HYPERTENSION

Hypertension

Blood pressure is the force exerted by the blood against the walls of the blood vessels. The pressure depends on the work being done by the heart and the resistance of the blood vessels.

Medical guidelines define hypertension as a blood pressure higher than 120 over 80 millimeters of mercury (mmHg), according to guidelines issued by the American Heart Association (AHA) in November 2017.

Hypertension and heart disease are global health concerns. The World Health Organization (WHO) suggests that the growth of the processed food industry has impacted the amount of salt in diets worldwide, and that this plays a role in hypertension.

This Hypertension Highlights publication summarizes key changes and information from the 2017 Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults. It focuses on recommendations and changes that are most significant for the treatment of patients with hypertension. For more detailed information and references, see the full 2017 Hypertension Guideline publication.

Important Statistics The 2017 Hypertension Guideline includes some important new statistics. Under the updated guideline, more people will be diagnosed with hypertension—nearly half of American adults (46%), up from 32% under the previous definition. But nearly all of these new patients can treat their hypertension with lifestyle changes instead of medications, and overall only a small percentage more adults will also require antihypertensive medications. Specifically, the updated guideline means that most black adults have hypertension—56% of women and 59% of men—and black men now have the highest rate of hypertension; previously, black women did. Hypertension rates will also nearly triple among all men 20 to 44 years of age, increasing to 30% from 11%. In addition, rates of hypertension will double among women younger than age 45, from 10% to 19%. Hypertension is also present in more than 80% of patients with atrial fibrillation, by far the most common comorbid condition regardless of age,18 and 80% of adults with diabetes mellitus have hypertension.19

Other statistics in the updated guideline show that only about 20% of patients with hypertension followed their treatment plan well enough to improve, and up to 25% of patients fail to even fill their initial prescription. Left untreated, systolic BP higher than 180 mm Hg or diastolic BP higher than 120 mm Hg can lead to a nearly 80% chance of the patient dying within a year. Average survival for this group is about 10 months.

Diagnosing Hypertension

Recommendation: BP categories are normal, elevated, or stage 1 or 2 hypertension.

The new Hypertension Guideline changes the definition of hypertension, which is now considered to be any systolic BP measurement of 130 mm Hg or higher or any diastolic BP measurement of 80 mm Hg or higher. Hypertension was previously defined as a systolic BP of 140 mm Hg or higher or a diastolic BP of 90 mm Hg or higher. With the updated guideline, measurements of 140/90 mm Hg or higher are considered stage 2 hypertension. Individuals with stage 1 or stage 2 hypertension should consult a healthcare provider for further treatment.

Extremely high BP (systolic higher tan 180 mm Hg or diastolic higher than 120 mm Hg) with target organ damage is still considered an emergency.

A continuous association exists between higher BP and increased CVD risk, so it is useful to categorize BP levels for clinical and public health decision-making: normal BP, elevated BP, stage 1 hypertension, and stage 2 hypertension.

Measurement of BP

Although measuring BP in office settings is relatively easy, errors commonly occur, which can obscure a patient’s true BP level. Growing evidence supports the use of automated office BP measurements.

Patient Evaluation and History

When evaluating patients, note that primary hypertension likely requires treatment and is not due to a modifiable factor while secondary hypertension causes need to be explored and corrected before you diagnose hypertension.

Certain historical features favor specific causes of hypertension. Features of primary hypertension include

• Gradual increase with slow rate of rise in BP

• Lifestyle factors that favor higher BP

• Family history of hypertension Features of secondary hypertension include

• BP lability, episodic pallor, and dizziness (pheochromocytoma)

• Snoring, hypersomnolence (obstructive sleep apnea)

• Prostatism (chronic kidney disease)

• Muscle cramps, weakness (hypokalemia from primary or secondary aldosteronism)

• Weight loss, palpitations, heat intolerance (hyperthyroidism)

• Edema, fatigue, frequent urination (kidney disease or failure)

• History of coarctation repair

• Central obesity, facial rounding, easy bruisability (Cushing syndrome)

• Medication or substance use (eg, alcohol, nonsteroidal anti-inflammatory drugs, cocaine)

• Absence of family history of hypertension.

Blibliography

• Burt, Vicki L., et al. "Prevalence of hypertension in the US adult population: results from the Third National Health and Nutrition Examination Survey, 1988-1991." Hypertension 25.3 (1995): 305-313.
• Ong, Kwok Leung, et al. "Prevalence, awareness, treatment, and control of hypertension among United States adults 1999–2004." Hypertension 49.1 (2007): 69-75.