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Table of contents

Hypertension

What's new

Updated 2024 ADA guidelines for the management of hypertension in diabetes.

Background

Overview

Definition
Elevated BP is defined as systolic pressure between 120 and 129 mmHg and diastolic pressure < 80 mmHg. Stage 1 HTN is defined as SBP > 130 mmHg or DBP > 80 mmHg.
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Pathophysiology
Primary HTN etiology is multifactorial and most frequently associated with a combination of environmental (unhealthy diet, increased sodium intake, insufficient potassium intake, inadequate physical activity, overweight/obesity) and genetic factors (multiple risk alleles, gene-gene interactions, fetal programming, epigenetic mechanisms). Secondary HTN etiology includes primary aldosteronism, renal HTN, renal parenchymal disease, pheochromocytoma/paraganglioma, Cushing's syndrome, hypothyroidism, hyperthyroidism, hypercalcemia and primary hyperparathyroidism, congenital adrenal hyperplasia, acromegaly, coarctation of the aorta, and medication or recreational drug use (amphetamines, cocaine, phencyclidine). White-coat HTN and isolated systolic HTN are essential subtypes.
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Epidemiology
HTN is highly prevalent worldwide. The prevalence of HTN in the US is estimated at 31,900 per 100,000 adults based on the 140/90 mmHg cutoff. Rates are highest in African Americans and increase with age.
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Risk factors
Risk factors for primary HTN include nonmodifiable factors, such as advancing age, African and Hispanic ancestry, and family history, and modifiable factors, include an unhealthy diet, high sodium intake, low potassium intake, physical inactivity, overweight or obesity, low socioeconomic status, and limited access to healthcare.
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Disease course
HTN is mostly asymptomatic until an acute hypertensive crisis or end-organ complications occur. Manifestations of end-organ damage in HTN include motor or sensory deficit (brain); hypertensive retinopathy (retina); and AF, arrhythmias, pulmonary congestion and peripheral edema (heart). Secondary HTN presents with symptoms of the causal condition, for example, abdominal bruit in renal artery stenosis or abdominal masses in polycystic kidney disease. A fourth heart sound is often the earliest sign of hypertensive heart disease. HTN decreases health-related QoL.
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Prognosis and risk of recurrence
Prognosis is highly dependant on the BP and end-organ damage. Higher BP and more severe retinopathy or organ damage are associated with a worse prognosis. Untreated or treatment-resistant HTN leads to lower survival rates. However, effective BP control raises 10-year survival rates to 70%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of hypertension are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024,2023,2022), the American Diabetes Association (ADA 2024), the American Society of Addiction Medicine (ASAM/AAAP 2024), the Canadian Cardiovascular Society (CCS/CAIC 2024), the European Reference Network on Rare Endocrine Conditions (Endo-ERN 2024), the ...
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Screening and diagnosis

Indications for screening, adults: as per AAFP 2023 guidelines, obtain screening for HTN with office BP measurements in adults. Confirm the diagnosis with home measurements or with 24-hour ambulatory monitoring before initiating antihypertensive medications.
A
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  • Indications for screening (pediatrics)

  • Indications for screening (pregnancy)

Classification and risk stratification

Staging
As per ESH 2023 guidelines:
Classify BP as follows based on office BP values:
Situation
Guidance
Optimal
< 120 mmHg SBP and < 80 mmHg DBP
Normal
120-129 mmHg SBP and 80-84 mmHg DBP
High normal
130-139 mmHg SBP and/or 85-89 mmHg DBP
Grade 1 HTN
140-159 mmHg SBP and/or 90-09 mmHg DBP
Grade 2 HTN
160-179 mmHg SBP and/or 100-109 mmHg DBP
Grade 3 HTN
≥ 180 mmHg SBP and/or ≥ 110 mmHg DBP
Isolated systolic HTN
≥ 140 mmHg SBP and < 90 mmHg DBP
Isolated diastolic HTN
< 140 mmHg SBP and ≥ 90 mmHg DBP
B
Distinguish stage 1, 2, and 3 HTN in addition to grades of HTN based on BP values:
Situation
Guidance
Stage 1
Uncomplicated HTN without HTN-mediated organ damage, diabetes, CVD, and without CKD ≥ stage 3
Stage 2
Presence of HTN-mediated organ damage, diabetes, or CKD stage 3
Stage 3
Presence of CVD or CKD stage 4 or 5
B

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  • Cardiovascular risk stratification

Diagnostic investigations

Office BP measurement: as per ESH 2023 guidelines, obtain office BP measurement for the diagnosis of HTN, as HTN-related risk, benefits of antihypertensive treatment, and treatment-related BP thresholds and goals are based on this method.
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  • Out-of-office BP measurement

  • Choice of measurement device

  • Initial investigations

  • Echocardiography

  • Evaluation for modifiable risk factors

  • Evaluation for drug or alcohol use

  • Evaluation for obstructive sleep apnea

  • Evaluation for renovascular disease

  • Evaluation for renal parenchymal disease

  • Evaluation for primary hyperaldosteronism

  • Evaluation for pheochromocytoma

  • Evaluation for aortic coarctation

  • Evaluation for thyroid disease

  • Evaluation for hyperparathyroidism

  • Evaluation for congenital adrenal hyperplasia

  • Evaluation for acromegaly

  • Genetic testing

Medical management

Indications for treatment, general population: as per ESH 2023 guidelines, initiate pharmacotherapy in 18-79 years old patients with an SBP ≥ 140 mmHg and/or a DBP ≥ 90 mmHg.
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  • Indications for treatment (elderly)

  • Indications for treatment (high CVD risk)

  • Goals of treatment (BP targets, general population)

  • Goals of treatment (BP targets, elderly)

  • Goals of treatment (BP targets, high CVD risk)

  • Goals of treatment (clinical targets)

  • Goals of treatment (safety measures)

  • Choice of antihypertensives (general principles)

  • Choice of antihypertensives (initial therapy)

  • Choice of antihypertensives (subsequent therapy)

  • Management of resistant HTN

  • Management of hypertensive emergencies

  • Lipid-lowering therapy (statins)

  • Lipid-lowering therapy (non-statins)

  • Antiplatelet therapy

Inpatient care

Management of hospitalized patients: as per AAFP 2024 guidelines, avoid administering acute management of severe asymptomatic HTN in hospitalized patients, as it increases the risk of adverse composite outcomes, AKI, and myocardial infarction.
D

Nonpharmacologic interventions

Lifestyle modifications: as per AAPA/ABC/ACC/ACPM/AGS/AHA/APhA/ASH/ASPC/NMA/PCNA 2018 guidelines, offer effective behavioral and motivational strategies for adults with HTN to achieve a healthy lifestyle including tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, reduced sodium intake, and consumption of a healthy diet.
B

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  • Dietary modifications

  • Salt restriction

  • Potassium supplementation

  • Alcohol restriction

  • Weight loss

  • Exercising

  • Smoking cessation

  • Stress management

  • Supplements

  • Telehealth interventions

  • Adjuncts to controlling HTN

Therapeutic procedures

Device-based therapies: as per ESC/ESH 2018 guidelines, avoid using device-based therapies for the routine treatment of HTN, unless in the context of clinical studies and RCTs, until further evidence regarding their safety and efficacy becomes available.
D

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  • Renal denervation

  • Renal artery revascularization

Perioperative care

Timing of surgery: as per ESH 2023 guidelines, do not defer noncardiac surgery routinely in patients with grade 1 or 2 HTN (BP < 180/110 mmHg).
D

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  • Preoperative assessment

  • Perioperative management of antihypertensives

Specific circumstances

Pediatric and adolescent patients: as per ESH 2023 guidelines, screen BP levels in pediatric patients starting from the age of 3 years.
B
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  • Elderly patients

  • Pregnant patients (BP measurement)

  • Pregnant patients (low-dose aspirin)

  • Pregnant patients (BP targets)

  • Pregnant patients (choice of antihypertensives)

  • Pregnant patients (management of severe HTN)

  • Patients of black background

  • Patients with stage 1 HTN

  • Patients with white coat HTN (screening and evaluation)

  • Patients with white coat HTN (management)

  • Patients with masked HTN

  • Patients with isolated systolic HTN

  • Patients with isolated diastolic HTN

  • Patients with night-time HTN

  • Patients with afferent baroreflex failure

  • Patients with efferent autonomic failure

  • Patients with obesity (weight loss)

  • Patients with obesity (weight loss medications)

  • Patients with obesity (bariatric surgery)

  • Patients with obesity (antihypertensive therapy)

  • Patients with diabetes mellitus (screening)

  • Patients with diabetes mellitus (lifestyle modifications)

  • Patients with diabetes mellitus (BP targets)

  • Patients with diabetes mellitus (pharmacotherapy)

  • Patients with diabetes mellitus (pediatric patients)

  • Patients with CKD (lifestyle modifications)

  • Patients with CKD (BP targets)

  • Patients with CKD (antihypertensives)

  • Patients with CKD (renal transplant recipients)

  • Patients with coronary artery disease

  • Patients with HF (reduced EF)

  • Patients with HF (preserved EF)

  • Patients with AIS (acute treatment, indications and BP targets)

  • Patients with AIS (acute treatment, induced HTN)

  • Patients with AIS (secondary prevention)

  • Patients with hemorrhagic stroke (general principles)

  • Patients with hemorrhagic stroke (subarachnoid hemorrhage)

  • Patients with hemorrhagic stroke (intracerebral hemorrhage)

  • Patients with valvular heart disease

  • Patients with thoracic aortic disease

  • Patients with PAD

  • Patients with AF (evaluation)

  • Patients with AF (antihypertensive therapy)

  • Patients with AF (rate control)

  • Patients with AF (anticoagulation)

  • Patients with obstructive sleep apnea

  • Patients with cancer (evaluation)

  • Patients with cancer (management)

  • Patients with cancer treatment-induced HTN

  • Patients with stimulant intoxication

  • Patients with glaucoma

Preventative measures

Body weight control
As per HC 2020 guidelines:
Advise maintaining a healthy body weight (BMI 18.5-24.9) and waist circumference (< 102 cm for males and < 88 cm for females) to prevent HTN in individuals not having HTN.
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Offer a multidisciplinary approach for weight loss, including dietary education, increased physical activity, and behavioral intervention.
B

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  • Antiplatelet therapy

  • Statin therapy

Follow-up and surveillance

Indications for specialist referral
As per AAPA/ABC/ACC/ACPM/AGS/AHA/APhA/ASH/ASPC/NMA/PCNA 2018 guidelines:
Refer adults with HTN and a positive screening test for primary aldosteronism to a HTN specialist or endocrinologist for further evaluation and treatment.
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Consider referring patients with secondary HTN to a HTN specialist with relevant expertise.
C

More topics in this section

  • Assessment of treatment response

  • Assessment of treatment adherence