Diagnosis and management of hypertension
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Diagnosis and Management of Hypertension
Definition and Classification
Blood pressure (BP) in adults is classified using the 2017 ACC/AHA system, which the 2025 AHA/ACC guideline retires the 2017 document and updates:
| Category | Systolic (SBP) | Diastolic (DBP) | |
|---|---|---|---|
| Normal | <120 mmHg | and | <80 mmHg |
| Elevated | 120-129 mmHg | and | <80 mmHg |
| Stage 1 Hypertension | 130-139 mmHg | or | 80-89 mmHg |
| Stage 2 Hypertension | ≥140 mmHg | or | ≥90 mmHg |
CVD risk is directly related to BP in a continuous fashion with no true threshold - risk increases even below the hypertension cutoff. - Fuster and Hurst's The Heart, 15th Edition
Diagnosis
Accurate BP Measurement
- Measure with the patient at rest, sitting, legs uncrossed, bladder empty, in a comfortable temperature
- Average ≥2 readings on ≥2 separate occasions before diagnosing hypertension
- Exception: Hypertension may be diagnosed on a single reading if BP >180/120 mmHg or if target organ damage is present
- Exclude pseudohypertension in elderly patients with stiff, noncompressible vessels (Osler sign: palpable artery persisting after cuff inflation)
- Home and ambulatory BP monitoring correlate better with target organ damage than clinic readings - Washington Manual of Medical Therapeutics
Evaluation: Initial Workup
A thorough history, physical exam, and basic investigations are performed to:
- Confirm the diagnosis
- Identify secondary causes
- Assess cardiovascular risk and target organ damage
Investigations:
- Urinalysis and urine microalbumin/creatinine (renal damage)
- Serum creatinine/eGFR (renal function)
- Electrolytes (K+ low in hyperaldosteronism)
- Fasting glucose, HbA1c (metabolic syndrome, DM)
- Fasting lipid panel (cardiovascular risk)
- ECG (LVH, arrhythmias)
- Thyroid function (secondary cause)
Secondary Hypertension
Screen especially in young patients, resistant hypertension, or atypical presentations:
| Cause | Clues |
|---|---|
| Renal artery stenosis | Abdominal bruit, flash pulmonary edema, worsening renal function on ACEi |
| Primary aldosteronism | Hypokalemia, elevated aldosterone/renin ratio |
| Pheochromocytoma | Episodic headache, palpitations, diaphoresis |
| Obstructive sleep apnea | Obesity, daytime somnolence, resistant HTN |
| Coarctation of aorta | Radio-femoral delay, reduced BP in legs |
| Cushing's syndrome | Central obesity, striae, hyperglycemia |
| Thyroid disease | Tachycardia/bradycardia, weight changes |
Pathophysiology
Hypertension arises from increased cardiac output, increased peripheral vascular resistance, or both. Renal mechanisms are central:
- Salt-sensitive hypertension: Reduced nephron mass, decreased glomerular filtration coefficient, or increased distal tubule sodium reabsorption - all shift the pressure-natriuresis curve rightward
- Salt-insensitive hypertension: Increased preglomerular resistance (e.g., renal artery stenosis) causes a parallel shift in the pressure-natriuresis relationship - Brenner and Rector's The Kidney
Key contributing factors:
- Excess sodium intake - higher dietary sodium and sodium/potassium ratios are associated with higher BP (INTERMAP data)
- Physical inactivity - risk of hypertension is dose-dependently reduced ~6% per 10 METs-hr/week of leisure activity
- Obesity - visceral adipocytes generate pro-inflammatory cytokines promoting vascular disease
- Social determinants - income, education, access to care; hypertension is more prevalent and harder to control in Black Americans - Fuster and Hurst's The Heart, 15th Edition
Management
Treatment Goals
- Target BP <130/80 mmHg for most patients
- The primary driver of cardiovascular risk reduction is the amount of BP reduction, not the specific drug class chosen
Lifestyle Modifications (First-line for all patients)
| Modification | Approximate SBP Reduction |
|---|---|
| Weight reduction (per 10-kg loss) | 5-20 mmHg |
| DASH diet | 8-14 mmHg |
| Dietary sodium reduction (<2 g/day) | 2-8 mmHg |
| Physical activity (150 min/week) | 4-9 mmHg |
| Alcohol moderation (<2 drinks/day) | 2-4 mmHg |
- Washington Manual of Medical Therapeutics
Most patients with Stage 1 hypertension without high cardiovascular risk should have a trial of lifestyle changes (approx. 1 month) before starting pharmacotherapy. Stage 2 hypertension or high-risk patients should start drugs sooner.
Pharmacologic Therapy
Drug classes and key points:
1. Thiazide Diuretics (e.g., hydrochlorothiazide, chlorthalidone)
- First-line for most patients
- Especially effective in Black patients and elderly
- Side effects: hypokalemia, hyponatremia, hyperuricemia, hyperglycemia, hyperlipidemia
- Reduce urinary calcium excretion (protective against fractures in women)
2. ACE Inhibitors (e.g., ramipril, lisinopril)
- Preferred in: heart failure, CKD with proteinuria, post-MI, diabetes, high renin states
- Reduce complications beyond BP reduction (HOPE trial: reduced MI, stroke, death)
- Side effects: dry cough (up to 20%), angioedema, hyperkalemia, worsening renal function in bilateral renal artery stenosis
- Contraindicated in pregnancy (teratogenic)
- Do not combine with ARBs (increased vascular events and renal dysfunction)
3. Angiotensin Receptor Blockers (ARBs) (e.g., losartan, valsartan)
- Alternative to ACEi, especially in ACEi-intolerant patients (e.g., cough)
- Useful in heart failure, CKD
- Side effects: rare angioedema, rash
- Contraindicated in pregnancy
4. Calcium Channel Blockers (CCBs)
- Dihydropyridines (e.g., amlodipine, nifedipine): cause peripheral vasodilation; effective in Black patients; side effects: edema, flushing, headache
- Non-dihydropyridines (verapamil, diltiazem): negative chronotropes; useful in AF; side effects: constipation (verapamil), heart block; avoid in HF with reduced EF
- No adverse effects on glucose, lipids, or electrolytes
5. Beta-Blockers (e.g., metoprolol, carvedilol, atenolol)
- Preferred in: ischemic heart disease, post-MI, heart failure with reduced EF, AF rate control
- Not first-line for uncomplicated hypertension (less effective for stroke prevention)
- Side effects: bradycardia, fatigue, sexual dysfunction, masking hypoglycemia, bronchospasm
- Avoid in asthma/COPD; avoid atenolol in pregnancy (fetal growth restriction risk)
- Abrupt discontinuation can trigger rebound hypertension (withdrawal syndrome within 24-72 hours); serious complications include stroke, MI, encephalopathy
6. ARNI (Sacubitril-Valsartan)
- Particularly useful in heart failure; reduces all-cause mortality vs enalapril
- Do not administer within 36 hours of switching to/from ACEi
- Contraindicated with aliskiren in diabetics or eGFR <60
7. Direct Renin Inhibitor (aliskiren)
- Used solely for hypertension
- Contraindicated in combination with ACEi/ARBs in diabetic patients
8. Alpha-Blockers, Central Agents (e.g., clonidine, methyldopa)
- Clonidine: reserved for resistant hypertension; rebound hypertension on abrupt withdrawal
- Methyldopa: safe in pregnancy (first-line)
Special Populations
Compelling indications and preferred agents:
| Condition | Preferred Drug(s) |
|---|---|
| Heart failure (HFrEF) | ACEi/ARB, beta-blocker, diuretic, MRA |
| HFpEF with volume overload | Diuretics; ACEi/ARB for LVH regression |
| Post-MI | Beta-blocker, ACEi |
| CKD with proteinuria | ACEi or ARB |
| Diabetes | ACEi or ARB (reduce proteinuria) |
| Black patients | Thiazides and CCBs are especially effective |
| Pregnancy | Labetalol, nifedipine, or methyldopa |
| PAD | ACEi beneficial; beta-blockers safe (do not worsen claudication) |
Hypertension in Pregnancy:
- Preeclampsia: New-onset HTN after 20 weeks + proteinuria (or end-organ features)
- Eclampsia: Preeclampsia + generalized seizures
- Treat when SBP ≥160 or DBP ≥100 mmHg in pregnancy
- First-line: labetalol, nifedipine, methyldopa
- Avoid: ACEi, ARBs (teratogenic), atenolol
- Washington Manual of Medical Therapeutics
Hypertensive Urgency and Emergency
| Feature | Urgency | Emergency |
|---|---|---|
| BP threshold | ≥180/110 mmHg | ≥180/110 mmHg (may be higher) |
| End-organ damage | Absent | Present |
| Symptoms | Asymptomatic or vague | Headache, vision changes, dyspnea, chest pain, altered mentation, seizures |
| Setting | Outpatient | Emergency room / ICU |
| Route of treatment | Oral | IV |
| Rate of BP reduction | Gradual (hours to days) | Controlled reduction over minutes-hours; avoid overly rapid drops (risk of ischemia) |
Hypertensive urgency: Restart/intensify oral agents; schedule prompt follow-up. Rapid reductions risk precipitating target organ ischemia.
Hypertensive emergency - common presentations:
- Hypertensive encephalopathy (obtundation, visual disturbances, papilledema, seizures, posterior leukoencephalopathy on MRI - no focal neurologic signs)
- Acute left ventricular failure / pulmonary edema
- Acute coronary syndrome
- Aortic dissection
- Eclampsia
- Pheochromocytoma crisis
IV agents used in hypertensive emergencies: labetalol, nicardipine, clevidipine, nitroprusside, nitroglycerin, hydralazine (eclampsia), phentolamine (pheochromocytoma)
Note: Previously used sublingual nifedipine is no longer recommended - it was associated with acute coronary events and ischemic strokes. - Swanson's Family Medicine Review
Resistant Hypertension
Defined as BP above goal despite optimal doses of 3 antihypertensive agents of different classes (including a diuretic), or BP requiring ≥4 agents to be controlled.
- Screen for secondary causes
- Assess medication adherence and white coat effect
- 42% of treatment-resistant hypertensive adults are physically inactive
- Additional agents: mineralocorticoid receptor antagonists (spironolactone), alpha-blockers, direct vasodilators
Key 2025 Guideline Update
The 2025 AHA/ACC/AANP et al. Guideline (PMID: 40815242) represents the most current comprehensive update, replacing the 2017 guideline. It is described as a "living document" incorporating evidence through 2024. Key areas include updated BP classification, treatment thresholds, lifestyle intervention evidence, and special population guidance. Note: an erratum was published (PMID: 42300826).
The Hypertension Canada 2025 guideline for primary care (PMID: 40419299) was also published in May 2025, offering a complementary primary care-focused perspective.
Sources:
- Fuster and Hurst's The Heart, 15th Edition - Classification, epidemiology, CVD risk, pathophysiology, lifestyle therapy
- Washington Manual of Medical Therapeutics - Diagnosis, medications, special populations, pregnancy
- Harrison's Principles of Internal Medicine, 22E (2025) - Race/sex disparities, hypertensive urgencies/emergencies
- Goldman-Cecil Medicine - Hypertensive emergency/urgency definition, clinical features, treatment
- Brenner and Rector's The Kidney - Renal mechanisms of hypertension
Diagnosis and management of hypertension
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Diagnosis and Management of Hypertension
1. Blood Pressure Measurement
Accurate measurement is the foundation of hypertension diagnosis. Errors are common in routine practice - SBP is overestimated by an average of ~7 mmHg in clinical settings, leading to a 15-20% overestimation of hypertension prevalence.
Key requirements for accurate measurement:
- Use a clinically validated oscillometric (automated) device
- Correct cuff size; apply to bare upper arm, 2-3 cm above the elbow crease
- Patient seated, back supported, feet flat, mid-arm at heart level
- No talking during rest period or between measurements
- Measure the arm with the highest reading at the first visit
- Average ≥2 readings at ≥2 separate visits before diagnosing hypertension
- When SBP and DBP fall in different categories, use the higher classification
2. Classification
The ACC/AHA classification system (the current standard, updated in the 2025 AHA/ACC guideline PMID 40811497 and the 2024 ESC guideline PMID 39210715):
| BP Category | Systolic (mmHg) | Diastolic (mmHg) | |
|---|---|---|---|
| Normal | <120 | and | <80 |
| Elevated | 120-129 | and | <80 |
| Stage 1 Hypertension | 130-139 | or | 80-89 |
| Stage 2 Hypertension | ≥140 | or | ≥90 |
When SBP and DBP fall in different categories, the higher category applies (e.g., 162/82 mmHg = Stage 2).
In children <13 years, classification is based on age-, sex-, and height-specific percentiles. Hypertension = average SBP/DBP at or above the 95th percentile, or ≥130/80 mmHg.
3. Out-of-Office BP Monitoring
Office readings alone can be misleading. Two important syndromes:
- White-coat hypertension: Office BP meets hypertension criteria, but out-of-office BP is normal (prevalence ~15-25%). CVD risk resembles those with normal BP. Manage with lifestyle changes and monitor carefully.
- Masked hypertension: Office BP appears controlled, but out-of-office BP is hypertensive (prevalence ~15-25%). CVD risk resembles sustained hypertension - treat with antihypertensives plus lifestyle changes.
Home BP targets (same thresholds as office): hypertension ≥130/80 mmHg, controlled <130/80 mmHg. Measure in morning and evening, 2-3 readings each, for 3 days before an office visit.
Ambulatory BP monitoring (ABPM) is the gold standard for out-of-office BP assessment.
- Harrison's Principles of Internal Medicine, 22nd Edition (2025)
4. Initial Evaluation
Purpose
- Confirm diagnosis and stage
- Identify secondary (reversible) causes
- Assess target organ damage (TOD)
- Quantify overall cardiovascular risk
History
- Duration of hypertension, prior BP levels, treatments
- Symptoms suggestive of secondary causes (episodic headache/palpitations/sweating = phaeochromocytoma; snoring/daytime somnolence = OSA)
- Family history of hypertension, CVD, renal disease
- Medications (NSAIDs, oral contraceptives, decongestants, stimulants, steroids, calcineurin inhibitors - all raise BP)
- Lifestyle: sodium intake, alcohol, exercise, weight, smoking
- Comorbidities: DM, CKD, sleep apnea, dyslipidemia
Physical Examination
- BP both arms (interarm difference >15 mmHg suggests coarctation or subclavian stenosis)
- Pulse, heart rate, BMI, waist circumference
- Fundoscopy (AV nicking, flame hemorrhages, papilledema = hypertensive retinopathy)
- Cardiovascular exam: S3/S4, displaced apex (LVH/HF)
- Abdomen: renal bruits (renovascular disease), palpable kidneys (polycystic kidney disease)
- Peripheral pulses, radio-femoral delay (coarctation)
- Signs of Cushing's, thyroid disease
Baseline Investigations
| Test | Purpose |
|---|---|
| Urinalysis + urine albumin/creatinine ratio | Proteinuria, hematuria (renal TOD) |
| Serum creatinine + eGFR | Renal function (TOD/secondary) |
| Serum electrolytes (K+, Na+) | Hypokalemia → hyperaldosteronism |
| Fasting glucose + HbA1c | Diabetes |
| Fasting lipid profile | Cardiovascular risk |
| ECG | LVH, arrhythmias, prior MI |
| Thyroid function (TSH) | Secondary cause |
| Full blood count | Polycythaemia |
Echocardiography is considered if LVH is suspected clinically.
5. Secondary Hypertension
Accounts for ~10% of all hypertension. Suspect in: young patients (<30 years), resistant hypertension, acute onset, hypokalaemia, asymmetric renal size, or abnormal urinalysis.
| Cause | Clues | Key Investigation |
|---|---|---|
| Renal parenchymal disease | Elevated creatinine, proteinuria, haematuria | eGFR, renal USS |
| Renovascular disease | Abdominal bruit, flash pulmonary oedema, worsening renal function on ACEi/ARB | Duplex USS, CT/MR angiography |
| Primary aldosteronism | Hypokalemia, adrenal incidentaloma | Aldosterone:renin ratio (ARR) |
| Phaeochromocytoma | Paroxysmal headache, palpitations, diaphoresis | 24h urinary metanephrines or plasma metanephrines |
| Obstructive sleep apnoea | Obesity, snoring, daytime somnolence | Polysomnography |
| Coarctation of aorta | Radio-femoral delay, lower BP in legs, rib notching on CXR | CT/MR aortography |
| Cushing's syndrome | Central obesity, moon face, striae, buffalo hump, hyperglycaemia | 24h urinary cortisol, overnight dexamethasone suppression test |
| Hypothyroidism/Hyperthyroidism | Bradycardia or tachycardia, weight changes | TSH |
| Primary hyperparathyroidism | Hypercalcaemia | Serum Ca2+, PTH |
6. Target Organ Damage (TOD)
Hypertension damages the heart, brain, kidneys, eyes, and peripheral vasculature:
| Organ | Manifestation |
|---|---|
| Heart | LVH, CAD, HF, AF |
| Brain | Stroke, TIA, vascular dementia, hypertensive encephalopathy |
| Kidneys | CKD, microalbuminuria, proteinuria |
| Eyes | Hypertensive retinopathy (AV nicking → flame haemorrhages → papilledema) |
| Vessels | Peripheral arterial disease, aortic aneurysm, aortic dissection |
7. Management
Treatment Goal
- <130/80 mmHg for most adults
- The magnitude of BP reduction, not the drug class chosen, is the primary driver of cardiovascular risk reduction
A. Lifestyle (Non-pharmacological) Modifications
First-line for ALL patients regardless of whether medication is needed. Can be sufficient to control Stage 1 hypertension in low-risk patients.
| Intervention | Expected SBP Reduction |
|---|---|
| Weight reduction (per 10 kg lost) | 5-20 mmHg |
| DASH diet | 8-14 mmHg |
| Dietary sodium reduction (<2 g/day) | 2-8 mmHg |
| Regular aerobic exercise (150 min/week) | 4-9 mmHg |
| Alcohol moderation (<2 drinks/day) | 2-4 mmHg |
| Potassium supplementation / salt substitution | ~4-5 mmHg |
The interventions show a linear dose-response, and combining multiple interventions (e.g., DASH + sodium restriction + weight loss) produces additive reductions. Non-pharmacological treatment also enhances the effect of antihypertensive medications. - Harrison's Principles of Internal Medicine, 22E (2025)
B. When to Start Pharmacotherapy
- Stage 1 (130-139/80-89 mmHg) with low CVD risk: lifestyle changes for 3-6 months first
- Stage 1 with established CVD, DM, CKD, or 10-year CVD risk ≥10%: start medication immediately alongside lifestyle
- Stage 2 (≥140/90 mmHg): initiate pharmacotherapy promptly, often with two drugs
- BP >180/120 mmHg with target organ damage: hypertensive emergency - IV treatment required
C. Drug Classes
Meta-analysis of 123 trials showed antihypertensive therapy reduces: major CVD by 20%, CHD by 17%, stroke by 27%, HF by 28%, and all-cause mortality by 13%. The five classes proven to prevent CVD are diuretics, beta-blockers, CCBs, ACEi, and ARBs - though in head-to-head RCTs, beta-blockers are inferior to the others (especially for stroke prevention).
1. Thiazide/Thiazide-like Diuretics
(e.g., chlorthalidone, hydrochlorothiazide, indapamide)
- Considered "best in class" for first-step antihypertensive therapy in meta-analyses
- Especially effective in Black patients and elderly
- Reduce urinary calcium excretion (fracture protection in women)
- Side effects: Hypokalemia, hyponatraemia, hyperuricaemia (gout), impaired glucose tolerance, hyperlipidaemia, erectile dysfunction
2. ACE Inhibitors (ACEi)
(e.g., ramipril, lisinopril, enalapril, perindopril)
- Preferred in: HF, post-MI, CKD with proteinuria, diabetes, renovascular hypertension (high-renin states), scleroderma renal crisis
- Reduce cardiovascular events beyond BP reduction (HOPE trial - ramipril reduced MI, stroke, death in high-risk patients without HF)
- Side effects: Dry cough (up to 20%), angioedema (<1%), hyperkalemia, worsening renal function in bilateral renal artery stenosis or severe renal insufficiency
- Contraindicated: Pregnancy (teratogenic), bilateral renal artery stenosis, hyperkalaemia
- Do NOT combine with ARBs (increased renal/vascular events)
3. Angiotensin Receptor Blockers (ARBs)
(e.g., losartan, valsartan, irbesartan, candesartan)
- Equivalent to ACEi in most indications; preferred in ACEi-intolerant patients (cough)
- Useful in HFrEF, CKD with proteinuria, post-MI
- Side effects: Rare angioedema, hyperkalaemia, worsening renal function
- Contraindicated: Pregnancy (teratogenic)
- Do NOT combine with ACEi
4. Calcium Channel Blockers (CCBs)
- Dihydropyridines (e.g., amlodipine, nifedipine, felodipine): peripheral vasodilators; good for stroke prevention; effective in Black patients and elderly
- Side effects: Peripheral oedema, flushing, headache, gingival hyperplasia
- Non-dihydropyridines (verapamil, diltiazem): also reduce heart rate; useful in AF/SVT rate control
- Side effects: Constipation (verapamil), bradycardia, heart block, nausea
- Avoid non-DHPs in HFrEF
- No adverse effect on glucose, lipids, or electrolytes
5. Beta-Blockers
(e.g., metoprolol succinate, carvedilol, bisoprolol, atenolol, labetalol)
- Not first-line for uncomplicated hypertension (inferior for stroke prevention in meta-analyses)
- Compelling indications: post-MI, HFrEF, stable angina, AF rate control, aortic aneurysm
- Side effects: Fatigue, bradycardia, bronchospasm, sexual dysfunction, cold extremities, masking of hypoglycaemia
- Avoid in: Asthma/reactive airway disease, heart block (>1st degree), cardiogenic shock
- Abrupt discontinuation causes rebound hypertension (worst with clonidine and beta-blockers) - taper when stopping; rebound can cause encephalopathy, stroke, MI
6. Mineralocorticoid Receptor Antagonists (MRAs)
(e.g., spironolactone, eplerenone)
- Especially useful in primary aldosteronism, resistant hypertension, HFrEF
- Spironolactone is most effective 4th-line agent in resistant hypertension (Pathway-2 trial)
- Side effects: Hyperkalaemia, gynaecomastia (spironolactone), menstrual irregularities
7. Other Classes
- Alpha-1 blockers (doxazosin): useful in BPH + hypertension; orthostatic hypotension risk
- Central alpha-2 agonists (clonidine, methyldopa): reserved for resistant hypertension or pregnancy (methyldopa); rebound syndrome on abrupt cessation
- Direct vasodilators (hydralazine, minoxidil): reserved for refractory cases; reflex tachycardia/fluid retention require co-medication
- ARNI (sacubitril-valsartan): approved for HFrEF; emerging data on BP reduction; do not use within 36 hours of switching to/from ACEi
- Direct renin inhibitor (aliskiren): do not combine with ACEi/ARBs in diabetics (FDA warning)
D. Initial Drug Selection Strategy
| Clinical Scenario | Preferred Agent(s) |
|---|---|
| Uncomplicated hypertension | Thiazide, CCB, ACEi, or ARB |
| Black race (without DM/CKD) | Thiazide or CCB (ACEi/ARBs less effective as monotherapy) |
| HF with reduced EF | ACEi or ARB + beta-blocker + MRA + diuretic |
| Post-MI | Beta-blocker + ACEi |
| CKD with proteinuria | ACEi or ARB |
| Diabetes | ACEi or ARB (reduce diabetic nephropathy) |
| Stable angina | Beta-blocker or CCB |
| AF (rate control) | Beta-blocker or non-DHP CCB |
| Primary aldosteronism | MRA (spironolactone) |
| Benign prostatic hyperplasia | Alpha-blocker |
| Pregnancy | Labetalol, nifedipine, or methyldopa |
Rational combination therapy: Most patients with Stage 2 hypertension require ≥2 agents. Preferred combinations: ACEi (or ARB) + CCB, or ACEi (or ARB) + thiazide. Adding a CCB to a RAAS blocker is preferred over RAAS + diuretic for most patients.
8. Resistant Hypertension
Defined as BP above goal despite the optimal doses of 3 antihypertensive agents of different classes (including a diuretic), or requiring ≥4 agents to be controlled.
Approach:
- Confirm true resistance (exclude pseudoresistance: white-coat effect, poor adherence, inaccurate measurement)
- Optimize lifestyle changes
- Review for secondary causes (especially primary aldosteronism and OSA)
- Review drug interactions and interfering substances (NSAIDs, stimulants, liquorice)
- Add a 4th agent: spironolactone is most evidence-based 4th-line agent (Pathway-2 trial)
- Consider referral to a hypertension specialist
9. Special Populations
Hypertension in Pregnancy
- Preeclampsia: New-onset hypertension after 20 weeks' gestation + proteinuria (or end-organ features: platelets <100,000, creatinine >1.1 mg/dL, LFTs >2x normal, pulmonary oedema, cerebral/visual symptoms)
- Eclampsia: Above + generalised seizures
- Chronic hypertension: Present before pregnancy or <20 weeks' gestation
- Gestational hypertension: BP ≥140/90 after 20 weeks without proteinuria/end-organ features
Treatment: Treat when SBP ≥160 or DBP ≥100 mmHg
- Safe first-line: Labetalol, nifedipine (oral), methyldopa
- Avoid: ACEi and ARBs (teratogenic - fetal renal toxicity, oligohydramnios, skull hypoplasia, death); atenolol (fetal growth restriction)
- Magnesium sulphate is used for seizure prophylaxis/treatment in eclampsia
- Washington Manual of Medical Therapeutics
Elderly Patients
- Higher prevalence of isolated systolic hypertension
- Higher prevalence of orthostatic hypotension - check standing BP
- Watch for pseudohypertension (Osler's sign: stiff arteries maintain palpable pulse after cuff inflation)
- Start drugs at lower doses; titrate slowly
- Thiazides and CCBs are effective; avoid alpha-blockers as first-line (fall risk)
- Target <130/80 in most elderly, but individualise in frail patients
Racial Disparities
Black Americans have higher prevalence, earlier onset, and worse outcomes from hypertension. Thiazides and CCBs are particularly effective; many require triple therapy. ACEi/ARBs are less effective as monotherapy in this population. Disparities are largely driven by social determinants of health rather than genetics. - Harrison's, 22E (2025)
10. Hypertensive Urgency and Emergency
| Feature | Urgency | Emergency |
|---|---|---|
| BP threshold | ≥180/110-120 mmHg | Usually ≥180/110-120 mmHg |
| Target organ damage | Absent | Present (new/worsening) |
| Symptoms | Asymptomatic or mild headache | Neurological (encephalopathy, seizures), chest pain, dyspnoea, visual disturbance, oliguria |
| Management setting | Outpatient | Emergency department / ICU |
| Treatment route | Oral | IV |
| Speed of BP reduction | Gradual over hours-days | Controlled reduction over minutes-hours |
Hypertensive Urgency
- Restart discontinued medications or intensify oral regimen
- Rapid BP reduction risks precipitating target organ ischaemia (cerebral, coronary, renal)
- Schedule close outpatient follow-up within 1-3 days
- Sublingual nifedipine is contraindicated - associated with acute coronary events and ischaemic strokes
Hypertensive Emergency - Key Presentations
| Presentation | Notes |
|---|---|
| Hypertensive encephalopathy | Headache, obtundation, visual disturbance, seizures, papilloedema; posterior reversible encephalopathy syndrome (PRES) on MRI; no focal deficits |
| Acute ischaemic stroke | BP lowering is cautious - only treat if BP >220/120 (or >185/110 if thrombolysis planned) |
| Haemorrhagic stroke | Target SBP <140 mmHg in first 6 hours |
| Acute LV failure / pulmonary oedema | IV nitrates + loop diuretics + IV ACEi (enalaprilat) |
| Acute aortic dissection | Most urgent scenario: target SBP <120 mmHg rapidly; IV labetalol or esmolol + nitroprusside |
| ACS/STEMI | IV nitrates, beta-blockers, heparin |
| Eclampsia | IV labetalol or hydralazine; MgSO4 for seizures |
| Phaeochromocytoma crisis | Phentolamine (alpha-blocker) first; then beta-blocker - never start beta-blocker first (paradoxical hypertension from unopposed alpha-stimulation) |
IV agents used in hypertensive emergencies:
| Drug | Onset | Indication |
|---|---|---|
| Labetalol (IV) | 5-10 min | Most emergencies, aortic dissection, eclampsia |
| Nicardipine (IV) | 5-15 min | Most emergencies, post-operative |
| Clevidipine (IV) | 2-4 min | Perioperative, general emergencies |
| Sodium nitroprusside | Seconds | Severe emergencies, aortic dissection (+ beta-blocker) |
| Nitroglycerin (IV) | 2-5 min | ACS, acute pulmonary oedema |
| Esmolol (IV) | 1-2 min | Aortic dissection, perioperative |
| Phentolamine | 1-2 min | Phaeochromocytoma, MAOI interactions, cocaine |
| Hydralazine (IV) | 10-30 min | Eclampsia |
- Goldman-Cecil Medicine; Harrison's Principles of Internal Medicine, 22E (2025)
11. Follow-up and Monitoring
- Reassess BP at 1 month after initiating or changing therapy
- Once controlled, follow-up every 3-6 months
- Monitor for side effects and adherence at each visit
- Annual: electrolytes, creatinine, urinalysis
- Reinforce lifestyle modifications at every visit
- Consider home BP monitoring to improve adherence and optimise titration
Current Guideline Summary
The 2025 AHA/ACC/AANP et al. Guideline (PMID: 40811497) is the current U.S. standard, replacing the 2017 guideline. It is designed as a "living document" incorporating evidence up to mid-2024. The 2024 ESC Guideline (PMID: 39210715) is the European counterpart. Both emphasise accurate BP measurement, lifestyle changes, and individualised pharmacotherapy with a goal of <130/80 mmHg for most patients.
Primary sources:
- Harrison's Principles of Internal Medicine, 22nd Edition (2025) - Classification, measurement, pharmacotherapy, special populations, emergencies
- Washington Manual of Medical Therapeutics - Drug classes, lifestyle modifications, pregnancy
- Goldman-Cecil Medicine - Hypertensive urgency/emergency management
- Fuster and Hurst's The Heart, 15th Edition - BP classification, pathophysiology, CVD risk
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