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Last Updated: 12/20/2013  

Essential Hypertension

Screening
  • Screen adults for hypertension every 1 to 2 years; screen all children and adolescents repeatedly after initial BP measurement at age 3, depending on initial value.

Diagnosis
  • Obtain proper BP measurement and diagnose patients with normotension (BP <120/80 mm Hg), prehypertension (SBP 120-139 mm Hg or DBP 80-89 mm Hg), stage 1 hypertension (SBP 140-159 mm Hg or DBP 90-99 mm Hg) or stage 2 hypertension (SBP ≥160 mm Hg or DBP ≥100 mm Hg).

  • Confirm the diagnosis by checking BP on a separate visit; consider offering ambulatory BP monitoring to confirm the diagnosis.

  • Evaluate prognostic and cardiac risk factors.

  • Use history, physical exam, and ECG to assess for target organ damage and check lab tests including electrolytes, urinalysis, and lipid profile.

  • Identify patients at high risk for imminent or ongoing target organ damage if they have signs or symptoms of target organ effects, usually with severe hypertension (BP ≥180/120 mm Hg).

  • Consider secondary hypertension in patients with acutely worse hypertension, very early onset of hypertension, or whose hypertension is difficult to control.

Therapy
  • Recommend lifestyle modification, including weight loss and sodium restriction, to all patients with hypertension and as the sole initial therapy in patients with stage 1 hypertension and no target end-organ damage.

  • Treat patients with uncomplicated hypertension initially with a diuretic, calcium-channel blocker, or ACE inhibitor.

  • Consider initiating therapy with a combination of antihypertensive medications, generally including diuretics, ACE inhibitors, and/or calcium-channel blockers in untreated patients presenting with stage 2 hypertension.

  • Individualize antihypertensive therapy for patients with specific comorbid conditions such as diabetes, heart failure, history of MI, and chronic kidney disease.

  • Target a goal BP of <140/90 mm Hg in most patients.

  • Use a parenteral agent in a monitored setting when the DBP is markedly elevated (>140 mm Hg) and there is evidence of progressive target organ damage.

  • Distinguish a pseudocrisis of hypertension from a true hypertensive emergency and treat with rapid-onset medications such as labetolol, captopril, nicardipine, or clonidine.

DOI: 10.7326/d226
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
Disclosures:
Raymond R. Townsend, MD serves on the American Society of Hypertension's Board of Directors and receives royalties from UpToDate. Raymond R. Townsend, MD serves on the American Society of Hypertension's Board of Directors and receives royalties from UpToDate.
Deborah Korenstein, MD, FACP, Editor in Chief, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Richard B. Lynn, MD, FACP, Editor, ACP Smart Medicine, has no relationships with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.
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