What are the signs and symptoms of hypertension in adults?

Signs and Symptoms of Hypertension

Hypertension is typically asymptomatic—most patients have no signs or symptoms until cardiovascular complications develop, which is why it is called the "silent killer." 1, 2

Primary (Essential) Hypertension: The Asymptomatic Reality

The vast majority of adults with hypertension experience no symptoms whatsoever. 1 This asymptomatic nature is precisely what makes hypertension dangerous, as patients remain unaware of their condition until serious complications like stroke, myocardial infarction, heart failure, or renal failure occur. 2

When symptoms do occur in uncomplicated hypertension, they are typically nonspecific and mild, including: 1

• Headaches (usually occipital and intermittent)
• Blurred vision
• Dizziness
• Nocturia
• Hematuria

These symptoms alone do not constitute acute target organ damage and should not be confused with hypertensive emergencies. 3

Symptoms Suggesting Hypertensive Complications

If a hypertensive patient develops specific symptoms, this signals potential target organ damage requiring urgent evaluation. 1 These warning symptoms include:

Cardiovascular Complications 1

• Chest pain (suggesting myocardial ischemia or infarction)
• Shortness of breath (suggesting heart failure or pulmonary edema)
• Palpitations (suggesting arrhythmias or cardiac dysfunction)
• Peripheral edema (suggesting heart failure)

Vascular Complications 1

• Claudication (suggesting peripheral arterial disease)
• Bruits on examination (carotid, abdominal, femoral)

Neurological Complications 1

• Severe headache with altered mental status (suggesting hypertensive encephalopathy)
• Visual disturbances beyond mild blurring (suggesting retinal hemorrhages or papilledema)

Physical Examination Findings

Physical signs are more reliable than symptoms for detecting hypertension and its complications. 1 Key findings include:

Cardiovascular Signs 1

• Abnormal pulse rate, rhythm, or character
• Displaced or abnormal apex beat (suggesting left ventricular hypertrophy)
• Extra heart sounds (S3 or S4 gallop)
• Basal crackles (suggesting pulmonary congestion)
• Jugular venous distension

Retinal Changes on Fundoscopy 1

• Arteriovenous nicking (chronic hypertensive changes representing target organ damage) 3
• Retinal hemorrhages
• Papilledema (in hypertensive emergencies)
• Vessel tortuosity

Other Physical Signs 1

• Radio-femoral delay (suggesting aortic coarctation)
• Enlarged kidneys on palpation
• Increased BMI and waist circumference

Red Flag Symptoms: Secondary Hypertension

Certain symptom patterns should immediately raise suspicion for secondary causes of hypertension, which occur in 20-40% of malignant hypertension cases. 3, 4 These include:

Endocrine Causes 1

• Pheochromocytoma: Episodic severe hypertension with palpitations, sweating, and headaches (the classic triad) 4
• Primary aldosteronism: Muscle weakness, tetany, cramps, arrhythmias (from hypokalemia) 1
• Cushing's syndrome: Central obesity, facial rounding, easy bruising, colored striae 1
• Thyroid disease: Weight loss, palpitations, heat intolerance (hyperthyroidism) 1

Renal Causes 1, 4

• Flash pulmonary edema (suggesting renal artery stenosis) 1
• Edema, fatigue, frequent urination (suggesting kidney disease)
• Prostatism symptoms (suggesting post-renal obstruction) 1

Sleep-Related Causes 1

• Snoring and witnessed apneas
• Daytime sleepiness (suggesting obstructive sleep apnea)
• Neck circumference >40 cm 1

Hypertensive Emergency vs. Urgency

Hypertensive emergencies require blood pressure typically >200/120 mm Hg PLUS acute target organ damage, not just elevated numbers alone. 3, 5 The distinction is critical:

Emergency (requires ICU admission) 5

• Severe BP elevation WITH acute neurologic, cardiac, renal, or vascular injury
• Encephalopathy with altered mental status
• Acute pulmonary edema
• Acute coronary syndrome
• Acute kidney injury

Urgency (can be managed outpatient) 5

• Severe BP elevation WITHOUT acute target organ damage
• Nonspecific symptoms like mild headache or dizziness 3

Common Clinical Pitfalls

Do not assume all patients with elevated BP and symptoms have a hypertensive emergency—most have chronic hypertension with incidental symptoms. 3, 5 Occipital headache and mild dizziness are nonspecific and do not constitute acute target organ damage. 3

Do not overlook secondary causes in patients with episodic symptoms—pheochromocytoma presenting with the classic triad of palpitations, diaphoresis, and headache requires specific diagnostic workup with plasma or 24-hour urine metanephrines. 4

Do not miss white coat or masked hypertension—confirm the diagnosis with out-of-office blood pressure measurements (home or ambulatory monitoring) before labeling someone as hypertensive, especially when office readings are 130-159/85-99 mm Hg. 1