What are the symptoms and treatment options for hypertension?

Symptoms and Treatment of Hypertension

Symptoms of Hypertension

Most patients with chronic hypertension are asymptomatic, which is why it is often called a "silent killer"—symptoms only appear when blood pressure becomes severely elevated or causes acute organ damage. 1, 2

Chronic Hypertension (Typically Asymptomatic)

• The vast majority of the 116 million American adults with hypertension have no symptoms at all 3
• Hypertension is usually discovered incidentally during routine blood pressure screening 4
• Patients may remain unaware of their condition for years while silent vascular damage accumulates 3

Hypertensive Emergency Symptoms (Require Immediate Medical Attention)

When blood pressure exceeds 180/110 mmHg with acute organ damage, patients develop life-threatening symptoms that demand immediate emergency care. 1, 5

Neurological Symptoms

• Severe headache indicating hypertensive encephalopathy or intracranial hemorrhage 1, 2
• Visual disturbances including blurred vision, vision loss, or cortical blindness from retinal damage 1, 2
• Confusion, altered mental status, or memory problems representing early hypertensive encephalopathy 1, 2
• Focal neurological deficits such as unilateral weakness, facial drooping, or difficulty speaking suggesting stroke 2
• Seizures or loss of consciousness indicating severe encephalopathy with imminent brain damage 1, 2
• Dizziness from impaired cerebral autoregulation 1, 2
• Somnolence and lethargy that may precede tonic-clonic seizures 1

Cardiovascular Symptoms

• Chest pain suggesting acute myocardial infarction, unstable angina, or aortic dissection 1, 2
• Shortness of breath indicating acute left ventricular failure or pulmonary edema 1, 2

Other Symptoms

• Abdominal pain, nausea, or loss of appetite (less specific but warrant evaluation) 2

Critical Clinical Context

• The rate of blood pressure rise is more important than the absolute value—patients with chronic hypertension often tolerate pressures above 200/120 mmHg, while previously normotensive individuals may develop symptoms at lower levels 1, 5, 2
• The presence of symptoms indicating organ damage—not the blood pressure number alone—defines a true emergency 5, 2

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Treatment of Hypertension

Lifestyle Modifications (First-Line for All Patients)

Every patient with blood pressure ≥120/80 mmHg should implement lifestyle changes, which are partially additive and enhance pharmacologic therapy effectiveness. 1, 3

• Weight loss for overweight/obese patients 1, 3
• Dietary sodium reduction to <2 grams per day and potassium supplementation 1, 3
• Healthy dietary pattern (DASH diet or Mediterranean diet) 1, 3
• Regular physical activity (at least 150 minutes of moderate-intensity exercise weekly) 1, 3
• Alcohol moderation or elimination 1, 3
• Smoking cessation (mandatory, especially for patients with COPD or CAD) 1

Pharmacologic Treatment Algorithm

When to Initiate Drug Therapy

Begin antihypertensive medication when blood pressure is ≥140/90 mmHg, regardless of cardiovascular risk. 1

Blood Pressure Targets

• Adults <65 years: Target <130/80 mmHg 1
• Adults ≥65 years: Target SBP <130 mmHg (but <140/80 mmHg acceptable in elderly/frail patients) 1
• Patients with diabetes or chronic kidney disease: Target <130/80 mmHg 1
• Patients with heart failure: Target <130/80 mmHg but >120/70 mmHg 1

First-Line Medication Classes

Start with one of three first-line drug classes: thiazide/thiazide-like diuretics, ACE inhibitors or ARBs, or calcium channel blockers. 6, 7, 3

1. Thiazide or thiazide-like diuretics (e.g., chlorthalidone, hydrochlorothiazide)

   • Particularly effective as initial monotherapy 3, 8
   • Use loop diuretics if eGFR <30 mL/min/1.73m² 1

2. ACE inhibitors (e.g., lisinopril, enalapril) or ARBs (e.g., candesartan, valsartan)

   • Preferred for patients with chronic kidney disease (reduce albuminuria) 1, 6
   • Preferred for patients with heart failure 1
   • First-line for patients with coronary artery disease 1

3. Calcium channel blockers (e.g., amlodipine)

   • Dihydropyridine CCBs are first-line 1, 7, 3
   • Particularly effective in Black patients 7

Combination Therapy Strategy

Most patients require more than one medication to achieve blood pressure goals—use combination therapy systematically. 1, 3

For Non-Black Patients:

• Start with ACE inhibitor or ARB 1
• Add dihydropyridine calcium channel blocker if needed 1
• Add thiazide or thiazide-like diuretic as third agent 1

For Black Patients:

• Start with ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide/thiazide-like diuretic 1
• Add the missing component (diuretic or ARB/ACE inhibitor) as third-line 1

Special Population Considerations

Coronary Artery Disease:

• Use RAS blockers (ACE inhibitors or ARBs) and beta-blockers as first-line, with or without calcium channel blockers 1
• Add lipid-lowering therapy targeting LDL-C <55 mg/dL 1
• Add antiplatelet therapy with aspirin 1

Previous Stroke:

• Use RAS blockers, calcium channel blockers, and diuretics as first-line 1
• Add lipid-lowering therapy targeting LDL-C <70 mg/dL for ischemic stroke 1
• Add antiplatelet therapy for ischemic stroke (not hemorrhagic) 1

Heart Failure with Reduced Ejection Fraction:

• Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1
• Consider angiotensin receptor-neprilysin inhibitor (sacubitril-valsartan) as alternative to ACE inhibitors or ARBs 1
• Use calcium channel blockers only for poor blood pressure control 1

Chronic Kidney Disease:

• Use RAS inhibitors as first-line (reduce albuminuria beyond blood pressure control) 1
• Add calcium channel blockers and diuretics (loop diuretics if eGFR <30 mL/min/1.73m²) 1
• Monitor eGFR, microalbuminuria, and electrolytes regularly 1

COPD:

• Use ARBs and calcium channel blockers with or without diuretics 1
• Beta-blockers (β1-selective) may be used in selected patients with CAD or heart failure 1
• Smoking cessation is mandatory 1

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Treatment of Hypertensive Emergencies

Hypertensive emergency (BP >180/110 mmHg with acute organ damage) requires immediate ICU admission with continuous blood pressure monitoring and intravenous antihypertensive therapy. 1, 5

Blood Pressure Reduction Targets

Standard Approach (Most Hypertensive Emergencies):

• Reduce mean arterial pressure by 20-25% within the first hour 1, 9, 5
• If stable, reduce to 160/100 mmHg over the next 2-6 hours 1, 5
• Cautiously normalize blood pressure over 24-48 hours 1, 5

Compelling Conditions Requiring More Aggressive Reduction:

• Aortic dissection: Reduce SBP to <120 mmHg and heart rate <60 bpm immediately 9, 5
• Acute coronary syndrome: Reduce SBP to <140 mmHg immediately 9, 5
• Acute pulmonary edema: Reduce SBP to <140 mmHg immediately 9, 5
• Severe preeclampsia/eclampsia: Follow obstetric guidelines 5

Conditions Requiring Cautious Blood Pressure Management:

• Acute ischemic stroke: Avoid blood pressure reduction within first 5-7 days unless BP >220/120 mmHg; if >220/120 mmHg, reduce MAP by 15% within 1 hour 9, 5
• Acute hemorrhagic stroke: If SBP ≥220 mmHg, carefully lower to 140-180 mmHg within 6 hours 1, 9, 5

First-Line Intravenous Medications

Nicardipine (preferred for most hypertensive emergencies):

• Initial dose: 5 mg/hr IV infusion 9, 5
• Titrate by 2.5 mg/hr every 15 minutes 9, 5
• Maximum: 15 mg/hr 9, 5
• Advantages: Predictable titration, maintains cerebral blood flow, does not increase intracranial pressure 9, 5

Labetalol (preferred for malignant hypertension with renal failure or hypertensive encephalopathy):

• Bolus: 0.25-0.5 mg/kg IV 9, 5
• Continuous infusion: 2-4 mg/min until goal BP reached, then 5-20 mg/hr maintenance 9, 5

Clevidipine (alternative first-line):

• Initial: 1-2 mg/hr IV infusion 5
• Double every 90 seconds until BP approaches target, then increase by less than double every 5-10 minutes 5
• Maximum: 32 mg/hr 5

Nitroglycerin (for acute pulmonary edema or acute coronary syndrome):

• Initial: 5-10 mcg/min IV infusion 5
• Titrate by 5-10 mcg/min every 5-10 minutes until desired BP reduction 5

Medications to Avoid

Never use immediate-release nifedipine due to unpredictable precipitous blood pressure drops and reflex tachycardia 9, 5

Avoid sodium nitroprusside except as last resort due to risk of cyanide toxicity with prolonged use (>48-72 hours) or renal insufficiency 5

Avoid hydralazine due to unpredictable effects 5

Critical Management Pitfalls

• Never reduce blood pressure to "normal" acutely—patients with chronic hypertension have altered cerebral autoregulation and acute normalization causes cerebral, renal, or coronary ischemia 1, 9, 5
• Avoid excessive acute drops >70 mmHg systolic—this precipitates organ ischemia 9, 5
• Do not use oral medications for initial management—hypertensive emergencies require IV therapy 5

Transition to Oral Therapy

After stabilization, transition to oral combination therapy:

• Long-acting calcium channel blocker plus ACE inhibitor or ARB plus diuretic 9
• Fixed-dose single-pill combination treatment is recommended for long-term management 5
• Screen for secondary hypertension causes (found in 20-40% of malignant hypertension cases) 9, 5

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Treatment of Hypertensive Urgency

Hypertensive urgency (BP >180/120 mmHg WITHOUT acute organ damage) does not require hospital admission or IV medications—manage with oral antihypertensives and outpatient follow-up within 2-4 weeks. 5

• Initiate or intensify oral antihypertensive therapy using the standard algorithm above 5
• Avoid rapid blood pressure reduction—up to one-third of patients normalize spontaneously 5
• Target blood pressure <130/80 mmHg (or <140/90 mmHg in elderly/frail) within 3 months 5

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Key Clinical Outcomes

A 10 mmHg reduction in systolic blood pressure decreases cardiovascular events by 20-30%, with the largest benefit being stroke risk reduction. 3

Without treatment, hypertensive emergencies carry a 1-year mortality rate >79% and median survival of only 10.4 months. 5

Despite proven benefits, only 44% of US adults with hypertension have their blood pressure controlled to <140/90 mmHg. 3