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Target Organ Damage or Why Should we Treat Hypertension?

Questions 1 Which organs are most affected by elevated blood pressure? Heart Brain Kidneys Eyes 2 How does hypertension effect target organs? Elevated blood pressure over many years can cause damage to several organs due to the direct effects of blood pressure on the vasculature of those organs as well as the effects of neurohormonal dysregulation. Sudden severe elevations in blood pressure can cause acute effects…

Physiology of Blood Pressure Regulation

Questions Short-Term Regulation of Blood Pressure 1 What are the two components of measured blood pressure and what do they represent? An individual’s blood pressure, or systemic arterial pressure, refers to the pressure measured within large arteries in the systemic circulation. This number splits into systolic blood pressure (SBP) and diastolic blood pressure (DBP). SBP refers to the maximum pressure within the large arteries when the…

The Epidemiology of Hypertension

Questions 1 What is the prevalence of hypertension? Hypertension is a major global public health problem and is estimated to impact nearly a third of the world’s population (1.13 billion people). In the 1970s, higher-income Western countries were known to have the highest prevalence of hypertension when compared to low-income countries, as evidenced by a pooled analysis of 1479 population studies from 200 countries. However, between…

Hypertensive Emergencies and Urgencies

Questions 1 What is a hypertensive emergency? A hypertensive emergency refers to large elevations in systolic and/or diastolic blood pressure with impending or progressive, acute, end-organ damage. The systolic blood pressure is usually 180 mm Hg or higher and/or diastolic blood pressure 120 mm Hg or higher. This definition implies that hospitalization for intravenous medication is required and that altering the blood pressure will improve end-organ damage. In-hospital…

Clinical Evaluation of the Patient with Hypertension

Questions 1 What are the objectives of clinical evaluation of a patient with hypertension? To identify potentially correctable causes of hypertension To identify other cardiovascular risk factors or concomitant disorders that may influence prognosis and guide treatment To assess end-organ damage (which may affect therapy) and identify baseline abnormalities To assess previous treatment experiences and obstacles to therapy 2 What is the appropriate method to check…

Ambulatory and Home Blood Pressure Monitoring

Questions 1 What is out-of-office blood pressure monitoring? Out-of-office blood pressure (BP) monitoring is the assessment of BP outside of the clinic setting using either ambulatory BP monitoring (ABPM) or self-monitoring of BP at home, also known as home BP monitoring (HBPM). 2 Why is out-of-office BP monitoring performed? Out-of-office BP monitoring is performed to confirm the diagnosis of hypertension and to assist with titration of…

Measurement of Blood Pressure in the Office

Questions 1 What is office blood pressure measurement? Blood pressure (BP) measurement in the office has been standard practice for over 100 years, and most physicians continue to use office BP for diagnosis and to follow patients with known or suspected hypertension. 2 What are the major types of office BP measurement? Two major types of office BP measurement exist. The auscultatory technique is performed with a…

Putting All Guidelines Into Perspective

Background The term “guideline” needs to be defined before any meaningful discussion can occur about their need and more importantly, interpretation. “Guideline” was originally defined as “a cord or rope to aid a passer over a difficult point or to permit retracing a course.” In medicine a guideline is a document that should influence decisions and provide criteria regarding diagnosis, management, and treatment in specific areas…

Updated American Heart Association/American College of Cardiology; European Society of Hypertension/European Society of Cardiology Guidelines

United States of America Hypertension Guidelines (Portion) Background Story The groundwork for the first United States hypertension guideline began with the first randomized trial of hypertension treatment in U.S. veterans, which was directed by Dr. Ed Freis, a Veterans Administration Physician. The trial was conducted by the Veterans Administration Cooperative Trial Study Group on Antihypertensive Agents. Two seminal publications resulted from this early effort. The first…

Understanding and Improving Medication Adherence

Disclaimer: The findings and conclusions in this document are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention. “Drugs don’t work in patients who don’t take them.” —C. Everett Koop, M.D. Medication adherence is a major and growing public health concern. However, adherence to antihypertension medication is crucial to not only hypertension control, but in…

Team-Based Care for Hypertension Management

Although blood pressure (BP) control has improved substantially in the last five decades, only half of the United States population with hypertension have adequate BP control. In contrast, BP control in some high-performing health systems is much better and can be as high as 80% to 90%. The strategies used by these high-performing systems may help other providers to improve BP control within their offices or…

Meta-Analyses of Blood Pressure Lowering Trials and the Blood Pressure Lowering Treatment Trialists’ Collaboration

Acknowledgments The authors would like to thank members of the Blood Pressure Lowering Treatment Trialists’ Collaboration: L. Agodoa (National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland); C. Anderson, J. Chalmers, S. MacMahon, A. Rodgers, and B. Neal (George Institute, Sydney, Australia); F. W. Asselbergs and W. H. van Gilst (University of Groningen, Groningen and Medical Centre Utrecht, Netherlands); C.…

Hypertensive Emergencies and Urgencies

Acknowledgments The author thanks Shakaib U. Rehman, MD, the late Donald G. Vidt, MD, and Jan N. Basile, MD, for their contributions to previous editions of this chapter. High blood pressure (BP), or hypertension, remains a major worldwide public health challenge, despite recent improvements in control rates in many developed nations. because it is a major contributor to cardiovascular disease (CVD), and is increasing in prevalence…

Aorta and Peripheral Arterial Disease in Hypertension

Aortic and peripheral arterial diseases may coexist in patients with hypertension. Although aortopathies and peripheral arterial disease can be seen in isolation, more often than not they present in patients with multiple cardiovascular risk factors, hypertension being chief among them. The following addresses the epidemiology and natural history of aortic and peripheral arterial disease, with a specific focus on the contribution of blood pressure to disease…

Hypertension and the Perioperative Period

There are few contemporary studies concerning the cardiovascular (CV) risks caused by hypertension or the benefits of its treatment during the perioperative period. Conversely, numerous trials have evaluated the potential benefits of specific antihypertensive medications, in particular beta-blockers. The 2007 American Heart Association (AHA) guidelines took a precautionary approach and considered severe high blood pressure (BP) (≥180 mm Hg systolic and/or ≥100 mm Hg diastolic) a…

Resistant Hypertension

Hypertension is the most common chronic disease in developed countries, with a prevalence of approximately 25% to 30% in adults. High blood pressure (BP) remains one of the leading risk factors influencing cardiovascular morbidity and mortality. The current management of hypertension is based on knowledge accumulated over more than a half a century, the availability of multiple orally active and potent antihypertensive drugs targeting different pathophysiological…

Orthostatic Hypotension

Orthostatic hypotension (OH) is a significant medical problem; it occurs in about 6% of healthy elderly in the community, 18% to 54% of nursing home residents, and up to 60% in hospitalized elderly. The incidence of OH increases exponentially after age 65, and its importance is likely to increase as our population ages. OH is not only a cause of disability and impaired quality of life,…

Hypertension in African Americans

Worldwide, hypertension remains a powerful, independent marker of cardiovascular mortality and death from all causes. In 2013, high systolic blood pressure (BP) accounted for more than 10 million deaths globally. In the United States, hypertension caused nearly 397,000 deaths in 2013; an increase of 61.8% since 2000. The highest hypertension-related age-adjusted death rate was seen in African Americans in whom the rate was 44% and 42%…

Hypertension in Older People

Older patients represent the most rapidly increasing segment of the United States population and account for the largest health care expenditures. Age is a major risk factor for the development of hypertension, and in particular, systolic hypertension. From 1999 to 2000, approximately 10 million men over the age of 65 and at least 17 million women over the same age had hypertension. From 2003 to 2006,…

Hypertension in Pregnancy

Hypertensive disorders are the most common medical conditions during pregnancy and are a leading cause of maternal and perinatal morbidity and mortality worldwide. Hypertension complicates 6% to 10% of pregnancies and, of 4 million women giving birth in the United States each year, an estimated 240,000 are affected by hypertension. Of concern, hypertension is the most important risk factor for stroke and there has been an…