systolic blood pressure over 180 mm Hg was nearly 15 times as high and the risk of fatal ischemic heart disease 7 times as high as the rates among individuals with optimal blood pressure.

60% of Caucasians over the age of 60 years have hypertension.

Most common disease in industrialized nations, with a prevalence greater than 20% in the general population.

Essential hypertension account for 90% of cases.

Pattern changes with age: before age 50 most cases related to diastolic hypertension, after age 50 as systolic pressure rises, and diastolic pressure tends to fall, isolated systolic hypertension predominates.

Pronounced elevation of systolic BP during stress, such as during a treadmill test associated with adverse long-term prognosis (Mundal R).

Secondary hypertension resulting from an underlying, identifiable, often correctable cause make up 5-10% of cases of hypertension.

Estimated prevalence of hypertension in children 2-5%.

Hypertension in children may be due to secondary factors or essential.

Majority of children and adolescents with mild to moderate hypertension have primary disease without a known cause.

Hypertension in children correlate with family history of hypertension, low birth weight and excessive weight.

Blood pressure in children and adolescents is increasing in parallel with weight gain.

Hypertension in children more commonly due to secondary factors such as renal disease, endocrine abnormalities and coarctation of the aorta.

Associated with increased CV disease related morbidity, mortality, blindness, chronic kidney disease and ESRD.

In a systematic review and metaanalysis of randomized controlled trials involving 44,900 participants intensive blood pressure lowering is associated with reduced risk of major cardiovascular events as well as stroke and myocardial infarction (Xie, X).

In elderly patients with hypertension, intensive treatment with systolic  blood pressure target of 110 to less than 130 mm Hg resulted in a lower incidence of cardiovascular events than standard treatment with the target of 132 less than 150 mmHg (Zhang W).

One of the most important preventable causes of premature morbidity and motality.

During childhood reflects an independent risk factor for hypertension in adulthood and is a marker for risk development of left ventricular hypertrophy, intima and media thickness atherosclerosis, diastolic dysfunction and arterial compliance changes.

White coat hypertension accounts for 20% of the patients with elevated readings.

Cushing’s and primary aldosteronism account for less than 10% of cases.

Prevalence of hypertension 1.5-2.0 times greater in African Americans than in white population.

Blacks have the highest morbidity and mortality from hypertension than any group in the U.S. and is among the highest in the world.

Blacks have sodium sensitivity with hypertension as a response.

Obstructive sleep apnea is an independent risk factor for hypertension.

May contribute to poor control of hypertension, and a very high percentage, that is greater than 70% of resistant hypertension patients have OSA.

Medications associated with HT: acetaminophen, NSAIDs, antidepressants, birth control pills, decongestants, corticosteroids, bevacizumab, tamoxifen, sorafenib,and aromatase inhibitors.

Commonly NSAIDs can increase blood pressure due to dose-dependent reduction in renal bloodflow and glomerular filtration rate, leading to and sodium retention.

Salt sensitive individuals with renal impairment, diabetes, or elderly are vulnerable to the development or worsening of hypertension due to fluid accumulation from nonsteroidal anti-inflammatory drugs.

Among the nearly 13,000,000 people in the USA is 80 years or older, approximately 80% have hypertension.

Lowering systolic blood pressure by 10, 20, or 30 mmHg to achieve treatment goals of 120-124 mmHg is associated with cardiovascular event rate reduction of 29%, 42%, and 54%, respectively.

With the exception of calcium channel blockers, almost all antihypertensives have their effects attenuated by NSAIDs.

After six months of highly active antiretroviral therapy (HAART) systolic blood pressure increases of 10 mmHg or more may be noted.

Treatment reduces the incidence of stroke, myocardial infarction, heart failure and cardiovascular disease and total mortality in men and women age 65 and older.

Modest reduction in blood pressure is associated with significant reductions in the risk of adverse cardiovascular events such as stroke, coronary heart disease, and death.

Fewer than 1/3 of patients with hypertension achieve recommended levels of blood pressure control.

The time of day at which patients take antihypertensive medications can affect circadian patterns of blood pressure.

Hypertensive patients with chronic kidney disease who take at least 1 of their antihypertensive medications at bedtime have an adjusted risk for total cardiovascular events that was approximately one third that of patients who took all of their medications upon awakening.

Estimated that as many as two-thirds of the very old have hypertension.

Prevalent in the elderly, with 64% of men and 68% of men having hypertension.

Among hypertensive adults, targeting systolic blood pressure of less than 120 mmHg compared with less than 140 mmHg is significantly associated with a small increase in cerebral white matter lesions volume and a greater decrease in total brain volume, although the differences are small.

Among hypertensive patients with increased cardiovascular risk, targeting a systolic blood pressure of less than 120 mmHg resulted in lower rates of major adverse cardiovascular events and lower all cause mortality than targeting a systolic blood pressure of less than 140 mmHg.

High prevalence in the elderly is related to age associated increase in arterial stiffness from media arterial structural change in collagen, interstitial fibrosis and calcifications.

Increased stiffness and tortuosity of the aorta and large arteries is reflected in increased systolic blood pressure and widened pulse pressure.

Elevated blood pressure causes vascular damage and accelerated conduit arterial stiffening.

Aortic and vascular stiffness increases pressure pulsatility and may increase systolic BP.

Elderly individuals with hypertension are more likely to have increased left ventricle mass, peripheral resistance, characteristic aortic impedance at rest, left atrial enlargement, reduced baroreceptor sensitivity, let ventricular early diastolic filling volume and cardiovascular response to catecholamines.

Hypertension is the most potent modifiable risk factor for cardiovascular disease in the elderly and is strongly associated with stroke, myocardial infarction, heart failure, peripheral arterial disease, kidney failure, and dementia.

When treating elderly with hypertension aggressively as in the SPRINT trial the risk for complications including hypotension, syncope, electrolyte abnormalities, and acute kidney injury are increased compared with less intensive therapy.

Sustained hypertension in midlife to late life and a pattern of midlife hypertension and late-life hypotension, compared with midlife and late-life normal blood pressure are associated with increased risk for dementia.

Lowering blood pressure in hypertension may be associated with a lower risk of dementia or cognitive impairment.

Baroreflex sensitivity reduction occurs when the age and with hypertension and leads to impaired barely oreflex mediated increase in systemic vascular resistance and inability to increase heart rate, so that elderly hypertensives are more likely to develop orthostatic and postprandial hypotension.

Inactivity and dyslipidemia are identified risk factors.

High body mass index, low physical activity, and low physical fitness are modifiable risk factors.

Hypertension in the elderly person accelerates renal function impairment.

Increased systolic blood pressure and pulse pressure in the elderly are stronger risk factors for cardiovascular morbidity and mortality then increased diastolic blood pressure.

Increased pulse pressure in older persons with isolated systolic hypertension indicates reduced vascular compliance in large arteries and is a better risk marker in systolic or diastolic blood pressure.

The Cardiovascular Health Study indicated that a brachial systolic blood pressure higher than 169 mmHg increased mortality rate 2.4 times in older men and women (Fried LP et al).

Many advocate treating blood pressure at 160/100 mm Hg as threshold since treating lower pressures is not effaciousness.

In men age 85 and older higher systolic blood pressure is associated with better survival.

In pregnancy BP 140/90 or higher.

Hypertensive disorders of pregnancy, have increased in the US coming contribute to adverse maternal and Child health outcomes and can increase the woman�s lifetime risk of cardiovascular disease.

Poorly controlled BP patients have increased BP with varying kinds of stress due to the association of increased sensitivity to BP elevating hormones due to thickened vascular smooth muscles in arterioles (Folkow B).

White coat elevations in BP only weakly associated with long-term prognosis compared to ambulatory BP measurements (Boggia J).

Nocturnal BP profile in the absence of physical activity, emotional stress, and environmental factors that are usually present during the day, is more representative of the true blood pressure status, and a stronger predictor of cardiovascular outcomes.

Altered circadian pattern of BP is associated with higher levels of proteinuria.

Ambulatory blood pressure monitoring is the only method to identify white coat hypertension and nighttime hypertension simultaneously.

Ambulatory bilood pressure measurement is superior to clinic blood pressnure measurements in predicting end stage renal disease and/or all cause mortality and cardiovascular events.

Ambulatory blood pressure measurement is a better predictor of renal and cardiovascular end points compared with office blood pressure measurement in patients with chronic kidney disease (Minutolo R et al).

Home blood pressure monitoring predicts cardiovascular risk better then office BP measurement.

Systolic ambulatory blood pressure measurement in the above study was a better predictor of adverse outcomes then was ambulatory diastolic blood pressure values.

Ambulatory blood pressure measurement of nighttime systolic blood pressure in the above study was a stronger predictor than daytime systolic blood pressure for cardiovascular endpoints.

Home blood pressure monitoring correlates better with end-organ damage than measurements in the clinic.

Physical fitness decreases blood pressure in both lean and obese subjects.

Only about 25% of patients with hypertension in the U.S. are being treated with a blood pressure level below 140/90.

Goal for BP management 140/90 or less, for diabetics less than 130/80 mmHg, for diabetics with chronic kidney disease 125/75 mmHg.

In young men, blood pressure above normal is significantly related to increased long-term mortality due to cardiovascular disease, coronary artery disease and all causes.

Increases the risk of renal cell cancer.

Goal of management should be set at <140/85 mm Hg.

Treatment results in reduction of strokes by 36%, coronary artery disease by 27% and all cardiovascular disease by 32%.

In a meta-analysis blood pressure reduction of 10 mm Hg in systolic blood pressure reduces the major cardiovascular disease events by 20%, coronary heart disease by 17%, stroke by 27%, heart failure by 28% and all-cause mortality by 13% (Ettehad D et al).

Cochrane review 2012: mild hypertension systolic BP 140-159 mm H and/or diastolic 90-99 mm Hg treated wit antihypertensive drugs has not been shown to reduce morbidity or mortality in randomized trials.

Treatment results in a 20% reduction in total mortality (Ford ES et al).

Most common risk factor for CHF.

Comparison trials of antihypertension medicines with placebo have consistently shown lowering of blood pressure reduces the incidence of coronary events, strokes and congestive heart failure, irrespective of age sex, severity of disease, presence of comorbid factors or type of antihypertensive agent utilized

At all ages, systolic blood pressure should be lowered to below 140 mm Hg.

For patients at any age with a diastolic blood pressure greater than 90 mm Hg, a reduction to below 90 mm Hg is appropriate.

For people older than 65 years with hypertension and diastolic blood pressure less than 90 mm Hg, caution is needed not to inadvertently lower than levels below 65 mm Hg when treating hypertension.

In the U.S. only 70% of hypertensive patients are aware of their problem, 59% are on treatment and only 34% are adequately controlled.

The initiation of antihypertensive drugs in the elderly is associated with an immediate increase in the risk of falls.

Antihypertensive treatment leading to lower blood pressure is associated with greater mortality risk in the elderly nursing home resident and has a negative effect in patients with cognitive impairment and slow gait.

Orthostatic hypotension with uncontrolled hypertension is a risk factor for falls.

Risk of cardiovascular disease increases with progressive and continuous elevations of systolic or diastolic blood pressure, with an approximate doubling for every 20 mm Hg in systolic and 10 mm Hg in diastolic increases within the range of 115/75 to 185/115 mm Hg.

Estimated 3.2% of adults older than 50 years have a low serum B12 levels.

Increase in cardiovascular disease risk occurs independently of other risk factors.

Elevated systolic blood pressure is more important than increased diastolic pressure as a risk factor for both cardiovascular and renal disease.

Premenopausal females with isolated hypertension have a relatively low absolute short term risk of cardiovascular disease compared with males.

Only 25% of African Americans have their blood pressure under control compared the 34% if whites.

In a randomized trial of 1094 black patients with hypertensive chronic kidney disease to receive either intensive with standard blood pressure control: primary clinical outcome was the progression of chronic kidney disease defined as a doubling of the serum creatinine or death with a follow-up from 8.8-12.2 years: intensive blood pressure control had no effect on kidney disease progression (Appel LJ et al).

In the African-American Study of Kidney Disease and Hypertension (AASK): intensive blood pressure control had no effect on the progression of kidney disease, although lowering blood pressure may retard progressive renal disease in patients with a protein-to-creatinine ratio of more than 0.22 at baseline (Appel LJ et al).

Prevalence of chronic kidney disease, stages 1-4, among adults in the United States increased from 10% from 1988-1994 to 13% from 1999-2004.

Average decline in GFR among black patients with hypertensive chronic kidney disease is approximately 2 mL per minute per 1.73 m� of body surface area or year, which is about twice the usual age associated decline in the general population (Wright JT et al Lindeman RD et al).

BP control worlwide is poor, below 10%.

Determination of serum creatinine is needed in all patients as a determination of target organ damage.

Frankly elevated creatinine is a poor prognosis factor.

Treatment reduces both ischemic and hemorrhagic strokes.

The Hypertension in the Very Elderly Trial (HYVET) 3845 patients 80 years or older wewre randomized to indapamide, with or without perindopril or placebo: Treated patients had a reduced sitting mean systolic and diastolic blood pressures of 15.0 and 6.1 mm Hg and had a 64% reduction in the rate of heart failure, 23% reduction in rate of cardiovascular death, and a 21% reduction in death of any cause, but no benefit to reducing stroke (Beckett NS et al).

Higher systolic blood pressure is associated with increased risk of mortality among elderly adults who have a medium to fast walking speed: In contrast among slow walking older adults there is not an association between elevated systolic blood dialogue diastolic blood pressure and mortality (Odden MC et al).

In coronary artery disease patients 1 in 10 have treatment resistant hypertension, which is common in elderly, women, black, and patients with multiple risk factors.

10 to 20% of patients have resistant hypertension, a high risk phenotype defined by uncontrolled blood pressure despite treatment with three or more antihypertensive drugs, or need for four or greater antihypertensive drugs regardless of blood pressure.

The prognosis with coronary artery disease and treatment resistant hypertension is poor, with marked increase in all cause mortality, coronary heart disease deaths, nonfatal myocardial infarction, angina, need for coronary revascularization procedures, and higher stroke risk.

Blood pressure control in the elderly is suggested at 140/90 mm HG.

Nearly a three-fold increase is the risk for developing hypercreatinemia in patients with diastolic blood pressure of 115 mm Hg or greater compared with those with a diastolic blood pressure between 90 and 104 mm Hg.

Sodium intake should be no more than 6 gm of sodium chloride per day.

Individuals with higher sodium intake have increased risk for hypertension.

Sodium is reported to be a modifiable determinant.

The INTERSALT study showed a modest association between higher levels of sodium intake and higher blood pressure.

In a study of estimated sodium and potassium excretion, and blood pressure recordings in 102,216 adults from 18 countries revealed a non-linear association of sodium and potassium excretion with blood pressure, which is most pronounced among persons consuming high sodium diet, persons with hypertension and older persons (PURE study).

Insulin resistance and hyperinsulism predispose individuals to develop hypertension via cellular abnormalities of insulin signaling and associated hemodynamic and metabolic abnormalities.

Insulin resistance abnormalities that predispose to hypertension include cellular cation imbalance, increased sympathetic nervous system activity, enhanced renin-angiotensin activity, increased inflammatory changes and oxidative stress.

Epidemiologic studies have demonstrated an inverse correlation between K+ intake and the prevalence of hypertension.

The Intersalt Study found that higher urinary K+ excretion associated with lower blood pressures, even when adjusted for Na+ intake.

The US Professional Men Cohort and the Nurses� Health Study found that increased K+ intake was associated with a decrease in risk for stroke.

K+ supplementation effective in lowering blood pressure in hypertensive individuals, and particularly among African Americans.

Sodium retention occurs in response to K+ depletion and vice versa.

K+ can stimulate endothelium-dependent vasodilatation, may increase nitric oxide synthesis and may lower sympathetic activity and reduce the negative actions of aldosterone.

Patients with hypertension have higher circulating aldosterone concentrations, and levels increase with the number of antihypertensive medications taken.

Consumption of a vegetarian diet is associated with lower blood pressures and is a useful nonpharmacological means of reducing blood pressure (Yokoyama Y et al).

Only 24% of patients with hypertension and on treatment have blood pressures of <140/90 mm Hg.

Treatment can reduce heart failure by 55%.

Initial evaluation includes assessment for other cardiovascular risk factors, end-organ damage analysis, assessment of concomitant diseases, identifying causes of hypertension, identifying lifestyle factors contributing to the process.

Systolic blood pressure and pulse pressure correlate more strongly with cardiovascular disease risk than does diastolic blood pressure.

Elevated diastolic pressures of greater than 120 mm Hg not associated with progressive or new end-organ damage can be managed over hours to days as an outpatient.

Marked elevation of diastolic blood pressures requires emergency management in an intensive care unit with parental medication treatment.

Reduction in systolic blood pressure of a little as 5 mm Hg reduces incidence of stroke by approximately 40% and myocardial infarction by 20%.

Weight reduction to a body mass index <24.9 kg/ m2 can decrease systolic pressure ranging from 5-20 mmHg with a 10 kg weight loss.

The DASH. diet should be implemented.

Exercise of 30 minutes of aerobic activity most days of the week encouraged.

First line drug therapy for hypertension consists of thiazide diuretics, calcium channel, blockers, and angiotensin converting enzyme inhibitors or angiotensin receptor blockers.

Among women with hypertension diuretic monotherapy, ACE inhibitors plus diuretics and B-blockers plus diuretics are superior to calcium channel blockers plus diuretics in preventing cardiovascular complications associated demonstrated in the Women’s Health Initiative Observational Study.

Diuretics, particularly thiazide type, are recommended as initial therapy for stage I hypertension (systolic blood pressure of 140-59 mm Hg or diastolic blood pressure of 90-99 mm Hg.

Beta blockers and not generally recommended for hypertension unless ischemic heart disease or heart failure is present.

In patients with hypertension and heart failure beta blockers may reduce the risk of death, and also may be useful to control angina in patients with hypertension and coronary artery disease.

Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial-a randomized double blind study involving hypertension compared an angiotensin converting enzyme (ACE) inhibitor benazepril (Lotensin) combined with the calcium channel blocking agent amlopidine (Norvasc) or the diuretic hydrochlorthiazide.

ACCOMPLISH results: the combination of benazepril and amlopidine compared to benazepril and hydrochlorthiazide revealed a 20% relative risk reduction and an absolute risk reduction of 2.2% of composite illness and death from cardiovascular causes, and a similar reduction from death due to cardiovascular reasons and nonfatal myocardial infarction.

ACCOMPLISH study patients was at high risk of cardiovascular disease with average age at entry was 68 years, a history of ischemic heart disease, peripheral vascular disease, left ventricular hypertrophy and diabetes were included.

In the second Nurses Health Study 83,882 adult women aged 27-44 yeas without hypertension were followed for 14 years for incident hypertension: low risk combinations of modifiable lifestyle factors such as maintaining a normal BMI, consuming a diet high in fruits, vegetables, low fat dairy products and low sodium , participating in vigorous daily physical activity, drinking a moderate amount of alcohol, avoidance of nonnarcotic and consuming folic acid were associated with a dramatic decrease in the incidence of hypertension (Forman JP).

Aggressive control of hypertension compared to standard treatment does not reduce all cause mortality  and rates of myocardial infarction, stroke, congestive heart failure major cardiovascular events and end-stage renal disease (Arguedas).

In a review of 22,000 participants with hypertension and comparing standard therapy with target treatment goals of lowering blood pressure to 140-160 mm Hg systolic and 90-100 mm Hg diastolic, while reducing systolic and diastolic blood pressure levels about 4 mm Hg and 3 mm Hg, respectively:  benefits were found to be limited (Cochrane Database).

European society of hypertension recommending threshold blood pressure levels of about 120 mm Hg systolic and 70 mm Hg diastolic for patients at high risk of cardiovascular complications from hypertension and suggest that further lowering of blood pressure is harmful (Sleight).

For stage 2 hypertension (systolic blood pressure ? 160 mm Hg or diastolic blood pressure ? 100 mm Hg) ACE inhibitors, angiotensin receptor blockers, B-blockers, or calcium channel blockers and combined therapy with thiazide diuretics plus another drug class are recommended agents.

Reduction of left ventricular mass with antihypertensive treatment can improve patients prognoses.

Persistence of LVH with antihypertensive drugs is associated with a poor prognosis.

Inhibition of the renin-angiotensin system with angiotensin-converting enzyme inhibitors, or angiotensin-II receptor blockers, should be the first line treatment in patients with nephropathy, with or without diabetes, to decrease proteinuria and slow progression of renal disease.

Hypertension Optimal Treatment (HOT) trial suggested reduced cardiovascular outcomes for diabetic patients assigned to diastolic treatment goal of less than 80 mm Hg compared to treatment with higher goals (Hannson L).

United Kingdom Prospective Diabetes Study group data indicated tight control of blood pressure reduced macrovascular and microvascular outcomes.

Tight control of systolic blood pressure among patients with diabetes and coronary artery disease is not associated with improved cardiovascular outcomes compared with usual control (Cooper-DeHoff, RM).

In the above study during 16893 patient-years of follow-up the same degree of cardiovascular outcomes was noted among the tight controlled group and the usual treatment control group (Cooper-DeHoff, RM).

Decreasing systolic blood pressure to lower than 130 mm Hg in patients with diabetes and coronary artery disease is not associated with further reduction in morbidity beyond that associated with systolic blood pressure lower than 140 mm Hg, and is associated with an increase in all-cause mortality (Cooper-DeHoff, RM).

Randomized blood pressure target strategy studies suggests systolic blood pressure target of less than 130 mmHg achieves an optimal balance between efficacy and safety.

Induction of left ventricular hypertrophy results in excess fibrous tissue deposition throughout the myocardium increasing the likelihood of ventricular arrhythmias than patients without LVH or with normal blood pressure.

12-27% of all hypertensive patients require at least 3 drugs for adequate blood pressure control, and a considered resistant hypertension patients.

Patients with resistant hypertension approximately 50% more likely to have a cardiovascular event than patients without resistant hypertension.

Patients with hypertension benefit from low levels of alcohol intake, although hypertensive guidelines advise that alcohol intake should not exceed two drinks per day among men and one drink per day among women.

In older individuals with mild cognitive deficits stopping antihypertensive treatment does not improve cognition, psychological or general daily function (Moonen JEF).

Endovascular catheter based denervation of the renal efferent and afferent nerves with minimal invasive procedures, can reduce blood pressure in individuals with uncontrolled hypertension.

Nearly one out of five American adults with hypertension is on a prescription drug known to raise blood pressure: National Health and Nutrition Examination Survey (NHANES).


The most widely used class of agents with this effect was antidepressants, used by 8.7%; followed by nonsteroidal anti-inflammatory drugs (NSAIDs), used by 6.5%; steroids, 1.9%; estrogens, 1.7%; and several other agents each used by fewer than 1% of the study cohort.


The use of prescription drugs known to raise blood pressure could prevent BP control depending on the exact blood pressure impact that various pressure-increasing drugs have.


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