Definition and Classification of Hypertension

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Hypertension, commonly known as high blood pressure, is a chronic medical condition characterized by persistently elevated pressure in the arteries. Blood pressure is the force exerted by circulating blood against the walls of blood vessels, and it is a critical factor in ensuring the proper flow of blood throughout the body. Hypertension occurs when this force is consistently too high, putting extra strain on the heart and blood vessels, and increasing the risk of various cardiovascular diseases, including heart attack, stroke, and heart failure.

Definition of Hypertension

Blood pressure is measured in millimeters of mercury (mm Hg) and is expressed as two numbers:

Systolic Blood Pressure (SBP): The first (higher) number represents the pressure in the arteries when the heart beats (contracts) and pumps blood. It reflects the maximum pressure exerted by the blood on the arterial walls.
Diastolic Blood Pressure (DBP): The second (lower) number represents the pressure in the arteries when the heart is at rest between beats. It reflects the minimum pressure within the arteries.

A typical blood pressure reading is written as SBP/DBP, such as 120/80 mm Hg.

Hypertension is defined as a condition in which the systolic blood pressure is consistently 130 mm Hg or higher and/or the diastolic blood pressure is 80 mm Hg or higher. The American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines, updated in 2017, set the current thresholds for the diagnosis of hypertension.

Classification of Hypertension

Hypertension is classified into several categories based on the level of blood pressure. The classification helps guide treatment decisions and risk stratification. The main classifications include:

1. Normal Blood Pressure

Systolic: Less than 120 mm Hg
Diastolic: Less than 80 mm Hg

Individuals with normal blood pressure have the lowest risk of cardiovascular complications and should maintain a healthy lifestyle to prevent hypertension.

2. Elevated Blood Pressure

Systolic: 120-129 mm Hg
Diastolic: Less than 80 mm Hg

Elevated blood pressure is not yet classified as hypertension but indicates a higher risk of developing hypertension in the future. Lifestyle modifications are strongly recommended to lower blood pressure and prevent progression to hypertension.

3. Hypertension Stage 1

Systolic: 130-139 mm Hg
Diastolic: 80-89 mm Hg

Stage 1 hypertension is the first level of high blood pressure. At this stage, treatment may involve lifestyle modifications and, depending on the presence of other cardiovascular risk factors, medications may be considered.

4. Hypertension Stage 2

Systolic: 140 mm Hg or higher
Diastolic: 90 mm Hg or higher

Stage 2 hypertension represents more severe high blood pressure and typically requires both lifestyle changes and medication to manage blood pressure effectively. The risk of cardiovascular events is significantly higher at this stage.

5. Hypertensive Crisis

A hypertensive crisis is a medical emergency and is divided into two categories:

Hypertensive Urgency:
- Systolic: 180 mm Hg or higher
- Diastolic: 120 mm Hg or higher
- Clinical Presentation: No acute target organ damage.

In hypertensive urgency, blood pressure is extremely high, but there is no evidence of immediate end-organ damage. Urgent medical intervention is required to lower blood pressure over hours to days.

Hypertensive Emergency:
- Systolic: 180 mm Hg or higher
- Diastolic: 120 mm Hg or higher
- Clinical Presentation: Acute target organ damage (e.g., stroke, heart attack, acute renal failure, or aortic dissection).

In a hypertensive emergency, immediate hospitalization is necessary, and blood pressure must be lowered promptly to prevent or limit organ damage.

Primary (Essential) vs. Secondary Hypertension

Hypertension is further classified into two major categories based on its underlying cause:

1. Primary (Essential) Hypertension

Primary, or essential, hypertension is the most common form, accounting for about 90-95% of all cases. It develops gradually over many years and does not have a specific identifiable cause. However, several factors contribute to the development of primary hypertension, including:

Genetic Factors: Family history of hypertension increases the risk, suggesting a hereditary component.
Age: The risk of hypertension increases with age, as blood vessels become less elastic.
Lifestyle Factors: Diet, physical activity levels, obesity, alcohol consumption, and smoking all contribute to the risk.
Environmental Factors: Stress, socioeconomic status, and exposure to pollutants can influence blood pressure.

2. Secondary Hypertension

Secondary hypertension accounts for about 5-10% of cases and results from an identifiable underlying condition. It often develops suddenly and can be more severe than primary hypertension. Common causes of secondary hypertension include:

Kidney Disease: Chronic kidney disease, glomerulonephritis, and polycystic kidney disease can lead to hypertension.
Hormonal Disorders: Conditions such as hyperthyroidism, hypothyroidism, Cushing’s syndrome, and pheochromocytoma (a tumor of the adrenal gland) can cause secondary hypertension.
Obstructive Sleep Apnea (OSA): OSA is a sleep disorder characterized by repeated interruptions in breathing during sleep, leading to elevated blood pressure.
Medications: Certain medications, such as oral contraceptives, steroids, decongestants, and nonsteroidal anti-inflammatory drugs (NSAIDs), can raise blood pressure.
Vascular Abnormalities: Conditions such as coarctation of the aorta (a narrowing of the aorta) and renal artery stenosis (narrowing of the arteries supplying the kidneys) can cause secondary hypertension.
Pregnancy: Pregnancy-related hypertensive disorders, such as preeclampsia, can result in elevated blood pressure.

Identifying and treating the underlying cause of secondary hypertension can often lead to the resolution or significant improvement of high blood pressure.

Isolated Systolic Hypertension

Isolated systolic hypertension (ISH) is a specific type of hypertension in which only the systolic blood pressure is elevated (≥130 mm Hg), while the diastolic blood pressure remains normal (<80 mm Hg). ISH is particularly common in older adults and is associated with increased stiffness of the large arteries, a condition known as arteriosclerosis.

ISH is a significant risk factor for cardiovascular events, particularly in the elderly, and requires careful management. Treatment of ISH can be challenging, as lowering systolic pressure without causing diastolic hypotension is important to avoid adverse effects, such as dizziness and falls.

Resistant Hypertension

Resistant hypertension is defined as blood pressure that remains above the target level despite the use of three or more antihypertensive medications of different classes, including a diuretic, at optimal doses. Alternatively, it can be defined as hypertension that requires four or more medications to achieve control.

Resistant hypertension is associated with a higher risk of cardiovascular events and often indicates the presence of secondary hypertension, inadequate medication adherence, or lifestyle factors that have not been adequately addressed. Management may involve the use of additional medications, lifestyle changes, and investigation for underlying secondary causes.

White Coat Hypertension and Masked Hypertension

White Coat Hypertension: This occurs when a patient’s blood pressure readings are elevated in a clinical setting but normal outside of the clinic. It is thought to result from anxiety or stress associated with being in a medical environment. While it was once considered benign, white coat hypertension is now recognized as a potential risk factor for developing sustained hypertension and cardiovascular disease.
Masked Hypertension: The opposite of white coat hypertension, masked hypertension occurs when a patient’s blood pressure readings are normal in a clinical setting but elevated outside the clinic. This condition can go undiagnosed and untreated, leading to an increased risk of cardiovascular complications. Ambulatory blood pressure monitoring or home blood pressure monitoring is often necessary to detect masked hypertension.

Pseudohypertension

Pseudohypertension is a condition in which blood pressure measurements are falsely elevated due to stiff arteries, often seen in elderly patients. The arteries become so rigid that standard blood pressure cuffs cannot compress them properly, leading to inaccurate readings. Pseudohypertension should be considered in patients with seemingly resistant hypertension, particularly if they do not exhibit symptoms or end-organ damage typically associated with high blood pressure.

Malignant Hypertension

Malignant hypertension, also known as hypertensive crisis, is a rare but life-threatening condition characterized by extremely high blood pressure (typically >180/120 mm Hg) accompanied by evidence of acute target organ damage, such as retinal hemorrhages, papilledema, renal failure, or encephalopathy. Malignant hypertension requires immediate medical intervention to prevent severe complications or death. It often requires intravenous medications in a hospital setting to rapidly lower blood pressure.

Conclusion

Hypertension is a complex and multifaceted condition with various classifications based on blood pressure levels, underlying causes, and the presence of specific patterns or conditions. Proper classification of hypertension is essential for guiding treatment decisions, managing the condition effectively, and reducing the risk of cardiovascular complications. Early diagnosis, regular monitoring, and appropriate treatment are critical to preventing the long-term health consequences associated with hypertension.

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