MD Nexus

Hypertension-Part 1

Epidemiology

General

  • Hypertension is the Leading Modifiable Risk for Factor for Cardiovascular Disease in the United States (Hypertension, 2024) [MEDLINE]
    • Observational Studies Have Demonstrated Graded Associations Between Higher Systolic Blood Pressure (SBP) and Diastolic Blood Pressure (DBP) and Increased Cardiovascular Disease Risk (Hypertension, 2018) [MEDLINE]

Prevalence (Hypertension, 2018) [MEDLINE]

  • Blood Pressure ≥130/80: 46% overall prevalence
    • Male: 48% prevalence
    • Female: 43% prevalence
    • Male, Age 20-44 y/o: 30% prevalence
    • Male, Age 65-74 y/o: 77% prevalence
    • Female, Age 20-44 y/o: 19% prevalence
    • Female, Age 65-74 y/o: 75% prevalence
    • Male, Non-Hispanic White: 47%% prevalence
    • Male, Non-Hispanic Black: 59%% prevalence
    • Male, Non-Hispanic Asian: 45% prevalence
    • Male, Hispanic: 44% prevalence
  • Blood Pressure ≥140/90: 32% overall prevalence
    • Male: 31% prevalence
    • Female: 32% prevalence
    • Male, Age 20-44 y/o: 11% prevalence
    • Male, Age 65-74 y/o: 64% prevalence
    • Female, Age 20-44 y/o: 10% prevalence
    • Female, Age 65-74 y/o: 63% prevalence
    • Male, Non-Hispanic White: 31%% prevalence
    • Male, Non-Hispanic Black: 42%% prevalence
    • Male, Non-Hispanic Asian: 29% prevalence
    • Male, Hispanic: 27% prevalence

Risk Factors for Hospitalization for Hypertension (Hypertension, 2024) [MEDLINE]

  • Low Socioeconomic Status
  • Poor Compliance with Antihypertensive Medication Regimen
  • Residence in Low Income Area
  • Underinsurance/Lack of Health Insurance

Hypertension in the Emergency Department (ED) Setting

  • In 2012, Hypertension was the Primary Diagnosis in Over 1 Million Emergency Department Visits (with Approximately 23% of These Resulting in Hospitalization) (Hypertension, 2024) [MEDLINE]

Hypertension in the Inpatient Setting

Clinical Data

  • Systematic Review of Studies of Hypertension in the Inpatient Setting (J Hosp Med, 2011) [MEDLINE]: n = 9 studies
    • Inpatient Hypertension (with or without Target-Organ Damage) is Present in Up 50.5-72% of Inpatients
    • Approximately 37-77% of Hypertensive Patients Remained Hypertensive at the Time of Discharge
    • Most Patients with Inpatient Hypertension Continued to Have Elevated Blood Pressures at the Time of Outpatient Follow-Up
  • Study of Hypertension in Adults in the Inpatient Setting (JAMA Intern Med, 2021) MEDLINE]: n = 22,834 patients admitted to a medicine service for non-cardiac diagnoses
    • Systolic Blood Pressure (Defined >140 mm Hg) was Present at Least One Time in 78% of Patients
  • Multi-Hospital Retrospective Cohort Study of Hypertension in the Inpatient Setting (J Clin Hypertens-Greenwich, 2022) [MEDLINE]: n = 224,265 hospitalized adults (admitted for reasons other than hypertension)
    • Approximately 10% of Patients Developed Severe Hypertension (of Which 40% were Treated)

Risk Factors for Asymptomatic Elevated Inpatient Blood Pressure and/or Hypertensive Emergencies (Hypertension, 2024) [MEDLINE]

Hypertensive Emergencies

Clinical Data

  • Data from the Nationwide Emergency Department Sample from 2006-2013 Indicated that Hypertensive Emergencies Occurred in Approximately 2/1,000 Adult Emergency Department Visits Overall (and in 6/1,000- Emergency Department Visits in Patients with a Prior Diagnosis of Hypertension) (Hypertension, 2024) [MEDLINE]
  • Systematic Review and Meta-Analysis (8 Studies) of Hypertensive Urgency/Emergency Patients Presenting to the Emergency Department (J Hypertens, 2020) [MEDLINE]
    • Prevalence of Hypertensive Urgency: 0.9%
    • Prevalence of Hypertensive Emergency: 0.3%
  • The Rate of Hypertensive Emergencies Has Increased Over the Past 20 yrs (Hypertension, 2024) [MEDLINE]
    • However, Over that Period of Time, Hypertensive Emergency Mortality Rates Have Decreased (Range from 0.2-11%)

Risk Factors for Asymptomatic Elevated Inpatient Blood Pressure and/or Hypertensive Emergencies (Hypertension, 2024) [MEDLINE]

Coexistence of Hypertension and Other Comorbid Conditions

Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]

  • In All Adults with Hypertension, Screening/Management of Other Modifiable Cardiovascular Disease Risk Factors are Recommended (Class of Recommendation: I, Level of Evidence: B-NR
    • Modifiable Risk Factors
      • Current Cigarette Smoking/Secondhand Smoking (see Tobacco)
      • Diabetes Mellitus (DM) (see Diabetes Mellitus)
      • Hyperlipidemia (see Hyperlipidemia)
      • Overweight/Obesity (see Obesity)
      • Physical Inactivity/Low Fitness Level
      • Unhealthy Diet
    • Relatively Fixed Risk Factors
      • Chronic Kidney Disease (CKD) (see Chronic Kidney Disease)
      • Family History of Cardiovascular Disease
      • Low Socioeconomic/Educational Status
      • Male Sex
      • Older Age
      • Obstructive Sleep Apnea (OSA) (see Obstructive Sleep Apnea)
      • Psychosocial Stress

Etiology/Risk Factors (Hypertension, 2018) [MEDLINE]

General Comments

Primary vs Secondary Hypertension

  • A Specific, Remediable Etiology of Hypertension Can Be Identified in Approximately 10% of Adult Patients with Hypertension (Hypertension, 2018) [MEDLINE]
  • Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]
    • Screening for Specific Forms of Secondary Hypertension is Recommended When the Specific Clinical/Physical Examination Findings (See Below) are Present or in Adults with Resistant Hypertension (Class of Recommendation: I, Level of Evidence: C-EO)
    • If an Adult with Sustained Hypertension Screens Positive for a Type of Secondary Hypertension, Referral to a Physician with Expertise in that Type of Hypertension May Be Reasonable for Diagnostic Confirmation and Treatment (Class of Recommendation: IIb, Level of Evidence: C-EO)

Age

  • Epidemiology
    • Advancing Age is Associated with Increased Blood Pressure (Especially Increased Systolic Blood Pressure), and an Increased Incidence of Hypertension

Cardiovascular

Aortic Coarctation (see Aortic Coarctation)

  • Epidemiology
    • Usually Diagnosed in Patient <30 y/o
  • Diagnosis
    • Echocardiogram (see Echocardiogram)
    • Thoracic/Abdominal Computed Tomography Angiogram (CT) (see xxxx)
    • Thoracic/Abdominal Magnetic Resonance Angiogram (MRA (see xxxx)
  • Clinical
    • Abdominal bruit
    • Absent Femoral Pulses
    • Continuous Murmur Over Back/Chest
    • Higher Blood Pressure in Upper Extremities than in Lower Extremities

Endocrine

Acromegaly (see Acromegaly)

  • Diagnosis
    • Brain Magnetic Resonance Imaging (MRI) (see Brain Magnetic Resonance Imaging)
    • Elevated Age/Sex-Matched IGF-1 Level
    • Serum Growth Hormone ≥1 ng/mL During Oral Glucose Load
  • Clinical
    • Acral Features
    • Diabetes Mellitus (see Diabetes Mellitus)
    • Enlarging Shoe/Glove/Hat Size
    • Frontal Bossing
    • Headache (see Headache)
    • Visual Disturbances

Congenital Adrenal Hyperplasia (CAH) (see Congenital Adrenal Hyperplasia)

  • Diagnosis
    • Low/Normal Aldosterone and Renin
    • 11-β-Hydroxylase Deficiency
      • Decreased Cortisol and Corticosterone
      • Increased 11-Deoxycortisol, 11-Deoxycorticosterone (DOC), Androstenedione, and Testosterone
    • 17-α-Hydroxylase Deficiency
      • Decreased Androgens and Estrogens
      • Increased 11-Deoxycorticosterone (DOC), Corticosterone, and 18-Hydroxycorticosterone
  • Clinical
    • Hypertension
    • Hypokalemia (see Hypokalemia)
    • Virilization
      • 11-β-Hydroxylase Deficiency
    • Incomplete Masculinization in Males/Primary Amenorrhea in Females
      • 17-α-Hydroxylase Deficiency

Cushing Syndrome (see Cushing Syndrome)

  • Diagnosis
    • 24 hr Urinary Free Cortisol Excretion (Preferably Multiple)
    • Midnight Salivary Cortisol
    • Overnight Dexamethasone Suppression Test (see Dexamethasone Suppression Test)
  • Clinical
    • “Buffalo Hump (Dorsal Fat Pad)
    • Central Obesity (see Obesity)
    • Depression (see Depression)
    • Dorsal/Supraclavicular Fat Pads
    • Easy Bruisability
    • Hirsutism
    • Hyperglycemia (see Hyperglycemia)
    • Moon Face
    • Muscle Weakness (see xxxx)
    • Rapid Weight Gain (Especially with Central Distribution) (see Weight Gain)
    • Supraclavicular Fat Pads
    • Wide (1 cm) Violaceous Striae (see Striae)

History of Gestational Hypertension/Preeclampsia (see Preeclampsia and Eclampsia)

  • Epidemiology
    • Females with a History of High Blood Pressure During Pregnancy are More Likely to Develop Sustained Hypertension Later in Life (Even if the Blood Pressure Normalizes Initially After Delivery)

Hyperthyroidism (see Hyperthyroidism)

Hypothyroidism (see Hypothyroidism)

Overweight/Obesity (see Obesity)

  • Epidemiology
    • Obesity/Weight Gain are Major Risk Factors for Hypertension
      • Obesity/Weight Gain are Also Contributors to the Rise in Blood Pressure Which is Commonly Observed with Aging (BMJ, 1989) [MEDLINE] (JAMA, 2009) [MEDLINE]
  • Diagnosis
    • Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]
      • Weight Loss is Recommended to Decrease Blood Pressure in Adults with Hypertension Who are Overweight/Obese (Class of Recommendation: I, Level of Evidence: A)

Other Mineralocorticoid Excess Syndrome (Other than Primary Aldosteronism)

  • Etiology
    • Deoxycorticosterone-Producing Adrenal Tumor
    • Genetic Syndrome of Apparent Mineralocorticoid Excess: rare
  • Diagnosis
    • Decreased Serum Aldosterone
    • Decreased Serum Renin
    • Genetic Testing
    • Urinary Cortisol Metabolites
  • Clinical
    • Hypokalemia (see Hypokalemia)
      • May be Severe Enough to Cause Arrhythmias

Pheochromocytoma/Paraganglionoma (see Pheochromocytoma)

Primary Hyperaldosteronism (see Hyperaldosteronism)

  • Epidemiology
    • Primary Hyperaldosteronism Accounts for Approximately 8-20% of Secondary Hypertension Cases (Hypertension, 2018) [MEDLINE]
  • Diagnosis
    • Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]
      • In adults with hypertension, screening for primary aldosteronism is recommended in the presence of any of the following concurrent conditions: resistant hypertension, hypokalemia (spontaneous or substantial, if diuretic induced), incidentally discovered adrenal mass, family history of early-onset hypertension, or stroke at a young age (<40 years) (Class of Recommendation: I, Level of Evidence: C-EO)
      • Use of the plasma aldosterone: renin activity ratio is recommended when adults are screened for primary aldosteronism (Class of Recommendation: I, Level of Evidence: C-LD)
      • In adults with hypertension and a positive screening test for primary aldosteronism, referral to a hypertension specialist or Evaluation and Treatment endocrinologist is recommended for further XXXXXX (Class of Recommendation: I, Level of Evidence: C-EO)
    • Plasma Aldosterone/Renin Ratio Under Standardized Conditions (Correction of Hypokalemia and Withdrawal of Aldosterone Antagonists for 4–6 wks)
    • Oral Sodium Loading Test (with 24 hr Urine Aldosterone)
    • Intravenous Saline Infusion Test with Plasma Aldosterone at 4 hrs of Infusion
    • Adrenal Computed Tomography (CT) (see Abdominal Computed Tomography)
    • Adrenal Vein Sampling
  • Clinical
    • Adrenal Mass (see Adrenal Mass)
    • Early-Onset/Resistant Hypertension
    • Hypokalemia (see Hypokalemia)
      • Either Spontaneous or Diuretic-Induced
      • May be Severe Enough to Induce Arrhythmias (Especially Atrial Fibrillation)
    • Muscle Cramps/Weakness (see Muscle Cramps and xxxx)

Primary Hyperparathyroidism (see Primary Hyperparathyroidism)

Environmental

Altered Gut Microbiota

  • Demonstrated as a Risk Factor in Animal Models

Inadequate Sleep

  • Short Sleep Duration (<7 hrs/Night) is Associated with a Higher Risk of Hypertension
  • increasing Sleep Duration May Decrease Blood Pressure

Low Physical Activity/Fitness

  • There is an Inverse Relationship Between Physical Activity/Physical Fitness and Hypertension
  • Exercise (Aerobic, Dynamic Resistance, and Isometric Resistance) is Effective in Decreasing Blood Pressure

Noise/Air Pollution

  • Exposure to Noise/Air Pollution Increases Blood Pressure
    • Exposure to Noise/Air Pollution May Be an Important Contributor to Disparities in Hypertension Prevalence and Control

Unhealthy Diet

  • Excess Dietary Sodium Intake
    • Excess Sodium Intake is Positively Associated with Blood Pressure in Migrant, Cross-Sectional, and Prospective Cohort Studies
    • Excess Sodium Intake Accounts for Much of the Age-Related Increase in Blood Pressure
  • Insufficient Dietary Intake of Potassium, Calcium, Magnesium, Protein (Especially from Vegetables), fiber, and Fish Fats
    • Potassium Intake is Inversely rRelated to Blood Pressure in Migrant, Cross-Sectional, and Prospective Cohort Studies
  • Overweight/Obesity (see Obesity)

Social Determinants of Health

  • Social Determinants of Health (Low Socioeconomic Status, Lack of Health Insurance, Food/Housing Insecurity, Exposure to Discrimination, and Lack of Access to Safe Spaces for Exercise) May Underlie Several of the Above Risk Factors for the Development of Hypertension (Such as Obesity, Poor Diet, Physical Inactivity, etc)* Social Factors Likely Account for a Large Part of the Observed Racial Disparities in Hypertension

Genetic

Hypertension is a Complex Polygenic Disorder in Which Many Genes or Gene Combinations Influence Blood Pressure

  • Although Several Monogenic Forms of Hypertension Have Been Identified (Such as Glucocorticoid-Remediable Aldosteronism, Liddle’s Syndrome, Gordon’s Syndrome) in Which Single-Gene Mutations Fully Account for the Pathophysiology of Hypertension, These Disorders are Rare
  • Known Genetic Variants Contributing to Hypertension Include >25 Rare Mutations and 120 Single-Nucleotide Polymorphisms

Family History of Hypertension

  • Hypertension is Approximately 2x as Common in Patients Who Have 1-2 Hypertensive Parents
  • Multiple Epidemiologic Studies Suggest that Genetic Factors Account for Approximately 30% of the Variation in Blood Pressure in Various Studied Populations (Lancet, 2003) [MEDLINE] (Arch Intern Med, 2008) [MEDLINE]

Race

  • Features of Hypertension in Black Patients
    • Higher Incidence of Hypertension
    • Hypertension Occurring Earlier in Life
    • Hypertension Tending to Be More Severe
    • Hypertension Association with Greater Target-Organ Damage

Hematologic

Complement-Mediated Thrombotic Microangiopathy

  • Epidemiology
    • New/Worsening Hypertension is Common in Complement-Mediated Thrombotic Microangiopathy (Occurring in 8-54% of Cases) (see xxxx)
      • Occurrence of Hypertension and Thrombotic Microangiopathy Together Should Especially Raise Suspicion if the Patient is Younger, Has a Poor Response to Antihypertensive Therapy, or if the Thrombotic Microangiopathy Does Not Improve with Antihypertensive Therapy Alone (Clin J Am Soc Nephrol, 2010) [MEDLINE] (Haematologica, 2019) [MEDLINE] (Hypertension, 2020) [MEDLINE]
  • Clinical

Immunologic

Mixed Cryoglobulinemia Syndrome (MCS) (see Cryoglobulinemia)

  • Renal Clinical Presentations: similar in both type II and type III mixed cryoglobulinemia
    • Acute Glomerulonephritis (see Glomerular Disease)
    • Acute Kidney Injury (AKI) (see Acute Kidney Injury): 9% of cases
    • Chronic Kidney Disease (CKD) without Significant Urinalysis Abnormalities (see Chronic Kidney Disease): 13% of cases
    • Hypertension (Which May Be Severe): 65% of cases
    • Microscopic Hematuria with Subnephrotic Proteinuria and with/without Chronic Kidney Disease (CKD) (see xxxx): 41% of cases
    • Nephrotic Syndrome with/without Chronic Kidney Disease (CKD) (see Chronic Kidney Disease): 22% of cases

Neurologic

Paroxysmal Sympathetic Hyperactivity (PSH) (see Paroxysmal Sympathetic Hyperactivity)

Pulmonary

Obstructive Sleep Apnea (OSA) (see Obstructive Sleep Apnea)

  • Epidemiology
    • Obstructive Sleep Apnea (OSA) is Present in Approximately 25-50% of Secondary Hypertension Cases (Hypertension, 2018) [MEDLINE]
  • Diagnosis
    • Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]
      • In Adults with Hypertension and Obstructive Sleep Apnea, the Effectiveness of Continuous Positive Airway Pressure (CPAP) to Decrease Blood Pressure is Not Well Established (Class of Recommendation: IIb, Level of Evidence: B-R)
    • Polysomnography (see Polysomnogram)
  • Clinical

Renal

Acute Glomerulonephritis

  • Epidemiology
    • Patients with Acute Glomerular Disease (Such as Poststreptococcal Glomerulonephritis) Tend to Be Volume Expanded and Edematous Due to Sodium Retention (Caused by Increased Sodium Reabsorption in the Collecting Tubules) (Am J Kidney Dis, 2008) [MEDLINE]
      • Elevation in blood pressure is primarily due to fluid overload, as evidenced by suppression of the renin-angiotensin-aldosterone system and enhanced release of atrial natriuretic peptide
      • Although these changes are most prominent with severe disease, the incidence of hypertension is increased even in patients with a normal serum creatinine concentration
      • Both a familial predisposition to hypertension and subclinical volume expansion are thought to be important in this setting
  • Clinical

Autosomal Dominant Polycystic Kidney Disease (ADPCKD) (see Autosomal Dominant Polycystic Kidney Disease)

  • Diagnosis
  • Clinical
    • Chronic Kidney Disease (CKD) (see Chronic Kidney Disease)
    • Cysts in Liver, Pancreas, Spleen, and/or Epididymis
    • Flank Pain (Due to Renal Hemorrhage (see Flank Pain)
    • Hematuria (see Hematuria)
    • Hypertension
      • Hypertension is Present in the Majority of Patients with Normal Renal Function and Have Reached the 4th Decade of Life
      • Hypertension Occurs in Almost 100% of Patients Who Have Advanced End-Stage Renal Disease
    • Obstructive Calculi
    • Proteinuria (see Proteinuria)
    • Urinary Tract Infection (UTI) (see Urinary Tract Infection)

Chronic Kidney Disease (CKD) (see Chronic Kidney Disease)

  • Epidemiology
    • Hypertension is Present in Approximately 80-85% of Patients with Chronic Kidney Disease (CKD)
  • Diagnosis
  • Clinical

Decreased Nephron Number

  • Epidemiology
    • Reduced Adult Nephron Mass May Predispose to the Development of Hypertension
      • Potential Determinants of Reduced Adult Nephron Mass
        • Genetic Factors
        • Intrauterine Developmental Disturbance (Such as Hypoxia, Drugs, Nutritional Deficiency)
        • Premature Birth
        • Postnatal Environment (Including Such Factors as Malnutrition and Infections)

Renal Artery Stenosis (see Renal Artery Stenosis)

  • Epidemiology
    • Renal Vascular Disease Accounts for Approximately 5-34% of Secondary Hypertension Cases
  • Diagnosis
    • Recommendations-2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Hypertension, 2018) [MEDLINE]
      • Medical Therapy is Recommended for Adults with Atherosclerotic Renal Artery Stenosis (Class of Recommendation: I, Level of Evidence: A)
      • In Adults with renal artery stenosis for whom medical management has failed (refractory hypertension, worsening renal function, and/or intractable HF) and those with nonatherosclerotic disease, including fibromuscular dysplasia, it may be reasonable to refer the patient for consideration of revascularization (percutaneous renal artery angioplasty and/or stent placement) (Class of Recommendation: IIb, Level of Evidence: C-EO)
    • Renal Ultrasound with Duplex Dopplers (see xxxx)
    • Magnetic Resonance Angiogram (MRA) (see xxxx)
    • Abdominal Computed Tomography (CT) (see xxxx)
    • Bilateral Selective Renal Intra-Arterial Angiogram
  • Clinical
    • Abdominal Systolic-Diastolic Bruit
    • Other Arterial Bruits
      • Carotid: Due to Atherosclerotic or Fibromuscular Dysplasia Disease
      • Femoral
    • Clinical Features Suggesting renal Vascular Disease as an Etiology of Hypertension
      • Resistant Hypertension
      • Abrupt Onset/Worsening/Increasingly Difficult to Control Hypertension
      • Flash Pulmonary Edema (Atherosclerotic)
      • Early-Onset Hypertension (Especially in Females, Associated with Fibromuscular Hyperplasia)

Scleroderma (see Scleroderma)

  • Epidemiology
    • Hypertension is Also Common in Acute Vascular Diseases, Such as Vasculitis or Scleroderma Renal Crisis
      • Elevation in blood pressure results from ischemia-induced activation of the renin-angiotensin system rather than volume expansion (Am J Kidney Dis, 2008) [MEDLINE]
  • Clinical
    • Hypertension

Reproductive

Hemolysis Elevated Liver Functions Low Platelets (HELLP) Syndrome (see xxxx)

Preeclampsia/Eclampsia (see Pre-Eclampsia, Eclampsia)

Rheumatologic

Vasculitis (see Vasculitis)

  • Epidemiology
    • Hypertension is also common in acute vascular diseases, such as vasculitis or scleroderma renal crisis
      • Elevation in blood pressure results from ischemia-induced activation of the renin-angiotensin system rather than volume expansion (Am J Kidney Dis, 2008) [MEDLINE]

Drug/Toxin

Abiraterone (Zytiga) (see Abiraterone)

  • Epidemiology
    • Single Center, Retrospective, Cohort Study of Patients with Metastatic Prostate Cancer (Ann Pharmacother, 2024) [MEDLINE]
      • Patients Who Received Abiraterone Acetate for Metastatic Prostate Cancer Had a Significantly Higher Incidence and Severity of Hypertension (Regardless of Prednisone Dose)
  • Pharmacology
    • Abiraterone is a CYP17 Inhibitor (Androgen Biosynthesis Inhibitor in Prostate, Testes, and Adrenal Glands)
      • Results in Mineralocorticoid Excess with Hypertension, Fluid Retention, and Hypokalemia (see Hypokalemia)

Acetaminophen (Tylenol) (see Acetaminophen)

  • Epidemiology
    • When Given at Doses of 4 g/Day for Several Weeks or More

Amphetamine (se Amphetamine)

  • Agents
    • Amphetamine
    • Dexmethylphenidate
    • Dextroamphetamine
    • Methylphenidate (Ritalin) (see Methylphenidate)
  • Pharmacology
    • Amphetamine is a Sympathomimetic
  • Clinical

Antidepressants

  • Agents
    • Monoamine-Oxidase (MAO) Inhibitors
    • Serotonin Norepinephrine Reuptake Inhibitors (SNRI’s)
    • Tricyclic Antidepressants (TCA’s)
  • Management
    • Avoid Tyramine-Containing Foods in Conjunction with MAO Inhibitor Use

Atypical Antipsychotics

Bevacizumab (Avastin) (see Bevacizumab)

  • Epidemiology
    • In Patients with Advanced Cancer, Bevacizumab is Associated with 4x Higher Risk for Hypertension
      • Intravitreal Bevacizumab Administration is Also Associated with the Hypertension in All Ages (Although Results are Mixed)
    • Risk Factors
      • Advanced Age
      • Dose (Risk May Be Increased with Higher Doses)
      • Genetic Polymorphisms of VEGF
      • Hyperlipidemia (see Hyperlipidemia)
      • Obesity (see Obesity)
      • Preexisting Hypertension/Cardiovascular Disease
      • Previous Treatment with Anthracycline

Caffeine (see Caffeine)

  • Epidemiology
    • Coffee Use in Patients with Hypertension is Associated with Acute Increases in Blood Pressure
    • Long-Term Caffeine Use is Not Associated with Increased Blood Pressure or Cardiovascular Disease
  • Management
    • Generally Limit Caffeine Intake to <300 mg Per Day
    • Avoid Use in Patients with Uncontrolled Hypertension

Calcineurin Inhibitors

  • Agents
  • Management
    • Tacrolimus is Associated with Fewer Hypertensive Effects than Cyclosporine

Cocaine Intoxication (see Cocaine)

  • Pharmacology
    • Cocaine is a Sympathomimetic
  • Clinical

Corticosteroids (Systemic) (see Corticosteroids)

Cyanide Intoxication (see Cyanide)

  • Clinical
    • Hypertension Occurs Early in the Course of Cyanide Intoxication

Decongestants

  • Agents
  • Management
    • Use for Shortest Duration Possible and Avoid in Severe/Uncontrolled Hypertension
    • Consider Alternative Therapies (Such as Nasal Saline, Intranasal Corticosteroids, Antihistamines), as Appropriate

Eculizumab (Soliris) (see Eculizumab)

  • Epidemiology
    • Hypertension Has Been Reported
      • Infants/Children: 22%
      • Adolescents/Adults: 17-59%
      • Severe Hypertension: 5-9%

Erythropoiesis-Stimulating Agents

  • Agents
  • Epidemiology
    • Erythropoietin-Induced Hypertension Has Been Reported in the Setting of Chronic Kidney Disease (CKD) (Cureus, 2021) [MEDLINE]
    • Risk Factors for Erythropoietin-Induced Hypertension
      • Family History of Hypertension
      • Intravenous Administration (vs Subcutaneous Administration)
      • Hemodialysis vs Continuous Ambulatory Peritoneal Dialysis (CAPD) or No Dialysis
      • Higher Erythropoiesis-Stimulating Agent Dose
      • Higher Hemoglobin Target
  • Pharmacology
    • Enhanced Vascular Responsiveness to Vasoconstrictors (and Impaired Action of Vasodilators)
      • Role of Blood Viscosity is Doubtful
  • Management
    • Incidence of Hypertension Can Be Decreased by Achieving Slow Correction of Anemia and by Switching to a Subcutaneous Route of Administration

Ethanol (see Ethanol)

  • Epidemiology
    • The Direct Relationship Between Alcohol Consumption and Blood Pressure was First Reported in 1915 and Has Been Repeatedly Identified in Contemporary Cross-Sectional and Prospective Cohort Studies
      • Alcohol Restriction Decreases Blood Pressure in Patients with Increased Alcohol Intake

Ethylene Glycol Intoxication (see Ethylene Glycol)

  • Clinical
    • Mild Hypertension May Be Observed During the Early-Mid Course, While Hypotension Predominates Late in the Course of Ethylene Glycol Intoxication

Glycyrrhizin (Traditional Black Licorice)

  • Epidemiology
    • Compound Found in Traditional Black Licorice

Herbal Supplements

  • Etiology
    • Arnica (Plast Reconstr Surg, 2013) [MEDLINE]
    • Bitter Orange (Plast Reconstr Surg, 2013) [MEDLINE]
    • Blue Cohosh (Plast Reconstr Surg, 2013) [MEDLINE]
    • Dong Quai (Plast Reconstr Surg, 2013) [MEDLINE]
    • Ginkgo (Plast Reconstr Surg, 2013) [MEDLINE]
    • Guarana (Plast Reconstr Surg, 2013) [MEDLINE]
    • Ma Huang (Ephedra) (see Ephedra) (Plast Reconstr Surg, 2013) [MEDLINE]
    • Pennyroyal Oil (Plast Reconstr Surg, 2013) [MEDLINE]
    • Scotch Broom (Plast Reconstr Surg, 2013) [MEDLINE]
    • Senna (Plast Reconstr Surg, 2013) [MEDLINE]
    • Southern Bayberry (Plast Reconstr Surg, 2013) [MEDLINE]
    • St. John’s Wort (in Conjunction with MAO Inhibitors, Yohimbine) (see St John’s Wort) (Plast Reconstr Surg, 2013) [MEDLINE]
    • Yohimbine (see Yohimbine) (Plast Reconstr Surg, 2013) [MEDLINE]

Ketamine (Ketalar) (see Ketamine)

  • Epidemiology
    • Hypertension Occurs Shortly After Intravenous Ketamine Injection
      • Blood Pressure Generally Returns to Normal within 15 min After Ketamine Injection

Methylenedioxypyrovalerone (MDPV, Bath Salts) (see Synthetic Cathinones)

  • Epidemiology
    • Drug of Abuse
  • Pharmacology
    • Increased Synaptic Concentrations of Dopamine, Serotonin, and/or Norepinephrine Neurotransmitters
      • Stimulation of α-Adrenergic and β-Adrenergic Receptors
  • Clinical

Methamphetamine Intoxication (see Methamphetamine)

Metoclopramide (Reglan) (see Metoclopramide)

  • Epidemiology
    • Cases Have Been Reported (Ann Pharmacother, 2013) [MEDLINE]

Nintedanib (Ofev) (see Nintedanib)

  • Epidemiology
    • Hypertension Occurs in 5% of Cases

Nonsteroidal Anti-Inflammatory Drug (NSAID (see Nonsteroidal Anti-Inflammatory Drug)

  • Pharmacology
    • Increased Renal Sodium Reabsorption, Usually Resulting in a Moderate Increase in Blood Pressure
  • Management
    • Avoid Systemic NSAID’s When Possible
    • Consider Alternative Analgesics (Such as Acetaminophen, Tramadol, Topical NSAID’s), Depending on Indication and Risk

Oral Contraceptives (OCP’s)

  • Epidemiology
    • Particularly Oral Contraceptives Containing Higher Doses of Estrogen
  • Management
    • Use low-dose (eg, 20–30 mcg ethinyl estradiol) agentsS5.4.1-16 or a progestin-only form of contraception, or consider alternative forms of birth control where appropriate (eg, barrier, abstinence, IUD)
  • Avoid use in women with uncontrolled hypertension

Serotonin Syndrome (see Serotonin Syndrome)

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV2) (COVID) Vaccination (see Severe Acute Respiratory Syndrome Coronavirus-2 Vaccine)

  • Epidemiology
    • Post-Vaccination Increased Blood Pressure Has Been Reported (J Cardiovasc Dev Dis, 2022) [MEDLINE]

Tyrosine Kinase Inhibitors

Withdrawal

Dexmedetomidine Withdrawal (see Dexmedetomidine)

  • Epidemiology
    • Risk Factors
      • Continuous Dexmedetomidine Infusion for a Longer Duration
      • Higher Cumulative Daily Dexmedetomidine Dose (>12 mcg/kg/Day)
      • Higher Peak Dexmedetomidine Rate (>0.8 mcg/kg/hr)
      • History of Hypertension

Rebound Hypertension After Antihypertensive Withdrawal

Other

Polycythemia Vera (see Polycythemia Vera)

  • Epidemiology
    • Hypertension Occurs in 46% of Polycythemia Vera Cases (Leukemia, 2013) [MEDLINE]

Ruptured Sinus of Valsalva Aneurysm (see Sinus of Valsalva Aneurysm)

  • Epidemiology
    • Hypertension May Occur

Physiology

Mechanisms of Hypertension in the Acute Care Setting (Hypertension, 2024) [MEDLINE]

  • Uncontrolled Chronic Hypertension
  • Biological Responses
    • Increased Plasma Cortisol
    • Increased Plasma Catecholamines
  • Use of Blood Pressure-Raising Medications
  • Change in Medication Use from Home Environment
    • Discontinuation of Outpatient Antihypertensives
      • One Study Reported that 41% of Patients Prescribed As-Needed Antihypertensives were Not Receiving Their Outpatient Antihypertensive Regimen During Hospitalization (Ther Adv Cardiovasc Dis, 2018) [MEDLINE]
      • Another Study of Postsurgical Inpatients Receiving ≥1 Dose of Intravenous Antihypertensive Medication Found that 25% of Patients were Not Started on Their Outpatient Antihypertensive Medication Regimen During Hospitalization (Am Surg, 2012) [MEDLINE]
    • Withdrawal from Substances/Medications
  • Inappropriate Blood Pressure Measurement Technique
    • Discrepancies Between Blood Pressure Cuff Device Measurements and Arterial Line-Measurements (in Critically Ill Patients)
    • Blood Pressure Measured without High-Quality Standards or with a Malfunctioning Device
      • Discrepancies in Patient Position/Position Relative to the Heart/Arm Support
      • Incorrect Blood Pressure Cuff Size
      • Leg Crossing
  • Sleep Deprivation/Poor Sleep Hygiene During Hospitalization
  • Acute Distress
    • Anxiety (see Anxiety)
    • Pain (see Pain)
    • Stress
    • Illness-Related Factors
  • Clinical Condition

References

General

Etiology

Physiology