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Hypertension (HTN or H.T.), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated.[11] High blood pressure usually does not cause symptoms. [1] Long-term high blood pressure is a significant 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 significant cause of premature death worldwide. [13]

High blood pressure is classified as primary (essential) Hypertension or secondary Hypertension.

[5] About 90–95% of cases are primary, defined as high blood pressure due to nonspecific lifestyle and genetic factors. [5] [6] Lifestyle factors that increase the risk include excess salt in the diet, excess body weight, smoking, and alcohol use. [1] [5] The remaining 5–10% of cases are categorized as secondary high blood pressure, defined as high blood pressure due to an identifiable cause, such as chronic kidney disease, narrowing of the kidney arteries, an endocrine disorder, or the use of birth control pills.[5]

Two measurements classify blood pressure, the systolic and diastolic pressures, which are the maximum and minimum pressures, respectively.[1] For most adults, normal blood pressure at rest is within the range of 100–130 millimeters mercury (mmHg) systolic and 60–80 mmHg diastolic.[8][14] For most adults, high blood pressure is present if the resting blood pressure is persistently at or above 130/80 or 140/90 mmHg.[5][8] Different numbers apply to children.[15] Ambulatory blood pressure monitoring over 24 hours appears more accurate than office-based blood pressure measurement.[5][11]

Lifestyle changes and medications can lower blood pressure and decrease the risk of health complications.[9] Lifestyle changes include weight loss, physical exercise, decreased salt intake, reduced alcohol intake, and a healthy diet.[5] If lifestyle changes are not sufficient, then blood pressure medications are used.[9] Up to three concurrent medications can control blood pressure in 90% of people.[5] Treating moderately high arterial blood pressure (defined as >160/100 mmHg) with medications is associated with an improved life expectancy.[16] The effect of treatment of blood pressure between 130/80 mmHg and 160/100 mmHg needs to be clarified, with some reviews finding benefits [8][17][18] and others finding unclear benefits.[19][20][21] High blood pressure affects between 16 and 37% of the population globally.[5] In 2010 hypertension was believed to have been a factor in 18% of all deaths (9.4 million globally).[10]

Video summary (script)
Signs and symptoms
Symptoms rarely accompany Hypertension, and its identification is usually through screening or when seeking healthcare for an unrelated problem. Some people with high blood pressure report headaches (particularly at the back of the head and in the morning), lightheadedness, vertigo, tinnitus (buzzing or hissing in the ears), altered vision, or fainting episodes.[22] However, these symptoms might be related to associated anxiety rather than high blood pressure.[23]

On physical examination, Hypertension may be associated with changes in the optic fundus seen by ophthalmoscopy.[24] The severity of the changes typical of hypertensive retinopathy is graded from I to IV; grades I and II may be challenging to differentiate.[24] The severity of the retinopathy correlates roughly with the duration or the severity of the Hypertension.[22]

Secondary Hypertension
Main article: Secondary Hypertension
Secondary Hypertension is Hypertension due to an identifiable cause and may result in specific additional signs and symptoms. For example, as well as causing high blood pressure, Cushing’s syndrome frequently causes truncal obesity,[25] glucose intolerance, moon face, a hump of fat behind the neck and shoulders (referred to as a buffalo hump), and purple abdominal stretch marks.[26] Hyperthyroidism frequently causes weight loss, increased appetite, fast heart rate, bulging eyes, and tremors. Renal artery stenosis (RAS) may be associated with a localized abdominal bruit to the left or right of the midline (unilateral RAS) or in both locations (bilateral RAS). Coarctation of the aorta frequently causes decreased blood 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.[26]

Hypertensive crisis
Main article: Hypertensive crisis
Severely elevated blood pressure (equal to or greater than a systolic 180 or diastolic of 110) is referred to as a hypertensive crisis.[27] A hypertensive crisis is categorized as either hypertensive urgency or emergency, according to the absence or presence of end-organ damage.[28][29]

In hypertensive urgency, there is no evidence of end-organ damage resulting from elevated blood pressure. In these cases, oral medications are used to lower the B.P. gradually over 24 to 48 hours.[30]

In a hypertensive emergency, there is evidence of direct damage to one or more organs.[31][32] The most affected organs include the brain, kidney, heart, and lungs, producing symptoms that may include confusion, drowsiness, chest pain, and breathlessness.[30] In a hypertensive emergency, the blood pressure must be reduced more rapidly to stop ongoing organ damage [30]; however, this approach lacks randomized controlled trial evidence.[32]

Main articles: Gestational Hypertension and Pre-eclampsia
Hypertension occurs in approximately 8–10% of pregnancies.[26] Two blood pressure measurements six hours apart or greater than 140/90 mm Hg are diagnostic of Hypertension in pregnancy.[33] High blood pressure in pregnancy can be classified as pre-existing Hypertension, gestational Hypertension, or pre-eclampsia.[34]

Pre-eclampsia is a serious condition in the second half of pregnancy and following delivery, characterized by increased blood pressure and protein in the urine.[26] It occurs in about 5% of pregnancies and is responsible for approximately 16% of all maternal deaths globally.[26] Pre-eclampsia also doubles the baby’s risk of death around the time of birth.[26] Usually, there are no symptoms of pre-eclampsia detected by routine screening. Pre-eclampsia occursccur, and the most common symptoms are headache, visual disturbance (often “flashing lights”), vomiting, pain in the stomach, and swelling. Pre-eclampsia can occasionally progress to a life-threatening condition called eclampsia, a hypertensive emergency with several serious complications, including vision loss, brain swelling, seizures, kidney failure, pulmonary edema, and disseminated intravascular coagulation (a blood clotting disorder).[26][35]

In contrast, gestational Hypertension is defined as new-onset Hypertension during pregnancy without protein in the urine.[34]

Failure to thrive, seizures, irritability, lack of energy, and difficulty breathing[36] can be associated with Hypertension in newborns and young infants. In older infants and children, Hypertension can cause headaches, unexplained irritability, fatigue, failure to thrive, blurred vision, nosebleeds, and facial paralysis.[36][37]
Primary Hypertension
Main article: Essential Hypertension
Hypertension results from a complex interaction of genes and environmental factors. Numerous common genetic variants with minor effects on blood pressure have been identified[38], as well as some rare genetic variants with significant effects on blood pressure.[39] Also, genome-wide association studies (GWAS) have identified 35 genetic loci related to blood pressure; 12 of these genetic loci influencing blood pressure were newly found.[40] Sentinel SNP for each new genetic locus identified has shown an association with DNA methylation at multiple nearby CpG sites. These sentinel SNP are located within genes related to vascular smooth muscle and renal function. DNA methylation might affect in some way linking common genetic variation to multiple phenotypes even though mechanisms underlying these associations are not understood. Single variant test performed in this study for the 35 sentinel SNP (known and new) showed that genetic variants singly or in aggregate contribute to the risk of clinical phenotypes related to high blood pressure.[40]

Blood pressure rises with aging when associated with a western diet and lifestyle, and the risk of becoming hypertensive in later life is significant.[41][42] Several environmental factors influence blood pressure. High salt intake raises blood pressure in salt-sensitive individuals; lack of exercise and central obesity can play a role in individual cases. The possible roles of other factors, such as caffeine consumption [43] and vitamin D deficiency[44], need to be clarified. Insulin resistance, which is common in obesity and is a component of syndrome X (or the metabolic syndrome), also contributes to Hypertension.[45]

Early life events such as low birth weight, maternal smoking, and lack of breastfeeding may be risk factors for essential adult hypertension. However, the mechanisms linking these exposures to adult hypertension remain unclear.[46] An increased rate of high blood uric acid has been found in untreated people with hypertension compared to people with normal blood pressure. However, whether the former plays a causal role or is, subsidiary to poor kidney function is uncertain.[47] Average blood pressure may be higher in the winter than in the summer.[48] Periodontal disease is also associated with high blood pressure.[49]

Secondary Hypertension
Main article: Secondary Hypertension
Secondary Hypertension results from an identifiable cause. Kidney disease is the most common secondary cause of Hypertension.[26] 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), hyperparathyroidism, and pheochromocytoma.[26][50] Other causes of secondary Hypertension include obesity, sleep apnea, pregnancy, coarctation of the aorta, excessive eating of licorice, excessive drinking of alcohol, certain prescription medicines, herbal remedies, and stimulants such as coffee, cocaine, and methamphetamine.[26][51] Arsenic exposure through drinking water has been shown to correlate with elevated blood pressure.[52][53] Depression was also linked to Hypertension.[54] Loneliness is also a risk factor.[55]

A 2018 review found that alcohol increased blood pressure in males while over one or two drinks increased the risk in females.[56]

Main article: Pathophysiology of Hypertension

Determinants of mean arterial pressure

Illustration depicting the effects of high blood pressure
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.[57] There is evidence that some younger people with prehypertension or ‘borderline hypertension’ have high cardiac output, an elevated heart rate, and everyday peripheral resistance, termed hyperkinetic borderline Hypertension.[58] These individuals develop the typical features of established essential Hypertension in later life as their cardiac output falls and peripheral resistance rises with age.[58] Whether this pattern is regular for all people who develop Hypertension is disputed.[59] The increased peripheral resistance in established Hypertension is mainly attributable to the structural narrowing of small arteries and arterioles [60]. However, a reduction in the number or density of capillaries may also contribute.[61]

It is unclear whether or not vasoconstriction of arteriolar blood vessels plays a role in Hypertension.[62] Hypertension is also associated with decreased peripheral venous compliance[63], which may increase venous return, increase cardiac preload, and cause diastolic dysfunction.

Pulse pressure (the difference between systolic and diastolic blood pressure) is frequently increased in older people with Hypertension.[64] This can mean that systolic pressure is abnormally high, but diastolic pressure may be normal or low, a condition termed isolated systolic Hypertension.[65] The high pulse pressure in older adults with Hypertension or isolated systolic Hypertension is explained by increased arterial stiffness, which typically accompanies aging and may be exacerbated by high blood pressure.[66]

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)[67] or abnormalities of the sympathetic nervous system.[68] These mechanisms are not mutually exclusive, and both likely contribute to some extent in most cases of essential Hypertension. It has also been suggested that endothelial dysfunction and vascular inflammation may contribute to increased peripheral resistance and vascular damage in Hypertension.[69][70] 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.[71]

Excessive sodium or insufficient potassium in the diet leads to excessive intracellular sodium, which contracts the vascular smooth muscle, restricting blood flow and so increases blood pressure.[72][73]

Hypertension is diagnosed based on persistently high resting blood pressure. The American Heart Association (AHA) recommends at least three resting measurements on at least two healthcare visits.[74] The U.K. National Institute for Health and Care Excellence recommends ambulatory blood pressure monitoring to confirm the diagnosis of Hypertension if a clinic blood pressure is 140/90 mmHg or higher.[75]

Measurement technique
For an accurate diagnosis of Hypertension, proper blood pressure measurement techniques must be used.[76] Improper measurement of blood pressure is common and can change the blood pressure reading by up to 10 mmHg, leading to misdiagnosis and misclassification of Hypertension.[76] 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, followed by applying a properly fitted blood pressure cuff to a bare upper arm.[76] The person should be seated with their back supported, feet flat on the floor, and legs uncrossed.[76] The person whose blood pressure is being measured should avoid talking or moving during this process.[76] The arm being measured should be supported on a flat surface at the level of the heart.[76] Blood pressure measurement should be done in a quiet room so the professional medical checking the blood pressure can hear the Korotkoff sounds while listening to the brachial artery with a stethoscope for accurate blood pressure measurements.[76][77] The blood pressure cuff should be deflated slowly (2–3 mmHg per second) while listening for the Korotkoff sounds.[77] 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.[76] Multiple blood pressure readings (at least two) spaced 1–2 minutes apart should be obtained to ensure accuracy.[77] Ambulatory blood pressure monitoring over 12 to 24 hours is the most accurate method to confirm the diagnosis.[78] An exception to this is those with very high blood pressure readings, especially when there is poor organ function.[79]

With the availability of 24-hour ambulatory blood pressure monitors and home blood pressure machines, the importance of not wrongly diagnosing those with white coat hypertension has led to a change in protocols. In the United Kingdom, the best practice is to follow up a single raised clinic reading with ambulatory measurement or, less ideally, with home blood pressure monitoring over seven days.[79] The United States Preventive Services Task Force recommends getting measurements outside the healthcare environment.[78] Pseudohypertension in the elderly or incompressibility 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. In contrast, intra-arterial blood pressure measurements are standard.[80] Orthostatic Hypertension is when blood pressure increases upon standing.[81]

Other investigations

Typical tests performed[82][83][84][85][86][87]
System Tests
Kidney Microscopic urinalysis, protein in the urine, BUN, creatinine
Endocrine Serum sodium, potassium, calcium, TSH
Metabolic Fasting blood glucose, HDL, LDL, total cholesterol, triglycerides
Other Hematocrit, electrocardiogram, chest radiographs
Once the diagnosis of Hypertension has been made, healthcare providers should attempt to identify the underlying cause based on risk factors and other symptoms, if present. 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.[88] Laboratory tests can also be performed to identify possible causes of secondary Hypertension and to determine whether Hypertension has caused damage to the heart, eyes, and kidneys. Additional tests for diabetes and high cholesterol levels are usually performed because these conditions are other risk factors for the development of heart disease and may require treatment.[6]

Initial assessment of hypertensive people should include a complete history and physical examination. Serum creatinine is measured to assess the presence of kidney disease, which can be either the cause or the result of Hypertension. Serum creatinine alone may overestimate the glomerular filtration rate, and recent guidelines advocate using predictive equations such as the Modification of Diet in Renal Disease (MDRD) formula to estimate the glomerular filtration rate (eGFR).[31] eGFR can also provide a baseline measurement of kidney function that can be used to monitor for side effects of certain antihypertensive drugs on kidney function. Additionally, urine sample testing for protein is a secondary indicator of kidney disease. Electrocardiogram (EKG/ECG) testing is done to check for evidence that the heart is under strain from high blood pressure. It may also show whether there is a thickening of the heart muscle (left ventricular hypertrophy) or whether the spirit has experienced a prior minor disturbance, such as a silent heart attack. A chest X-ray or an echocardiogram may also be performed to look for signs of heart enlargement or damage to the heart.[26]

Classification in adults
Classification in adults (Persons with systolic and diastolic in different categories are assigned to the higher class.[8])
Category Systolic, mmHg Diastolic, mmHg
Hypotension < 90 < 60 Normal 90–119[8] 90–129[89] 60–79[8] 60–84[89] Prehypertension (high normal, elevated[8]) 120–129[8] 130–139[89][90] 60–79[8] 85–89[89][90] Stage 1 hypertension 130–139[8] 140–159[89] 80–89[8] 90–99[89] Stage 2 hypertension >140[8]
160–179[89] >90[8]
Hypertensive crises ≥ 180[8] ≥ 120[8]
Isolated systolic hypertension ≥ 140[8] < 90[8] Isolated diastolic hypertension[91][92] < 140 ≥ 90 In people aged 18 years or older, Hypertension is defined as either a systolic or a diastolic blood pressure measurement consistently higher than an accepted normal value (this is above 129 or 139 mmHg systolic, 89 mmHg diastolic, depending on the guideline).[5][8] Other thresholds (135 mmHg systolic or 85 mmHg diastolic) are used if measurements are derived from 24-hour ambulatory or home monitoring.[79] Recent international hypertension guidelines have also created categories below the hypertensive range to indicate a risk continuum with higher blood pressures in the normal range. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) published in 2003[31] uses the term prehypertension for blood pressure in the range 120–139 mmHg systolic or 80–89 mmHg diastolic, while European Society of Hypertension Guidelines (2007)[93] and British Hypertension Society (BHS) IV (2004)[94] use optimal, normal and high normal categories to subdivide pressures below 140 mmHg systolic and 90 mmHg diastolic. Hypertension is also sub-classified: JNC7 distinguishes hypertension stage I, hypertension stage II, and isolated systolic Hypertension. Isolated systolic Hypertension refers to elevated systolic pressure with normal diastolic pressure and is common in the elderly.[31] The ESH-ESC Guidelines (2007)[93] and BHS IV (2004)[94] additionally define a third stage (stage III hypertension) for people with systolic blood pressure exceeding 179 mmHg or a diastolic pressure over 109 mmHg. Hypertension is classified as "resistant" if medications do not reduce blood pressure to normal levels.[31] In November 2017, the American Heart Association and American College of Cardiology published a joint guideline that updates the recommendations of the JNC7 report.[95] The 2020 International Society of Hypertension guidelines define Hypertension based on office blood pressure ≥140/90 mmHg or home monitoring blood pressure ≥135/85 mmHg, or 24-hour ambulatory blood pressure average ≥130/80 mmHg (daytime average ≥135/85 mmHg or nighttime average B.P.≥120/70 mmHg).[96] Children Hypertension occurs in around 0.2 to 3% of newborns; however, blood pressure is not measured routinely in healthy newborns.[37] Hypertension is more common in high-risk newborns. A variety of factors, such as gestational age, postconceptional age, and birth weight, need to be taken into account when deciding if blood pressure is expected in a newborn.[37] 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. Hypertension is defined as an average systolic or diastolic blood pressure on three or more occasions equal to or higher than the 95th percentile appropriate for the sex, age, and height of the child. However, high blood pressure must be confirmed on repeated visits before characterizing a child as having Hypertension.[97] Prehypertension in children has been defined as average systolic or diastolic blood pressure greater than or equal to the 90th percentile but less than the 95th percentile.[97] In adolescents, it has been proposed that Hypertension and prehypertension are 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 not labeled as hypertensive.[94] Consequently, population strategies are required to reduce the consequences of high blood pressure and the need for antihypertensive medications. Lifestyle changes are recommended to lower blood pressure before starting medications. The 2004 British Hypertension Society guidelines[94] proposed lifestyle changes consistent with those outlined by the U.S. National High B.P. Education Program in 2002[98] for the primary prevention of Hypertension: maintain normal body weight for adults (e.g., body mass index 20–25 kg/m2) reduce dietary sodium intake to <100 mmol/ day (<6 g of sodium chloride or <2.4 g of sodium per day) engage in regular aerobic physical activity such as brisk walking (≥30 min per day, most days of the week) limit alcohol consumption to no more than three units/day in men and no more than two units/day in women consume a diet rich in fruit and vegetables (e.g., at least five portions per day); Stress reduction[99] Avoiding or learning to manage stress can help a person control blood pressure. A few relaxation techniques that can help relieve stress are: meditation warm baths yoga going on long walks[99] 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.[94] 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.[100] Estimated sodium intake ≥6g/day and <3g/day are both associated with a high risk of death or significant cardiovascular disease, but the association between high sodium intake and adverse outcomes is only observed in people with Hypertension.[101] Consequently, in the absence of results from randomized controlled trials, the wisdom of reducing levels of dietary salt intake below 3g/day has been questioned.[100] ESC guidelines mention periodontitis is associated with poor cardiovascular health status.[102] The value of routine screening for Hypertension is debated.[103][104][105] In 2004 the National High Blood Pressure Education Program recommended that children aged three 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.[106] However, the American Academy of Family Physicians[107] 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.[108][109] The U.S. Preventive Services Task Force recommends screening adults 18 years or older for Hypertension with office blood pressure measurement.[105][110] Management Main article: Management of Hypertension According to one review published in 2003, a reduction of blood pressure by five 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.[111] Target blood pressure See also: Comparison of international blood pressure guidelines. 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 of 140–160 / 90–100 mmHg for the general population.[14][15][112][113] Cochrane reviews recommend similar targets for subgroups such as people with diabetes[114] and people with prior cardiovascular disease.[115] 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.[116] These findings may not apply to other populations.[116] Many expert groups recommend a slightly higher target of 150/90 mmHg for those between 60 and 80.[14][112][113][117] The JNC-8 and American College of Physicians recommend the target of 150/90 mmHg for those over 60 years of age,[15][118] but some experts within these groups disagree with this recommendation.[119] Some expert groups have also recommended slightly lower targets for those with diabetes[14] or chronic kidney disease with protein loss in the urine [120]. Still, others recommend the same target for the general population.[15][114] The issue of the best target and whether targets should differ for high-risk individuals still need to be solved [121]. However, some experts propose more intensive blood pressure lowering than some guidelines advocate.[122] For people who have never experienced cardiovascular disease with 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 B.P. is >90 mmHg.[8] 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 B.P. is >80 mmHg.[8]

Lifestyle modifications
The first line of treatment for Hypertension is lifestyle changes, including dietary changes, physical exercise, and weight loss. Though these have all been recommended in scientific advisories,[123] a Cochrane systematic review found no evidence (due to lack of data) for the effects of weight loss diets on death, long-term complications, or adverse events in persons with Hypertension.[124] The review did find a decrease in body weight and blood pressure.[124] Their potential effectiveness is similar to and sometimes exceeds a single medication.[14] If Hypertension is high enough to justify the immediate use of drugs, lifestyle changes are still recommended in conjunction with medication.

Dietary changes shown to reduce blood pressure include diets with low sodium,[125][126] the DASH diet (Dietary Approaches to Stop Hypertension),[127] which was the best against 11 other diets in an umbrella review,[128] and plant-based diets.[129] There is some evidence green tea consumption may help lower blood pressure, but this is insufficient for it to be recommended as a treatment.[130] There is evidence from randomized, double-blind, placebo-controlled clinical trials that Hibiscus tea consumption significantly reduces systolic blood pressure (-4.71 mmHg, 95% CI [-7.87, -1.55]) and diastolic blood pressure (-4.08 mmHg, 95% CI [-6.48, -1.67]).[131][132] Beetroot juice consumption also significantly lowers the blood pressure of people with high blood pressure.[133][134][135]

Increasing dietary potassium has a potential benefit for lowering the risk of Hypertension.[136][137] The 2015 Dietary Guidelines Advisory Committee (DGAC) stated that potassium is one of the shortfall nutrients under-consumed in the United States.[138] 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 potassium levels.[139]

Physical exercise regimens shown to reduce blood pressure include isometric resistance exercise, aerobic exercise, resistance exercise, and device-guided breathing.[140]

Stress reduction techniques such as biofeedback or transcendental meditation may be considered an add-on to other treatments to reduce Hypertension. Still, they do not have evidence for preventing cardiovascular disease alone.[140][141][142] Self-monitoring and appointment reminders might support other strategies to improve blood pressure control but need further evaluation.[143]

Several classes of medications collectively referred to as antihypertensive drugs 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).[144][15] These medications may be used alone or in combination (ACE inhibitors and ARBs are not recommended for use in combination); the latter option may serve to minimize counter-regulatory mechanisms that act to restore blood pressure values to pre-treatment levels,[15][145] although the evidence for first-line combination therapy is not strong enough.[146] Most people require more than one medication to control their Hypertension.[123] Medications for blood pressure control should be implemented by a stepped-care approach when target levels are not reached.[143] Withdrawal of such medications in the elderly can be considered by a healthcare professional because there is no strong evidence for an effect on mortality, myocardial infarction, and stroke.[147]

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 beta-blockers results are inferior to other antihypertensive medications in preventing cardiovascular disease.[148]

The prescription of antihypertensive medication for children with Hypertension has limited evidence. There is little evidence that compares it with a placebo and it shows a modest effect on blood pressure in the short term. Administration of a higher dose did not reduce blood pressure more significantly.[149]

Resistant Hypertension
Resistant Hypertension is defined as high blood pressure that remains above a target level despite being prescribed three or more antihypertensive drugs simultaneously with different mechanisms of action.[150] Failing to take prescribed medications as directed is an important cause of resistant Hypertension.[151] Resistant Hypertension may also result from the chronically high activity of the autonomic nervous system, an effect known as neurogenic Hypertension.[152] Electrical therapies that stimulate the baroreflex are being studied as an option for lowering blood pressure in people in this situation.[153]

Some common secondary causes of resistant Hypertension include obstructive sleep apnea, pheochromocytoma, renal artery stenosis, coarctation of the aorta, and primary aldosteronism.[154] As many as one in five people with resistant Hypertension have primary aldosteronism, a treatable and sometimes curable condition.[155]

Refractory Hypertension
Main article: Refractory Hypertension
Refractory Hypertension is characterized by uncontrolled elevated blood pressure unmitigated by five or more antihypertensive agents of different classes, including a long-acting thiazide-like diuretic, a calcium channel blocker, and a blocker of the renin-angiotensin system.[156] 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.[156][157]

Non-modulating essential Hypertension is a salt-sensitive Hypertension, where sodium intake does not modulate either adrenal or renal vascular responses to angiotensin II. Individuals with this subset have been termed non-modulators.[158] They make up 25–30% of the hypertensive population.

Heart disease remains one of the top causes of mortality in the Unites States. Consider the various types of heart disease covered in class this week. For your discussion, complete these items:

The etiology of the selected heart disease
Modifiable factors
Non-modifiable factors
Use at least one scholarly source to support your findings. Examples of scholarly sources include academic journals, textbooks, reference texts, and CINAHL nursing guides. Be sure to cite your sources in-text and on a References page using APA format.

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