Elsevier

The Lancet

Volume 398, Issue 10296, 17–23 July 2021, Pages 249-261
The Lancet

Seminar
Arterial hypertension

https://doi.org/10.1016/S0140-6736(21)00221-XGet rights and content

Summary

Arterial hypertension is the most important contributor to the global burden of disease; however, disease control remains poor. Although the diagnosis of hypertension is still based on office blood pressure, confirmation with out-of-office blood pressure measurements (ie, ambulatory or home monitoring) is strongly recommended. The definition of hypertension differs throughout various guidelines, but the indications for antihypertensive therapy are relatively similar. Lifestyle adaptation is absolutely key in non-pharmacological treatment. Pharmacologically, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, calcium channel blockers, and diuretics are the first-line agents, with advice for the use of single-pill combination therapy by most guidelines. As a fourth-line agent, spironolactone should be considered. The rapidly evolving field of device-based therapy, especially renal denervation, will further broaden therapeutic options. Despite being a largely controllable condition, the actual rates of awareness, treatment, and control of hypertension are disappointingly low. Further improvements throughout the process of patient screening, diagnosis, treatment, and follow-up need to be urgently addressed.

Section snippets

Epidemiology

Hypertension is one of the most important modifiable risk factors for cardiovascular disease and one of the largest contributors to morbidity and mortality worldwide. In a systematic analysis done for the Global Burden of Disease Study 2017, high systolic blood pressure (SBP) was the leading risk factor for mortality (10·4 million deaths) and disability-adjusted life-years (218 million).1 In a study including 8·69 million participants from 154 countries, it was estimated that between 1990 and

Pathophysiology

Hypertension can be classified as essential or secondary, with most patients having essential hypertension.13 The cause of hypertension is multifactorial in nature, with environment, genetics, and social determinants having the potential to contribute to its development.13 A better understanding of the interplay between these components has continued to unfold.14

Increasing knowledge has also been gathered on the pathophysiology of hypertension. Besides the traditional environmental factors (eg,

Blood pressure measurements

Accurate and reliable blood pressure measurements are essential for the diagnosis of hypertension. Blood pressure changes constantly in response to endogenous factors and exogenous stimuli; therefore, standardisation is essential for an accurate measurement.40 Unfortunately, the problem of unstandardised measurements has persisted for decades, despite efforts in education and simplification of the measurement process. The widespread availability of non-validated blood pressure devices might

Non-pharmacological and pharmacological management of hypertension

Within the past 4 years, four major guideline writing entities have published updates regarding hypertension management: the ACC–AHA, the ESC–ESH, the National Institute for Health and Care Excellence (NICE), and, most recently, the ISH guidelines. The intent of the ISH guideline was to be written in a manner that would be easy to use and apply in low-income, middle-income, and high-income countries.50

Each set of guidelines notes that sodium restriction in patients with hypertension is needed

Future perspectives

For a largely controllable condition, the rates of awareness, treatment, and control of hypertension are disappointingly low. There is room for improvement among the various levels of health care and throughout the process of patient screening, diagnosis, treatment, and follow-up. Previous initiatives have reviewed the necessary actions to improve management of blood pressure worldwide.44

Medications available for hypertension management have not changed profoundly throughout previous decades.

Search strategy and selection criteria

We searched PubMed and MEDLINE for articles published from Jan 1, 2010, to Oct 25, 2020. We used the search terms “blood pressure”, “hypertension”, “arterial hypertension”, in combination with the terms “guidelines”, “chronotropy”, “resistant hypertension”, “diabetes”, “ambulatory blood pressure monitoring”, “home blood pressure measurement”, “digital health”, “mobile health”, “lifetime risk”, “prospective studies”, “epidemiology”, “population”, “lifetime blood pressure”, “diet”, “lifestyle”,

Declaration of interests

IS reports consulting fees, speaker fees, and travel grants from Amgen, AstraZeneca, Boston Scientific, Daiichi Sankyo, Medtronic, Novartis, Recordati, Sanofi, and Servier. All other authors declare no competing interests.

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