What is hypertension
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I now have comprehensive information from the medical library and the 2025 ACC/AHA guidelines. Here is a full, synthesized answer:
Hypertension (High Blood Pressure)
Definition
Hypertension is a chronic condition in which the force of blood against artery walls is persistently elevated. The definition is, by necessity, somewhat arbitrary because blood pressure in a population is distributed as a continuous bell-shaped curve - there is no sharp natural cut-off between normal and high BP. Rather, the dividing line is set operationally based on cardiovascular risk data.
- Traditional threshold (most global guidelines, ESC/WHO): systolic BP >= 140 mmHg and/or diastolic BP >= 90 mmHg
- US ACC/AHA 2025 guideline threshold: >= 130/80 mmHg (aligning the diagnostic and treatment threshold)
Diagnosis requires averaging two or more readings on two or more occasions after initial screening, with the patient properly rested and seated.
- Park's Textbook of Preventive and Social Medicine
Blood Pressure Classification
| Category | Systolic (mmHg) | Diastolic (mmHg) |
|---|---|---|
| Optimal | < 120 | and < 80 |
| Normal | 120-129 | and/or 80-84 |
| High-Normal | 130-139 | and/or 85-89 |
| Grade 1 Hypertension | 140-159 | and/or 90-99 |
| Grade 2 Hypertension | 160-179 | and/or 100-109 |
| Grade 3 Hypertension | >= 180 | and/or > 110 |
| Isolated Systolic HTN | >= 140 | and < 90 |
When systolic and diastolic readings fall into different categories, the higher category is used to classify the individual.
- Park's Textbook of Preventive and Social Medicine
Types of Hypertension
1. Primary (Essential) Hypertension
- Accounts for ~90% of all cases
- No single identifiable cause; results from a combination of genetic, environmental, and lifestyle factors
- Risk factors: age, obesity, high dietary salt intake, physical inactivity, stress, family history, race
2. Secondary Hypertension
- Accounts for ~10% of cases
- Caused by an identifiable underlying condition, including:
- Renal disease - chronic glomerulonephritis, chronic pyelonephritis, renovascular disease (renal artery stenosis)
- Endocrine disorders - primary aldosteronism (most common secondary cause), pheochromocytoma, Cushing's syndrome, hypothyroidism/hyperthyroidism
- Structural - coarctation of the aorta
- Sleep disorders - obstructive sleep apnea (OSA)
- Drug-induced - NSAIDs, oral contraceptives, sympathomimetics, certain immunosuppressants
- Pregnancy-related - preeclampsia, gestational hypertension
- Park's Textbook of Preventive and Social Medicine; Harrison's Principles of Internal Medicine 22E
Why It Matters: Organ Damage & Complications
Hypertension is the most common cardiovascular disorder and accounts for 20-50% of all cardiovascular deaths. It is a major risk factor for:
- Stroke (ischemic and hemorrhagic)
- Coronary artery disease and myocardial infarction
- Heart failure
- Chronic kidney disease (CKD)
- Peripheral artery disease (PAD) - hypertension confers a 2.5- to 3.9-fold increased risk
- Aortic aneurysm and dissection
- Retinopathy
The relationship between BP and cardiovascular risk is direct and continuous - higher BP = higher risk of both stroke and coronary events, at all ages.
- Park's Textbook of Preventive and Social Medicine; Textbook of Family Medicine 9e
Symptoms
Hypertension is often called the "silent killer" because it typically produces no symptoms until serious target organ damage has occurred. Occasionally patients experience headache, dizziness, or visual disturbances at very high BP levels.
Diagnosis & Measurement
Proper BP measurement requires:
- Patient seated and rested for 3-5 minutes
- Arm at heart level, no talking during measurement
- Appropriate cuff size (bladder covers >= 80% of arm circumference)
- Two readings averaged per visit, over at least 2 separate visits
Out-of-office monitoring (home BP, ambulatory BP monitoring/ABPM) is increasingly central to diagnosis in the 2025 AHA/ACC guidelines - these methods reduce white-coat effects and guide long-term management.
- Brenner and Rector's The Kidney; 2025 AHA/ACC Guideline
Treatment
Non-Pharmacologic (Lifestyle) Interventions
These are first-line for all hypertensive patients:
- Dietary changes - DASH diet, reduced sodium intake (salt substitutes are now specifically endorsed in 2025 guidelines)
- Weight loss - every 1 kg reduction lowers SBP by ~1 mmHg
- Regular physical activity
- Limit alcohol consumption
- Smoking cessation
When to Start Medication (2025 AHA/ACC)
- All adults with BP >= 140/90 mmHg (plus lifestyle changes)
- Adults with BP >= 130/80 mmHg who have clinical CVD, prior stroke, diabetes, CKD, or 10-year CVD risk >= 7.5% (using the PREVENT calculator)
First-Line Drug Classes
| Drug Class | Examples | Key Use Cases |
|---|---|---|
| Thiazide/thiazide-like diuretics | Chlorthalidone, hydrochlorothiazide | Most patients (first-line) |
| ACE Inhibitors (ACEi) | Enalapril, lisinopril | Diabetes, CKD, heart failure |
| Angiotensin Receptor Blockers (ARB) | Losartan, valsartan | ACEi-intolerant, CKD |
| Calcium Channel Blockers (CCB) | Amlodipine, nifedipine | Elderly, isolated systolic HTN |
| Beta-blockers | Metoprolol, labetalol | Heart failure, post-MI, pregnancy |
| Mineralocorticoid Receptor Antagonists (MRA) | Spironolactone | Resistant hypertension, primary aldosteronism |
Resistant Hypertension
- Defined as BP above goal despite 3 antihypertensive agents at optimal doses (usually including a diuretic)
- The 2025 AHA/ACC guideline introduced renal denervation as a Class IIb adjunctive option for eligible patients with shared decision-making
- Harrison's Principles of Internal Medicine 22E; 2025 AHA/ACC Guideline (JACC 2025)
Special Populations
- CKD: Target BP < 130/80 mmHg; ACEi or ARB preferred to slow progression
- Diabetes: Same target (< 130/80 mmHg); RAAS blockers preferred
- Pregnancy: ACEi and ARBs are contraindicated (teratogenic); preferred agents are labetalol, nifedipine (CCB), and methyldopa
- Preeclampsia: Hypertension + proteinuria or target organ damage after 20 weeks of gestation; can progress to HELLP syndrome and eclampsia
- Harrison's Principles of Internal Medicine 22E
Key 2025 Guideline Updates (AHA/ACC)
- Risk now estimated using the PREVENT calculator (10- and 30-year CVD risk), replacing the older Pooled Cohort Equations
- Broader screening for primary aldosteronism (regardless of serum potassium level)
- Expanded guidance for CKD, diabetes, neurological disease, pregnancy, and cognition
- Terminology shift from "hypertensive urgency" to "severe hypertension"
- 2025 AHA/ACC Hypertension Guideline summary (JACC, July 2025)
Sources consulted:
- Park's Textbook of Preventive and Social Medicine
- Harrison's Principles of Internal Medicine 22E (2025)
- Brenner and Rector's The Kidney, 2-Volume Set
- Textbook of Family Medicine 9e
- 2025 AHA/ACC/Multisociety Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
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