Anteroposterior x-ray from a 28-year old woman who presented with congestive heart failure secondary to her chronic hypertension, or high blood pressure. The enlarged cardiac silhouette on this image is due to congestive heart failure due to the effects of chronic high blood pressure on the left ventricle. The heart then becomes enlarged, and fluid accumulates in the lungs, known as pulmonary congestion.
Of the non-pharmacological methods being investigated to lower blood pressure 20, the effects of renal denervation are highly relevant and very topical. This interventional treatment was aimed at ablating the effects of augmented sympathetic drive to the kidney, which contributes to the pathogenesis of hypertension primarily owing to sympathetic activation and the release of renin. To this end, Symplicity HTN-1 49 and Symplicity HTN-2 50 trials used a minimally invasive catheter-based radiofrequency strategy to cause renal nerve denervation in an attempt to lower blood pressure in patients with TRH. These trials were very successful, with the reductions in blood pressure maintained for up to 3 years in many cases 51, 52. However, procedural concerns were raised about the study design (including lack of blinding or true resistant hypertension 53), which prompted the large multi-centre, sham-controlled, blinded Symplicity HTN-3 trial 54. Surprisingly, no significant blood pressure reductions were observed between the renal denervation and the sham groups after 6 months of follow-up 54, which has resulted in considerable controversy in the field of renal denervation. This discrepancy from earlier trials has been attributed to incomplete ablation after renal denervation, since later analysis revealed that complete renal denervation was rarely achieved in patients in Symplicity HTN-3 55, most likely related to the inexperience of many trial operators and lack of procedural checks 55, 56. Recently, it has been cogently argued that the rationale for renal denervation for TRH remains valid 56. However, “smarter” renal denervation trials, with respect to design, location of ablation energy delivery, and testing of achieved denervation 56, are awaited with intense interest. The devil will be in the detail as to how this field, which holds great promise, progresses.

Medical therapy is indicated in patients with adrenal hyperplasia, patients with adenoma who are poor surgical risks, and patients with bilateral adenomas. These patients are best treated with sustained salt and water depletion. Hydrochlorothiazide or furosemide in combination with either spironolactone or amiloride corrects hypokalemia and normalizes the blood pressure. Some patients may require the addition of a vasodilator or a beta-blocker for better control of hypertension.

Being under stress can also increase your blood pressure temporarily, but stress is not a proven risk factor for hypertension. Still, some studies have linked mental stress and depression with risk of high blood pressure. A 2003 study published in the Journal of the American Medical Association found that people who felt pressed for time or were inpatient had higher odds of developing high blood pressure over a 15-year period, than people who did not feel such time pressure.
Approximately 3-45% of adult patients presenting to an emergency department have at least one increased BP during their stay in the ED, but only a small percentage of patients will require emergency treatment. However, medical therapy and close follow-up are necessary in patients who present to the ED with acutely elevated BPs (systolic BP >200 mm Hg or diastolic BP >120 mm Hg) that remain significantly elevated until discharge. [90]
Shahin M, Sá A, Webb A, Gong Y, Langaee T, McDonough C, Riva A, Beitleshees A, Chapman A, Gums J, Turner S, Boerwinkle E, Scherer S, Sadee W, Cooper-DeHoff R and Johnson J (2017) Genome-Wide Prioritization and Transcriptomics Reveal Novel Signatures Associated With Thiazide Diuretics Blood Pressure Response, Circulation: Genomic and Precision Medicine, 10:1, Online publication date: 1-Feb-2017.
In one study, investigators determined that a true diagnosis of resistant hypertension with ambulatory BP monitoring (ABPM) is associated with a more severe degree of vascular dysfunction (versus white-coat resistant hypertension), as measured by hyperemia-induced forearm vasodilation (HIFV) and serum biomarkers. [107] However, there is no direct association between BP levels and other types of abnormalities in vascular function (eg, compliance). [107]

Lifestyle modifications are generally sufficient for the management of pregnant women with stage 1 hypertension who are at low risk for cardiovascular complications during pregnancy. [1] Restrictions to lifestyle modifications may include aerobic exercise (theoretical increased preeclampsia risk from inadequate placental blood flow) and weight reduction, even in obese pregnant women. Reduction of sodium intake and avoidance of tobacco and alcohol use are similar to those for individuals with primary hypertension. [2]


The primary symptoms of malignant hypertension is a blood pressure of 180/120 or higher and signs of organ damage. Other symptoms of malignant hypertension include bleeding and swelling of blood vessels in the retina, anxiety, nosebleeds, severe headache, and shortness of breath. Malignant hypertension may cause brain swelling, but this symptom is very rare.

Over 50% of patients with hypertension will require more than one drug for blood pressure control. [4] In stage 1 hypertension, a single agent is generally sufficient to reduce BP, whereas in stage 2, a multidrug approach may be needed. Initiation of 2 antihypertensive agents, either as 2 separate prescriptions or as a fixed-dose combination, should also be considered when BP is more than 20 mm Hg above the systolic goal (or 10 mm Hg above the diastolic goal). [2]

If lifestyle modifications are insufficient to achieve the goal blood pressure (BP), there are several drug options for the treatment and management of hypertension. Based on the Seventh Report of the Joint National Committee of Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and the 2010 Institute for Clinical Systems Improvement (ICSI) guideline on the diagnosis and treatment of hypertension recommendations, thiazide diuretics were the preferred initial agents in the absence of compelling indications. [2]
Cirrhosis of the liver is the most common cause of portal hypertension. In cirrhosis, the scar tissue (from the healing of liver injury caused by hepatitis, alcohol, or other liver damage) blocks the flow of blood through the liver. Blood clots in the portal vein, blockages of the veins that carry blood from the liver to the heart, parasitic infection (schistosomiasis), and focal nodular hyperplasia are also causes of portal hypertension.
Regarding immediate clinic management of hypertension, a major unresolved issue is to define the exact clinical utility and wide applicability of ambulatory BP monitoring as well as the role of home BP monitoring. We know that the 24-h average BP per ABPM predicts hypertension outcome better than office BP – the standard used in almost all the trials cited above. We also know for the same level of office BP, people with non-dipping night BP has worse prognosis in CV outcomes (47). Wider use of ABPM can further reduce the high incidence of stroke and heart failure in the overall population.
Emergency department visits for hypertension with complications and secondary hypertension also rose, from 71.2 per 100,000 population in 2006 to 84.7 per 100,000 population in 2011, while again, admission rates fell, dropping from 77.79% in 2006 to 68.75% in 2011. The in-hospital mortality rate for admitted patients dropped as well, from 1.95% in 2006 to 1.25% in 2011. [37]
Subsequently, an open-label prospective, randomized study conducted in 24 centers in Europe, Australia, and New Zealand (Symplicity HTN-2) confirmed the safety and efficacy of this treatment in 106 patients randomized to renal denervation with previous treatment (n = 52) or to previous treatment alone (n = 54). [104] At 6 months, renal denervation resulted in a reduction in SBP of 10 mm Hg or more in 84% of patients, compared to 35% of controls. No serious procedure-related or device-related complications occurred.
Formal guidelines for measuring blood pressure state that it should be measured in a quiet, warm environment after you have been sitting restfully for at least five minutes. You should not have had coffee or used tobacco for at least 30 minutes. At least two blood pressure measurements should be taken under these conditions at least five minutes apart. This should be repeated until the measurements agree to within 5 mmHg.
Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
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