A persistent elevation of arterial blood pressure measured in clinic — confirmed by repeated readings, ABPM or HBPM.
| Category (ACC/AHA 2017 staging) | Systolic (mmHg) | Diastolic (mmHg) | |
|---|---|---|---|
| Normal | < 120 | and | < 80 |
| Elevated | 120–129 | and | < 80 |
| Stage 1 HTN | 130–139 | or | 80–89 |
| Stage 2 HTN | ≥ 140 | or | ≥ 90 |
| Hypertensive crisis | ≥ 180 | and/or | ≥ 120 |
ESH 2023 calls 130–139/85–89 “high-normal”; ESC 2024 introduced a separate “Elevated BP” band (120–139 / 70–89) — partial convergence with the US.
Diagnose with out-of-office BP (ABPM/HBPM) preferred, or ≥2 elevated office readings on ≥2 occasions.
Sources: Mancia 2023 (ESH); McEvoy 2024 (ESC); Whelton 2017 (ACC/AHA).
The threshold for “hypertension” has been re-drawn five times in 20 years — driven by trial evidence, especially SPRINT (2015).
HTN ≥ 140/90. Created “prehypertension” (120–139 / 80–89) to flag rising risk.
Relaxed treatment threshold in ≥60 yrs to ≥150/90 (controversial; ESH/AHA disagreed). Did not redefine staging.
Intensive target SBP <120 vs <140 → −25 % MACE, −27 % all-cause mortality in high-CV-risk non-diabetics. Reset the field.
Lowered HTN threshold to ≥130/80. New staging: Elevated 120–129/<80, Stage 1 130–139/80–89, Stage 2 ≥140/90. Overnight, ~46 % of US adults became hypertensive.
Europe kept ≥140/90. Endorsed lower targets (<130/80) in tolerated, high-risk patients — but rejected US relabelling.
Reaffirmed ≥140/90. Pushed single-pill combinations as first step in nearly all patients.
HTN still ≥140/90, but a new “Elevated BP” category (120–139 / 70–89) bridges toward the US view. New treatment target SBP 120–129 mmHg if tolerated (post-SPRINT/STEP). Out-of-office BP strongly recommended.
Bottom line: Europe and the US still disagree on the label, but converge on the action — treat earlier, aim lower, prefer combination therapy.
Verified against original guideline texts (JAMA, NEJM, Hypertension, Eur Heart J, J Hypertens) and ACC.org guideline summary, Sept 2024.
Hypertension is the world's leading modifiable risk factor for cardiovascular death.
Blood pressure = cardiac output × systemic vascular resistance
Essential hypertension is rarely caused by a single mechanism — genetics, salt intake, RAAS, sympathetic drive, endothelium and renal sodium handling all interact. No single villain — that's why monotherapy often fails.
Renin–Angiotensin–Aldosterone System — the body's blood-pressure thermostat, and the central drug target.
Most patients have no identifiable cause — but always screen the rest.
Sustained pressure injures every vascular bed in the body.
Stroke (ischemic + hemorrhagic), vascular dementia, hypertensive encephalopathy
Hypertensive retinopathy: AV-nicking, cotton-wool spots, papilledema (KW grading)
LV hypertrophy → diastolic HF → systolic HF, MI, atrial fibrillation
Atherosclerosis, aortic aneurysm & dissection, peripheral artery disease
Hypertensive nephrosclerosis → CKD → ESRD (second most common cause after DM)
Prescribed for everyone — even those on drugs. Cumulative effects can match a single antihypertensive.
< 2 g Na⁺ (< 5 g salt) per day (WHO)
Fruits, veg, whole grains, low-fat dairy, low saturated fat (Sacks 2001, NEJM)
~1 mmHg per kg lost (BMI < 25 ideal)
≥ 150 min/week moderate intensity
≤ 14 units/week (♂) · ≤ 8 units/week (♀) — ESH 2023
Doesn't lower BP much, but slashes CV risk
Start with combination therapy (single pill if possible). Aim < 130/80 in most patients.
| Class | Mechanism | Best for | Watch out |
|---|---|---|---|
| ACE inhibitorsenalapril, ramipril, perindopril | Block conversion Ang I → Ang II | DM, CKD, HF, post-MI | Cough, ↑K⁺, AKI, angioedema · contraindicated in pregnancy |
| ARBslosartan, valsartan, telmisartan | Block AT₁ receptor | Same as ACEi · ACEi-intolerant | ↑K⁺, AKI (no cough) · contraindicated in pregnancy |
| CCB (dihydropyridine)amlodipine, nifedipine | Block L-type Ca²⁺ → vasodilation | Elderly, isolated systolic, Black pts | Ankle oedema, flushing, headache |
| Thiazide diureticsindapamide, hydrochlorothiazide | Block Na⁺/Cl⁻ in distal tubule | Elderly, low-renin, Black pts | ↓K⁺, ↓Na⁺, ↑uric acid, ↑glucose |
| β-blockersbisoprolol, metoprolol, carvedilol | ↓ HR & contractility · ↓ renin | Only with compelling indication: post-MI, HF, AF, angina, pregnancy (labetalol) | Bradycardia, fatigue, bronchospasm · not first-line in NICE/JNC-8/ACC-AHA |
| Mineralocorticoid antagonistsspironolactone, eplerenone | Block aldosterone receptor | Resistant HTN (4th-line), HF, Conn | ↑K⁺, gynaecomastia (spiro) |
Start with a single-pill ACEi/ARB + CCB or thiazide → if uncontrolled → triple SPC → still uncontrolled → add spironolactone (= resistant HTN). Aim < 140/90 first; then < 130/80 if tolerated.
SBP ≥ 180 or DBP ≥ 120 mmHg — but the next question is the only one that matters: is there acute end-organ damage?
Labetalol (most settings) · Nicardipine / Clevidipine · Nitroglycerin (ACS, pulm. edema) · Nitroprusside (last resort — cyanide) · Esmolol (aortic dissection, with vasodilator)
All numbers, thresholds and algorithms in this deck cross-checked against the primary literature.
Each citation independently verified against PubMed / DOI / publisher record (April 2026). Guideline texts cross-checked at escardio.org, acc.org, nice.org.uk and who.int.