High Blood Pressure (Hypertension)

Diagnosis
Your doctor will ask questions about your medical history and do a physical examination. The doctor, nurse or other medical assistant will place an inflatable arm cuff around your arm and measure your blood pressure using a pressure-measuring gauge.

Your blood pressure generally should be measured in both arms to determine if there is a difference. It’s important to use an appropriate-sized arm cuff.

Blood pressure measurements fall into several categories:

Normal blood pressure. Your blood pressure is normal if it’s below 120/80 mm Hg.
Elevated blood pressure. Elevated blood pressure is a systolic pressure ranging from 120 to 129 mm Hg and a diastolic pressure below (not above) 80 mm Hg. Elevated blood pressure tends to get worse over time unless steps are taken to control blood pressure. Elevated blood pressure may also be called prehypertension.
Stage 1 hypertension. Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.
Stage 2 hypertension. More-severe hypertension, stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.
Hypertensive crisis. A blood pressure measurement higher than 180/120 mm Hg is an emergency situation that requires urgent medical care. If you get this result when you take your blood pressure at home, wait five minutes and retest. If your blood pressure is still this high, contact your doctor immediately. If you also have chest pain, vision problems, numbness or weakness, breathing difficulty, or any other signs and symptoms of a stroke or heart attack, call 911 or your local emergency medical number.

Both numbers in a blood pressure reading are important. But after age 50, the systolic reading is even more important. Isolated systolic hypertension is a condition in which the diastolic pressure is normal (less than 80 mm Hg) but systolic pressure is high (greater than or equal to 130 mm Hg). This is a common type of high blood pressure among people older than 65.

Because blood pressure normally varies during the day and may increase during a doctor visit (white coat hypertension), your doctor will likely take several blood pressure readings at three or more separate appointments before diagnosing you with high blood pressure.

Taking your blood pressure at home
Your doctor may ask you to record your blood pressure at home to provide additional information and confirm if you have high blood pressure.

Home monitoring is an important way to confirm if you have high blood pressure, to check if your blood pressure treatment is working or to diagnose worsening high blood pressure.

Home blood pressure monitors are widely available and inexpensive, and you don’t need a prescription to buy one. Home blood pressure monitoring isn’t a substitute for visits to your doctor, and home blood pressure monitors may have some limitations.

Make sure to use a validated device, and check that the cuff fits. Bring the monitor with you to your doctor’s office to check its accuracy once a year. Talk to your doctor about how to start checking your blood pressure at home.

Devices that measure your blood pressure at your wrist or finger aren’t recommended by the American Heart Association because they can provide less reliable results.

Tests
If you have high blood pressure, your doctor may recommend tests to confirm the diagnosis and check for underlying conditions that can cause hypertension.

Ambulatory monitoring. This 24-hour blood pressure monitoring test is used to confirm if you have high blood pressure. The device used for this test measures your blood pressure at regular intervals over a 24-hour period and provides a more accurate picture of blood pressure changes over an average day and night. However, these devices aren’t available in all medical centers, and they may not be reimbursed.
Lab tests. Your doctor may recommend a urine test (urinalysis) and blood tests, including a cholesterol test.
Electrocardiogram (ECG or EKG). This quick and painless test measures your heart’s electrical activity.
Echocardiogram. Depending on your signs and symptoms and test results, your doctor may order an echocardiogram to check for more signs of heart disease. An echocardiogram uses sound waves to produce images of the heart.

Treatment
Changing your lifestyle can help control and manage high blood pressure. Your doctor may recommend that you make lifestyle changes including:

Eating a heart-healthy diet with less salt
Getting regular physical activity
Maintaining a healthy weight or losing weight if you’re overweight or obese
Limiting the amount of alcohol you drink

But sometimes lifestyle changes aren’t enough. If diet and exercise don’t help, your doctor may recommend medication to lower your blood pressure.

Medications
The type of medication your doctor prescribes for high blood pressure depends on your blood pressure measurements and overall health. Two or more blood pressure drugs often work better than one. Sometimes finding the most effective medication or combination of drugs is a matter of trial and error.

You should aim for a blood pressure treatment goal of less than 130/80 mm Hg if:

You’re a healthy adult age 65 or older
You’re a healthy adult younger than age 65 with a 10% or higher risk of developing cardiovascular disease in the next 10 years
You have chronic kidney disease, diabetes or coronary artery disease

Ask your doctor what your blood pressure treatment goal should be. Also, the ideal blood pressure treatment goal can vary with age and health conditions, particularly if you’re older than age 65.

Medications used to treat high blood pressure include:

Diuretics. Diuretics, sometimes called water pills, are medications that help your kidneys eliminate sodium and water from the body. These drugs are often the first medications tried to treat high blood pressure.
There are different classes of diuretics, including thiazide, loop and potassium sparing. Which one your doctor recommends depends on your blood pressure measurements and other health conditions, such a kidney disease or heart failure. Diuretics commonly used to treat blood pressure include chlorthalidone, hydrochlorothiazide (Microzide) and others.

A common side effect of diuretics is increased urination, which could reduce potassium levels. If you have a low potassium level, your doctor may add a potassium-sparing diuretic — such as triamterene (Dyazide, Maxide) or spironolactone (Aldactone) — to your treatment.
Angiotensin-converting enzyme (ACE) inhibitors. These medications — such as lisinopril (Prinivil, Zestril), benazepril (Lotensin), captopril and others — help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels.
Angiotensin II receptor blockers (ARBs). These medications relax blood vessels by blocking the action, not the formation, of a natural chemical that narrows blood vessels. ARBs include candesartan (Atacand), losartan (Cozaar) and others.
Calcium channel blockers. These medications — including amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others) and others — help relax the muscles of your blood vessels. Some slow your heart rate. Calcium channel blockers may work better for older people and people of African heritage than do ACE inhibitors alone.
Don’t eat or drink grapefruit products when taking calcium channel blockers. Grapefruit increases blood levels of certain calcium channel blockers, which can be dangerous. Talk to your doctor or pharmacist if you’re concerned about interactions.

Additional medications sometimes used to treat high blood pressure. If you’re having trouble reaching your blood pressure goal with combinations of the above medications, your doctor may prescribe:

Alpha blockers. These medications reduce nerve signals to blood vessels, lowering the effects of natural chemicals that narrow blood vessels. Alpha blockers include doxazosin (Cardura), prazosin (Minipress) and others.
Alpha-beta blockers. Alpha-beta blockers block nerve signals to blood vessels and slow the heartbeat to reduce the amount of blood that must be pumped through the vessels. Alpha-beta blockers include carvedilol (Coreg) and labetalol (Trandate).
Beta blockers. These medications reduce the workload on your heart and widen your blood vessels, causing your heart to beat slower and with less force. Beta blockers include acebutolol, atenolol (Tenormin) and others.
Beta blockers aren’t usually recommended as the only medication you’re prescribed, but they may be effective when combined with other blood pressure medications.
Aldosterone antagonists. These drugs also are considered diuretics. Examples are spironolactone and eplerenone (Inspra). These drugs block the effect of a natural chemical that can lead to salt and fluid buildup, which can contribute to high blood pressure. They may be used to treat resistant hypertension.
Renin inhibitors. Aliskiren (Tekturna) slows the production of renin, an enzyme produced by your kidneys that starts a chain of chemical steps that increases blood pressure.
Due to a risk of serious complications, including stroke, you shouldn’t take aliskiren with ACE inhibitors or ARBs.
Vasodilators. These medications include hydralazine and minoxidil. They work directly on the muscles in the walls of your arteries, preventing the muscles from tightening and your arteries from narrowing.
Central-acting agents. These medications prevent your brain from telling your nervous system to increase your heart rate and narrow your blood vessels. Examples include clonidine (Catapres, Kapvay), guanfacine (Intuniv) and methyldopa.

Treating resistant hypertension
If your blood pressure remains stubbornly high despite taking at least three different types of high blood pressure drugs, one of which usually should be a diuretic, you may have resistant hypertension.

You’re also considered to have resistant hypertension if you have controlled high blood pressure but are taking four different types of medications at the same time to achieve that control. If you do, your doctor should investigate the possibility of a secondary cause of the high blood pressure.

Having resistant hypertension doesn’t mean your blood pressure will never get lower. If you and your doctor can determine the cause, a more effective treatment plan can be created to help you meet your goal blood pressure.

Treating resistant hypertension may involve many steps, including:

Changing your high blood pressure medications to determine which combinations and doses work best
Reviewing all the medications you take, including those that you take for other conditions or buy without a prescription
Monitoring your blood pressure at home to see if going to the doctor causes your blood pressure to increase (white coat hypertension)
Making healthy lifestyle changes, such as eating a healthy diet with less salt, maintaining a healthy weight and limiting alcohol

You should always take blood pressure medications as prescribed. Never skip a dose or abruptly stop taking your blood pressure medication. Suddenly stopping certain blood pressure drugs, such as beta blockers, can cause a sharp increase in blood pressure (rebound hypertension).

If you skip doses because you can’t afford the medications, because you have side effects or because you simply forget to take your medications, talk to your doctor about solutions. Don’t change your treatment without your doctor’s guidance.

Potential future treatments
Researchers continue to study catheter-based ultrasound and radiofrequency ablation of the kidney’s sympathetic nerves (renal denervation) as a treatment for resistant hypertension. Early studies showed some benefit, but more-robust studies found that the therapy does not significantly lower blood pressure in people with resistant hypertension. More research is underway to determine what role, if any, this therapy may have in treating hypertension.