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Hypertension (HTN)

Brief Overview: Hypertension is a chronic medical condition characterized by persistently elevated blood pressure in the arteries. It is often asymptomatic but significantly increases the risk of cardiovascular disease, stroke, kidney disease, and other complications if not adequately managed. Hypertension may be primary (essential) with no single identifiable cause, or secondary to another medical condition. Management focuses on long-term blood pressure control, risk reduction, and prevention of end-organ damage.

Per UpToDate, blood pressure parameters are:

  • “Normal blood pressure – Systolic <120 mmHg and diastolic <80 mmHg
  • Elevated blood pressure – Systolic 120 to 129 mmHg and diastolic <80 mmHg
  • Hypertension:
    • Stage 1 – Systolic 130 to 139 mmHg or diastolic 80 to 89 mmHg
    • Stage 2 – Systolic at least 140 mmHg or diastolic at least 90 mmHg

If there is a disparity in category between the systolic and diastolic pressures, the higher value determines the stage.”

Prevalence: According to the World Health Organization (WHO), “An estimated 1.4 billion adults aged 30–79 years worldwide had hypertension in 2024; this represents 33% of the population in this age range.”

Etiology:

  • Primary: According to UpToDate, “The pathogenesis of primary hypertension (formerly called "essential" hypertension) is poorly understood but is most likely the result of numerous genetic and environmental factors that have multiple compounding effects on cardiovascular and kidney structure and function.”
  • Secondary: According to UpToDate, “A number of common and uncommon medical conditions may increase blood pressure and lead to secondary hypertension. In many cases, these causes may coexist with risk factors for primary hypertension and are significant barriers to achieving adequate blood pressure control. Major causes of secondary hypertension include:
    • Prescription or over-the-counter medications [2,11]:
      • Oral contraceptives, particularly those containing higher doses of estrogen
      • Anti-inflammatory agents (NSAIDs), particularly chronic use
      • Acetaminophen, when given at doses of 4 grams per day for several weeks or more
      • Antidepressants, including tricyclic antidepressants, selective serotonin reuptake inhibitors, and monoamine oxidase inhibitors
      • Corticosteroids, including both glucocorticoids and mineralocorticoids
      • Decongestants, such as phenylephrineand pseudoephedrine
      • Glycyrrhizin (traditional black licorice)
      • Sodium-containing antacids
      • Erythropoietin
      • Cyclosporineor tacrolimus
      • Stimulants, including methylphenidate, amphetamines, and some weight-loss medications
      • Atypical antipsychotics, including clozapineand olanzapine
      • Angiogenesis inhibitors, such as bevacizumab
      • Tyrosine kinase inhibitors, such as sunitiniband sorafenib
    • Illicit drug use – Drugs such as methamphetamines and cocaine can raise blood pressure.
    • Primary kidney disease – Both acute and chronic kidney disease can lead to hypertension.
    • Primary aldosteronism
    • Renovascular hypertension
    • Obstructive sleep apnea
    • Pheochromocytoma
    • Cushing's syndrome
    • Other endocrine disorders – Hypothyroidism, hyperthyroidism, and hyperparathyroidism may also induce hypertension
    • Coarctation of the aorta

Risk Factors:

  • Age
  • Obesity
  • Social determinants – low SES, lack of health insurance, food and housing insecurity, exposure to discrimination, and lack of access to safe spaces for exercise
  • African American race
  • High sodium diet
  • Excessive alcohol consumption
  • Physical inactivity
  • Reduced nephron number
  • Insufficient sleep
  • History of gestational HTN or preeclampsia
  • Noise and air pollution

Commonly Associated Conditions:

  • Coronary artery disease
  • Heart failure
  • Stroke and transient ischemic attack (TIA)
  • Chronic kidney disease
  • Peripheral arterial disease
  • Atrial fibrillation
  • Metabolic syndrome

Common Medications:

Medication selection depends on comorbidities, age, race, kidney function, and tolerance.

  • First-line agents:
    • Thiazide-like or thiazide-type diuretics – HCTZ, chlorthalidone
    • Long-acting calcium channel blockers – amlodipine, diltiazem
    • Angiotensin-converting enzyme (ACE) inhibitors – lisinopril, benazepril, enalapril
    • Angiotensin II receptor blockers (ARBs) – losartan, valsartan
  • Additional/adjunctive agents:
    • Beta-blockers: metoprolol, atenolol (often used with CAD, AFib, HF)
    • Aldosterone antagonists: spironolactone (resistant HTN)
    • Loop diuretics: furosemide (CKD or HF)
    • Alpha blockers or central agents: clonidine, hydralazine (selected cases)

Many patients require more than one medication for adequate control.

Common Labs, Imaging, and Tests:

  • Electrolytes (including calcium) and serum creatinine (to calculate the estimated glomerular filtration rate)
  • Fasting glucose
  • Urinalysis
  • Complete blood count
  • Thyroid-stimulating hormone
  • Lipid profile
  • Electrocardiogram
  • Calculate 10-year atherosclerotic cardiovascular disease risk
  • Echocardiogram may be indicated for some

Common Symptoms:

  • Can be asymptomatic
  • According to the WHO, “Very high blood pressure can cause headaches, blurred vision, chest pain and other symptoms. 
  • People with very high blood pressure (usually 180/120 or higher) can experience symptoms including:
    • severe headaches
    • chest pain
    • dizziness
    • difficulty breathing
    • nausea
    • vomiting
    • blurred vision or other vision changes
    • anxiety
    • confusion
    • buzzing in the ears
    • nosebleeds
    • abnormal heart rhythm”

Common Treatments:

  • Lifestyle modifications:
    • DASH diet
    • Exercise
    • Limit alcohol intake
    • Stress management
    • Weight loss
    • Dietary salt restriction
    • Potassium supplementation, preferably dietary
  • Medication (see above)
  • Home blood pressure monitoring
  • Management of contributing conditions (diabetes, OSA, CKD)
  • Regular follow-up and medication titration
  • Patient education on adherence and long-term risks

Physical Findings:

  • Elevated blood pressure readings
  • Often normal physical exam
  • Signs of target-organ damage in advanced disease:
    • Retinopathy
    • Left ventricular hypertrophy
    • Peripheral edema
    • Carotid bruits

Potential Complications and Contraindications:

  • Potential complications:
    • Stroke
    • Myocardial infarction (heart attack)
    • Heart failure
    • Chronic kidney disease
    • Vision loss, hypertensive retinopathy
    • Peripheral arterial disease
    • Atrial fibrillation
    • CAD
    • Cognitive impairment, dementia
    • Erectile dysfunction
  • Contraindications / cautions:
    • ACE inhibitors/ARBs contraindicated in pregnancy
    • Monitor electrolytes and kidney function with diuretics and RAAS blockers
    • Orthostatic hypotension risk in older adults
    • Avoid abrupt discontinuation of certain agents (e.g., beta-blockers, clonidine)

General Health and Lifestyle Guidance:

  • Follow DASH-style diet (low sodium, high fruits/vegetables)
  • Limit sodium intake (<1,500–2,300 mg/day typically recommended) as directed by healthcare provider
  • Maintain optimal body weight, as recommended by healthcare provider
  • Engage in regular physical activity, as tolerated, and as approved by healthcare provider
  • Limit alcohol intake
  • Avoid tobacco use
  • Manage stress and improve sleep quality
  • Encourage home BP monitoring and tracking

Suggested Questions to Ask Patients:

  1. Do you monitor your blood pressure at home? What are your typical readings?
  2. Are you taking your medications daily as prescribed?
  3. Any side effects (dizziness, swelling, cough)?
  4. Any recent ER visits, chest pain, or neurologic symptoms?
  5. How is your diet and sodium intake?
  6. Do you exercise regularly?
  7. Any history of kidney disease, diabetes, or heart disease?

Suggested Talking Points:

  • High blood pressure often has no symptoms, but it can cause serious damage over time.
  • Taking medication consistently is key—even when you feel well.
  • Lifestyle changes can significantly lower blood pressure and reduce medication needs.
  • Home blood pressure readings can help guide treatment decisions.
  • Controlling blood pressure lowers the risk of heart attack, stroke, and kidney disease.
  • Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  

Sources:

Blood Pressure Categories

BLOOD PRESSURE CATEGORY

SYSTOLIC mm Hg (top/upper number)

and/or

DIASTOLIC mm Hg (bottom/lower number)

NORMAL

LESS THAN 120

and

LESS THAN 80

ELEVATED

120 – 129

and

LESS THAN 80

STAGE 1 HYPERTENSION (High Blood Pressure)

130 – 139

or

80 – 89

STAGE 2 HYPERTENSION (High Blood Pressure)

140 OR HIGHER

or

90 OR HIGHER

SEVERE HYPERTENSION (If you don’t have symptoms*, call your health care professional.)

HIGHER THAN 180

and/or

HIGHER THAN 120

HYPERTENSIVE EMERGENCY (If you have any of these symptoms*, call 911.)

HIGHER THAN 180

and/or

HIGHER THAN 120

*symptoms: chest pain, shortness of breath, back pain, numbness, weakness, change in vision or difficulty speaking

*Graphic from the American Heart Association

 

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.