Hypertension, commonly known as high blood pressure, is a long-term medical condition where the force of blood against the artery walls is persistently too high. It is often called a “silent killer” because it usually has no symptoms but can lead to serious complications like heart disease, stroke, and kidney failure if not treated. Hypertension is one of the leading preventable causes of early death worldwide.
Causes
- Primary (essential) hypertension: No identifiable cause, develops gradually over many years
- Secondary hypertension: Caused by another condition such as kidney disease, endocrine disorders (e.g., hyperthyroidism, Cushing’s syndrome), obstructive sleep apnoea, certain medications (like steroids, NSAIDs, oral contraceptives), or excessive alcohol use
Pathophysiology
Hypertension arises when there is an imbalance between the cardiac output and the systemic vascular resistance. Factors such as increased blood volume, increased arterial stiffness, or overactivity of the sympathetic nervous system can raise blood pressure. Long-term high pressure damages blood vessel walls, promotes atherosclerosis, increases heart workload leading to left ventricular hypertrophy, and impairs organ perfusion.
Signs and Symptoms
- Headaches, especially early in the morning
- Dizziness or light-headedness
- Blurred vision
- Shortness of breath
- Nosebleeds (rare)
- Chest pain (indicating complications)
Symptoms usually appear only when blood pressure reaches dangerously high levels.
Risk Factors
- Age: risk increases with age
- Family history of hypertension
- Overweight or obesity
- Sedentary lifestyle
- High salt intake
- Excessive alcohol consumption
- Smoking
- Stress
- Certain ethnic backgrounds (e.g., African-Caribbean origin)
Investigation (Imaging or Labs)
- Blood pressure measurement: At least two readings on two separate occasions using validated devices, ideally using ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) as recommended by NICE
- Urinalysis: To detect proteinuria or haematuria suggesting kidney involvement
- Blood tests: Kidney function (creatinine, eGFR), blood glucose, cholesterol profile
- Electrocardiogram (ECG): To check for heart strain, left ventricular hypertrophy, arrhythmias
- Echocardiography: If indicated for heart function assessment
- Fundoscopy: To check for hypertensive retinopathy
Management
1. Non-Pharmacological Management
Lifestyle changes are first-line for all patients.
- Dietary Approaches to Stop Hypertension (DASH diet): rich in fruits, vegetables, and low-fat dairy
- Reducing salt intake to less than 6g/day
- Weight loss if overweight
- Regular aerobic physical activity (at least 150 minutes/week)
- Limiting alcohol intake
- Smoking cessation
- Stress management through relaxation techniques
2. Pharmacological Management
Medication is tailored based on individual risk factors, comorbidities, and tolerability.
First-line treatment:
- People under 55 years and not of black African or African-Caribbean origin: ACE inhibitor or angiotensin II receptor blocker (ARB).
- People over 55 years or of black African/African-Caribbean origin: Calcium channel blocker (CCB).
Secondary prevention:
Combination of ACE inhibitor (or ARB) plus CCB
Third-line treatment:
Add a thiazide-like diuretic (e.g., indapamide)
Resistant hypertension:
Consider adding spironolactone or seeking specialist advice
Surgical Management
There is no routine surgical treatment for hypertension itself. However, if secondary causes like renal artery stenosis are found, revascularisation procedures (e.g., angioplasty) may be considered
Complications
- Coronary artery disease (leading to angina or myocardial infarction)
- Heart failure
- Stroke (both ischaemic and haemorrhagic)
- Chronic kidney disease and renal failure
- Retinopathy leading to vision loss
- Aortic aneurysm or dissection
- Cognitive impairment and vascular dementia
References
- National Institute for Health and Care Excellence (NICE) Hypertension in Adults: Diagnosis and Management (NG136)
- British Hypertension Society (BHS) Guidelines
- Royal College of Physicians Hypertension Pathways
- General Medical Council (GMC) Good Medical Practice Guideline
- European Society of Hypertension and Cardiology Guidelines as adapted in UK practice