High blood pressure (hypertension or abbreviated as HTN) is a very common diagnosis in the US and worldwide. It is estimated that nearly 50% of Americans hold this diagnosis, which is a staggering statistic.
Hypertension is largely asymptomatic, and therefore patients may not know or realize their blood pressure is higher than it should be. It is important to diagnose, however, since high blood pressure significantly increases the risk for heart disease, stroke, nephropathy (kidney disease), and retinopathy (disease of the back of the eye that can lead to blindness).
Before moving on, it is worth discussing what blood pressure means, and how it is optimally measured.
Blood pressure is commonly reported as "systolic over diastolic," e.g. "120 over 80" or "120/80."
A normal blood pressure depends on age, and older patients tend to have higher blood pressure than younger patients. As a general principle, lower blood pressure is favorable (as it means the heart doesn't have to work as hard, and patients are at lower risk for the aforementioned complications) as long as patients don't have symptoms of blood pressure being too low, such as feeling lightheaded when standing or sitting up (called "orthostasis").
According to the most recent guidelines published by the American Heart Association and American College of Cardiology, normal blood pressure is below 120/80. Anything above this is a form of hypertension:
| NORMAL | Less than 120/80 |
| ELEVATED | Systolic 120-129 and Diastolic <80 |
| STAGE 1 HYPERTENSION | Systolic 130-139 OR Diastolic 80-89 |
| STAGE 2 HYPERTENSION | Systolic >140 OR Diastolic >90 |
| HYPERTENSIVE CRISIS | Systolic >180 AND/OR Diastolic >120 |
For patients 60 years or older, there is a more lenient goal, at least according to the American College of Physicians: Anything less than 150 mmHg systolic is acceptable (unless the patient has a history of stroke). However, there are still some experts that believe this goal is a bit too lenient and stricter blood pressure control should be pursued.
Many patients have experienced a scenario where their blood pressure is higher than expected when in a health care setting. This can certainly be due to anxiety about the visit or some transient stress, sure, however more often than not this is due to improper technique in measurement.
Patients are supposed to sit still for 5 minutes prior to measuring blood pressure, which rarely (if ever) occurs in a healthcare setting (who has the time?). This may be doing a disservice to our patients as it makes it more likely patients are misdiagnosed with hypertension.
Since patients (luckily) don't live in the doctor's office, home measurements can be invaluable to help distinguish between true hypertension and white coat hypertension (which is hypertension only at the doctor's office).
The American College of Cardiology has published their own guidelines on how to counsel patients to properly measure blood pressure at home. Two important aspects to keep in mind are that upper arm cuffs are superior to wrist cuffs, and cuffs should never be applied over clothing/sleeves.
Before medications are offered, diet and lifestyle should both be optimized.
The best studied (and most recommended) diet is called the DASH diet, which stands for Dietary Approaches to Stop Hypertension. There are many resources that explain this well, however one of my favorites is this PDF from NHBLI.
Exercise is also crucial for helping to manage hypertension - intense cardiovascular exercise in particular (at a minimum - 20 minutes of intense walking several days per week) is vital to lowering blood pressure.
Sadly, many patients either cannot or do not adhere to proper diet and exercise to lower their blood pressure. Some patients DO adhere properly but still need help with lowering their blood pressure. In these cases, we reach for medication.
There are dozens of medications that are commonly used, and the FDA has put together a fairly comprehensive guide for patients to dive in and learn more.
The 3 most common classes of medications that are offered as first-line agents to patients are:
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