Heart Disease

Hypertension and High Blood Pressure

An Overview of Hypertension (High Blood Pressure)

Hypertension, or high blood pressure, is one of the most common medical problems. Unfortunately, hypertension often goes undiagnosed. Worse, when it is diagnosed, it is often inadequately treated despite the fact that it is usually not very difficult to treat. So, while everyone “knows” about hypertension, it remains a leading cause of heart attackstrokekidney disease, and other serious medical problems.

Because hypertension is so common and so consequential, it is important for everyone to have their blood pressure checked periodically. And if you have hypertension, it is important to work closely with your doctor to find an effective treatment that will allow you to avoid the dire consequences and live a long, healthy life.

What Is Hypertension and Why Is It So Important?

Hypertension is a condition in which the pressure in the arteries is high enough to eventually produce damage to the blood vessels, and ultimately to the organs for which they supply blood.

 

As the heart beats, it propels blood through the arteries and to the body’s organs. The pressure generated by the beating heart moves the blood forward and stretches the elastic walls of the arteries. In between heartbeats, as the heart muscle relaxes, the arterial walls snap back to their original shape, thus keeping the blood moving forward to the body’s tissues. (The expanding of the arteries with each heart beat is what allows us to feel a “pulse.”) 

So, it is the blood pressure within the arteries—generated by the beating heart and the elastic arteries working together—that keeps the blood circulating.

If the blood pressure is too low (a condition called hypotension), the body’s organs suffer because they do not receive sufficient blood flow. But a blood pressure that is chronically too high (hypertension) causes its own problems. Hypertension can greatly accelerate atherosclerosis, which leads to coronary artery disease and heart attacksheart failure, strokes, kidney failureperipheral artery disease, and aortic aneurysms

This is why hypertension is a major risk factor for premature disability and death, and why diagnosing it and treating it is so critically important to good health and a long life.

Normal flow of blood through the heart.

What Are the Symptoms of Hypertension?

Hypertension is an insidious disease. Most people who have hypertension never develop any symptoms from the high blood pressure itself, and often seem and feel completely healthy for many years—until it has caused irreversible damage to a vital organ. So the very first sign of hypertension, unfortunately, is very often a sudden heart attack or a stroke—apparently out of the blue.

This is why hypertension is often called the “silent killer.”

How Is Hypertension Diagnosed?

Hypertension is diagnosed when your blood pressure at rest is found to be persistently elevated.

It is important to measure blood pressure correctly to avoid over-diagnosing or under-diagnosing hypertension. In today's typically harried medical office, the correct procedures for accurately measuring blood pressure are all too often overlooked. Since you are the one who has to live with the diagnosis (or with the consequences of a missed diagnosis), you ought to have some idea of the right way to diagnose hypertension.

A blood pressure measurement is expressed as two numbers—the systolic and the diastolic blood pressures—like this: 120mmHg/80mmHg, or more simply, 120/80 (“one twenty over eighty.”) The higher number, the systolic pressure, represents the pressure within the artery at the moment the heart is contracting. The lower number, the diastolic pressure, represents the arterial pressure in between heart beats, while the heart is relaxing.

Formal guidelines for measuring blood pressure stipulate that the measurement must be made in a quiet, warm environment after you have been sitting restfully for at least five minutes. You should not have had coffee or used tobacco for at least 30 minutes. At least two blood pressure measurements should be taken under these conditions, at least five minutes apart, and should be repeated as many times as necessary until the measurements agree to within 5 mmHg.

Anyone who has been to a doctor’s office in the last few years knows how unlikely it is that all these conditions are met. Still, before a doctor commits you to a permanent diagnosis of hypertension, he or she ought to feel obligated to make the diagnosis correctly. And you ought to insist that he or she does so.

Another complicating factor in diagnosing hypertension in the doctors’ office is the phenomenon of “white coat hypertension”—which means that blood pressure levels are elevated in the doctor’s office, but are normal just about any other time.

Most experts feel that white coat hypertension does not require treatment.

Because of the inherent difficulties involved in making the proper diagnosis of hypertension in a doctor’s office, hypertension experts are coming around to the view that the most accurate way to diagnose hypertension is not in the doctor’s office at all, but rather, with ambulatory blood pressure monitoring. Accumulating evidence strongly recommends this approach and some recent medical guidelines stipulate that ambulatory monitoring is preferred for diagnosing hypertension.

What Are the Risk Factors for Hypertension?

Hypertension is very common among all groups in Western societies. However, some people are at particularly high risk to develop hypertension.

Hypertension is more common and more severe in black people and in people who have a family history of hypertension. Excess salt intake is an important factor in developing hypertension for many people. High alcohol intake (greater than two drinks per day) is associated with hypertension. Elevated blood-lipid levels (cholesterol and triglycerides in your blood) are associated with an increased incidence of hypertension. And, of course, there’s the most common risk factor—being overweight or obese.

What Are the Causes of Hypertension?

The causes of hypertension are usually divided into two general categories: hypertension that is primary (“essential hypertension”) and hypertension that is secondary to some underlying medical problem. 

The vast majority of people with hypertension have essential hypertension, which means, simply, that no specific underlying cause can be identified—it happens for no apparent reason. While a lot of research has been done to try to pinpoint the real underlying cause (or causes) of essential hypertension, so far the cause remains elusive.

It's more uncommon that hypertension is secondary to some identifiable—and often treatable and/or reversible—underlying disorder. Conditions that can produce secondary hypertension include kidney disease, sleep apnea, coarctation of the aorta, disease of the blood vessels supplying the kidneys, various endocrine gland disorders, and the use of oral contraceptives, drinking alcohol, chronic use of non-steroidal anti-inflammatory drugs (NSAIDs), or antidepressants.

A careful medical history, physical examination, and an evaluation of routine blood work should tip off your physician as to whether further steps ought to be taken to look for a potential cause of secondary hypertension.

What Are the Stages of Hypertension?

When hypertension is diagnosed, the “stage” of the hypertension is an important factor in determining what kind of therapy is used initially. The stage of a person’s hypertension is just another way of saying how severe it is—in other words, how high the blood pressure is.

The stages of hypertension are:

  • Stage 1 hypertension: systolic pressure 140-159mmHg OR diastolic pressure 90-99mmHg
  • Stage 2 hypertension: systolic pressure greater than 159mmHg OR pressure diastolic greater than 99mmHg

In addition to these two formal “stages,” doctors will also talk about an informal stage called ​prehypertension, in which the blood pressure is higher than the desirable range, but not high enough (yet) to be labeled hypertension.

Prehypertension is said to be present if the systolic pressure falls between 120-139mmHg or the diastolic pressure is between 80-89mmHg. Because people with prehypertension have a very high risk of becoming frankly hypertensive, they need to have their blood pressure monitored at least every 6-12 months. Some doctors even believe they should be treated for hypertension. At the very least, they ought to adopt lifestyle changes that will reduce their risk of developing hypertension and cardiovascular disease.​

In addition to prehypertension and stage 1 and stage 2 hypertension, there is a rare form of severe hypertension called malignant hypertension. Malignant hypertension is diagnosed when the blood pressure is extremely high and is accompanied by evidence of acute damage to the organs caused by the rupture of blood vessels exposed to suddenly very high blood pressure.

This acute organ damage is most commonly manifested by bleeding in the retina of the eyes, bleeding from the kidneys, acute cardiac damage, or stroke. The symptoms experienced by people with malignant hypertension are related to the organ or organs being damaged. Malignant hypertension is always a medical emergency and generally requires aggressive, intensive medical care.​

Recently Diagnosed With Hypertension? Finding the Right Treatment

If you have been diagnosed with hypertension, the good news is that there is a huge array of effective therapies to choose from. The bad news is that there's also a huge array of effective therapies to choose from—which sometimes can make selecting the "right" treatment a little complicated.

The treatment of hypertension always starts with diet, exercise, weight management, and sodium restriction. In some cases (especially in people with prehypertension or stage 1 hypertension) these sorts of lifestyle changes are enough, and drug therapy may not be necessary.

However, in the majority of people with stage 1 hypertension, and with anyone who has stage 2 hypertension, drug therapy is required to sufficiently reduce blood pressure.

Because a vast number of prescription medications have been approved for the treatment of hypertension, selecting the “right” drug (or a combination of drugs) for any given person with hypertension may at first seem a little daunting. However, guidelines have been developed to help doctors quickly find an effective, well-tolerated (and usually quite affordable) treatment regimen for almost anyone with hypertension.

So, if you and your doctor take a logical, step-wise approach, there is an excellent chance that you will quickly settle on the treatment that is right for you. 

If you are 65 years old or older, it may be that your hypertension is primarily systolic hypertension—that is, your systolic blood pressure is high, while your diastolic blood pressure remains in the normal range. If so, you and your doctor should take special precautions as you begin therapy for your hypertension.

Living With Hypertension

When you are first diagnosed with hypertension, you can expect there to be a period of time when you will be seeing your doctor more often than usual. You will need some baseline testing to look for an underlying cause for your hypertension, and you will probably need several doctor visits before your optimal treatment regimen is found.

But once this initial period is over, you can expect to get back to a completely normal life. Of course, there may be a few lifestyle adjustments you will need to get used to, but they probably will be lifestyle changes you should have made a long time ago.

The good news is—now that your hypertension is adequately treated—that “normal life” is likely to last a lot longer and be substantially healthier than it otherwise might have been.

A Word From Verywell

Hypertension is a very common medical disorder that often has severe consequences. By learning all you can about hypertension, you can work with your doctor to make the right diagnosis in a timely fashion and quickly arrive at the optimal therapy you need. 

Sources:

Chobanian, AV, Bakris, GL, Black, HR, Cushman, WC. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report. JAMA 2003; 289:2560.

Go AS, Bauman M, Coleman King SM, et al. An effective approach to high blood pressure control: A science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention. Hypertension 2013; available at http://hyper.ahajournals.org.

James PA, Oparil S, Carter BL, et al. 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). JAMA 2014; DOI:10.1001/jama.2013.284427. Available at: http://jama.jamanetwork.com/journal.aspx.

Kaplan NM, Victor RG. Chapter 8: Hypertensive Crises. In: Kaplan's Clinical Hypertension, 10th Ed, Lippincott, Williams & Wilkins, Philadelphia 2010. p.274.

Mancia G, Bombelli M, Brambilla G, et al. Long-term prognostic value of white coat hypertension: an insight from diagnostic use of both ambulatory and home blood pressure measurements. Hypertension 2013; 62:168.

Myers, MG. Ambulatory blood pressure monitoring for routine clinical practice. Hypertension 2005; 45:483.

Pierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: an updated meta analysis. Am J Hypertens 2011; 24:52.

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