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]
For Diagnosis and Management of Hypertension, Proper Methods are Recommended for Accurate Measurement and Documentation of Blood Pressure (Class of Recommendation: I, Level of Evidence: C-EO)
Step 1: Properly Prepare the Patient
Have the patient relax, sitting in a chair (feet on floor, back supported) for >5 min
The patient should avoid caffeine, exercise, and smoking for at least 30 min before measurement
Ensure patient has emptied his/her bladder
Neither the patient nor the observer should talk during the rest period or during the measurement
Remove all clothing covering the location of cuff placement
Measurements made while the patient is sitting or lying on an examining table do not fulfill these criteria
Step 2: Use Proper Technique for Blood Pressure Measurements
Use a BP measurement device that has been validated, and ensure that the device is calibrated periodically
Support the patient’s arm (eg, resting on a desk)
Position the middle of the cuff on the patient’s upper arm at the level of the right atrium (the midpoint of the sternum)
Use the correct cuff size, such that the bladder encircles 80% of the arm, and note if a larger or smaller-than-normal cuff size is used
Arm Circumference 22–26 cm: small adult cuff
Arm Circumference 27-34 cm: adult cuff
Arm Circumference 35-44 cm: large adult cuff
Arm Circumference 45-52 cm: adult thigh cuff
Either the stethoscope diaphragm or bell may be used for auscultatory readings
Step 3: Take the Proper Measurements Needed for Diagnosis and Treatment of Hypertension
At the first visit, record BP in both arms. Use the arm that gives the higher reading for subsequent readings.
Separate repeated measurements by 1–2 min
For auscultatory determinations, use a palpated estimate of radial pulse obliteration pressure to estimate SBP. Inflate the cuff 20–30 mm Hg above this level for an auscultatory determination of the BP level.
For auscultatory readings, deflate the cuff pressure 2 mm Hg per second, and listen for Korotkoff Sounds
Step 4: Properly Document Accurate Blood Pressure Readings
Record SBP and DBP. If using the auscultatory technique, record SBP and DBP as onset of the first Korotkoff sound and disappearance of all Korotkoff sounds, respectively, using the nearest even number
Note the time of most recent BP medication taken before measurements
Step 5: Average the Blood Pressure Readings
Use an average of ≥2 readings obtained on ≥2 Occasions to estimate the individual’s level of Blood Pressure
Step 6: Provide Blood Pressure Readings to the Patient
Provide Patients the Systolic Blood Pressure (SBP)/Diastolic Blood Pressure (DBP) Readings Both Verbally and in Writing
Out-of-Office Blood Pressure Measurements are Recommended to Confirm the Diagnosis of Hypertension and for Titration of Antihypertensives, in Conjunction with Telehealth Counseling or Clinical Interventions (Class of Recommendation: I, Level of Evidence: A)
In adults with an untreated SBP greater than 130 mm Hg but less than 160 mm Hg or DBP greater than 80 mm Hg but less than 100 mm Hg, it is reasonable to screen for the presence of white coat hypertension by using either daytime Ambulatory Blood Pressure Monitoring (ABPM)or Home Blood Pressure Monitoring (HBPM) before diagnosis of hypertension (Class of Recommendation: IIa, Level of Evidence: B-NR)
In adults with white coat hypertension, periodic monitoring with either ABPM or HBPM is reasonable to detect transition to sustained hypertension (Class of Recommendation: IIa, Level of Evidence: C-LD)
In adults being treated for hypertension with office BP readings not at goal and HBPM readings suggestive of a significant white coat effect, confirmation by ABPM can be useful (Class of Recommendation: IIa, Level of Evidence: C-LD)
In adults with untreated office BPs that are consistently between 120 mm Hg and 129 mm Hg for SBP or between 75 mm Hg and 79 mm Hg for DBP, screening for masked hypertension with HBPM (or ABPM) is reasonable (Class of Recommendation: IIa, Level of Evidence: B-NR)
In adults on multiple-drug therapies for hypertension and office BPs within 10 mm Hg above goal, it may be reasonable to screen for white coat effect with HBPM (or ABPM) (Class of Recommendation: IIb, Level of Evidence: C-LD)
It may be reasonable to screen for masked uncontrolled hypertension with HBPM in adults being treated for hypertension and office readings at goal, in the presence of target organ damage or increased overall CVD risk (Class of Recommendation: IIb, Level of Evidence: C-EO)
In adults being treated for hypertension with elevated HBPM readings suggestive of masked uncontrolled hypertension, confirmation of the diagnosis by ABPM might be reasonable before intensification of antihypertensive drug treatment (Class of Recommendation: IIb, Level of Evidence: C-EO)
Arterial Lines are Preferred for Monitoring the Rate of Blood Pressure Decline and the Use of Intravenous Antihypertensive Medications in the Setting of Hypertensive Emergency
Studies have found that when BPs are >180/100 mm Hg in critical care or surgical inpatient populations, oscillometric devices may underestimate BP by as much as 50/30 mm Hg compared with BP from an arterial line (Anesthesiology, 2011) [MEDLINE] (Sci World J, 2014) [MEDLINE]
Even research-quality manual auscultatory methods with aneroid or mercury devices exhibit notable discrepancies compared with arterial line readings (Crit Care Med, 2013 [MEDLINE] (J Hypertens, 2017) [MEDLINE]
Electrocardiogram (EKG) is Necessary to Assess for Cardiac Organ Manifestations of Hypertension (Left Ventricular Hypertrophy, etc) and Myocardial Ischemia/Infarction (MI)
May Be Useful to Assess for Left Ventricular Hypertrophy (LVH) (Indicative of Longstanding Hypertension)
Clinical Manifestations of Essential Hypertension
General
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]
Classification of Blood Pressure
Blood Pressure Should Be Categorized as Normal, Elevated, Stage 1, or Stage 2 Hypertension to Prevent and Treat Hypertension (Class of Recommendation: I, Level of Evidence: B-NR)
Normal
Systolic Blood Pressure (SBP) <120 mm Hg and Diastolic Blood Pressure (DBP) <80 mm Hg
Elevated Blood Pressure
Systolic Blood Pressure (SBP) 120-129 mm Hg and Diastolic Blood Pressure (DBP) <80 mm Hg
Stage 1 Hypertension
Systolic Blood Pressure (SBP) 130-139 mm Hg or Diastolic Blood Pressure (DBP) 80-89 mm Hg
Stage 2 Hypertension
Systolic Blood Pressure (SBP) ≥140 mm Hg or Diastolic Blood Pressure (DBP) ≥90 mm Hg
Indications for Screening for Secondary Hypertension (Hypertension, 2018) [MEDLINE]
Abrupt Onset of Hypertension
Concomitant Adrenal Nodule
Disproportionate Target Organ Damage for Degree of Hypertension
Drug-Resistant/Drug-Induced Hypertension
Exacerbation of Previously Controlled Hypertension
Left Ventricular Hypertrophy is Associated with Body Size (Particularly Lean Body Mass), Tobacco Use, Heart Rate (Inverse Relationship), and Longstanding Diabetes Mellitus
Electrocardiographic Criteria for Left Ventricular Hypertrophy Correlate Weakly with Echocardiographic and Cardiac MRI Definitions of Left Ventricular Hypertrophy and are Less Strongly Associated with Adverse Cardiovascular Disease Outcomes
Clinical
Left Ventricular Hypertrophy (LVH) is a Secondary Manifestation of Hypertension and is an Independent Predictor of Cardiovascular Events
Blood Pressure Reduction Results in a Decrease in Left Ventricular Mass (Which Decreases the Risk of Cardiovascular Disease, Even in the Absence of Decrease in Blood Pressure)
Angiotensin Converting Enzyme Inhibitors (ACE-I), Angiotensin Receptor Blockers (ARB’s), and Calcium Channel Blockers are Superior to β-Blockers in Terms of Effectiveness in Decreasing Left Ventricular Hypertrophy (Hypertension, 2018) [MEDLINE]
Meta-Analysis of Alzheimer and Non-Alzheimer Dementia Risk in Patients with Hypertension (Neurology, 2024) [MEDLINE]: n = 31,250 (from 14 countries)
Participants with Untreated Hypertension had a 36% (Hazard Ratio 1.36; 95% CI: 1.01-1.83, p = 0.0406) and 42% (Hazard Ratio 1.42; 95% CI: 1.08-1.87, p = 0.0135) Increased Risk of Alzheimer Dementia, as Compared with Healthy Controls and Those with Treated Hypertension, Respectively
Compared with Healthy Controls, Both Those with Treated Hypertension (Hazard Ratio 1.29; 95% CI: 1.03-1.60, p = 0.0267) and Untreated Hypertension (Hazard Ratio 1.69: 95% CI: 1.19-2.40, p = 0.0032) Had Greater Non-Alzheimer Dementia Risk, But There was No Difference Between the Treated and Untreated Groups
Baseline Diastolic Blood Pressure Had a Significant U-Shaped Relationship (p = 0.0227) with Non-Alzheimer Dementia Risk in an Analysis Restricted to Those with 5 yr Follow-Up, But Otherwise There was No Significant Relationship Between Baseline Blood Pressure and Either Alzheimer or Non-Alzheimer Dementia Risk
Antihypertensive Use was Associated with Decreased Alzheimer Dementia Risk (But Not Non-Alzheimer Dementia Risk) Throughout Late Life
Treating Hypertension Throughout Late Life Continues to Be Crucial in Alzheimer Dementia Risk Mitigation
Systolic Blood Pressure (SBP) >180 mm Hg or Diastolic Blood Pressure (DBP) >110 mm Hg without Evidence of New/Worsening Target-Organ Damage
Asymptomatic Elevated Inpatient Blood Pressure
Systolic Blood Pressure (SBP) ≥130 mm Hg or Diastolic Blood Pressure (DBP) ≥80 mm Hg without Evidence of New/Worsening Target-Organ Damage
Assessment for Target-Organ Damage
BARKHO Acronym
Brain
Arteries
Retina
Kidney
Heart
Other
Relationship of Clinical Symptoms to Blood Pressure
Blood Pressure-Related Target-Organ Damage May be Present Even with Systolic Blood Pressure (SBP) ≤180 mm Hg and Diastolic Blood Pressure (DBP) ≤110 mm Hg
Specific Clinical Symptoms (Chest Pain, Dyspnea, Focal Neurological Symptoms, and/or Headache) were More Common in Patients with Hypertensive Emergency, as Compared to Hypertensive Urgency (J Hypertens, 2020) [MEDLINE]
Brain Manifestations
Hypertensive Encephalopathy
Epidemiology
Systematic Review and Meta-Analysis (8 Studies) of Hypertensive Urgency/Emergency Patients Presenting to the Emergency Department (J Hypertens, 2020) [MEDLINE]
Acute Heart Failure/Cardiogenic Pulmonary Edema: accounted for 32% of hypertensive emergency presentations
Ischemic Cerebrovascular Accident: accounted for 29% of hypertensive emergency presentations
Acute Coronary Syndrome: accounted for 18% of hypertensive emergency presentations
Hemorrhagic Stroke: accounted for 11% of hypertensive emergency presentations
Acute Aortic Disssection Stroke: accounted for 2% of hypertensive emergency presentations
Hypertensive Encephalopathy: accounted for 2% of hypertensive emergency presentations
Physiology
In the Setting of Severe Hypertension, Cerebral Autoregulation Cannot Prevent an Increase in Intracranial Pressure (ICP), Resulting in Cerebral Edema
Especially in the Posterior Brain Regions, Where Sympathetic Innervation is Less Pronounced Leading to Less Effective Damping of Blood Pressure Oscillations (Brain Res, 1976) [MEDLINE]
Histopathological Changes in Hypertensive Encephalopathy
Hypertensive Encephalopathy is an Etiology of Posterior Reversible Encephalopathy Syndrome (PRES)
Posterior Reversible Encephalopathy Syndrome (PRES is Also Observed in other Disorders Characterized by Acute Microcirculatory Damage (Such as Antiphospholipid Antibody Syndrome, Thrombotic Thrombocytopenic Purpura, Hemolytic Uremic Syndrome, Use of Cytotoxic Drugs, Use of Anti-Angiogenic Drugs, etc)
Epidemiology-Hypertension as a Risk Factor for Ischemic Cerebrovascular Accident (CVA)
Hypertension is a Well-Established Risk Factor for Ischemic Cerebrovascular Accident (CVA)
Epidemiology-Hypertension During the Course of Ischemic Cerebrovascular Accident (CVA)
Hypertension is Common During Ischemic Cerebrovascular Accident (CVA) (Stroke, 2013) [MEDLINE]
In an Observational Study, Systolic Blood Pressure was >139 mm Hg in 77% of Cases and >184 mm HG in 15 of Cases of Ischemic Cerebrovascular Accident (CVA) on Emergency Department Arrival (Am J Emerg Med, 2007) [MEDLINE]
Physiology
Theoretically, Moderate Hypertension During Acute Ischemic Cerebrovascular Accident (CVA) Might Be Advantageous by Improving Cerebral Perfusion of the Ischemic Tissue
However, Hypertension Might Be Detrimental by Exacerbating Cerebral Edema and Hemorrhagic Transformation of the Ischemic Tissue
Extreme Hypertension is Clearly Detrimental, as it Decreases Perfusion of the Ischemic Brain (and Other Organs), Exacerbating the Ischemic Brain Injury
Based on the Above Observations and Studies, the Optimal Blood Pressure Range in the Setting of Acute Ischemic Cerebrovascular Accident (CVA) Consists of Systolic Blood Pressure Ranging from 121-200 mm Hg and Diastolic Blood Pressure Ranging from 81-110 mm Hg (Stroke, 2013) [MEDLINE]
However, Elevated In-Hospital Blood Pressure During Acute Ischemic Cerebrovascular Accident (CVA) Has Been Associated with Worse Clinical Outcomes with a More Linear Relationship
Clinical
Blood Pressure is Frequently Higher in Acute Ischemic Cerebrovascular Accident (CVA) Patients with a History of Hypertension than in Patients without Premorbid Hypertension
Blood Pressure Typically Decreases Spontaneously During the Acute Phase of Ischemic Cerebrovascular Accident (CVA), Starting within 90 min After the Onset of Stroke Symptoms
Optimal Blood Pressure Range May Be Dependent on Stroke Subtype and/or Patient-Specific Comorbidities
Systematic Review and Meta-Analysis (8 Studies) of Hypertensive Urgency/Emergency Patients Presenting to the Emergency Department (J Hypertens, 2020) [MEDLINE]
Acute Heart Failure/Cardiogenic Pulmonary Edema: accounted for 32% of hypertensive emergency presentations
Ischemic Cerebrovascular Accident: accounted for 29% of hypertensive emergency presentations
Acute Coronary Syndrome: accounted for 18% of hypertensive emergency presentations
Hemorrhagic Stroke: accounted for 11% of hypertensive emergency presentations
Acute Aortic Disssection Stroke: accounted for 2% of hypertensive emergency presentations
Hypertensive Encephalopathy: accounted for 2% of hypertensive emergency presentations
Microangiopathic Hemolytic Anemia (MAHA) (“Malignant Hypertension”) (see Hemolytic Anemia)
Epidemiology
Microangiopathic Hemolytic Anemia (MAHA) Can Occur with Severe Hypertension (Systolic Blood Pressure >220 mm Hg/Diastolic Blood Pressure >100 mm Hg)
Clarification of the Temporal Relationship Between Hematologic Abnormalities and the Hypertension
Thrombotic Microangiopathy-Associated Acute Kidney Injury (AKI) May Be the Etiology of the Hypertension
However, New/Worsening Hypertension is Also Common in Complement-Mediated Thrombotic Microangiopathy (Occurring in 8-54% of Cases) (see xxxx)
This is Especially True 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]
Physiology
Activation of Pro-Inflammatory and Pro-Coagulant Pathways
Endothelial Detachment is a Pathological Hallmarks of Hypertensive Microangiopathy and is Believed to Result from High Shear Forces
Exposure of Blood to the Subendothelium Results in Coagulation Activation, Platelet Activation, and the Formation of a Fibrin Network
Formation of Platelet-Rich Thrombi with Obliteration of the Microcirculation
Platelet Consumption and Intravascular Hemolysis (Due to Trapping and Destruction of Red Blood Cells within the Fibrin Network)
Diagnosis
Discrimination of Malignant Hypertension from Other Etiologies of Thrombotic Microangiopathy (Such as Thrombotic Thrombocytopenic Purpura and Hemolytic Uremic Syndrome (HUS) May be Difficult
Malignant Hypertension-Associated Thrombotic Microangiopathy is Usually Less Severe, as Compared to Patients with Thrombotic Thrombocytopenic Purpura (TTP) and Hemolytic Uremic Syndrome (HUS)
Malignant Hypertension-Associated Thrombotic Microangiopathy Typically Has Only Moderate Thrombocytopenia and Few Schistocytes on the Peripheral Smear
Additionally, the Coexistence of a Severe Hypertension with Advanced Retinopathy is Usually Sufficient to Discriminate Hypertension-Associated Thrombotic Microangiopathy from Other Etiologies of Thrombotic Microangiopathy
A Disintegrin And Metalloprotease with a Thrombospondin Type 1 Motif, Member 13 (ADAMTS13) Activity (see ADAMTS13 Activity)
Blood Pressure Control Alone Will Usually Result in Clinical Improvement in Malignant Hypertension-Associated Thrombotic Microangiopathy within 24-48 hrs (Whereas, Thrombotic Thrombocytopenic Purpura and Hemolytic Uremic Syndrome Will Require Other Therapies)
Systematic Review and Meta-Analysis (8 Studies) of Hypertensive Urgency/Emergency Patients Presenting to the Emergency Department (J Hypertens, 2020) [MEDLINE]
Acute Heart Failure/Cardiogenic Pulmonary Edema: accounted for 32% of hypertensive emergency presentations
Ischemic Cerebrovascular Accident: accounted for 29% of hypertensive emergency presentations
Acute Coronary Syndrome: accounted for 18% of hypertensive emergency presentations
Hemorrhagic Stroke: accounted for 11% of hypertensive emergency presentations
Acute Aortic Disssection Stroke: accounted for 2% of hypertensive emergency presentations
Hypertensive Encephalopathy: accounted for 2% of hypertensive emergency presentations
Systematic Review and Meta-Analysis (8 Studies) of Hypertensive Urgency/Emergency Patients Presenting to the Emergency Department (J Hypertens, 2020) [MEDLINE]
Acute Heart Failure/Cardiogenic Pulmonary Edema: accounted for 32% of hypertensive emergency presentations
Ischemic Cerebrovascular Accident: accounted for 29% of hypertensive emergency presentations
Acute Coronary Syndrome: accounted for 18% of hypertensive emergency presentations
Hemorrhagic Stroke: accounted for 11% of hypertensive emergency presentations
Acute Aortic Disssection Stroke: accounted for 2% of hypertensive emergency presentations
Hypertensive Encephalopathy: accounted for 2% of hypertensive emergency presentations
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Impact of hypertensive emergency and rare complement variants on the presentation and outcome of atypical hemolytic uremic syndrome. Haematologica. 2019;104(12):2501 [MEDLINE]
Diagnostic and Risk Factors for Complement Defects in Hypertensive Emergency and Thrombotic Microangiopathy. Hypertension. 2020;75(2):422 [MEDLINE]
2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022 Jul;53(7):e282-e361. doi: 10.1161/STR.0000000000000407 [MEDLINE]
The relationship between obstructive sleep apnea and risk of renal impairment in patients with hypertension, a longitudinal study. Sleep Med. 2023 Jun 20;109:18-24. doi: 10.1016/j.sleep.2023.05.020 [MEDLINE]
Blood Pressure, Antihypertensive Use, and Late-Life Alzheimer and Non-Alzheimer Dementia Risk: An Individual Participant Data Meta-Analysis. Neurology. 2024 Sep 10;103(5):e209715. doi: 10.1212/WNL.0000000000209715 [MEDLINE]
