a) Normal: systolic less than 120 mmHg; diastolic less than 80 mmHg
b) Prehypertension: systolic 120 to 139 mmHg; diastolic 80 to 89 mmHg
c) Stage 1: systolic 140 to 159 mm Hg; diastolic 90 to 99 mmHg
d) Stage 2: systolic 160 mmHg; diastolic 100 mmHg
CONSEQUENCES OF HYPERTENSION: Hypertension is a major risk factor for atherosclerotic cardiovascular disease, HF, stroke, and kidney failure. Hypertension carries the risk for premature morbidity or mortality, which increases as systolic and diastolic pressures rise. Prolonged blood pressure elevation damages blood vessels in target organs (heart, kidneys, brain, and eyes).
Essential (Primary) Hypertension: In the adult population with hypertension, between 90% and 95% have essential (primary) hypertension, which has no identifiable medical cause; it appears to be a multifactorial, polygenic condition. For high blood pressure to occur, an increase in peripheral resistance and/or cardiac output must occur secondary to increased sympathetic stimulation, sodium reabsorption, increased renin–angiotensin–aldosterone system activity, decreased vasodilation of the arterioles, or resistance to insulin action. Hypertensive emergencies and urgencies may occur in patients whose hypertension has been poorly controlled, whose hypertension has been undiagnosed, or in those who have abruptly discontinued their medications.
Secondary Hypertension: Secondary hypertension is characterized by elevations in blood pressure with a specific cause, such as narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism (mineralocorticoid hypertension), certain medications, pregnancy, and coarctation of the aorta. Hypertension can also be acute, a sign of an underlying condition that causes a change in peripheral resistance or cardiac output.
CLINICAL MANIFESTATIONS: Physical examination may reveal no abnormality other than high blood pressure. Changes in the retinas with hemorrhages, exudates, narrowed arterioles, and cotton–wool spots (small infarctions), and papilledema may be seen in severe hypertension. Symptoms usually indicate vascular damage related to organ systems served by involved vessels. Coronary artery disease with angina or myocardial infarction is the most common consequence. Left ventricular hypertrophy may occur; HF ensues. Pathologic changes may occur in the kidney (nocturia and increased BUN and creatinine levels). Cerebrovascular involvement may occur (stroke or transient ischemic attack [TIA] [ie, alterations in vision or speech, dizziness, weakness, a sudden fall, or transient or permanent hemiplegia]).
ASSESSMENT AND DIAGNOSTIC METHODS: History and physical examination, including retinal examination; laboratory studies for organ damage, including urinalysis, blood chemistry (sodium, potassium, creatinine, fasting glucose, total and high-density lipoprotein); ECG; and echocardiography to assess left ventricular hypertrophy. Additional studies, such as creatinine clearance, renin level, urine tests, and 24-hour urine protein, may be performed.
MEDICAL MANAGEMENT: The goal of any treatment program is to prevent death and complications by achieving and maintaining an arterial blood pressure at or below 140/90 mm Hg (130/80 mm Hg for people with diabetes mellitus or chronic kidney disease), whenever possible. Nonpharmacologic approaches include weight reduction; restriction of alcohol and sodium; regular exercise and relaxation. A DASH (Dietary Approaches to Stop Hypertension) diet high in fruits, vegetables, and low-fat dairy products has been shown to lower elevated pressures. Select a drug class that has the greatest effectiveness, fewest side effects, and best chance of acceptance by patient. Two classes of drugs are available as first-line therapy: diuretics and beta-blockers. Promote compliance by avoiding complicated drug schedules.
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