Hypertension

Is defined as a systolic BP greater than or equal to 140 mmhg and diastolic BP

greater than or equal to 90mmhg.
Hypertension is classified as either primary (essential) hypertension or secondary
hypertension.
About 90-95 % of cases of Hypertension are primary hypertension, defined as high
BP with no obvious underlying cause. The remaining 5-10% of cases of hypertension
are secondary hypertension defined as hypertension due to an identifiable cause.
The cause of essential hypertension is not clearly understood but genetic as well as
environmental factors including, high salt intake, lack of exercise and stress are
thought to have a role in the pathogenesis.
The genetic basis of essential hypertension is also poorly understood but increased
sensitivity to salt due to variations of genes that encode components of the rennin
angiotensin aldosterone pathway is thought to have a role.
Essential hypertension is classified as stage 1 and stage 2.
In stage 1 hypertension-systolic BP is between 140 and 159, diastolic BP is between
90 and 99.
In stage 2
and 109.

systolic BP is between 160 and 179 and diastolic BP is between 100

Treatment generally include A. lifestyle modification including low Na diet, exercise,

weight loss and B. medications.
In stage 1 hypertension, often one of the following five classes of medications is
initiated, either 1. A thiazide diuretic, 2. ACE inhibitor, 3. Angiotensin receptor
antagonist 4. Beta adrenergic antagonist or 5. Calcium channel antagonist.
In individuals with diabetes or renal insufficiency, oftentimes ACE inhibitor is
initiated for instance Enalapril, because ACE inhibitor delays development of
diabetic nephropathy and in individuals with renal insufficiency ACE inhibitor has
been demonstrated to slow progression of renal insufficiency. In individuals with
coronary artery disease, often times Beta Adrenergic Antagonist is initiated,
because in individuals with coronary artery disease beta adrenergic antagonist has
been demonstrated to decrease incidence of ventricular arrhythmia and improve
survival. Otherwise in individuals with no compelling indication to start other class
of medications, generally a thiazide diuretic is initiated.
The goal of therapy is to lower systolic BP to less than 135 or 140 mmhg and to
lower diastolic BP to less than 85 mmhg. Most of the antihypertensive medications
reduce systolic BP by 7-13mmhg and reduce diastolic BP by 4-8mmhg. Therefore

even in stage 1 hypertension, if systolic BP was for instance 155 mmhg or diastolic
BP was 98 mmhg, target BP may not be attained with only medication and adding a
second drug might be required.