Essential Hypertension. Part I: Definition and Etiology. Oscar A. Carretero; and; Suzanne Oparil; From the Hypertension and Vascular Research Division, Heart. Essential hypertension is the form of hypertension that by definition has no identifiable cause. It is the most common type of hypertension, affecting 95% of. In as many as 95% of reported high blood pressure cases in the U.S., the underlying cause cannot be determined. This type of high blood pressure is called.
However, certain risk factors that make the condition more likely have been identified. Those with a family history of essential hypertension are more likely to be at risk of developing the condition themselves. Fifty genes have been identified as linked to high blood pressure. Multiple factors related to aging have been shown to increase the likelihood of essential hypertension. These include the stiffening of the arteries and the onset of certain renal microvascular diseases not yet perceived as a cause.
It is thought that long-term or chronic mental stress is linked to the development of essential hypertension. Excessive salt sodium consumption, defined by the American Heart Association as eating over mg per day, can play a role in the onset of essential hypertension.
Salt increases retention of water in the body, which in turn increases the volume of blood and, consequently, blood pressure. People with both low and high levels of renin are at risk of the condition. The link between leading a sedentary lifestyle and an increased chance of essential hypersensitivity is well studied.
To lead a healthy lifestyle and reduce the risk of high blood pressure, it is recommended that adults engage in at least 30 minutes of moderate physical activity five days a week. Research indicates that hypertension is often more common in people of Afro-Caribbean descent.
Hypertension also tends to occur earlier in life, be more severe and be associated with a higher risk of organ damage in people from this group.
Excessive alcohol intake, defined by the U. Department of Health as consuming more than one drink per day for women and two drinks per day for men, is associated with hypertension.
A lack of physical activity is associated with hypertension. Exercise is one of the key methods of managing high blood pressure. Essential hypertension is diagnosed by taking blood pressure measurements using a blood pressure monitor, which is also called a sphygmomanometer or an aneroid device.
These tests are routinely carried out as part of a normal medical examination. To do this, a doctor may ask people to measure their own blood pressure daily, at home or at a pharmacy. Blood pressure readings are expressed as two numbers, for example: The first number is systolic pressure, which shows the amount of force being exerted on the artery walls as the heart pumps.
The second number is diastolic pressure, which shows the amount of force being exerted on the artery walls between beats of the heart. A healthy systolic reading is or lower. A healthy diastolic reading is 80 or lower. Between 80 and 89 is considered normal, but not optimum, and over 90 is hypertensive.
These values can be used as a general guide, but it should be noted that the thresholds for healthy and hypertensive blood pressure tend to differ between countries. People worried about their risk of hypertension should visit a doctor for testing. The free Ada app can also be used to carry out a symptom assessment.
Doctors may recommend a range of lifestyle adjustments that will commonly include: If lifestyle changes do not produce satisfactory results, a doctor may prescribe medication aimed at lowering blood pressure. People diagnosed with essential hypertension generally stand a good chance of lowering their blood pressure through lifestyle changes, medication or a combination of the two.
Depending on the person, medications may need to be taken indefinitely. In some cases, the use of medication can be stopped after blood pressure has fallen, with these lower levels then maintained through lifestyle alterations. If essential hypertension is left untreated, it can lead to a variety of potentially serious complications. The heart, arteries and vascular system can be damaged, leading to:. Essential hypertension is a factor in approximately one percent of pregnancies. Some women develop hypertension during pregnancy; this is a seperate condition called gestational high blood pressure.
Typically, the blood pressure levels of women with essential hypertension during pregnancy will remain stable or fall in the early stages of pregnancy, before accelerating in around the second or third trimester. Essential hypertension in pregnancy may cause complications including: Women with essential hypertension in pregnancy will have their blood pressure levels monitored regularly by their doctor or midwife. If levels become high, the urine will be checked for protein, and symptoms of preeclampsia will be checked for.
If signs of preeclampsia are found, a specialist will be brought in for treatment. If blood pressure levels are high but there are no signs of preeclampsia, treatment will depend on the severity of the hypertension and the risks posed to the pregnancy.
To identify potential risks, ensure proper care is given and monitor the health of the baby. Women may be admitted to hospital to undergo blood tests, ultrasounds and other tests. In some cases, medication may be prescribed to lower blood pressure levels.
Can essential hypertension be treated successfully? Yes, in many cases, there is a good chance that blood pressure can be lowered if the appropriate treatment methods are followed. To ensure blood pressure remains at a healthy level, most people will be required to maintain lifestyle changes and, if required, take medication, possibly for the rest of their lives.
What is malignant essential hypertension? Malignant essential hypertension, sometimes called accelerated hypertension, is a form of hypertensive emergency. It involves high blood pressure that develops very quickly, causing serious complications. The malignant variety is extremely rare, affecting roughly one percent of those with high blood pressure, but if it is suspected, it should be treated as a medical emergency. What is benign essential hypertension?
Intensification of BP regimen needs to be individualized. Options include full titration of the first drug to maximal dose before adding a second drug, or adding a second drug in submaximal dose to the first drug at submaximal dose. These findings have led to a paradigm shift from a step-wise approach in which the dose of the first drug would be maximized before other drug could be added, to the current recommended approach starting the second drug while the patient is on half standard dose of the first drug.
Several different classes of antihypertensive drugs exist and the selection of the initial agent s depends on:. In most patients with uncomplicated hypertension, cardiovascular risk reduction is related to the amount of BP reduction and not the initial choice of antihypertensive drug therapy. In patients with comorbidities, selection of the drug is guided by the safety of the drug with certain comorbidities and the benefit of additional cardiovascular risk reduction, beyond BP reduction.
The advantages and disadvantages of different antihypertensive drugs are listed in Figure 8 , and preferred drugs for compelling conditions are listed in Figure 9. Using a higher dose of a single medication in some patients may be offset by the cost of increased risk of side effects. Combination therapies often display near additive effects on BP reduction. This may be related to the ability of one drug to block the counter regulatory responses of the other.
The combination of a thiazide diuretic and RAAS blocker is perhaps the most commonly used drug combination. Selection of combination therapies should be based on their complementary action, additional cardiovascular reduction beyond BP control, safety profile, and presence of a specific indication in addition to BP control. Several potentially beneficial combinations are listed in Figure The combination therapy of ACEI and ARB or an ARB and inhibitor that was earlier advocated for proteinuria reduction in the management of patients with CKD is not recommended due to lack of any clinical benefit and is potentially harmful.
In the recently published VA - NEPHRON - D trial, combined use of ACEI and ARB showed no significant benefit in proteinuria reduction in diabetic patients and the data monitoring safety committee stopped the trial before completion due to increased episodes of hyperkalemia and acute kidney injury in patients on dual therapy. It is safe to conclude that combination RAAS blockade therapy should be avoided in all patients. Obesity is a growing epidemic in the US, affecting one third of its population, which significantly increases the risk of hypertension.
Obesity is associated with multiple other comorbidities such as diabetes, coronary heart disease, stroke and obstructive sleep apnea OSA that further increase the risk of cardiovascular disease.
Obesity is particularly prevalent in AA and Hispanics and individuals of low socioeconomic status. Over two thirds of hypertensive individuals have been shown to be overweight or obese, suggesting a possible relationship between these two major public health issues. Multiple pathophysiological mechanisms exist in the development of hypertension in obese individuals.
Several animal and human studies have proved that RAAS is upregulated in obese individuals. This upregulation of RAAS cascade is directly linked to the selective production of angiotensinogen by the adipocytes which increase the circulating systemic levels leading to RAAS activation and hypertension.
Abundant evidence exists that SNS activity is exacerbated in obese individuals but the mechanisms are largely unclear. Best proposed hypothesis suggests a possible role of leptin secreted by adipocytes to directly increase SNS activity though the mechanism by which this occurs remains unexplained. Other molecules such as adiponectin, resistin and insulin have also been identified as other possible molecules involved in SNS activation. Intermittent hypoxia is a common manifestation in these patients and has been implicated in enhancing SNS activity which promotes the development of hypertension.
Besides, there is evidence of impairment of endothelium mediated vasodilation of peripheral vessels, thereby contributing to an increase in peripheral resistance. Endothelin-1 levels have been found to be increased in OSA patients and correlate with the severity of hypertension. How does the treatment of hypertension differ in obese individuals as compared to the general hypertensive population?
The treatment of hypertension in obese patients should specifically target the pathophysiologic mechanisms that play a role in raising BP. Weight reduction achieved with DASH diet and physical exercise is perhaps the cornerstone in the treatment of hypertension in obese patients.
It is vital that patients be educated that even slight reduction in weight is beneficial in reducing BP, though it is extremely important that weight loss be sustained to see this benefit. Pathophysiologically, weight loss leads to reduction in RAAS activity, SNS activity which leads to decrease in cardiac output, peripheral resistance and left ventricular mass, all of which promote improvement in BP and improve cardiovascular health.
Additionally, leptin, endothelin-1 and insulin resistance is lowered with weight loss. Other non-pharmacological measures like a low sodium, high potassium diet are equally important.
Recent animal studies also indicate that a subset of obese patients may have salt sensitive hypertension, giving us another good reason to recommend low sodium diet in this population. The metabolic effects of RAAS blockade include reduction in proteinuria and lower norepinephrine, leptin and insulin levels with heightened insulin sensitivity, all of whom lead to lowering of BP in this population.
Although limited, the best clinical evidence comes from TROPHY study in which treatment of hypertension in obese patients with lisinopril not only led to improvement in BP but no metabolic side effects were noted as compared to the other arm in which treatment with thiazide diuretics was associated with increased incidence of hyperglycemia.
Similar findings were noted in other study that used amlodipine versus aliskiren or irbesartan in patients already on thiazide diuretics. Patients on amlodipine reported high rate of peripheral edema.
Though clinical trials specifically using aldosterone blockade are lacking in obese patients, a growing body of evidence indicates that aldosterone activation is associated with insulin insensitivity, glucose intolerance in addition to its hypertensive action, thereby suggesting a beneficial role of aldosterone blockade in the management of hypertension in obese patients.
Therefore RAAS inhibitors such as ACE inhibitors, ARB, direct renin inhibitors and possibly aldosterone blockers should be used as first line drugs in the management of hypertension in obese patients. Thazide diuretics are useful for BP control due to their natriuretic effect, as was noted in the TROPHY study but their unsafe metabolic profile with increased insulin resistance, predisposition to hyperglycemia and risk of visceral obesity precludes its use as a first line agent in obese patients.
It still can be used as an adjunctive therapy in patients already on RAAS blockers. Calcium channel blockers are a preferred adjunctive therapy in management of hypertension because of their ability to reduce peripheral resistance, induce mild natriuresis and diuresis, and offer a safe metabolic profile.
Moreover, they lower blood pressure effectively regardless of age, gender, ethnicity, and salt consumption. Although drugs that cause SNS blockade are effective in obese patients, they are generally less preferred due to side effects. Alpha-2 blockers may be poorly tolerated by patients due to increase side effects such as dry mouth and sedation. In the older individuals, hypertension increases the risk for cardiovascular events stroke and CHF , incident diabetes, atrial fibrillation and CKD.
Contrary to the older belief that hypertension in older patients is an adaptive response to aging to support organ perfusion, clinical trial evidence, particularly the Framingham Heart study, SHEP, and other epidemiologic studies have conclusively indicates that elevation in SBP in older individuals is associated with adverse cardiovascular events, particularly stroke and CHF, and progression to ESRD.
Aging causes stiffness in the large blood vessels due to increased collagen deposition and a decrease in elastin. These alterations decrease arterial compliance and elasticity thereby resulting in increased SBP, decreased DBP and widened pulse pressure. In addition, older people have increased salt sensitivity due to altered handling in sodium by the kidney and reduction on sodium potassium: ATPase activity with age that promotes an increase in peripheral resistance.
Hypertension in older patients is associated with much more increased risk of stroke and CHF as compared to younger individuals. Older patients are at increased risk of symptomatic hypotension due to high prevalence of autonomic dysfunction. It is therefore advisable to check BP in both the sitting and standing position in older patients with progressive reduction of BP. In older patients with concomitant ischemic heart disease, DBP should probably not be lowered below 60 mmHg.
Careful individualization of blood pressure targets is needed in all, but especially older patients. The magnitude of SBP elevation in older patients is much greater than younger after individuals necessitating 2 or 3 medications, preferably with long acting diuretics, or CCBs, and RAAS inhibitors. The use of RAAS blocking agents may provide additional benefit of cardiovascular risk.
Older patients are at increased risk of falls and medication side effects, particularly electrolyte abnormalities and worsening kidney function. Close monitoring every few months is therefore recommended.
Hypertension affects one third of adult US population, but minorities such as AA, non-white Hispanics and South Asians are disproportionately more affected. AA patients are generally younger, have stage 2 hypertension, and are more likely to have associated target end organ damage such as LVH, diastolic dysfunction and CKD compared to non-AA.
On the contrary, Mexican-Americans have the lowest awareness of their condition, and are therefore less likely to receive treatment and have BP under control. This is likely due to their low socioeconomic status and lack of access to healthcare. Although somewhat speculative, genetic tendencies may likely predispose to hypertension in AA.
Additionally, genetic alterations involving sodium handling by the kidneys, RAAS polymorphisms, endothelial stiffness, and altered NO synthesis and metabolism have all been suggested as putative factors in increasing hypertension prevalence in this population. Prevalence preterm birth and small for gestational age are more common in minority populations. These conditions may predispose to future risk of CKD and hypertension.
In addition, pre-eclampsia is common in AA and predisposes to the future risk of hypertension in the offspring. Obesity is more prevalent in minorities, particularly in AA, and non-white Hispanics. This coupled with low rates of physical activity, significantly increases the risk of hypertension. Poor dietary habits such as high salt intake, high calorie foods also increase hypertension risk. Coexisting medical conditions such as diabetes and CKD and contribute to the burden of high hypertension in this population.
Lastly, low socioeconomic status and literacy along with lack of access to quality health care and physician perception towards difficulty in BP control in minorities may form important impediments in better identification and treatment of hypertension. The evidence-based goal of systolic blood pressure in all patients irrespective of ethnicity and socioeconomic status is. However, all BP goals need to be carefully individualized. The management of hypertension requires therapeutic lifestyle changes to play an important central role in blood pressure reduction.
These recommendations are well supported by the ALLHAT trial that compared chlorthalidone with lisinopril and amlodipine as a first line treatment of hypertension.
Chlorthalidone use was associated with a reduction in BP and led to better reduction in stroke, heart failure, and combined CV outcomes in the AA population. Lisinopril use led to less reduction in the incidence of stroke and combined CV outcomes. This was largely explainable by less reduction in BP. They provide almost similar blood pressure reduction. It is important to note that the angioedema can occur after being on the ACEI for a long time and recent reports have suggested recurrent abdominal pain in patients due to gut angioedema.
Limited data exists of any specific benefit of using one class of antihypertensive drugs over another in Hispanics and Asians. It is therefore reasonable to follow general guidelines for BP management in these populations. Post-transplant hypertension is associated with increased CV mortality, acute rejection and chronic allograft loss.
Multiple factors contribute to the development of hypertension in kidney transplant recipients KTRs. These include preexisting recipient factors, donor specific factors, use of immunosuppressive agents, and chronic allograft dysfunction Figure The use of calcineurin inhibitors CNIs is perhaps the most important cause in the pathogenesis of hypertension. CNIs cause hypertension due to salt retention with resultant volume expansion.
In addition, CNIs also activate SNS activity, intra-renal renin synthesis, and constriction of preglomerular vasculature, all of which promote development of hypertension. Tacrolimus TAC is associated with less risk of hypertension compared to cyclosporine. This is likely a dose-related side effect. Transplant renal artery stenosis tRAS is another important etiologic factor in the development of hypertension following kidney transplantation.
Late tRAS is rarely related to surgical complications. Several risk factors have been implicated in the development of late tRAS, including graft rejection, CMV infection, prolonged cold ischemia time, delayed graft function, and pediatric donor source.
This recommendation is largely derived from extrapolation of results from epidemiologic data and is not strictly evidence based.
CCBs are often recommended as first line agents in the management of post-transplant HTN due to their ability to attenuate the effect of CNI-induced preglomerular vasoconstriction. Early studies in KTRs discouraged the use of RAAS inhibitors due to the concerns of hyperkalemia, anemia and risk of acute kidney injury.
However, recent studies have demonstrated an increasing acceptance of the use of RAAS blockers because of their cardiovascular benefits and antiproteinuric effects. Their role in the preservation of long term allograft function is unclear. Often KTRs will need some diuretic support for BP control, especially if there is evidence of graft dysfunction. Hypertension is a major independent risk factor for coronary artery disease in adults. The target goals for BP in patients for primary and secondary prevention of coronary artery disease are listed in Figure 5.
How do the recommendations for patients with CAD differ from general population, and why? Certain differences exist in the treatment of hypertension in patients with ischemic heart disease. This phenomenon is likely due to impaired coronary perfusion during diastole beyond the autoregulatory threshold of the endothelium due to decreased DBP in patients with CAD.
It should however be stated that this phenomena has not been consistently demonstrated in clinical studies and merits further review. Moreover, the influence of heart rate has never been evaluated. It is likely that as heart increases above 80 that the ischemic risk of low DBP increases. Lowering of the BP below mmHg with amlodipine or enalapril was associated with decreased cardiovascular events. What are the important differences in the management of hypertension in patients with CAD, acute coronary syndromes and patients with ischemic LV dysfunction?
There is general agreement that the amount of BP reduction rather than the choice of antihypertensive drug is a major determinant of reduction in cardiovascular risk.
Thiazide diuretics are acceptable alternatives though there are concerns about their long-term metabolic effects. If combination therapy is needed, these three agents still remain first line agents even in the absence of diabetes and left ventricular dysfunction.
The presence of systolic dysfunction however, precludes their use in management of these patients. Thiazide diuretics can be used for additional BP control. Loop diuretics may be preferable in volume overloaded patients or when renal dysfunction is present. These drugs reduce risk of cardiovascular death and benefits may be seen beyond BP reduction.
Amlodipine and other dihydrpyridine CCBs appear safe but do not offer any cardiovascular benefit beyond BP reduction. N Engl J Med. No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC. Essential Hypertension By Matthew R. Prevalence What tests to perform? What tests are routinely indicated in the initial evaluation of patients with hypertension? When should additional testing be considered? How should patients with essential hypertension be managed?
Are BP measurements obtained at sites other than the arm reliable? What is the role of 24 hour ambulatory blood pressure monitoring ABPM and home blood pressure monitoring HBPM in the management of patients with hypertension? How is pre-hypertension defined and how should we treat it? How should patients with pre-hypertension be managed? What is the goal blood pressure in the management of patients with hypertension and how low should we go? What are the risks of excessive BP lowering? What is the role of lifestyle modification in management of patients with hypertension?
Lower sodium intake Higher potassium intake DASH diet Alcohol consumption Weight loss Physical activity When should drug treatment be initiated in the management of patients with hypertension? How should antihypertensive drugs be selected in management of hypertension in the general population?
What combination of drugs is preferred and which ones should be avoided? Which combination antihypertensive therapies should be preferred and which ones should be avoided? How is hypertension managed in these special populations?
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Essential hypertension is high blood pressure that doesn't have a known cause. Get information on risk factors, diagnosis, treatment, and more. Typically diagnosed by screening of an asymptomatic individual. Treatment of uncontrolled hypertension reduces the risks of mortality and of cardiac, vascular, . For most adults, there's no identifiable cause of high blood pressure. This type of high blood pressure, called primary (essential) hypertension.