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Hypertension

Hypertension, also known as high blood pressure,

is a long-term medical condition in which the blood Hypertension
pressure in the arteries is persistently elevated.[11] High Other names Arterial hypertension, high
blood pressure usually does not cause symptoms blood pressure
itself.[1] It is, however, a major risk factor for stroke,
coronary artery disease, heart failure, atrial fibrillation,
peripheral arterial disease, vision loss, chronic kidney
disease, and dementia.[2][3][4][12] Hypertension is a
major cause of premature death worldwide.[13]

High blood pressure is classified as primary (essential)

hypertension or secondary hypertension.[5] About 90– Automated arm blood pressure meter showing
95% of cases are primary, defined as high blood arterial hypertension (shown by a systolic
pressure due to nonspecific lifestyle and genetic blood pressure 158 mmHg, diastolic blood
factors.[5] Lifestyle factors that increase the risk include pressure 99 mmHg and heart rate of 80 beats
excess salt in the diet, excess body weight, smoking, per minute)
physical inactivity and alcohol use.[1][5] The remaining
Specialty Cardiology, Nephrology
5–10% of cases are categorized as secondary
hypertension, defined as high blood pressure due to a Symptoms None[1]
clearly identifiable cause, such as chronic kidney Complications Coronary artery disease,
disease, narrowing of the kidney arteries, an endocrine stroke, heart failure,
disorder, or the use of birth control pills.[5] peripheral arterial disease,
vision loss, chronic kidney
Blood pressure is classified by two measurements, the disease, dementia[2][3][4]
systolic (first number) and diastolic (second number)
Causes Usually lifestyle and genetic
pressures.[1] For most adults, normal blood pressure at factors[5]
rest is within the range of 100–140 millimeters mercury
Risk factors Lack of sleep, excess salt,
(mmHg) systolic and 60–90 mmHg diastolic.[6][7] For
excess body weight,
most adults, high blood pressure is present if the resting
smoking, alcohol[1][5]
blood pressure is persistently at or above 130/80 or
140/90 mmHg.[5][6][7] Different numbers apply to Diagnostic Resting blood pressure in
children.[14] Ambulatory blood pressure monitoring method adults
over a 24-hour period appears more accurate than ≥ 130/80 mmHg[6] or
office-based blood pressure measurement.[5][11] ≥ 140/90 mmHg[7]
Treatment Lifestyle changes,
Lifestyle changes and medications can lower blood medications[8]
pressure and decrease the risk of health
complications.[8] Lifestyle changes include weight loss,
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physical exercise, decreased salt intake, reducing Frequency 33% (all adults), 16%
[5]
alcohol intake, and a healthy diet. If lifestyle changes (diagnosed)
are not sufficient, blood pressure medications are (globally, 2019)[9][10]
[8]
used. Up to three medications taken concurrently can Deaths 10.4 million; 19% of deaths
control blood pressure in 90% of people. [5] The (globally, 2019)[9]
treatment of moderately high arterial blood pressure
(defined as >160/100 mmHg) with medications is associated with an improved life expectancy.[15]
The effect of treatment of blood pressure between 130/80 mmHg and 160/100 mmHg is less clear,
with some reviews finding benefit[6][16][17] and others finding unclear benefit.[18][19][20] High blood
pressure affects 33% of the population globally.[9] About half of all people with high blood pressure do
not know that they have it.[9] In 2019, high blood pressure was believed to have been a factor in 19%
of all deaths (10.4 million globally).[9]

Signs and symptoms CC

Hypertension is rarely accompanied by symptoms.[1]

Half of all people with hypertension are unaware that
they have it.[9] Hypertension is usually identified as part
of health screening or when seeking healthcare for an 3:39
unrelated problem.
Video summary (script)
Some people with high blood pressure report headaches,
as well as lightheadedness, vertigo, tinnitus (buzzing or
hissing in the ears), altered vision or fainting episodes.[21] These symptoms, however, might be related
to associated anxiety rather than the high blood pressure itself.[22]

Long-standing untreated hypertension can cause organ damage with signs such as changes in the
optic fundus seen by ophthalmoscopy.[23] The severity of hypertensive retinopathy correlates roughly
with the duration or the severity of the hypertension.[21] Other hypertension-caused organ damage
include chronic kidney disease and thickening of the heart muscle.[9]

Secondary hypertension
Secondary hypertension is hypertension due to an identifiable cause, and may result in certain specific
additional signs and symptoms. For example, as well as causing high blood pressure, Cushing's
syndrome frequently causes truncal obesity,[24] glucose intolerance, moon face, a hump of fat behind
the neck and shoulders (referred to as a buffalo hump), and purple abdominal stretch marks.[25]
Hyperthyroidism frequently causes weight loss with increased appetite, fast heart rate, bulging eyes,
and tremor. Renal artery stenosis may be associated with a localized abdominal bruit to the left or
right of the midline, or in both locations. Coarctation of the aorta frequently causes a decreased blood

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pressure in the lower extremities relative to the arms, or delayed or absent femoral arterial pulses.
Pheochromocytoma may cause abrupt episodes of hypertension accompanied by headache,
palpitations, pale appearance, and excessive sweating.[25]

Hypertensive crisis
Severely elevated blood pressure (equal to or greater than a systolic 180 mmHg or diastolic of 120
mmHg) is referred to as a hypertensive crisis.[26] Hypertensive crisis is categorized as either
hypertensive urgency or hypertensive emergency, according to the absence or presence of end organ
damage, respectively.[27][28]

In hypertensive urgency, there is no evidence of end organ damage resulting from the elevated blood
pressure. In these cases, oral medications are used to lower the BP gradually over 24 to 48 hours.[29]

In hypertensive emergency, there is evidence of direct damage to one or more organs.[30][31] The most
affected organs include the brain, kidney, heart and lungs, producing symptoms which may include
confusion, drowsiness, chest pain and breathlessness.[29] In hypertensive emergency, the blood
pressure must be reduced more rapidly to stop ongoing organ damage;[29] however, there is a lack of
randomized controlled trial evidence for this approach.[31]

Pregnancy
Hypertension occurs in approximately 8–10% of pregnancies.[25] Two blood pressure measurements
six hours apart of greater than 140/90 mmHg are diagnostic of hypertension in pregnancy.[32] High
blood pressure in pregnancy can be classified as pre-existing hypertension, gestational hypertension,
or pre-eclampsia.[33] Women who have chronic hypertension before their pregnancy are at increased
risk of complications such as premature birth, low birthweight or stillbirth.[34] Women who have high
blood pressure and had complications in their pregnancy have three times the risk of developing
cardiovascular disease compared to women with normal blood pressure who had no complications in
pregnancy.[35][36]

Pre-eclampsia is a serious condition of the second half of pregnancy and following delivery
characterised by increased blood pressure and the presence of protein in the urine.[25] It occurs in
about 5% of pregnancies and is responsible for approximately 16% of all maternal deaths globally.[25]
Pre-eclampsia also doubles the risk of death of the baby around the time of birth.[25] Usually there are
no symptoms in pre-eclampsia and it is detected by routine screening. When symptoms of pre-
eclampsia occur the most common are headache, visual disturbance (often "flashing lights"),
vomiting, pain over the stomach, and swelling. Pre-eclampsia can occasionally progress to a life-
threatening condition called eclampsia, which is a hypertensive emergency and has several serious
complications including vision loss, brain swelling, seizures, kidney failure, pulmonary edema, and
disseminated intravascular coagulation (a blood clotting disorder).[25][37]

In contrast, gestational hypertension is defined as new-onset hypertension during pregnancy without

protein in the urine.[33]

Children
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Failure to thrive, seizures, irritability, lack of energy, and difficulty in breathing[38] can be associated
with hypertension in newborns and young infants. In older infants and children, hypertension can
cause headache, unexplained irritability, fatigue, failure to thrive, blurred vision, nosebleeds, and
facial paralysis.[38][39]

Causes

Primary hypertension
Primary (also termed essential) hypertension results from a complex interaction of genes and
environmental factors. More than 2000 common genetic variants with small effects on blood pressure
have been identified in association with high blood pressure,[40] as well as some rare genetic variants
with large effects on blood pressure.[41] There is also evidence that DNA methylation at multiple
nearby CpG sites may link some sequence variation to blood pressure, possibly via effects on vascular
or renal function.[42]

Blood pressure rises with aging in societies with a western diet and lifestyle,[43] and the risk of
becoming hypertensive in later life is substantial in most such societies.[44] Several environmental or
lifestyle factors influence blood pressure. Reducing dietary salt intake lowers blood pressure;[45] as
does weight loss,[46] exercise training,[47] vegetarian diets,[48] increased dietary potassium intake[49]
and high dietary calcium supplementation.[50] Increasing alcohol intake is associated with higher
blood pressure,[51] but the possible roles of other factors such as caffeine consumption,[52] and
vitamin D deficiency[53] are less clear. Average blood pressure is higher in the winter than in the
summer.[54]

Depression is associated with hypertension[55] and loneliness is also a risk factor.[56] Periodontal
disease is also associated with high blood pressure.[57] Arsenic exposure through drinking water is
associated with elevated blood pressure.[58] Air pollution is associated with hypertension.[59] Whether
these associations are causal is unknown. Gout and elevated blood uric acid are associated with
hypertension[60] and evidence from genetic (Mendelian Randomization) studies and clinical trials
indicate this relationship is likely to be causal.[61] Insulin resistance, which is common in obesity and
is a component of syndrome X (or metabolic syndrome), can cause hyperuricemia and gout[62] and is
also associated with elevated blood pressure.[63]

Events in early life, such as low birth weight, maternal smoking, and lack of breastfeeding may be risk
factors for adult essential hypertension, although strength of the relationships is weak and the
mechanisms linking these exposures to adult hypertension remain unclear.[64]

Secondary hypertension
Secondary hypertension results from an identifiable cause. Kidney disease is the most common
secondary cause of hypertension.[25] Hypertension can also be caused by endocrine conditions, such
as Cushing's syndrome, hyperthyroidism, hypothyroidism, acromegaly, Conn's syndrome or
hyperaldosteronism, renal artery stenosis (from atherosclerosis or fibromuscular dysplasia),

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hyperparathyroidism, and pheochromocytoma.[25][65]

Other causes of secondary hypertension
include obesity, sleep apnea, pregnancy, coarctation of the aorta, excessive eating of liquorice,
excessive drinking of alcohol, certain prescription medicines, herbal remedies, and stimulants such as
cocaine and methamphetamine.[25][66]

A 2018 review found that any alcohol increased blood pressure in males while over one or two drinks
increased the risk in females.[67]

Pathophysiology
In most people with established essential
hypertension, increased resistance to blood flow
(total peripheral resistance) accounts for the high
pressure while cardiac output remains normal.[68]
There is evidence that some younger people with
prehypertension or 'borderline hypertension' have
high cardiac output, an elevated heart rate and
normal peripheral resistance, termed hyperkinetic
borderline hypertension.[69] These individuals may
develop the typical features of established essential
hypertension in later life as their cardiac output falls
and peripheral resistance rises with age.[69] Whether
Determinants of mean arterial pressure
this pattern is typical of all people who ultimately
develop hypertension is disputed.[70] The increased
peripheral resistance in established hypertension is
mainly attributable to structural narrowing of small
arteries and arterioles,[71] although a reduction in the
number or density of capillaries may also
contribute.[72]

It is not clear whether or not vasoconstriction of

arteriolar blood vessels plays a role in
hypertension.[73] Hypertension is also associated with
decreased peripheral venous compliance,[74] which
may increase venous return, increase cardiac preload
and, ultimately, cause diastolic dysfunction. For
patients having hypertension, higher heart rate
variability (HRV) is a risk factor for atrial
fibrillation.[75]

Pulse pressure (the difference between systolic and

diastolic blood pressure) is frequently increased in
older people with hypertension.[76] This can mean Illustration depicting the effects of high blood
that systolic pressure is abnormally high, but diastolic pressure
pressure may be normal or low, a condition termed

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isolated systolic hypertension.[77]

The high pulse pressure in elderly people with hypertension or
isolated systolic hypertension is explained by increased arterial stiffness, which typically accompanies
aging and may be exacerbated by high blood pressure.[78]

Many mechanisms have been proposed to account for the rise in peripheral resistance in
hypertension. Most evidence implicates either disturbances in the kidneys' salt and water handling
(particularly abnormalities in the intrarenal renin–angiotensin system)[79] or abnormalities of the
sympathetic nervous system.[80] These mechanisms are not mutually exclusive and it is likely that
both contribute to some extent in most cases of essential hypertension. It has also been suggested that
endothelial dysfunction and vascular inflammation may also contribute to increased peripheral
resistance and vascular damage in hypertension.[81][82] Interleukin 17 has garnered interest for its
role in increasing the production of several other immune system chemical signals thought to be
involved in hypertension such as tumor necrosis factor alpha, interleukin 1, interleukin 6, and
interleukin 8.[83]

Excessive sodium or insufficient potassium in the diet leads to excessive intracellular sodium, which
contracts vascular smooth muscle, restricting blood flow and so increases blood pressure.[84][85] Non-
modulating essential hypertension is a form of salt-sensitive hypertension, where sodium intake does
not modulate either adrenal or renal vascular responses to angiotensin II.[86] They make up 25% of
the hypertensive population.[87]

Diagnosis
Hypertension is diagnosed on the basis of a persistently high resting blood pressure. Elevated blood
pressure measurements on at least two separate occasions is required for a diagnosis of
hypertension.[6][7][13]

Measurement technique
For an accurate diagnosis of hypertension to be made, it is essential for proper blood pressure
measurement technique to be used.[88] Improper measurement of blood pressure is common and can
change the blood pressure reading by up to 10 mmHg, which can lead to misdiagnosis and
misclassification of hypertension.[88] Correct blood pressure measurement technique involves several
steps. Proper blood pressure measurement requires the person whose blood pressure is being
measured to sit quietly for at least five minutes which is then followed by application of a properly
fitted blood pressure cuff to a bare upper arm.[88] The person should be seated with their back
supported, feet flat on the floor, and with their legs uncrossed.[88] The person whose blood pressure is
being measured should avoid talking or moving during this process.[88] The arm being measured
should be supported on a flat surface at the level of the heart.[88] Blood pressure measurement should
be done in a quiet room so the medical professional checking the blood pressure can hear the
Korotkoff sounds while listening to the brachial artery with a stethoscope for accurate blood pressure
measurements.[88][89] The blood pressure cuff should be deflated slowly (2–3 mmHg per second)
while listening for the Korotkoff sounds.[89] The bladder should be emptied before a person's blood
pressure is measured since this can increase blood pressure by up to 15/10 mmHg.[88] Multiple blood
pressure readings (at least two) spaced 1–2 minutes apart should be obtained to ensure accuracy.[89]
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Ambulatory blood pressure monitoring over 12 to 24 hours is the most accurate method to confirm
the diagnosis.[90] An exception to this is those with very high blood pressure readings especially when
there is poor organ function.[91]

With the availability of 24-hour ambulatory blood pressure monitors and home blood pressure
machines, the importance of not wrongly diagnosing those who have white coat hypertension has led
to a change in protocols. In the United Kingdom, current best practice is to follow up a single raised
clinic reading with ambulatory measurement, or less ideally with home blood pressure monitoring
over the course of 7 days.[91] The United States Preventive Services Task Force also recommends
getting measurements outside of the healthcare environment.[90] Pseudohypertension in the elderly
or noncompressibility artery syndrome may also require consideration. This condition is believed to
be due to calcification of the arteries resulting in abnormally high blood pressure readings with a
blood pressure cuff while intra arterial measurements of blood pressure are normal.[92] Orthostatic
hypertension is when blood pressure increases upon standing.[93]

Other investigations
Once the diagnosis of hypertension has been made, further testing may be performed to find
secondary hypertension, identify comorbidities such as diabetes, identify hypertension-caused organ
damage such as chronic kidney disease or thickening of the heart muscle, and for cardiovascular
disease risk stratification.[9]

Secondary hypertension is more common in preadolescent children, with most cases caused by kidney
disease. Primary or essential hypertension is more common in adolescents and adults and has
multiple risk factors, including obesity and a family history of hypertension.[94]

Initial assessment upon diagnosis of hypertension should include a complete history and physical
examination. The World Health Organization suggests the following initial tests: serum electrolytes,
serum creatinine, lipid panel, HbA1c or fasting glucose, urine dipstick and electrocardiogram
(ECG/EKG).[9] Serum creatinine is measured to assess for the presence of kidney disease, which can
be either the cause or the result of hypertension.[30] eGFR can also provide a baseline measurement of
kidney function that can be used to monitor for side effects of certain anti-hypertensive drugs on
kidney function. Testing of urine samples for protein is used as a secondary indicator of kidney
disease. Lipid panel and glucose tests are done to identify comorbidities such as diabetes and
hyperlipidemia and for cardiovascular risk stratification. Electrocardiogram (EKG/ECG) testing is
done to check for evidence that the heart is under strain from high blood pressure, such as thickening
of the heart muscle or whether the heart has experienced a prior minor disturbance such as a silent
heart attack.

Classification in adults
Blood pressure measurements can be influenced by circumstances of measurement.[95] Guidelines use
different thresholds for office (also known as clinic), home (when the patient measures their own
blood pressure at home), and ambulatory blood pressure (using an automated device over a 24-hour
period).[95]

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Blood pressure classifications

Categories Systolic blood pressure, mmHg Diastolic blood pressure, mmHg
and/or
Method Office Home 24h ambulatory Office Home 24h ambulatory

American College of Cardiology/American Heart Association (2017)[96]

Normal <120 <120 <115 and <80 <80 <75

Elevated 120–129 120–129 115–124 and <80 <80 <75

Hypertension, stage 1 130–139 130–134 125–129 or 80–89 80–84 75–79

Hypertension, stage 2 ≥140 ≥135 ≥130 or ≥90 ≥85 ≥80

European Society of Cardiology (2024)[95]

Non-elevated <120 <120 <115 and <70 <70 <65

Elevated 120–139 120–135 115–129 and 70–89 70–85 65–79

Hypertension ≥140 ≥135 ≥130 or ≥90 ≥85 ≥80

European Society of Hypertension/International Society of Hypertension (2023)[7]

Optimal <120 — — and <80 — —

Normal 120–129 — — and/or 80–84 — —

High normal 130–139 — — and/or 85–89 — —

Hypertension, grade 1 140–159 ≥135 ≥130 and/or 90–99 ≥85 ≥80

Hypertension, grade 2 160–179 — — and/or 100–109 — —

Hypertension, grade 3 ≥180 — — and/or ≥110 — —

Children
Hypertension occurs in around 0.2 to 3% of newborns; however, blood pressure is not measured
routinely in healthy newborns.[39] Hypertension is more common in high risk newborns. A variety of
factors, such as gestational age, postconceptional age and birth weight needs to be taken into account
when deciding if a blood pressure is normal in a newborn.[39]

Hypertension defined as elevated blood pressure over several visits affects 1% to 5% of children and
adolescents and is associated with long-term risks of ill-health.[97] Blood pressure rises with age in
childhood and, in children, hypertension is defined as an average systolic or diastolic blood pressure
on three or more occasions equal or higher than the 95th percentile appropriate for the sex, age and
height of the child. High blood pressure must be confirmed on repeated visits however before
characterizing a child as having hypertension.[97] In adolescents, it has been proposed that
hypertension is diagnosed and classified using the same criteria as in adults.[97]

Prevention
Much of the disease burden of high blood pressure is experienced by people who are not labeled as
hypertensive.[98] Consequently, population strategies are required to reduce the consequences of high
blood pressure and reduce the need for antihypertensive medications. Lifestyle changes are
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recommended to lower blood pressure.

Recommended lifestyle changes for the prevention of hypertension include:

maintain normal body weight for adults (e.g. body mass index below 25 kg/m2)[7]
reduce dietary sodium intake to <100 mmol/day (<6 g of salt (sodium chloride) or <2.4 g of sodium
per day)[7]
engage in regular aerobic physical activity with moderate intensity (minimum 150 minutes per
week)[7]
limit alcohol consumption,[7] max 1 drink for women and 2 for men per day[13]
consume a diet rich in whole grains, fruit and vegetables,[7] such as the DASH diet[7]
not smoking[7]
stress reduction and management,[7] e.g. by meditation and yoga[7]
Effective lifestyle modification may lower blood pressure as much as an individual antihypertensive
medication. Combinations of two or more lifestyle modifications can achieve even better results.[98]
There is considerable evidence that reducing dietary salt intake lowers blood pressure, but whether
this translates into a reduction in mortality and cardiovascular disease remains uncertain.[99]
Estimated sodium intake ≥6 g/day and <3 g/day are both associated with high risk of death or major
cardiovascular disease, but the association between high sodium intake and adverse outcomes is only
observed in people with hypertension.[100] Consequently, in the absence of results from randomized
controlled trials, the wisdom of reducing levels of dietary sodium intake below 3 g/day has been
questioned.[99] ESC guidelines mention periodontitis is associated with poor cardiovascular health
status.[101]

The value of routine screening for hypertension is debated.[102][103][104] In 2004, the National High
Blood Pressure Education Program recommended that children aged 3 years and older have blood
pressure measurement at least once at every health care visit[97] and the National Heart, Lung, and
Blood Institute and American Academy of Pediatrics made a similar recommendation.[105] However,
the American Academy of Family Physicians[106] supports the view of the U.S. Preventive Services
Task Force that the available evidence is insufficient to determine the balance of benefits and harms
of screening for hypertension in children and adolescents who do not have symptoms.[107][108] The US
Preventive Services Task Force recommends screening adults 18 years or older for hypertension with
office blood pressure measurement.[104][109]

Management
According to one review published in 2003, reduction of the blood pressure by 5 mmHg can decrease
the risk of stroke by 34%, of ischemic heart disease by 21%, and reduce the likelihood of dementia,
heart failure, and mortality from cardiovascular disease.[110]

Target blood pressure

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Various expert groups have produced guidelines regarding how low the blood pressure target should
be when a person is treated for hypertension. These groups recommend a target below the range 140–
160 / 90–100 mmHg for the general population.[7][14][111][112] Cochrane reviews recommend similar
targets for subgroups such as people with diabetes[113] and people with prior cardiovascular
disease.[114] Additionally, Cochrane reviews have found that for older individuals with moderate to
high cardiovascular risk, the benefits of trying to achieve a lower than standard blood pressure target
(at or below 140/90 mmHg) are outweighed by the risk associated with the intervention.[115] These
findings may not be applicable to other populations.[115]

Many expert groups recommend a slightly higher target of 150/90 mmHg for those over somewhere
between 60 and 80 years of age.[111][112][116] The JNC 8 and American College of Physicians
recommend the target of 150/90 mmHg for those over 60 years of age,[14][116] but some experts
within these groups disagree with this recommendation.[117] Some expert groups have also
recommended slightly lower targets in those with diabetes[118] or chronic kidney disease,[119] but
others recommend the same target as for the general population.[14][113] The issue of what is the best
target and whether targets should differ for high risk individuals is unresolved,[120] although some
experts propose more intensive blood pressure lowering than advocated in some guidelines.[121]

For people who have never experienced cardiovascular disease who are at a 10-year risk of
cardiovascular disease of less than 10%, the 2017 American Heart Association guidelines recommend
medications if the systolic blood pressure is >140 mmHg or if the diastolic BP is >90 mmHg.[6] For
people who have experienced cardiovascular disease or those who are at a 10-year risk of
cardiovascular disease of greater than 10%, it recommends medications if the systolic blood pressure
is >130 mmHg or if the diastolic BP is >80 mmHg.[6]

Lifestyle modifications
The first line of treatment for hypertension is lifestyle changes, including dietary changes, physical
activity, and weight loss. Though these have all been recommended in scientific advisories,[122] a
Cochrane systematic review found no evidence (due to lack of data) for effects of weight loss diets on
death, long-term complications or adverse events in persons with hypertension.[123] The review did
find a decrease in body weight and blood pressure.[123] Their potential effectiveness is similar to and
at times exceeds a single medication.[7] If hypertension is high enough to justify immediate use of
medications, lifestyle changes are still recommended in conjunction with medication.

Dietary changes shown to reduce blood pressure include diets with low sodium,[124][125] the DASH
diet (Dietary Approaches to Stop Hypertension),[126] which was the best against 11 other diet in an
umbrella review,[127] and plant-based diets.[128] A 2024 clinical guideline recommended an increase
dietary fiber intake,[129] with a minimum of 28g/day for women and 38g/day for men diagnosed with
hypertension.[130]

Increasing dietary potassium has a potential benefit for lowering the risk of hypertension.[131][132] The
2015 Dietary Guidelines Advisory Committee (DGAC) stated that potassium is one of the shortfall
nutrients which is under-consumed in the United States.[133] However, people who take certain
antihypertensive medications (such as ACE-inhibitors or ARBs) should not take potassium
supplements or potassium-enriched salts due to the risk of high levels of potassium.[134]

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Physical exercise regimens which are shown to reduce blood pressure include isometric resistance
exercise, aerobic exercise, resistance exercise, and device-guided breathing.[135]

Stress reduction techniques such as biofeedback or transcendental meditation may be considered as

an add-on to other treatments to reduce hypertension, but do not have evidence for preventing
cardiovascular disease on their own.[135][136][137] Self-monitoring and appointment reminders might
support the use of other strategies to improve blood pressure control, but need further evaluation.[138]

Medications
Several classes of medications, collectively referred to as antihypertensive medications, are available
for treating hypertension.

First-line medications for hypertension include thiazide-diuretics, calcium channel blockers,

angiotensin converting enzyme inhibitors (ACE inhibitors), and angiotensin receptor blockers
(ARBs).[139][14] These medications may be used alone or in combination (ACE inhibitors and ARBs
are not recommended for use together); the latter option may serve to minimize counter-regulatory
mechanisms that act to restore blood pressure values to pre-treatment levels,[14][140] although the
evidence for first-line combination therapy is not strong enough.[141] Most people require more than
one medication to control their hypertension.[122] Medications for blood pressure control should be
implemented by a stepped care approach when target levels are not reached.[138] Withdrawal of such
medications in the elderly can be considered by healthcare professionals, because there is no strong
evidence of an effect on mortality, myocardial infarction, or stroke.[142]

Previously, beta-blockers such as atenolol were thought to have similar beneficial effects when used as
first-line therapy for hypertension. However, a Cochrane review that included 13 trials found that the
effects of beta-blockers are inferior to that of other antihypertensive medications in preventing
cardiovascular disease.[143]

The prescription of antihypertensive medication for children with hypertension has limited evidence.
There is limited evidence which compare it with placebo and shows modest effect to blood pressure in
short term. Administration of higher dose did not make the reduction of blood pressure greater.[144]

Resistant hypertension
Resistant hypertension is defined as high blood pressure that remains above a target level, in spite of
being prescribed three or more antihypertensive drugs simultaneously with different mechanisms of
action.[145] Failing to take prescribed medications as directed is an important cause of resistant
hypertension.[146]

Some common secondary causes of resistant hypertension include obstructive sleep apnea, primary
aldosteronism and renal artery stenosis, and some rare secondary causes are pheochromocytoma and
coarctation of the aorta.[147] As many as one in five people with resistant hypertension have primary
aldosteronism, which is a treatable and sometimes curable condition.[148] Resistant hypertension may
also result from chronically high activity of the autonomic nervous system, an effect known as
neurogenic hypertension.[149] Electrical therapies that stimulate the baroreflex are being studied as an
option for lowering blood pressure in people in this situation.[150]
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Refractory hypertension is described by one source as elevated blood pressure unmitigated by five or
more concurrent antihypertensive agents of different classes.[151] People with refractory hypertension
typically have increased sympathetic nervous system activity, and are at high risk for more severe
cardiovascular diseases and all-cause mortality.[151][152]

Epidemiology

Adults
As of 2019, one in three or 33% of the world
population were estimated to have
hypertension. [9][10] Of all people with
hypertension, about 46% do not have a diagnosis
of hypertension and are unaware that they have
the condition.[13][9] In 1975, almost 600 million Rates of hypertension in adult men in 2014[153]
people had a diagnosis of hypertension, a number
which increased to 1.13 billion by 2015 mostly due
to risk factors for hypertension increasing in low-
and middle-income countries.[13]

Hypertension is slightly more frequent in men.[10]

In people aged under 50 years, more men than
women have hypertension,[10] and in ages above
50 years the prevalence of hypertension is the
same in men and women.[10] In ages above 65 Disability-adjusted life year for hypertensive heart
years, more women than men have disease per 100,000 inhabitants in 2004:[154]
[7] no data 660–770
hypertension. Hypertension becomes more
<110 770–880
common with age.[5] Hypertension is common in
110–220 880–990
high, medium, and low-income countries.[13][2] It
220–330 990–1100
is more common in people of low socioeconomic
330–440 1100–1600
status.[155] Hypertension is around twice as
440–550 >1600
common in diabetics.[156]
550–660

In 2019, rates of diagnosed hypertension were

highest in Africa (30% for both sexes), and lowest
in the Americas (18% for both sexes).[10] Rates also vary markedly within regions with country-level
rates as low as 22.8% (men) and 18.4% (women) in Peru and as high as 61.6% (men) and 50.9%
(women) in Paraguay.[10]

In 1995 it was estimated that 24% of the United States population had hypertension or were taking
antihypertensive medication.[157] By 2004 this had increased to 29%[158][159] and further to 32% (76
million US adults) by 2017.[6] In 2017, with the American guidelines' change in definition for

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hypertension, 46% of people in the United States are affected.[6] African-American adults in the
United States have among the highest rates of hypertension in the world at 44%.[160] Differences in
hypertension rates are multifactorial and under study.[161]

Children
Rates of high blood pressure in children and adolescents have increased in the last 20 years in the
United States.[162] Childhood hypertension, particularly in pre-adolescents, is more often secondary
to an underlying disorder than in adults. Kidney disease is the most common secondary cause of
hypertension in children and adolescents. Nevertheless, primary or essential hypertension accounts
for most cases.[163]

Prognosis
Hypertension is the most important preventable risk
factor for premature death worldwide.[164] It
increases the risk of ischemic heart disease,[165]
stroke,[25] peripheral vascular disease,[166] and other
cardiovascular diseases, including heart failure, aortic
aneurysms, diffuse atherosclerosis, chronic kidney
disease, atrial fibrillation, cancers, leukemia and
pulmonary embolism.[12][25] Hypertension is also a
risk factor for cognitive impairment and
dementia.[25] Other complications include
hypertensive retinopathy and hypertensive
nephropathy.[30]

History Diagram illustrating the main complications of

persistent high blood pressure

Measurement
Modern understanding of the cardiovascular system began with
the work of physician William Harvey (1578–1657), who described
the circulation of blood in his book "De motu cordis". The English
clergyman Stephen Hales made the first published measurement
of blood pressure in 1733.[167][168] However, hypertension as a
Image of veins from Harvey's clinical entity came into its own with the invention of the cuff-
Exercitatio Anatomica de Motu based sphygmomanometer by Scipione Riva-Rocci in 1896.[169]
Cordis et Sanguinis in Animalibus This allowed easy measurement of systolic pressure in the clinic.
In 1905, Nikolai Korotkoff improved the technique by describing

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the Korotkoff sounds that are heard when the artery is ausculted with a stethoscope while the
sphygmomanometer cuff is deflated.[168] This permitted systolic and diastolic pressure to be
measured.

Identification
The symptoms similar to symptoms of patients with hypertensive crisis are discussed in medieval
Persian medical texts in the chapter of "fullness disease".[170] The symptoms include headache,
heaviness in the head, sluggish movements, general redness and warm to touch feel of the body,
prominent, distended and tense vessels, fullness of the pulse, distension of the skin, coloured and
dense urine, loss of appetite, weak eyesight, impairment of thinking, yawning, drowsiness, vascular
rupture, and hemorrhagic stroke.[171] Fullness disease was presumed to be due to an excessive amount
of blood within the blood vessels.

Descriptions of hypertension as a disease came among others from Thomas Young in 1808 and
especially Richard Bright in 1836.[167] The first report of elevated blood pressure in a person without
evidence of kidney disease was made by Frederick Akbar Mahomed (1849–1884).[172]

Until the 1990s, systolic hypertension was defined as systolic blood pressure of 160 mm Hg or
greater.[173] In 1993, the WHO/ISH guidelines defined 140 mmHg as the threshold for
hypertension.[174]

Treatment
Historically the treatment for what was called the "hard pulse disease" consisted in reducing the
quantity of blood by bloodletting or the application of leeches.[167] This was advocated by The Yellow
Emperor of China, Cornelius Celsus, Galen, and Hippocrates.[167] The therapeutic approach for the
treatment of hard pulse disease included changes in lifestyle (staying away from anger and sexual
intercourse) and dietary program for patients (avoiding the consumption of wine, meat, and pastries,
reducing the volume of food in a meal, maintaining a low-energy diet and the dietary usage of spinach
and vinegar).

In the 19th and 20th centuries, before effective pharmacological treatment for hypertension became
possible, three treatment modalities were used, all with numerous side-effects: strict sodium
restriction (for example the rice diet[167]), sympathectomy (surgical ablation of parts of the
sympathetic nervous system), and pyrogen therapy (injection of substances that caused a fever,
indirectly reducing blood pressure).[167][175]

The first chemical for hypertension, sodium thiocyanate, was used in 1900 but had many side effects
and was unpopular.[167] Several other agents were developed after the Second World War, the most
popular and reasonably effective of which were tetramethylammonium chloride, hexamethonium,
hydralazine, and reserpine (derived from the medicinal plant Rauvolfia serpentina). None of these
were well tolerated.[176][177] A major breakthrough was achieved with the discovery of the first well-
tolerated orally available agents. The first was chlorothiazide, the first thiazide diuretic and developed

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from the antibiotic sulfanilamide, which became available in 1958.[167][178] Subsequently, beta
blockers, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin
receptor blockers, and renin inhibitors were developed as antihypertensive agents.[175]

Society and culture

Awareness
The World Health Organization has identified
hypertension (high blood pressure) as the leading
cause of cardiovascular mortality.[179] The World
Hypertension League (WHL), an umbrella
organization of 85 national hypertension societies
and leagues, recognized that more than 50% of the
hypertensive population worldwide are unaware of
their condition.[179] To address this problem, the
WHL initiated a global awareness campaign on
hypertension in 2005 and dedicated 17 May of each
Graph showing prevalence of awareness, treatment
year as World Hypertension Day.[180]
and control of hypertension compared between the
four studies of NHANES[158]
Economics
High blood pressure is the most common chronic medical problem prompting visits to primary health
care providers in US. The American Heart Association estimated the direct and indirect costs of high
blood pressure in 2010 as $76.6 billion.[160] In the US 80% of people with hypertension are aware of
their condition, 71% take some antihypertensive medication, but only 48% of people aware that they
have hypertension adequately control it.[160] Adequate management of hypertension can be hampered
by inadequacies in the diagnosis, treatment, or control of high blood pressure.[181] Health care
providers face many obstacles to achieving blood pressure control, including resistance to taking
multiple medications to reach blood pressure goals. People also face the challenges of adhering to
medicine schedules and making lifestyle changes. Nonetheless, the achievement of blood pressure
goals is possible, and most importantly, lowering blood pressure significantly reduces the risk of death
due to heart disease and stroke, the development of other debilitating conditions, and the cost
associated with advanced medical care.[182][183]

Other animals
Hypertension in cats is indicated with a systolic blood pressure greater than 150 mmHg, with
amlodipine the usual first-line treatment. A cat with a systolic blood pressure above 170 mmHg is
considered hypertensive. If a cat has other problems such as any kidney disease or retina detachment
then a blood pressure below 160 mmHg may also need to be monitored.[184]

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Normal blood pressure in dogs can differ substantially between breeds but hypertension is often
diagnosed if systolic blood pressure is above 160 mmHg particularly if this is associated with target
organ damage.[185] Inhibitors of the renin-angiotensin system and calcium channel blockers are often
used to treat hypertension in dogs, although other drugs may be indicated for specific conditions
causing high blood pressure.[185]

See also
Comparison of international blood pressure guidelines
Health effects of ultra-processed foods

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Further reading
2024 ESC guideline: McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, et al. (30
August 2024). "2024 ESC Guidelines for the management of elevated blood pressure and
hypertension: Developed by the task force on the management of elevated blood pressure and
hypertension of the European Society of Cardiology (ESC) and endorsed by the European Society
of Endocrinology (ESE) and the European Stroke Organisation (ESO)" (https://doi.org/10.1093%2
Feurheartj%2Fehae178). European Heart Journal. 45 (38): 3912–4018.
doi:10.1093/eurheartj/ehae178 (https://doi.org/10.1093%2Feurheartj%2Fehae178). ISSN 0195-
668X (https://search.worldcat.org/issn/0195-668X). PMID 39210715 (https://pubmed.ncbi.nlm.nih.
gov/39210715).
2023 ESH guideline: Mancia G, Kreutz R, Brunström M, Burnier M, Grassi G, et al. (1 December
2023). "2023 ESH Guidelines for the management of arterial hypertension The Task Force for the
management of arterial hypertension of the European Society of Hypertension: Endorsed by the
International Society of Hypertension (ISH) and the European Renal Association (ERA)" (https://d
oi.org/10.1097%2FHJH.0000000000003480). Journal of Hypertension. 41 (12): 1874–2071.
doi:10.1097/HJH.0000000000003480 (https://doi.org/10.1097%2FHJH.0000000000003480).
hdl:11379/603005 (https://hdl.handle.net/11379%2F603005). ISSN 1473-5598 (https://search.worl
dcat.org/issn/1473-5598). PMID 37345492 (https://pubmed.ncbi.nlm.nih.gov/37345492).
2022 AAFP guideline: Coles S, Fisher L, Lin KW, Lyon C, Vosooney AA, Bird MD (December
2022). "Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From
the AAFP". American Family Physician. 106 (6): Online. ISSN 1532-0650 (https://search.worldcat.
org/issn/1532-0650). PMID 36521481 (https://pubmed.ncbi.nlm.nih.gov/36521481). Key
recommendations (https://www.aafp.org/dam/AAFP/documents/journals/afp/AAFPHypertensionG
uideline.pdf).
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2019 NICE guideline: "Hypertension in adults: diagnosis and management" (https://www.nice.org.

uk/guidance/NG136). National Institute for Health and Clinical Excellence (NICE). 28 August
2019.
2017 ACC/AHA guideline: Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, et al. (15
May 2018). "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" (https://
doi.org/10.1016%2Fj.jacc.2017.11.006). Journal of the American College of Cardiology. 71 (19):
e127–e248. doi:10.1016/j.jacc.2017.11.006 (https://doi.org/10.1016%2Fj.jacc.2017.11.006).
PMID 29146535 (https://pubmed.ncbi.nlm.nih.gov/29146535).
2014 JNC 8 guideline: James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C,
Handler J, et al. (February 2014). "2014 evidence-based guideline for the management of high
blood pressure in adults: report from the panel members appointed to the Eighth Joint National
Committee (JNC 8)" (https://doi.org/10.1001%2Fjama.2013.284427). JAMA. 311 (5): 507–20.
doi:10.1001/jama.2013.284427 (https://doi.org/10.1001%2Fjama.2013.284427). PMID 24352797
(https://pubmed.ncbi.nlm.nih.gov/24352797).

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