Hypertension

Also known as High blood pressure · Essential hypertension · Raised blood pressure

GP-fellowship guide to hypertension: the measurement technique and out-of-office confirmation that underpin every diagnosis, white-coat and masked phenotypes, primary aldosteronism screening with the aldosterone-to-renin ratio, quantified lifestyle interventions, the stepwise drug ladder built on ALLHAT and network meta-analysis evidence, intensive targets from SPRINT and their limits in diabetes (ACCORD), resistant hypertension and PATHWAY-2's spironolactone answer, hypertensive urgency versus emergency, and the special situations — pregnancy, older age, CKD — where the GP's judgement matters most.

high35 referencesUpdated 21 Aug 202614 min readVerification in progress

Practise this topic

Key points

Hypertension is defined by clinic blood pressure of 140/90 mm Hg or higher, but diagnosis requires confirmation with out-of-office measurement — home or ambulatory readings of 135/85 mm Hg or higher — because 3–20% of clinic hypertension is white-coat and a larger masked burden hides behind normal clinic readings.
Every 10 mm Hg reduction in systolic pressure cuts major cardiovascular events by 20%, stroke by 27% and heart failure by 28%; treatment works, and most of it is delivered in general practice.
First-line drug therapy rests on four classes — ACE inhibitor or ARB, calcium channel blocker, and thiazide-like diuretic — started as low-dose dual combination when pressure is markedly raised; beta-blockers are not first-line without a compelling indication.
Resistant hypertension on three drugs at maximally tolerated doses means adding spironolactone: in PATHWAY-2 it lowered home systolic pressure 8.70 mm Hg more than placebo and beat both doxazosin and bisoprolol.^[12]

Overview

Hypertension is the condition in which persistently elevated arterial pressure damages the heart, brain, kidneys, eyes and large vessels, long before it causes symptoms. It affects roughly 45% of adults and is the most commonly diagnosed condition at outpatient office visits.^[2] It is a major contributing risk factor for heart failure, myocardial infarction, stroke and chronic kidney disease.^[2]

The disease is almost always silent. Its clinical presentation IS its complications: left ventricular hypertrophy, albuminuria, retinopathy, lacunar infarction. That asymmetry — massive organ burden, absent symptoms — is why screening at every adult encounter and rigorous diagnostic technique are the two highest-yield acts in this entire topic.^[2]

Two definitions coexist. The ANZ/NICE convention diagnoses hypertension at 140/90 mm Hg or higher in the clinic, confirmed out of office. The 2017 ACC/AHA guideline reclassified pressure of 130/80 mm Hg or higher as stage 1 hypertension, relying more heavily on cardiovascular risk calculation and lifestyle therapy before drugs.^[1] Both systems agree on what matters: sustained pressure above normal damages organs, and the threshold for drug therapy falls as absolute risk rises.

References35Show

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[2]Krist AH, Davidson KW, Mangione CM, et al. Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement JAMA, 2021.PMID 33904861
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