2017 140/90 135/85 135/85 120/70 130/80 ESC/ESH Guidelines [2] 2018 BP: blood pressure; SBP: systolic blood pressure; DBP: diastolic blood pressure; HBPM: home blood pressure monitoring; ABPM: ambulatory blood pressure monitoring; ACC/AHA: American College of Cardiology/American Heart Association; ESC/ESH: European Society of Cardiology/European Society of Hypertension. Data from: 1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 71:e127. 2. Williams B, Giuseppe M, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:3021. Graphic 119219 Version 1.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 39/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Diagnosis of hypertension in adults https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 40/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 41/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate ABPM: ambulatory blood pressure monitoring; AOBPM: automated office blood pressure monitoring. Home blood pressure must be performed adequately in order for the measurements to be used for diagnosis and management. To be adequate: The accuracy of the home device should be verified in the clinician's office; the patient should measure their blood pressure while seated (with feet flat on the floor), with arm supported (such as on a table), and after several minutes of rest; the blood pressure should be measured at different times per day and over a series of multiple days. A common strategy is to have the patient measure their blood pressure twice daily (once in the morning and once in the evening) for 7 days. Readings from the first day are discarded, and the remaining 12 measurements are averaged. Home blood pressure should not be used for diagnosis and management if it cannot be performed adequately. Adequate home blood pressure should be possible in most cases. Inexpensive devices to measure blood pressure at home are available over the counter. Alternatively, such devices can be borrowed (eg, provided by the clinic). Only rarely are such devices unavailable or unaffordable. ABPM is performed by having the patient wear, typically for 24 hours, an electronic blood pressure device that automatically measures the blood pressure, usually every half-hour during the day and hourly at night. We use the mean daytime value to determine the presence of hypertension. ABPM is possible if it is available in the clinic or via an external vendor and if it can be paid for by the patient's insurance or by the patient. Blood pressure measured in the office may vary according to the manner in which it is obtained. If blood pressure in the office is to be used for the diagnosis of hypertension (rather than using out-of- office blood pressures), we suggest performing unattended AOBPM (using a device that can average multiple readings while the patient sits alone in a room). Unattended AOBPM may provide a measurement that is 5 to 10 mmHg less than a manual measurement (ie, with a stethoscope). Office blood pressure must be performed with proper technique (eg, patient given time to rest, seated with feet flat on the floor, use of multiple measurements, appropriate-sized cuff placed on bare arm, etc). Office blood pressure measured with improper technique should not be used for diagnosis and management of hypertension. Refer to UpToDate topics on measurement of blood pressure for details of proper technique. Graphic 105050 Version 7.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 42/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Corresponding values of SBP/DBP for clinic, HBPM, daytime, nighttime, and 24-hour ABPM measurements Daytime Nighttime Clinic HBPM 24-hour ABPM ABPM ABPM 120/80 120/80 120/80 100/65 115/75 130/80 130/80 130/80 110/65 125/75 140/90 135/85 135/85 120/70 130/80 160/100 145/90 145/90 140/85 145/90 SBP: systolic blood pressure; DBP: diastolic blood pressure; HBPM: home blood pressure monitoring; ABPM: ambulatory blood pressure monitoring. References: 1. Uhlig K, Balk EM, Patel K, et al. Self-Measured Blood Pressure Monitoring: Comparative E ectiveness. Agency for Healthcare Research and Quality, Rockville, MD 2012. 2. Margolis KL, Asche SE, Bergdall AR, et al. E ect of home blood pressure telemonitoring and pharmacist management on blood pressure control: a cluster randomized clinical trial. JAMA 2013; 310:46. 3. McManus RJ, Mant J, Haque MS, et al. E ect of self-monitoring and medication self-titration on systolic blood pressure in hypertensive patients at high risk of cardiovascular disease: the TASMIN-SR randomized clinical trial. JAMA 2014; 312:799. 4. Siu AL. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015; 163:778. 5. Yi SS, Tabaei BP, Angell SY, et al. Self-blood pressure monitoring in an urban, ethnically diverse population: a randomized clinical trial utilizing the electronic health record. Circ Cardiovasc Qual Outcomes 2015; 8:138. 6. Agarwal R, Bills JE, Hecht TJW, et al. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension 2011; 57:29. 7. O'Brien E, Stergiou GS. The pursuit of accurate blood pressure measurement: a 35-year travail. J Clin Hypertens (Greenwich) 2017; 19:746. 8. Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013; 34:2159. 9. Pickering TG, Miller NH, Ogedegbe G, et al. Call to action on use and reimbursement for home blood pressure monitoring: a joint scienti c statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension 2008; 52:10. 10. National Clinical Guideline Centre. Hypertension: The Clinical Management of Primary Hypertension in Adults: Update of Clinical Guidelines 18 and 34. Roayl College of Physicians, London 2011. Reproduced from: Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol 2017. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 116037 Version 1.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 43/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Reasons to evaluate a patient for masked or white coat hypertension Antihypertensive Suspected Reason treatment status classification Not on treatment Masked hypertension Office-based blood pressures 10 mmHg or less below the patient's goal (eg, systolic pressure 120 to 129 mmHg) On treatment Masked uncontrolled Office-based blood pressures below the patient's goal plus any of the following: hypertension Elevated atherosclerotic cardiovascular disease risk (eg, 10-year atherosclerotic cardiovascular disease risk >10%) Chronic kidney disease Diabetes mellitus Evidence of new or worsening end-organ damage (eg, prior atherosclerotic cardiovascular event, heart failure, left ventricular hypertrophy, hypertensive retinopathy) Not on treatment White coat hypertension Office-based blood pressures above the patient's goal (but <180/120 mmHg) despite a 3-month trial of lifestyle modifications, and no evidence of hypertensive end-organ damage On a minimum of 3 medications White coat effect Office-based blood pressures above the patient's goal On treatment White coat effect Office-based blood pressures at or above the patient's goal with symptoms of hypotension (eg, lightheadedness, falls) at home or work Not on treatment or on All of the above Labile office-based blood pressures treatment Adapted from: 1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension 2018; 71:e13. 2. Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:3021. 3. Nerenberg KA, Zarnke KB, Leung AA, et al. Hypertension Canada's 2018 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults and children. Can J Cardiol 2018; 34:506. Graphic 126949 Version 1.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 44/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Selection criteria for blood pressure cuff size for measurement of blood pressure in adults [1,2] Arm circumference Usual cuff size 22 to 26 cm Small adult 27 to 34 cm Adult 35 to 44 cm Large adult 45 to 52 cm Adult thigh References: 1. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation 2005; 111:697. 2. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension 2018; 71:e13. Graphic 115863 Version 2.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 45/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Procedures for use of home blood pressure monitoring Patient training should occur under medical supervision, including: Information about hypertension. Selection of equipment. Acknowledgment that individual BP readings may vary substantially. Interpretation of results. Devices: Verify use of automated validated devices. Use of auscultatory devices (mercury, aneroid, or other) is not generally useful for HBPM because patients rarely master the technique required for measurement of BP with auscultatory devices. Monitors with provision for storage of readings in memory are preferred. Verify use of appropriate cuff size to fit the arm. Verify that left/right inter-arm differences are insignificant. If differences are significant, instruct patient to measure BPs in the arm with higher readings. Instructions on HBPM procedures: Remain still: Avoid smoking, caffeinated beverages, or exercise within 30 minutes before BP measurements. Ensure 5 minutes of quiet rest before BP measurements. Sit correctly: Sit with back straight and supported (on a straight-backed dining chair, for example, rather than a sofa). Sit with feet flat on the floor and legs uncrossed. Keep arm supported on a flat surface (such as a table), with the upper arm at heart level. Bottom of the cuff should be placed directly above the antecubital fossa (bend of the elbow). Take multiple readings: Take at least 2 readings 1 minute apart in morning before taking medications and in evening before supper. Optimally, measure and record BP daily. Ideally, obtain weekly BP readings https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 46/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate beginning 2 weeks after a change in the treatment regimen and during the week before a clinic visit. Record all readings accurately: Monitors with built-in memory should be brought to all clinic appointments. BP should be based on an average of readings on 2 occasions for clinical decision making. The information above may be reinforced with videos available online: https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure- readings/monitoring-your-blood-pressure-at-home https://targetbp.org/tools_downloads/self-measured-blood-pressure-video/ BP: blood pressure; HBPM: home blood pressure monitoring. Reproduced from: Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol 2017. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 115864 Version 5.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 47/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Cardiovascular risk with LVH by echocardiography Four-year, age-adjusted incidence of cardiovascular events in men and women in the Framingham Study according to left ventricular mass determined by echocardiography. Subjects with increased left ventricular mass (far right panel) had a marked increase in cardiovascular risk. LVH: left ventricular hypertrophy; CV: cardiovascular. Adapted from: Levy D, Garrison RJ, Savage DD, et al. Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study. N Engl J Med 1990; 322:1561. Graphic 52329 Version 4.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 48/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Coronary heart disease mortality related to blood pressure and age Coronary heart disease (CHD) mortality rate, pictured on a log scale with 95% confidence intervals (CI), in each decade of age in relation to the estimated usual systolic and diastolic blood pressure at the start of that decade. CHD mortality increases with both higher pressures and older ages. For diastolic pressure, each age- specific regression line ignores the left-hand point (ie, at slightly less than 75 mmHg) for which the risk lies significantly above the fitted regression line (as indicated by the broken line below 75 mmHg). IHD: ischemic heart disease. Reproduced from: Lewington S, Clarke R, Qizilbash N, et al. Age-speci c relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002; 360:1903. Illustration used with the permission of Elsevier. All rights reserved. Graphic 75106 Version 9.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 49/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Stroke mortality related to blood pressure and age Stroke mortality rate, pictured on a log scale with 95% CI, in each decade of age in relation to the estimated usual systolic and diastolic blood pressure at the start of that decade. Stroke mortality increases with both higher pressures and older ages. For diastolic pressure, each age-specific regression line ignores the left-hand point (ie, at slightly less than 75 mmHg) for which the risk lies significantly above the fitted regression line (as indicated by the broken line below 75 mmHg). CI: confidence interval. Data from Prospective Studies Collaboration, Lancet 2002; 360:1903. Graphic 66793 Version 5.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 50/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Additive effects of risk factors on cardiovascular disease at 5 years Cumulative absolute risk of CVD at 5 years according to systolic blood pressure and specified levels of other risk factors. The reference category is a non-diabetic, non-smoking 50-year-old woman with a serum TC of 154 mg/dL (4.0 mmol/L) and HDL cholesterol of 62 mg/dL (1.6 mmol/L). The CVD risks are given for systolic blood pressure levels of 110, 130, 150, and 170 mmHg. In the other categories, the additional risk factors are added consecutively. As an example, the diabetes category is a 50-year-old diabetic man who is a smoker and has a TC of 270 mg/dL (7 mmol/L) and HDL cholesterol of 39 mg/dL (1 mmol/L). BP: blood pressure; CVD: cardiovascular disease; HDL: high-density lipoprotein; TC: total cholesterol. Adapted from: Jackson R, Lawes CM, Bennett DA, et al. Lancet 2005; 365:434. Graphic 55353 Version 12.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 51/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Important aspects of the history in the patient with hypertension Duration of hypertension Presence of other risk factors Last known normal blood pressure Smoking Course of the blood pressure Diabetes Dyslipidemia Prior treatment of hypertension Physical inactivity Drugs: types, doses, side effects Dietary history Intake of agents that may cause hypertension Sodium Nonsteroidal antiinflammatory drugs Processed foods Estrogens Alcohol Adrenal steroids Saturated fats Cocaine Psychosocial factors Sympathomimetics Family structure Excessive sodium Work status Family history Educational level Hypertension Sexual function Premature cardiovascular disease or death Features of sleep apnea Familial diseases: pheochromocytoma, renal disease, diabetes, gout Early morning headaches Daytime somnolence Symptoms of secondary causes Loud snoring Muscle weakness Erratic sleep Spells of tachycardia, sweating, tremor Thinning of the skin Flank pain Symptoms of target-organ damage Headaches Transient weakness or blindness Loss of visual acuity Chest pain Dyspnea Claudication https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 52/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Graphic 77599 Version 6.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 53/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Important aspects of the physical examination in the hypertensive patient Accurate measurement of blood pressure General appearance Distribution of body fat Skin lesions Muscle strength Alertness Fundoscopy Hemorrhage Papilledema Cotton wool spots Arteriolar narrowing and arteriovenous nicking Neck Palpation and auscultation of carotids Thyroid Heart Size Rhythm Sounds Lungs Rhonchi Rales Abdomen Renal masses Bruits over aorta or renal arteries Femoral pulses Extremities Peripheral pulses Edema Neurologic assessment https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 54/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Visual disturbance Focal weakness Confusion Graphic 69470 Version 4.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 55/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Best proven nonpharmacologic interventions for prevention and treatment of hypertension* Approximate impact on SBP Nonpharmacologic Dose intervention Hypertension Normotension Refere Weight loss Weight/body fat 5 mmHg 3 mmHg [1] Best goal is ideal body weight, but aim for at least a 1 kg reduction in body weight for most adults who are overweight. Expect about 1 mmHg for every 1 kg reduction in body weight. Healthy diet DASH dietary pattern 11 mmHg 3 mmHg [2,3] Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. Reduced intake of Dietary sodium 5 to -6 mmHg 2 to -3 mmHg [4,5] Optimal goal is <1500 mg/day, but aim for at dietary sodium least a 1000 mg/day reduction in most adults. Enhanced Dietary potassium 4 mmHg 2 mmHg [6] Aim for 3500 to 5000 intake of dietary mg/day, preferably by potassium https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 56/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate consumption of a diet rich in potassium. Physical activity Aerobic 5 to -8 mmHg 2 to -4 mmHg [7,8] 90 to 150 minutes/week. 65 to 75% heart rate reserve. Dynamic resistance 4 mmHg 2 mmHg [7] 90 to 150 minutes/week. 50 to 80% of maximum 1 repetition weight. 6 exercises, 3 sets/exercise, 10 repetitions/set. Isometric resistance 5 mmHg 4 mmHg [9,10] 4 2 minutes (hand grip), 1 minute rest between exercises, 30 to 40% maximum voluntary contraction, 3 sessions/week. 8 to 10 weeks. Moderation Alcohol consumption 4 mmHg 3 mmHg [11-13] In individuals in alcohol who drink alcohol, intake reduce alcohol to: Men: 2 drinks daily. Women: 1 drink daily. SBP: systolic blood pressure; DASH: Dietary Approaches to Stop Hypertension. https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 57/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. In the United States, one "standard" drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), [14] and 1.5 oz of distilled spirits (usually about 40% alcohol). Resources: National Heart, Lung, and Blood Institute. Your Guide to Lowering Your Blood Pressure With DASH. Available at: https://www.nhlbi.nih.gov/ les/docs/public/heart/new_dash.pdf (Accessed on August 16, 2019). Top 10 DASH Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp (Accessed on September 18, 2017). References: 1. Neter JE, Stam BE, Kok FJ, et al. In uence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2003; 42:878. 2. Appel LJ, Champagne CM, Harsha DW, et al. E ects of comprehensive lifestyle modi cation on blood pressure control: main results of the PREMIER clinical trial. JAMA 2003; 289:2083. 3. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the e ects of dietary patterns on blood pressure. DASH Collaborative Research Group. N Engl J Med 1997; 336:1117. 4. Aburto NJ, Ziolkovska A, Hooper L, et al. E ect of lower sodium intake on health: systematic review and metaanalyses. BMJ 2013; 346:f1326. 5. He FJ, Li J, MacGregor GA. E ect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ 2013; 346:f1325. 6. Whelton PK, He J, Cutler JA, et al. E ects of oral potassium on blood pressure. Meta-analysis of randomized controlled clinical trials. JAMA 1997; 277:1624. 7. Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc 2013; 2:e004473. 8. Whelton SP, Chin A, Xin X, et al. E ect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002; 136:493. 9. Carlson DJ, Dieberg G, Hess NC, et al. Isometric exercise training for blood pressure management: a systematic review and meta-analysis. Mayo Clin Proc 2014; 89:327. 10. Inder JD, Carlson DJ, Dieberg G, et al. Isometric exercise training for blood pressure management: a systematic review and meta-analysis to optimize bene t. Hypertens Res 2016; 39:88. 11. Whelton SP, Chin A, Xin X, et al. E ect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002; 136:493. 12. Xin X, He J, Frontini MG, et al. E ects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension 2001; 38:1112. 13. Roerecke M, Kaczorowski J, Tobe SW, et al. The e ect of a reduction in alcohol consumption on blood pressure: a systematic review and meta-analysis. Lancet Public Health 2017; 2:e108. 14. National Institute on Alcohol Abuse and Alcoholism (NIAAA). What Is A Standard Drink? Available at: https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/what-standard-drink (Accessed on August 16, 2017). Reproduced from: Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Am Coll Cardiol 2017. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 116041 Version 3.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 58/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Blood pressure change and sodium reduction Pooled results from all sodium-reduction trials concerning the mean net change in blood pressure due to restrictions in sodium intake among various subsets of patients. SBP: systolic blood pressure; DBP: diastolic blood pressure. The mean change is compared with control values. Data from: Cutler JA, Follmann D, Allender PS. Am J Clin Nutr 1997; 65:643S. Graphic 81634 Version 4.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 59/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Weight loss-induced reduction in diastolic blood pressure Relationship between the quantity of weight lost and the fall in diastolic blood pressure in 308 moderately obese patients given a weight reduction regimen for 18 months. The patients began with a diastolic pressure between 80 and 89 mmHg; those who lost the most weight had the largest reduction in diastolic pressure. The decreases in the systolic pressure were similar. BP: blood pressure. Data from: Stevens VJ, Corrigan SA, Obarzanek E, et al. Weight loss intervention in phase 1 of the Trials of Hypertension Prevention. The TOHP Collaborative Research Group. Arch Intern Med 1993; 153:849. Graphic 60178 Version 6.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 60/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Cardiovascular benefit of treating mild hypertension Reduced incidence of fatal and total coronary heart disease (CHD) events and strokes following antihypertensive therapy in 17 controlled studies involving almost 48,000 patients with mild to moderate hypertension. The number of patients having each of these events is depicted, with active treatment lowering the incidence of coronary events by 16 percent and stroke by 40 percent. However, the absolute benefit (as shown, in percent, by the numbers at the top of the graph) was much less. Treatment for approximately four to five years prevented a coronary event or a stroke in 2 percent of patients (0.7 + 1.3), including prevention of death in 0.8 percent. CVA: cerebrovascular accident (stroke). Data from: Hebert PR, Moser M, Mayer J, et al. Recent evidence on drug therapy of mild to moderate hypertension and decreased risk of coronary heart disease. Arch Intern Med 1993; 153:578. Graphic 52231 Version 8.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 61/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Considerations for individualizing antihypertensive therapy Indication or Antihypertensive drugs contraindication Compelling indications (major improvement in outcome independent of blood pressure) Heart failure with reduced ejection fraction ACE inhibitor or ARB, beta blocker, diuretic, aldosterone antagonist* Postmyocardial infarction ACE inhibitor or ARB, beta blocker, aldosterone antagonist Proteinuric chronic kidney ACE inhibitor or ARB disease Angina pectoris Beta blocker, calcium channel blocker Atrial fibrillation rate control Beta blocker, nondihydropyridine calcium channel blocker Atrial flutter rate control Beta blocker, nondihydropyridine calcium channel blocker Likely to have a favorable effect on symptoms in comorbid conditions Benign prostatic hyperplasia Alpha blocker Essential tremor Beta blocker (noncardioselective) Hyperthyroidism Beta blocker Migraine Beta blocker, calcium channel blocker Osteoporosis Thiazide diuretic Raynaud phenomenon Dihydropyridine calcium channel blocker Contraindications Angioedema Do not use an ACE inhibitor Bronchospastic disease Do not use a non-selective beta blocker Liver disease Do not use methyldopa Pregnancy (or at risk for) Do not use an ACE inhibitor, ARB, or renin inhibitor (eg, aliskiren) Second- or third-degree heart block Do not use a beta blocker, nondihydropyridine calcium channel blocker unless a functioning ventricular pacemaker Drug classes that may have adverse effects on comorbid conditions Depression Generally avoid beta blocker, central alpha-2 agonist Gout Generally avoid loop or thiazide diuretic Hyperkalemia Generally avoid aldosterone antagonist, ACE inhibitor, ARB, renin inhibitor Hyponatremia Generally avoid thiazide diuretic https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 62/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Renovascular disease Generally avoid ACE inhibitor, ARB, or renin inhibitor ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker. A benefit from an aldosterone antagonist has been demonstrated in patients with NYHA class III-IV heart failure or decreased left ventricular ejection fraction after a myocardial infarction. Adapted from: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA 2003; 289:2560. Graphic 63628 Version 15.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 63/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Hypertensive emergencies Grades III to IV hypertensive retinopathy with severely elevated blood pressures Cerebrovascular Hypertensive encephalopathy Atherothrombotic brain infarction with severe hypertension Intracerebral hemorrhage Subarachnoid hemorrhage Cardiac Acute aortic dissection Acute left ventricular failure Acute or impending myocardial infarction After coronary bypass surgery Renal Acute glomerulonephritis Renal crises from collagen vascular diseases Severe hypertension after kidney transplantation Microangiopathic hemolytic anemia Excessive circulating catecholamines Pheochromocytoma crisis Food or drug interactions with monoamine-oxidase inhibitors Sympathomimetic drug use (cocaine) Rebound hypertension after sudden cessation of antihypertensive drugs Eclampsia Surgical Severe hypertension in patients requiring immediate surgery Postoperative hypertension Postoperative bleeding from vascular suture lines Severe body burns Severe epistaxis Graphic 54145 Version 5.0 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 64/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Contributor Disclosures Jan Basile, MD Grant/Research/Clinical Trial Support: Ablative Solutions [Hypertension]; Recor Pharma [Hypertension]. Consultant/Advisory Boards: Eli Lilly [SURPASS Diabetes Trial]. All of the relevant financial relationships listed have been mitigated. Michael J Bloch, MD, FACP, FASH, FSVM, FNLA Grant/Research/Clinical Trial Support: Amgen [Lipids]; Recor [Hypertension]. Consultant/Advisory Boards: Amgen [Lipids]; Esperion [Lipids]; Janssen [Hypertension]; Medtronic [Hypertension]; Novartis [Lipids]; Recor [Hypertension]. Speaker's Bureau: Esperion [Lipids]; Janssen [Anticoagulation]. All of the relevant financial relationships listed have been mitigated. George L Bakris, MD Grant/Research/Clinical Trial Support: Bayer [Diabetic nephropathy]; KBP Biosciences [Resistant hypertension]; Novo Nordisk [Diabetic kidney disease]. Consultant/Advisory Boards: Alnylam [Resistant hypertension]; AstraZeneca [Diabetic nephropathy]; Bayer [Nephropathy]; Ionis [Resistant hypertension]; KBP BioSciences [Resistant hypertension]; Vifor [Hyperkalemia]. All of the relevant financial relationships listed have been mitigated. William B White, MD Consultant/Advisory Boards: AB Science [Alzheimer's disease, mastocytosis]; Alynam [Heart failure]; AstraZeneca [Lupus, lung disease]; Bristol-Myers Squibb [Psoriasis]; Cadence [Oral contraception]; Cerevel Therapeutics [Cancer, schizophrenia]; Chinook [IgA nephropathy]; JAZZ [Narcolepsy]; Marius [Hypogonadism]; Medtronics [Renal denervation]; Takeda [Gout, narcolepsy, cancer]; Travere [IgA nephropathy]; UCB [Psoriasis, arthritis]. All of the relevant financial relationships listed have been mitigated. John P Forman, MD, MSc No relevant financial relationship(s) with ineligible companies to disclose. Karen Law, MD No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 65/65