7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Official reprint from UpToDate www.uptodate.com 2023 UpToDate, Inc. and/or its affiliates. All Rights Reserved. Overview of hypertension in adults : Jan Basile, MD, Michael J Bloch, MD, FACP, FASH, FSVM, FNLA : George L Bakris, MD, William B White, MD : John P Forman, MD, MSc, Karen Law, MD All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jun 2023. This topic last updated: Jan 05, 2023. INTRODUCTION The global prevalence of hypertension is high, and among nonpregnant adults in the United States, treatment of hypertension is the most common reason for office visits and for the use of chronic prescription medications [1-3]. In addition, roughly one-half of hypertensive individuals do not have adequate blood pressure control. The prevalence and control of hypertension are discussed in other topics. (See "The prevalence and control of hypertension in adults" and "Patient adherence and the treatment of hypertension".) This topic provides a broad overview of the definitions, pathogenesis, complications, diagnosis, evaluation, and management of hypertension. Detailed discussions of all these issues are found separately. The reader is directed, when necessary, to more detailed discussions of these issues in other topics. DEFINITIONS Hypertension The following definitions and staging system, which are based upon appropriately measured blood pressure ( table 1), were suggested in 2017 by the American College of Cardiology/American Heart Association (ACC/AHA) [4]; proper measurement technique, which is detailed below, is of paramount importance when identifying patients as having hypertension (see 'Blood pressure measurement' below): Normal blood pressure Systolic <120 mmHg and diastolic <80 mmHg https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 1/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate 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. Isolated systolic hypertension is defined as a blood pressure 130 mmHg systolic and <80 mmHg diastolic, and isolated diastolic hypertension is defined as a blood pressure <130 mmHg systolic and 80 mmHg diastolic. Patients with a blood pressure 130 mmHg systolic and 80 mmHg diastolic are considered to have mixed systolic/diastolic hypertension. In clinical practice, patients who are taking medications for hypertension are usually defined as having hypertension, specifically treated hypertension, regardless of their observed blood pressure. European guidance on the definition of hypertension contrasts with that of the ACC/AHA. The European Society of Cardiology and European Society of Hypertension (ESC/ESH), the International Society of Hypertension (ISH), as well as the National Institute for Health and Care Excellence (NICE) guidelines, define hypertension, using office-based blood pressure, as a systolic pressure 140 mmHg or diastolic pressure 90 mmHg ( table 2) [5-7]. In general, definitions for hypertension are based upon the relationship between blood pressure and the incidence of cardiovascular events in large populations, derived from numerous observational studies and randomized trials, in which blood pressure was measured in various types of office settings with variable equipment and technique [8]. (See 'Complications of hypertension' below.) When evaluating an individual patient, making the diagnosis of hypertension is complex and requires integration of repeated blood pressure measurements, using appropriate technique, both in and out of the office. The schema for establishing the diagnosis of hypertension is presented below ( algorithm 1 and table 3). (See 'Making the diagnosis of hypertension' below.) Definitions based upon ambulatory and home readings The diagnosis of hypertension requires integration of home or ambulatory blood pressure monitoring (ABPM), whereas routine measurements made in the clinical setting should be used primarily for detection purposes. (See 'Making the diagnosis of hypertension' below.) https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 2/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate The use of ABPM and home blood pressure monitoring in adults is discussed in detail elsewhere. (See "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring" and "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Ambulatory blood pressure monitoring'.) The following diagnostic criteria were suggested by the 2017 ACC/AHA guidelines; meeting one or more of these criteria using ABPM qualifies as confirmation of hypertension ( table 3) [4]. A 24-hour mean of 125 mmHg systolic or 75 mmHg diastolic Daytime (awake) mean of 130 mmHg systolic or 80 mmHg diastolic Nighttime (asleep) mean of 110 mmHg systolic or 65 mmHg diastolic We find the daytime (awake) average of 130 mmHg systolic or 80 mmHg diastolic to be the most useful of these definitions. Home readings correlate more closely with the results of daytime ambulatory measurements than with blood pressures that are typically obtained in the clinician's office (ie, using a manual cuff and stethoscope or using an oscillometric device with the care provider present in the room). We believe that hypertension can be confirmed by repeated home blood pressure readings that average 130/ 80 mmHg. Guidelines from the ESC/ESH, ISH, and NICE differ somewhat from the ACC/AHA guidelines; using ambulatory or home blood pressures, the ESC/ESH, ISH, and NICE define hypertension as a 24-hour mean of 130 mmHg systolic or 80 mmHg diastolic or a daytime mean (or an average of home readings) that is 135 mmHg systolic or 85 mmHg diastolic ( table 2) [5-7]. Both white coat hypertension and masked hypertension are conditions that can only be defined based upon the comparison of out-of-office blood pressure measurements (ABPM and home) with office-based blood pressure measurements. White coat hypertension White coat hypertension is defined as blood pressure that is consistently elevated by office readings but does not meet diagnostic criteria for hypertension based upon out-of-office readings. Identifying patients who should be evaluated for white coat hypertension, and the diagnosis of white coat hypertension, is presented elsewhere ( table 4). (See "White coat and masked hypertension" and "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".) Masked hypertension Masked hypertension is defined as blood pressure that is consistently elevated by out-of-office measurements but does not meet the criteria for https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 3/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate hypertension based upon office readings. Identifying patients who should be evaluated for masked hypertension, and the diagnosis of masked hypertension, is discussed separately ( table 4). (See "White coat and masked hypertension" and "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".) BLOOD PRESSURE MEASUREMENT Appropriate, standardized technique for blood pressure measurement, as described below, is critically important both in the office and at home [9,10]. Detailed discussions on ambulatory blood pressure monitoring (ABPM), home blood pressure monitoring, and office-based blood pressure measurement can be found in other topics. (See "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring" and "Blood pressure measurement in the diagnosis and management of hypertension in adults".) Office-based blood pressure measurement Proper technique and interpretation of the blood pressure is essential in the diagnosis and management of hypertension. A number of steps should ideally be followed to achieve maximum accuracy ( table 1) [5,9-11]. An appropriately sized cuff must be used ( table 5). (See "Blood pressure measurement in the diagnosis and management of hypertension in adults".) Rather than an auscultatory device (one that requires a stethoscope), we recommend using an oscillometric blood pressure device designed specifically for the office setting. Automated devices can take multiple consecutive readings in the office with the patient sitting and resting alone (ie, unattended measurement) or with an observer present. Either unattended or attended automated office blood pressure (AOBP) measurement predict the results of awake ABPM better than traditional office blood pressure measurement and may reduce the white coat effect [12]. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Automated office blood pressure measurement'.) Given the importance of obtaining accurate and reproducible blood pressure readings, we suggest that all providers work towards having access to ABPM, automated office blood pressure monitoring (AOBPM), or both. However, if AOBP measurement is not available, office measurements should be performed with the patient positioned properly and allowed to rest comfortably for at least five minutes, and measurements should be repeated at least twice ( table 1). The average of these readings should also be provided to the patient. https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 4/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate In addition to obtaining multiple blood pressure measurements, blood pressure should be measured in both arms, at least at the initial visit. In older individuals or those with potential orthostatic symptoms, postural measurements should also be taken: Systolic blood pressure readings in the left and right arms should be roughly equivalent. A discrepancy of more than 15 mmHg may indicate subclavian stenosis and, hence, peripheral arterial disease. If there is a significant difference in blood pressure between the two arms, the higher of the two should be used for measurement at subsequent visits. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults".) Postural hypotension, defined as a 20 mmHg or greater fall in systolic pressure upon rising from supine to an unassisted upright position, should be pursued in patients over age 65 years, those experiencing dizziness or weakness upon standing, or those with diabetes or Parkinson disease. (See "Mechanisms, causes, and evaluation of orthostatic hypotension".) Ambulatory blood pressure monitoring Twenty-four-hour ABPM is the preferred method for confirming the diagnosis of hypertension and white coat hypertension but has limited availability in routine clinical practice. High-quality data suggest that ABPM predicts target-organ damage and cardiovascular events better than office blood pressure readings. ABPM records the blood pressure at preset intervals (usually every 15 to 20 minutes during the day and every 30 to 60 minutes during sleep). ABPM can identify or confirm white coat and masked hypertension and can also be used to confirm normal blood pressure readings obtained by self-monitoring at home ( table 3) [13]. It is also the only method of blood pressure measurement that can reliably obtain nocturnal readings. (See "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".) In addition to patients with suspected white coat hypertension, ABPM should be considered in the following circumstances: Suspected episodic hypertension (eg, pheochromocytoma) Determining therapeutic response (ie, blood pressure control) in patients who are known to have a substantial white coat effect) Hypotensive symptoms while taking antihypertensive medications Resistant hypertension Autonomic dysfunction Suspected masked hypertension Home blood pressure monitoring Appropriate training and equipment are paramount to obtaining accurate home blood pressure readings. Patients should be instructed to use a https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 5/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate validated, automated oscillometric device that measures blood pressure in the brachial artery (upper arm) and to perform measurements in a quiet room after five minutes of rest in the seated position with the back and arm supported and legs uncrossed. At least 12 to 14 measurements should be obtained, with both morning and evening measurements taken, over a period of one week every month ( table 6). Many patients require the use of a large cuff, usually sold separately. The mean of all available readings should be used for clinical decision- making. Moderate-quality data suggest that blood pressure taken at home or work by the patient correlates more closely with the results of 24-hour or daytime ambulatory monitoring, with AOBPM, and with target-organ damage than usual blood pressure taken in the office [14,15]. (See "Blood pressure measurement in the diagnosis and management of hypertension in adults", section on 'Home blood pressure monitoring' and "Out-of-office blood pressure measurement: Ambulatory and self-measured blood pressure monitoring".) Home readings should be used to complement office readings to determine whether a patient's blood pressure is under control. If there is a discrepancy between office and home blood pressures (ie, white coat or masked hypertension), ABPM should be obtained, if possible, to confirm the accuracy of home blood pressure measurements. If ABPM is not available, AOBPM can be used. (See 'Making the diagnosis of hypertension' below.) PRIMARY HYPERTENSION Pathogenesis Maintenance of arterial blood pressure is necessary for organ perfusion. In general, the arterial blood pressure is determined by the following equation: Blood pressure (BP) = Cardiac output (CO) x Systemic vascular resistance (SVR) Blood pressure reacts to changes in the environment to maintain organ perfusion over a wide variety of conditions. The primary factors determining the blood pressure are the sympathetic nervous system, the renin-angiotensin-aldosterone system, and the plasma volume (largely mediated by the kidneys). 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. Some of these factors are discussed in the ensuing section. https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 6/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Risk factors for primary (essential) hypertension Although the exact etiology of primary hypertension remains unclear, a number of risk factors are strongly and independently associated with its development, including: Age Advancing age is associated with increased blood pressure, particularly systolic blood pressure, and an increased incidence of hypertension. Obesity Obesity and weight gain are major risk factors for hypertension and are also determinants of the rise in blood pressure that is commonly observed with aging [16,17]. (See "Overweight, obesity, and weight reduction in hypertension".) Family history Hypertension is approximately twice as common in subjects who have one or two hypertensive parents, and multiple epidemiologic studies suggest that genetic factors account for approximately 30 percent of the variation in blood pressure in various populations [18,19]. (See "Genetic factors in the pathogenesis of hypertension".) Race Hypertension tends to be more common, be more severe, occur earlier in life, and be associated with greater target-organ damage in Black patients. (See "Burden of hypertension in Black individuals".) Reduced nephron number Reduced adult nephron mass may predispose to hypertension, which may be related to genetic factors, intrauterine developmental disturbance (eg, hypoxia, drugs, nutritional deficiency), premature birth, and postnatal environment (eg, malnutrition, infections). (See "Possible role of low birth weight in the pathogenesis of primary (essential) hypertension".) High-sodium diet Excess sodium intake (eg, >3 g/day [sodium chloride]) increases the risk for hypertension, and sodium restriction lowers blood pressure in those with a high sodium intake. (See "Salt intake, salt restriction, and primary (essential) hypertension".) Excessive alcohol consumption Excess alcohol intake is associated with the development of hypertension, and alcohol restriction lowers blood pressure in those with increased intake. (See "Cardiovascular benefits and risks of moderate alcohol consumption", section on 'Hypertension'.) Physical inactivity Physical inactivity increases the risk for hypertension, and exercise (aerobic, dynamic resistance, and isometric resistance) is an effective means of lowering blood pressure [16,20]. (See "Exercise in the treatment and prevention of hypertension".) Insufficient sleep Short sleep duration (eg, <7 hours per night) is associated with a higher risk of hypertension [21-23], and increasing the duration of sleep may lower blood pressure https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 7/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate [24,25]. (See "Insufficient sleep: Definition, epidemiology, and adverse outcomes".) Social determinants Social determinants of health, such as low socioeconomic status, lack of health insurance, food and housing insecurity, and lack of access to safe spaces for exercise may underlie several of the above risk factors for hypertension (obesity, poor diet, physical inactivity, etc) [26,27]. These social factors likely account in large part for racial disparities in hypertension. (See "Burden of hypertension in Black individuals".) SECONDARY OR CONTRIBUTING CAUSES OF HYPERTENSION 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. (See "Evaluation of secondary hypertension" and "Definition, risk factors, and evaluation of resistant hypertension", section on 'Secondary causes of hypertension'.) Major causes of secondary hypertension include: Prescription or over-the-counter medications [4,5]: Oral contraceptives, particularly those containing higher doses of estrogen (see "Contraception: Hormonal contraception and blood pressure") Nonsteroidal antiinflammatory agents (NSAIDs), particularly chronic use (see "NSAIDs and acetaminophen: Effects on blood pressure and hypertension") Antidepressants, including tricyclic antidepressants, selective serotonin reuptake inhibitors, and monoamine oxidase inhibitors Corticosteroids, including both glucocorticoids and mineralocorticoids Decongestants, such as phenylephrine and pseudoephedrine Some weight-loss medications Sodium-containing antacids Erythropoietin Cyclosporine or tacrolimus Stimulants, including methylphenidate and amphetamines https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 8/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Atypical antipsychotics, including clozapine and olanzapine Angiogenesis inhibitors, such as bevacizumab Tyrosine kinase inhibitors, such as sunitinib and 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. (See "Overview of hypertension in acute and chronic kidney disease".) Primary aldosteronism The presence of primary mineralocorticoid excess, primarily aldosterone, should be suspected in any patient with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis. However, up to 50 to 70 percent of patients will have a normal plasma potassium concentration. Other disorders or ingestions can mimic primary aldosteronism (apparent mineralocorticoid excess syndromes), including chronic licorice intake. (See "Pathophysiology and clinical features of primary aldosteronism" and "Diagnosis of primary aldosteronism" and "Apparent mineralocorticoid excess syndromes (including chronic licorice ingestion)".) Renovascular hypertension Renovascular hypertension is often due to fibromuscular dysplasia in younger patients and to atherosclerosis in older patients. (See "Establishing the diagnosis of renovascular hypertension".) Obstructive sleep apnea Disordered breathing during sleep appears to be an independent risk factor for systemic hypertension. (See "Obstructive sleep apnea and cardiovascular disease in adults".) Pheochromocytoma Pheochromocytoma is a rare cause of secondary hypertension. Approximately one-half of patients with pheochromocytoma have paroxysmal hypertension; most of the rest have what appears to be primary hypertension. (See "Clinical presentation and diagnosis of pheochromocytoma" and "Treatment of pheochromocytoma in adults".) Cushing's syndrome Cushing's syndrome is a rare cause of secondary hypertension, but hypertension is a major cause of morbidity and death in patients with Cushing's syndrome. (See "Epidemiology and clinical manifestations of Cushing syndrome".) Other endocrine disorders Hypothyroidism, hyperthyroidism, and hyperparathyroidism may also induce hypertension. (See "Cardiovascular effects of hypothyroidism" and https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 9/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate "Cardiovascular effects of hyperthyroidism" and "Primary hyperparathyroidism: Clinical manifestations", section on 'Cardiovascular'.) Coarctation of the aorta Coarctation of the aorta is one of the major causes of secondary hypertension in young children, but it may also be diagnosed in adulthood [28]. (See "Clinical manifestations and diagnosis of coarctation of the aorta".) COMPLICATIONS OF HYPERTENSION Hypertension is associated with a significant increase in risk of adverse cardiovascular and kidney outcomes. Each of the following complications is closely associated with the presence of hypertension (see "Cardiovascular risks of hypertension"): Left ventricular hypertrophy (LVH) ( figure 1) [29,30] Heart failure, both reduced ejection fraction (systolic) and preserved ejection fraction (diastolic) [31] (see "Epidemiology of heart failure") Ischemic stroke [32,33] (see "Clinical diagnosis of stroke subtypes", section on 'Ecology and risk factors') Intracerebral hemorrhage [32,34] (see "Spontaneous intracerebral hemorrhage: Pathogenesis, clinical features, and diagnosis") Ischemic heart disease, including myocardial infarction and coronary interventions [32,35] (see "Overview of established risk factors for cardiovascular disease") Chronic kidney disease and end-stage kidney disease [36,37] (see "Clinical features, diagnosis, and treatment of hypertensive nephrosclerosis" and "Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults") Quantitatively, hypertension is the most prevalent modifiable risk factor for premature cardiovascular disease, being more common than cigarette smoking, dyslipidemia, or diabetes, which are the other major risk factors [35]. Hypertension often coexists with these other risk factors as well as with overweight/obesity, an unhealthy diet, and physical inactivity. The presence of more than one risk factor increases the risk of adverse cardiovascular events [4]. The likelihood of having a cardiovascular event increases as blood pressure increases. In a meta- analysis of over one million adults, risk began to rise in all age groups with blood pressures >115 mmHg systolic or >75 mmHg diastolic ( figure 2A-B) [8]. For every 20 mmHg higher systolic https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 10/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate and 10 mmHg higher diastolic blood pressure, the risk of death from heart disease or strokes doubles. The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of hypertension summarized the available meta-analyses of observational data by comparing the cardiovascular risk of different blood pressure strata with a reference group that had a blood pressure <120 mmHg systolic and <80 mmHg diastolic [4]. A blood pressure of 120 to 129 mmHg systolic and 80 to 84 mmHg diastolic was associated with a hazard ratio of 1.1 to 1.5 for cardiovascular events, and blood pressure of 130 to 139 mmHg systolic and 85 to 89 mmHg diastolic was associated with a hazard ratio of 1.5 to 2.0. This relationship was consistent across sex and race/ethnic subgroups but was somewhat attenuated among older adults. The prognostic significance of systolic and diastolic blood pressure as a cardiovascular risk factor appears to be age dependent. The systolic pressure and the pulse pressure are greater predictors of risk in patients over the age of 50 to 60 years [38]. Under age 50 years, diastolic blood pressure is a better predictor of mortality than systolic readings [39]. When the systolic blood pressure is <130 mmHg, isolated diastolic hypertension does not predict an increased cardiovascular risk, regardless of age [40]. Systolic hypertension and pulse pressure in older individuals are discussed in detail separately. (See "Treatment of hypertension in older adults, particularly isolated systolic hypertension" and "Increased pulse pressure".) While hypertension is associated with a relative increase in cardiovascular risk regardless of other cardiovascular risk factors, importantly, the absolute risk of cardiovascular risk is dependent on age and other cardiovascular risk factors in addition to the level of blood pressure ( figure 3) [41]. (See "Cardiovascular risks of hypertension".) MAKING THE DIAGNOSIS OF HYPERTENSION Different clinical trials have used different definitions of hypertension and different methodology for measuring blood pressure. In addition, the relationship between blood pressure and cardiovascular risk is graded and continuous, without an obvious inflection point. Thus, we believe that the data supporting any particular threshold for the definition of hypertension is relatively weak. In an individual patient, we feel that making the diagnosis of hypertension requires the integration of multiple blood pressure readings, the use of appropriate technique, and also the use of measurements made outside of the usual office setting. https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 11/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Detection For patients without a previous history of hypertension, we agree with the 2021 US Preventive Services Task Force (USPSTF) guidelines, the 2017 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, and the 2018 European Society of Cardiology and European Society of Hypertension (ESC/ESH) guidelines that all individuals 18 years or older should be properly evaluated, with appropriate technique, for elevated blood pressure in the office or other clinical setting [4,5,42]. In practice, blood pressure measurement is simple and quick and should be performed at every clinical encounter. At a minimum, the frequency of evaluation should be as follows: Adults with normal blood pressure should have reassessment of their blood pressure every year. Adults should be evaluated at least semiannually if they have risk factors for hypertension (eg, obesity) or if their previously measured systolic blood pressure was 120 to 129. Diagnosis Our approach is consistent with but not identical to recommendations from the USPSTF, the 2017 ACC/AHA guidelines, the 2018 ESC/ESH guidelines, the 2020 ISH guidelines, and the Canadian Hypertension Education Program (CHEP) ( algorithm 1) [4-6,43,44]: A diagnosis can be made, without further confirmatory readings, in the following uncommon scenarios: A patient who presents with hypertensive urgency or emergency (ie, patients with blood pressure 180 mmHg systolic or 120 mmHg diastolic) (see "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults" and "Evaluation and treatment of hypertensive emergencies in adults") A patient who presents with an initial blood pressure 160 mmHg systolic or 100 mmHg diastolic and who also has known target end-organ damage (eg, left ventricular hypertrophy [LVH], hypertensive retinopathy, ischemic cardiovascular disease) In all other patients who have an elevated office blood pressure, the diagnosis of hypertension should be confirmed using out-of-office blood pressure measurement whenever possible. Ambulatory blood pressure monitoring (ABPM) is considered the gold standard in determining out-of-office blood pressure. However, many payers require evidence of normal out-of-office readings (suspected white coat hypertension) for reimbursement of ABPM. As such, we suggest home blood pressure measurement as the initial strategy to confirm the diagnosis of hypertension in most patients [14,15,45]: https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 12/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Hypertension is diagnosed if the mean home blood pressure, when measured with appropriate technique and with a device that has been validated in the office, is 130 mmHg systolic or 80 mmHg diastolic. ABPM is an alternative to home blood pressure monitoring in settings where ABPM is readily available, particularly if adequate home blood pressures cannot be obtained, if there is doubt about the validity of home readings or if there is a large discrepancy between office and home readings. When using ABPM, hypertension is diagnosed if the mean daytime blood pressure is 130 mmHg systolic or 80 mmHg diastolic. Occasionally, out-of-office confirmation of hypertension is not possible because of issues with availability of equipment, insurance, and cost. In these situations, a diagnosis of hypertension can be confirmed by serial (at least three) office-based blood pressure measurements spaced over a period of weeks to months with a mean of 130 mmHg systolic or 80 mmHg diastolic. While use of appropriate technique is important in all patients, it is particularly essential in those in whom the diagnosis of hypertension is based solely upon office readings ( table 1). In settings where out-of-office blood pressure measurement is not readily available, we suggest using automated office blood pressure monitoring (AOBPM). Patients found to have an office blood pressure of 130 mmHg systolic or 80 mmHg diastolic but an out-of-office blood pressure (either mean daytime or mean home) of <130 mmHg systolic and <80 mmHg diastolic have white coat hypertension rather than true hypertension [4]. In patients with home readings suggestive of white coat hypertension, we recommend confirmation with ABPM ( algorithm 1). Patients with white coat hypertension should undergo reevaluation with out-of-office blood pressure monitoring at least yearly since these patients can develop hypertension over time. Patients who have office readings of 120 to 129 mmHg systolic or 75 to 79 mmHg diastolic and established cardiovascular disease, known kidney disease, or elevated cardiovascular risk should also undergo out-of-office blood pressure measurement [4]. Patients with office blood pressure <130 mmHg systolic and <80 mmHg diastolic but an out-of-office blood pressure (either mean daytime or mean home) 130 mmHg systolic or 80 mmHg diastolic have masked hypertension. Although there are no randomized clinical trials, based upon risk, we believe that patients with masked hypertension should be treated the same as other patients with the diagnosis of hypertension. EVALUATION https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 13/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate When hypertension is suspected based upon office readings or confirmed based upon out-of- office blood pressure readings, an evaluation should be performed to determine the following (see "Initial evaluation of adults with hypertension"): The extent of target-organ damage, if any The presence of established cardiovascular or kidney disease The presence or absence of other cardiovascular risk factors (see "Overview of established risk factors for cardiovascular disease") Lifestyle factors that could potentially contribute to hypertension (see 'Risk factors for primary (essential) hypertension' above) Potential interfering substances (eg, chronic use of nonsteroidal antiinflammatory drugs [NSAIDs], estrogen-containing oral contraceptives) (see 'Secondary or contributing causes of hypertension' above) History The history should search for those facts that help to determine the presence of precipitating or aggravating factors (including prescription medications, nonprescription NSAIDs, and alcohol consumption), the duration of hypertension, previous attempts at treatment, the extent of target-organ damage, and the presence of other known risk factors for cardiovascular disease ( table 7). Physical examination The main goals of the physical examination are to evaluate for signs of end-organ damage, for established cardiovascular disease, and for evidence of potential causes of secondary hypertension. The physical examination should include the underutilized but important funduscopic examination to evaluate for hypertensive retinopathy ( table 8). Laboratory testing The following tests should be performed in all patients with newly diagnosed hypertension [4,46,47] (see "Initial evaluation of adults with hypertension", section on 'Laboratory testing'): 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 https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 14/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate Calculate 10-year atherosclerotic cardiovascular disease risk (calculator 1) Additional tests Additional tests may be indicated in certain settings: Urinary albumin to creatinine ratio. Increased albuminuria is recognized as an independent risk factor for cardiovascular disease; it should be performed in all patients with diabetes or chronic kidney disease [48]. (See "Moderately increased albuminuria (microalbuminuria) and cardiovascular disease" and "Epidemiology of chronic kidney disease".) Echocardiography is a more sensitive means of identifying the presence of left ventricular hypertrophy (LVH) than an electrocardiogram, but its use is limited by expense and the lack of clinical trials that define outcome-based treatment differences when LVH is diagnosed [49]. Testing for secondary hypertension Secondary causes of hypertension are relatively uncommon, and testing for secondary hypertension may produce false-positive results. Thus, evaluation for secondary causes is not recommended for all patients with primary hypertension. Instead, a targeted approach is indicated whereby evaluation for secondary causes should be performed only in patients with one or more of the following features (see "Evaluation of secondary hypertension"): An unusual presentation of hypertension (eg, new onset at an especially young or especially old age, presentation with stage 2 hypertension, abrupt onset of hypertension in a patient with previously normal blood pressure, or significant recent elevation in blood pressure in a patient with previously well-controlled hypertension despite adherence to their antihypertensive regimen) Drug-resistant hypertension The presence of a clinical clue for a specific cause of hypertension, such as an abdominal bruit (suggestive of renovascular hypertension) or low serum potassium (suggestive of primary aldosteronism) TREATMENT Lifestyle modification should be prescribed to all patients with elevated blood pressure or hypertension; however, not all patients diagnosed with hypertension require pharmacologic therapy. https://www.uptodate.com/contents/overview-of-hypertension-in-adults/print 15/65 7/6/23, 12:49 PM Overview of hypertension in adults - UpToDate There are strong data supporting treatment decisions in some patient populations, such as those with severely elevated blood pressure, those at high cardiovascular risk, and older adults. However, data are weak and largely indirect for many other patient populations. As such, good clinical judgment and shared decision-making between patient and provider are paramount. Nonpharmacologic therapy Treatment of hypertension should involve nonpharmacologic therapy (also called lifestyle modification) alone or in concert with antihypertensive drug therapy ( table 9) [4,5,50]. We suggest that at least one aspect of nonpharmacologic therapy should be addressed at every office visit. Dietary salt restriction In well-controlled randomized trials, the overall impact of moderate sodium reduction is a fall in blood pressure in hypertensive and normotensive individuals of 4.8/2.5 and 1.9/1.1 mmHg, respectively ( figure 4) [51,52]. The effects of sodium restriction on blood pressure, cardiovascular disease, and mortality as well as specific recommendations for sodium intake, are discussed in detail elsewhere. (See "Salt intake, salt restriction, and primary (essential) hypertension".) Potassium supplementation, preferably by dietary modification, unless contraindicated by the presence of chronic kidney disease or use of drugs that reduce potassium excretion [4]. (See "Potassium and hypertension".) Weight loss Weight loss in overweight or obese individuals can lead to a significant fall in blood pressure independent of exercise. The decline in blood pressure induced by weight loss can also occur in the absence of dietary sodium restriction [53], but even modest sodium restriction may produce an additive antihypertensive effect [54]. The weight loss- induced decline in blood pressure generally ranges from 0.5 to 2 mmHg for every 1 kg of weight lost ( figure 5) [55]. (See "Diet in the treatment and prevention of hypertension" and "Overweight, obesity, and weight reduction in hypertension".) DASH diet The Dietary Approaches to Stop Hypertension (DASH) dietary pattern is high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, and nuts and low in sweets, sugar-sweetened beverages, and red meats. The DASH dietary pattern is consequently rich in potassium, magnesium, calcium, protein, and fiber but low in