What is Hypertension?
Hypertension is defined as persistent systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg, and is the leading risk factor for cardiovascular disease globally.
Diagnostic Criteria
Hypertension is classified according to the following blood pressure categories 1:
| Category | Systolic BP (mmHg) | Diastolic BP (mmHg) |
|---|---|---|
| Normal | <120 | and <80 |
| Elevated | 120-129 | and <80 |
| Stage 1 Hypertension | 130-139 | or 80-89 |
| Stage 2 Hypertension | ≥140 | or ≥90 |
Proper diagnosis requires:
- Blood pressure measurements at least twice during two or more separate visits over 1-several weeks
- Use of properly calibrated devices and correct measurement technique
- Consideration of white-coat or masked hypertension
Pathophysiology and Clinical Impact
Hypertension is a nutritional-hygienic disease with multiple contributing factors 2:
- Prolonged caloric intake exceeding energy expenditures
- Chronic supraphysiological intake of dietary sodium
- Excessive alcohol consumption
- Psychosocial stressors
- Physical inactivity
The relationship between blood pressure and cardiovascular risk is continuous, graded, and direct, with no evidence of a threshold, starting from blood pressure as low as 110 mmHg systolic 1.
Complications and Target Organ Damage
Elevated blood pressure, particularly systolic BP, is linked to multiple adverse clinical outcomes 2, 1:
- Stroke
- Heart failure
- Myocardial infarction
- Renal insufficiency/failure
- Peripheral vascular disease
- Retinopathy
- Dementia
- Premature mortality
These outcomes are typically preceded by pressure-related target-organ damage such as:
- Left ventricular hypertrophy
- Renal insufficiency
- Proteinuria
Hypertensive Emergencies
Hypertensive emergencies are situations where very high BP values are associated with acute hypertension-mediated organ damage 2. They include:
Malignant hypertension: Severe BP elevation (usually >200/120 mmHg) with advanced retinopathy (bilateral flame-shaped hemorrhages, cotton wool spots, or papilledema)
Hypertensive encephalopathy: Severe hypertension with neurological symptoms (seizures, lethargy, cortical blindness, coma)
Hypertensive thrombotic microangiopathy: Severe BP elevation with hemolysis and thrombocytopenia
Other presentations include severe hypertension associated with:
- Cerebral hemorrhage
- Acute stroke
- Acute coronary syndrome
- Cardiogenic pulmonary edema
- Aortic aneurysm/dissection
- Severe preeclampsia and eclampsia
Management Approach
Lifestyle Modifications
The cornerstone of hypertension prevention and management includes 1:
- Mediterranean or DASH diet
- Regular aerobic exercise and resistance training
- Weight management (BMI 20-25 kg/m²)
- Limiting alcohol consumption
- Smoking cessation
- Restricting sodium intake
Pharmacological Treatment
For confirmed hypertension (≥140/90 mmHg), both lifestyle measures and pharmacological treatment should be initiated promptly 1:
First-line medications include:
Combination therapy is recommended for most patients with confirmed hypertension, preferably as fixed-dose single-pill combinations for better adherence 1
Treatment targets: The American College of Cardiology recommends targeting a systolic blood pressure of 120-129 mmHg for most adults if well tolerated 1, 5
Special Considerations
Elderly patients: Consider frailty and orthostatic hypotension when initiating therapy 1
Comorbidities: Patients with specific comorbidities (diabetes, chronic kidney disease, coronary artery disease) require individualized medication choices and blood pressure goals 1
Pregnancy: Hypertension in pregnancy requires specific management approaches and medication choices 2
Monitoring and Long-term Management
- Blood pressure should be measured at every routine clinical visit or at least every 6 months
- Treatment should be maintained lifelong if well tolerated
- Medications should be taken at the most convenient time of day to improve adherence 1
Effective blood pressure control provides significant benefits, including reduced mortality from coronary heart disease, stroke, and all-cause mortality 1, 5.