This chapter discusses the diagnosis and treatment of patients with hypertension. Hypertension is usually a silent disorder, and initially identified during a regular clinical check-up or assessment for nonemergent symptoms. The importance of out-of-office (either 24h ambulatory or home) blood pressure (BP) measurement for accurate prognosis is becoming increasingly apparent. Despite improved detection rates, research indicates that hypertension is likely to remain a considerable challenge for the prevention of cardiovascular disease over the next few decades. With use of effective available treatments, however, reductions in this risk factor could have more impact on the prevention of premature cardiovascular death over the next decade than reductions of other common risk factors. Effective treatment involves lifestyle changes as well as prescription of antihypertensive medications (see summary figure). Multiple pharmacotherapies exist over an array of drug classes. Most hypertensive individuals require treatments from two or three drug classes to effectively control their blood pressure. Interventional modalities, such as renal denervation and baroreflex activation therapy, are being investigated for use in patients with hypertension that is resistant to drug therapy.
Hypertension, elevated systemic arterial pressure, is a recognized risk factor and cause of fatal and nonfatal cardiovascular and renal disease that has become a public health problem worldwide.1,2 Furthermore, treatment of hypertension with widely available antihypertensive drugs is highly effective for long-term prevention of cardiovascular disease, as demonstrated in well-controlled randomized clinical trials.3 Of the most common risk factors for premature cardiovascular mortality, the reduction of hypertension-through effective treatment-has been predicted to have the greatest preventive effect globally over the next decade.4
BLOOD PRESSURE CLASSIFICATION
The diagnosis of hypertension has, in the past, been based on measurements in the office or clinic. Clinic blood pressures have been the basis for assessing response to treatment in the large randomized clinical trials that have provided the evidence for establishing the effectiveness of antihypertensive drug treatment. However, the development of technologies for accurate measurement of arterial pressure outside the clinic and during usual activity, through 24-hour ambulatory blood pressure monitoring and home blood pressure assessment, has led to expansion of the terms used to define hypertension. Table 25–1 provides current classification of hypertensive disorders as recommended in recent guidelines.
TABLE 25–1.Glossary: Classification of Hypertension in Adult Patients |Favorite Table|Download (.pdf) TABLE 25–1. Glossary: Classification of Hypertension in Adult Patients
|Definition ||Blood Pressure Range (mm Hg) ||Comment |
|Normal (optimal pressure) ||< 120/80 ||All guidelines |
|Prehypertension ||120–139/80–89 ||JNC 7 |
|High-normal pressure ||130–139/85–89 ||ESH&ESC |
|Hypertension ||≥ 140/90 ||All guidelines |
|Resistant hypertension ||≥ 140/90 ||On treatment with three or more antihypertensive drugs, usually including a diuretic |
|White coat hypertension ||Clinic pressures ≥ 140/90 and 24-hour ABP < 130/80 or HBP < 135/85 ||Untreated |
|White coat effect ||Clinic pressures ≥140/90 and 24-hour ABP < 130/80 or HBP < 135/85 ||Treated patients |
|Masked hypertension ||Clinic ...|