Persistently elevated BP ≥130/80 (ACC/AHA 2017 thresholds, retained in the 2025 AHA/ACC guideline); cornerstone modifiable cardiovascular risk factor.
Also known as: HTN, high blood pressure, essential hypertension, primary hypertension
Overview
Sustained elevation of arterial blood pressure ≥130/80 mmHg (ACC/AHA 2017 thresholds) based on average of ≥2 properly measured readings on ≥2 occasions. Stage 1: 130-139/80-89. Stage 2: ≥140/90. Hypertensive crisis: >180/>120; severe hypertension (formerly called urgency) if no acute target-organ damage, hypertensive emergency if acute target-organ damage is present (2025 AHA/ACC).
Epidemiology
Affects nearly half of US adults under current guidelines. Leading modifiable risk factor for cardiovascular disease, stroke, CKD, and dementia worldwide.
Try two board-style Hypertension questions
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Question 1CardiovascularMedium
A 62-year-old man presents with acute confusion and headache. His blood pressure is 218/128 mm Hg, fundoscopy shows papilledema, and his serum creatinine has risen acutely from 0.9 to 2.4 mg/dL. He is alert but disoriented to time and place. Which of the following is the most appropriate initial antihypertensive agent?
AIntravenous nicardipine
BOral nifedipine
COral captopril
DIntravenous furosemide
EIntravenous hydralazine
Reveal answer & full explanation
Correct answer: A — Intravenous nicardipine
AIntravenous nicardipine✓
BOral nifedipine
COral captopril
DIntravenous furosemide
EIntravenous hydralazine
Why Intravenous nicardipine is correct
This patient has a hypertensive emergency: severely elevated blood pressure with acute end-organ damage (encephalopathy with confusion, papilledema, and acute kidney injury).
The goal is a controlled, titratable reduction of mean arterial pressure by no more than about 25% in the first hour, then gradual normalization over 24-48 hours, because abrupt drops can cause cerebral, renal, or coronary hypoperfusion and ischemic stroke.
Intravenous nicardipine is a titratable dihydropyridine calcium channel blocker that allows this smooth, controlled reduction and is a guideline-preferred agent (labetalol is the other first-line choice).
Why the others are wrong
Oral nifedipine — oral immediate-release nifedipine causes a rapid, unpredictable, and uncontrolled blood pressure drop that has precipitated strokes and myocardial infarction; it is contraindicated in hypertensive emergencies.
Intravenous furosemide — treats volume overload and may be adjunctive in pulmonary edema, but this patient has no signs of fluid overload, and aggressive diuresis can worsen the hypoperfusion driving his acute kidney injury.
Oral captopril — has too slow and unpredictable an onset for an emergency requiring minute-to-minute titration, and an ACE inhibitor is risky in the setting of acute kidney injury.
Intravenous hydralazine — a first-line agent for severe hypertension in pregnancy, but its blood pressure response is unpredictable and prolonged and it cannot be finely titrated, so it risks the excessive drop this patient's brain and kidneys cannot tolerate; it is not a preferred agent for hypertensive encephalopathy.
Question 2CardiovascularEasy
A 55-year-old man is seen for an annual visit and feels well. He has no chronic medical conditions and takes no medications. His blood pressure today is 130/82 mm Hg, confirmed on a repeat reading, and his pulse is 70 beats per minute. His estimated 10-year cardiovascular disease risk is 4%. According to current American College of Cardiology/American Heart Association blood pressure guidelines, which of the following best describes his blood pressure classification and the most appropriate initial management?
EElevated blood pressure; reassessment in 3-6 months
Why Stage 1 hypertension; lifestyle modification is correct
Under current ACC/AHA blood pressure guidance, a confirmed office reading of 130–139/80–89 mm Hg is stage 1 hypertension; this patient's 130/82 mm Hg falls in that band.
Initial drug therapy in stage 1 is reserved for patients with established cardiovascular disease, diabetes, chronic kidney disease, or an estimated 10-year cardiovascular disease risk of 7.5% or higher on the PREVENT calculator.
He has none of these conditions and his estimated risk is well below that threshold, so guideline-directed initial care is comprehensive lifestyle modification.
Lifestyle measures include the DASH dietary pattern, sodium restriction, weight loss, regular aerobic activity, and limiting alcohol, with blood pressure reassessed in 3–6 months; medication is added only if it remains above goal.
Why the others are wrong
Normal blood pressure; reassessment in 1 year — normal is below 120/80 mm Hg (120–129/<80 is elevated); a confirmed 130/82 mm Hg sits in the stage 1 band. Trap for learners anchored to the older 140/90 mm Hg cutoff, under which this reading did not meet the definition of hypertension (it was labeled prehypertension, not normal).
Stage 2 hypertension; two-drug pharmacotherapy — stage 2 begins at 140/90 mm Hg and is what triggers starting two agents up front; applying it here overtreats. Premature closure on 'hypertension means start drugs.'
Stage 1 hypertension; single-drug pharmacotherapy — the classification is right, but starting a drug in stage 1 requires clinical cardiovascular disease, diabetes, chronic kidney disease, or a 10-year risk of 7.5% or higher; at 4% risk with no comorbidity he belongs in the lifestyle-only group. Trap: acting on the stage 1 label without applying the risk estimate.
Elevated blood pressure; reassessment in 3-6 months — the 3-6 month recheck interval is part of guideline follow-up, but elevated blood pressure is 120 to 129 mm Hg systolic with a diastolic below 80 mm Hg; a confirmed 130/82 mm Hg reaches the stage 1 threshold on both numbers, so the classification is wrong, and stage 1 hypertension calls for starting lifestyle modification now, not reassessment alone. Trap: treating 130 mm Hg as the top of the elevated range.
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Elevated office BP — confirm with ambulatory or home BP monitoring (rule out white-coat HTN); out-of-office equivalents of office 130/80 are home 130/80, daytime ABPM 130/80, nighttime ABPM 110/65, 24-h ABPM 125/75. Normal nocturnal dip is 10-20%; a dip <10% is non-dipping and a night average above the day average is reverse dipping (both carry higher CV risk)
Asymmetric pulses or BP arm-to-arm differences (suggest dissection or coarctation)
Differential diagnosis
White-coat hypertension — Office BP elevated, ambulatory or home BP normal; ~20% of office HTN patients; no end-organ damage on workup
Masked hypertension — Office BP normal, out-of-office BP elevated; carries worse cardiovascular prognosis than white-coat; suspect with end-organ damage despite 'normal' office readings
Pseudohypertension (elderly) — Calcified non-compressible arteries cause falsely elevated cuff readings; radial artery remains palpable as a rigid, pulseless tube with the cuff inflated above SBP (Osler sign)
Renal artery stenosis — Abdominal bruit, refractory HTN, ↑ creatinine after ACEi/ARB; FMD in young women, atherosclerotic in older men; renal artery Doppler or MRA
Primary hyperaldosteronism (Conn syndrome) — Hypokalemia and metabolic alkalosis when present (most patients are normokalemic), suppressed renin, elevated aldosterone-to-renin ratio; adrenal CT
Pheochromocytoma — Paroxysmal HTN with the '5 H's' — headache, hypertension, hyperhidrosis, heart palpitations, hyperglycemia; plasma or 24-h urine metanephrines
Coarctation of the aorta — Upper-extremity HTN with weak/delayed femoral pulses; radio-femoral delay; rib notching on CXR (children/young adults)
Obstructive sleep apnea — Snoring, witnessed apneas, daytime somnolence, obesity; polysomnography; CPAP can lower BP
Drug or substance-induced — NSAIDs, OCPs, decongestants (pseudoephedrine), stimulants (cocaine, amphetamines), SNRIs, corticosteroids, licorice (mineralocorticoid effect)
Diagnostic workup
Labs
BMP (Cr, K, glucose), UA with albumin-to-creatinine ratio
Lipid panel, A1c, TSH
CBC
If secondary HTN suspected: 24-h urine or plasma metanephrines, renal artery Doppler/MRA, polysomnography. Screen with an aldosterone-to-renin ratio regardless of K+ in resistant HTN, hypokalemia (spontaneous or diuretic-induced), adrenal incidentaloma, OSA, or family history of early-onset HTN or stroke, and consider it in stage 2 HTN (2025 AHA/ACC)
Imaging
12-lead ECG — LVH (Cornell or Sokolow-Lyon criteria), prior MI
Echocardiogram if LVH on ECG, HF symptoms, or diagnostic uncertainty
Resistant HTN (uncontrolled on ≥3 drugs incl. a diuretic, or needing ≥4)
Add spironolactone; investigate secondary causes
Hypertension drug selection by compelling indication. When comorbidities are present, the choice of antihypertensive should target both BP and the comorbid condition.
Pharmacologic — stage 1: start a drug if clinical CVD, DM, CKD, or PREVENT 10-yr CVD risk ≥7.5%; otherwise lifestyle for 3-6 months, then add a drug if BP stays ≥130/80. Stage 2: start drugs at diagnosis (2025 AHA/ACC):
• First-line classes (any of, by representative agent):
• ARB — losartan, valsartan, candesartan, telmisartan, irbesartan; no bradykinin cough; losartan is uricosuric, so switch from a thiazide to losartan in HTN with gout
• Race: the 2025 AHA/ACC guideline no longer selects first-line drugs by race; choose by comorbidity, response, and adverse effects (the 2017 ACC/AHA guideline and JNC 8 preferred a thiazide or CCB over ACEi/ARB monotherapy in Black patients without HF/CKD)
Second-line / adjunct
Stage 2 (≥140/90): start 2 first-line agents from different classes, preferably as a single-pill combination (2025 AHA/ACC)
Add second drug from different class if monotherapy insufficient
Compelling indications (drug choice driven by comorbidity):
• HFrEF: ARNI (or ACEi/ARB if ARNI not feasible) + evidence-based BB + MRA + SGLT2 inhibitor; loop diuretic for congestion
• Post-MI: BB + ACEi/ARB
• CKD with proteinuria: ACEi or ARB
• Diabetes: any first-line class; ACEi or ARB preferred if albuminuria (UACR ≥30 mg/g) or eGFR <60
• Recurrent stroke prevention: thiazide + ACEi
• BPH: alpha-blocker (doxazosin) — symptomatic relief but NOT first-line for HTN alone (ALLHAT)
Resistant HTN (BP uncontrolled on 3 drugs including a diuretic): add spironolactone (PATHWAY-2 trial); investigate secondary causes
Hypertensive heart disease: concentric LVH from pressure overload (eccentric hypertrophy is the volume-overload pattern) → HFpEF → HFrEF, AFib
Chronic kidney disease — second leading cause of ESRD after diabetes
Hypertensive retinopathy
Aortic dissection
Hypertensive emergency with end-organ damage (encephalopathy, pulmonary edema, AKI)
PANCE pearls
Proper BP measurement: seated, back supported, feet flat, arm at heart level, no caffeine/exercise/smoking 30 min prior, appropriate cuff size. Average of ≥2 readings on ≥2 occasions.
ACEi cough (10-20% of patients, bradykinin-mediated) → switch to ARB. Angioedema → stop the ACEi permanently (class effect) and avoid sacubitril/valsartan; an ARB may be used cautiously ≥6 weeks after the ACEi is stopped (recurrence risk low, ~2-3%).
Severe hypertension (formerly urgency; >180/>120 without acute target-organ damage): restart or intensify oral therapy and lower BP gradually over 24-48 h to days with close outpatient follow-up. Hypertensive emergency: ICU admission with a titratable IV agent (nicardipine, clevidipine, or labetalol first-line; nitroprusside is a less-favored backup because of cyanide toxicity; IV furosemide only if volume overloaded). Lower BP by no more than ~25% in the first hour, then, if stable, to 160/100 over the next 2-6 h, then to normal over 24-48 h. Compelling conditions: SBP <140 in the first hour for severe preeclampsia/eclampsia or pheochromocytoma crisis, and SBP <120 within minutes for aortic dissection (IV beta-blocker such as esmolol first, then a vasodilator).
Avoid sublingual nifedipine — unpredictable, can cause stroke or MI from rapid hypotension. Never FDA-approved for this use; abandoned after reports of stroke and MI from precipitous hypotension.
Lower 'goal' to <130/80 in most patients per SPRINT (intensive control reduces CV events but increases AKI, syncope, electrolyte abnormalities).
Images
Left ventricular hypertrophy — chronic hypertension causes voltage criteria (Sokolow-Lyon, Cornell) and "strain" pattern
References
ACC/AHA 2017 — 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (Whelton et al., Hypertension 2018)
SPRINT — A Randomized Trial of Intensive versus Standard Blood-Pressure Control (SPRINT Research Group, NEJM 2015)
ALLHAT — Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) (ALLHAT Officers and Coordinators, JAMA 2002;288:2981-2997)
PATHWAY-2 — Spironolactone vs Placebo, Bisoprolol, Doxazosin for Resistant HTN (Williams et al., Lancet 2015)
JNC 8 — 2014 Evidence-Based Guideline for the Management of High Blood Pressure (James et al., JAMA 2014)
ALLHAT doxazosin arm — Major Cardiovascular Events in Hypertensive Patients Randomized to Doxazosin vs Chlorthalidone: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) (ALLHAT Collaborative Research Group, JAMA 2000;283:1967-1975)
AHA/ACC 2025 — 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults (Jones DW, Ferdinand KC, Taler SJ, et al., Hypertension 2025;82(10):e212-e316; doi:10.1161/HYP.0000000000000249)
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