Essential Hypertension

Cardiovascular

Description

Essential hypertension is a chronic elevation of systemic arterial blood pressure in which no single secondary cause can be identified. It accounts for about 90 % of all hypertension diagnoses and affects nearly one adult in two in the United States; National Center for Health Statistics data from October 2024 estimate a prevalence of 47.7 % among people ≥ 18 years, higher in men than women. Worldwide, the World Health Organization reports over 1.3 billion adults living with raised blood pressure, making it the leading modifiable contributor to cardiovascular morbidity and mortality.

Symptoms

Essential hypertension is typically asymptomatic, earning its moniker “the silent killer.” When blood pressure reaches very high levels patients may experience throbbing occipital headaches, tinnitus, visual blurring, palpitations, or epistaxis, but these are neither sensitive nor specific. Many individuals discover the condition only during routine screening or after a cardiovascular event.

Risk Factors

Advancing age, Black or South-Asian ancestry, a positive family history, and male sex confer non-modifiable risk. Modifiable drivers include central obesity, physical inactivity, high-sodium or low-potassium diet, excess alcohol, cigarette smoking, obstructive sleep apnoea, chronic psychosocial stress, and the insulin-resistance cluster of type 2 diabetes and dyslipidaemia. Pregnancy-related hypertensive disorders, nephron-reducing kidney disease, and long-term use of NSAIDs, corticosteroids, cyclosporine, or oral contraceptives can reveal latent essential hypertension.

Diagnosis

Diagnosis requires two or more properly measured seated blood-pressure readings ≥ 130/80 mm Hg on two separate occasions, or corresponding values on home or ambulatory monitoring, after five minutes of rest with an appropriately sized cuff. Contemporary European and North-American guidelines emphasise confirming office readings with out-of-office measurements to unmask white-coat or masked hypertension. Baseline evaluation includes serum electrolytes, creatinine, fasting glucose, lipid profile, complete blood count, thyroid-stimulating hormone, urinalysis, and an electrocardiogram; further testing targets suspected secondary causes.

Treatment

Management starts with lifestyle optimisation: 150 minutes per week of moderate aerobic exercise, weight reduction to body-mass-index < 25 kg m⁻², sodium intake < 1500 mg day⁻¹, at least 3500 mg day⁻¹ of dietary potassium, limited alcohol, and adoption of the DASH or Mediterranean diet, which lowers systolic pressure by up to 11 mm Hg. First-line pharmacotherapy comprises one of four classes—thiazide or thiazide-like diuretics, calcium-channel blockers, angiotensin-converting–enzyme inhibitors, or angiotensin-receptor blockers—titrated to achieve a target < 130/80 mm Hg in most adults, with combination therapy initiated if baseline blood pressure exceeds target by ≥ 20/10 mm Hg. Beta-blockers, mineralocorticoid-receptor antagonists, central sympatholytics, or alpha-blockers are added for resistant hypertension, and newer agents such as the non-steroidal mineralocorticoid antagonist finerenone and sodium–glucose cotransporter-2 inhibitors offer modest additional pressure reductions in patients with diabetic kidney disease. The SPRINT trial demonstrated that intensive control to a systolic goal < 120 mm Hg in high-risk patients reduced cardiovascular events and all-cause mortality, albeit with more hypotension and electrolyte disturbances.

Outlook

When blood pressure is maintained below guideline targets, the relative risk of stroke, myocardial infarction, heart failure, and premature death falls markedly; meta-analysis indicates that each 10 mm Hg systolic reduction confers roughly a 20 % lower risk of major cardiovascular events. Conversely, every decade of uncontrolled hypertension accelerates atherosclerotic disease and doubles the lifetime probability of chronic kidney disease and vascular dementia.

Complications

Long-standing uncontrolled essential hypertension promotes concentric left-ventricular hypertrophy progressing to heart failure, accelerates coronary and cerebrovascular atherosclerosis culminating in myocardial infarction and ischaemic or haemorrhagic stroke, induces chronic kidney disease and end-stage renal failure, precipitates aortic dissection, peripheral arterial disease, hypertensive retinopathy with vision loss, and vascular dementia.

Prevention

Maintaining a normal body weight, engaging in regular physical activity, limiting sodium and alcohol, prioritising fruits, vegetables, whole grains, and low-fat dairy, quitting smoking, and managing stress with mindfulness or cognitive-behavioural strategies can delay or prevent hypertension onset, especially in genetically predisposed individuals.

Support

Daily home blood-pressure monitoring with a validated upper-arm cuff, logging results in a digital or paper diary, and sharing them with clinicians improves adherence and facilitates timely medication adjustment. Partnering with dietitians for DASH-aligned meal planning, enrolling in supervised exercise or cardiac-rehabilitation programmes, using smartphone reminders for pills, and joining peer-support groups enhance long-term success.