Hypertension
Hypertension (High Blood Pressure): A Comprehensive, Evidence-Based Guide
Hypertension—commonly known as high blood pressure—is one of the most widespread cardiovascular conditions in the world. Often called the “silent killer,” it rarely causes symptoms in its early stages yet silently damages the heart, arteries, kidneys, eyes, and brain over many years. In the UK and globally, hypertension remains one of the most preventable causes of heart attacks, heart failure, stroke, kidney disease, and premature death.
Hypertension is defined as persistently elevated pressure within the arteries. It occurs when the force of blood pushing against the arterial walls is too high for too long. Blood pressure is measured using two numbers:
Systolic pressure (top number): pressure when the heart contracts.
Diastolic pressure (bottom number): pressure when the heart relaxes.
Normal blood pressure for adults is typically below 120/80 mmHg.
The commonly used UK categories include:
| Category | Systolic (mmHg) | Diastolic (mmHg) |
|---|---|---|
| Normal | <120 | <80 |
| Elevated / High-normal | 120–139 | 80–89 |
| Hypertension (Stage 1) | 140–159 | 90–99 |
| Hypertension (Stage 2) | ≥160 | ≥100 |
| Severe Hypertension / Hypertensive urgency | >180 | >120 (without organ damage) |
| Hypertensive emergency | >180 | >120 with organ damage |
Most people with high blood pressure have no symptoms at all, which is why routine screening is crucial. However, when symptoms occur, they may include:
Commonly reported symptoms of hypertension (often non-specific):
- Headaches (especially at the back of the head)
- Dizziness
- Fatigue
Blurred vision
- Palpitations
- Shortness of breath
- Nosebleeds (uncommon but can occur)
Symptoms of severely elevated blood pressure:
A severe rise in blood pressure—especially above 180/120 mmHg—may cause:
- Severe headache
- Chest pain
- Breathlessness
- Confusion
- Visual changes
- Nausea and vomiting
- Weakness or numbness
These symptoms may indicate a hypertensive emergency, a life-threatening condition requiring immediate hospital treatment.
Symptoms related to long-term complications:
Chronic uncontrolled hypertension can silently lead to:
Heart failure symptoms (breathlessness, leg swelling)
Reduced kidney function (swelling, fatigue, foamy urine)
Stroke symptoms (weakness, speech difficulty)
Loss of vision due to hypertensive retinopathy
You should seek medical advice if:
You have a blood pressure reading:
Consistently above 140/90 mmHg at home
Above 180/120 mmHg even without symptoms
Above 180/120 mmHg with symptoms — this is an emergency
You experience new symptoms:
Chest pain or pressure
Breathlessness
Sudden weakness on one side
Difficulty speaking
Severe headaches
Vision changes
Palpitations or fainting
You have risk factors for hypertension:
Family history of high blood pressure or heart disease
Diabetes
Obesity
High cholesterol
Sedentary lifestyle
Smoking
Excessive alcohol intake
High-salt diet
Pregnant individuals:
Seek urgent review if you experience high readings, headaches, swelling, vision issues, or abdominal pain—this may indicate pre-eclampsia, a serious condition.
Diagnosing hypertension involves more than a single reading. UK and European guidelines recommend:
Blood Pressure Measurement
Clinic Blood Pressure
Measured by your GP or nurse. If elevated for the first time, it must be confirmed by home or ambulatory monitoring.
Home Blood Pressure Monitoring (HBPM)
You take two readings morning and evening for 7 days using a validated monitor. Helpful for:
Confirming diagnosis
Monitoring response to treatment
Detecting white coat hypertension (high BP only in clinic)
Detecting masked hypertension (normal in clinic, high at home)
24-Hour Ambulatory Blood Pressure Monitoring (ABPM)
Considered the gold standard for diagnosis. The device measures BP every 20–30 minutes during the day and night. It identifies:
Night-time hypertension
Dipping patterns
True uncontrolled hypertension
Physical Examination
Your doctor may check for:
Heart murmurs
Enlarged heart
Kidney enlargement
Narrowed arteries
Swelling
Eye changes (hypertensive retinopathy)
ECG (Electrocardiogram)
Assesses for:
Left ventricular hypertrophy (LVH)
Arrhythmias (e.g., atrial fibrillation)
Previous silent heart attacks
Echocardiogram
A heart ultrasound may be used to assess:
Heart muscle thickness
Pump function
Valve abnormalities
Additional Tests for Secondary Hypertension
Requested when hypertension is severe, early-onset, or resistant to treatment:
Renal ultrasound
Renal artery Doppler
CT/MRI for adrenal or renal disease
Sleep studies (for sleep apnoea)
Echocardiogram
A heart ultrasound may be used to assess:
Heart muscle thickness
Pump function
Valve abnormalities
Treatment aims to lower blood pressure safely and reduce long-term complications. The best approach combines lifestyle measures and medication when required.
Lifestyle Modifications for high blood pressure
• Reduce salt intake
<6 g per day (one teaspoon total)
Avoid processed foods high in sodium
• Achieve a healthy weight
Losing 5–10% of body weight can dramatically lower BP.
• Regular exercise
150 minutes of moderate activity per week
Include brisk walking, cycling, swimming, or resistance training
• Healthy diet
Adopt the DASH diet, rich in:
Fruits
Vegetables
Whole grains
Lean protein
Low-fat dairy
Nuts and legumes
Avoid:
Excess sugar
Saturated fats
Processed foods
• Limit alcohol: Men & women: ≤14 units per week, spread across several days
• Quit smoking: Smoking accelerates arterial damage.
• Reduce caffeine intake: Some people respond strongly to caffeine.
• Manage stress
Medications (Antihypertensives)
Most patients with Stage 2 Hypertension or high cardiovascular risk require medication.
Even after achieving good blood pressure control, hypertension requires lifelong attention. Many people live long, healthy lives with well-controlled blood pressure.
Living With Hypertension
1. Monitor at home
Use a validated upper-arm BP monitor
Keep a log to share with your GP
2. Take medications exactly as prescribed: Missing doses increases the risk of stroke and heart attack.
3. Follow a heart-healthy diet: Maintain the DASH diet or Mediterranean diet.
4. Stay physically active: Consistent moderate exercise is more effective than occasional high-intensity workouts.
5. Maintain a healthy sleep routine: Poor sleep can raise blood pressure.
6. Limit stress: Chronic stress contributes to hypertension.
7. Avoid smoking and recreational drugs: Substances such as cocaine can cause dangerous spikes.
8. Attend regular check-ups
Blood tests
Kidney function
Electrolyte monitoring
Medication review
9. Reduce alcohol and caffeine: Helps stabilise blood pressure.
10. Educate yourself: Understanding your condition empowers you to make better lifestyle choices.
Prognosis (Long-Term Outlook) of hypertension:
Hypertension is a manageable condition. The prognosis varies depending on:
- How early it is diagnosed
- How well it is controlled
- Co-existing conditions (diabetes, kidney disease, high cholesterol)
With good control:
- Risk of stroke drops by 30–40%
- Risk of heart attack drops by 20–25%
- Reduced risk of heart failure and kidney disease
With poor or no control:
- Higher risk of heart attack, stroke, heart failure
- Faster progression of kidney disease
- Damage to small arteries in the eyes and brain
- Reduced life expectancy
The good news: Even modest reductions in blood pressure significantly improve life expectancy and reduce complications.
- Hypertension is called the “silent killer” because it usually causes no symptoms.
- It affects 1 in 3 adults globally.
- Lowering blood pressure by just 10 mmHg reduces stroke risk by ~27%.
- Home blood pressure monitoring is more accurate than single clinic readings.
- Lifestyle changes alone can reduce BP significantly.
- Most patients require long-term medications.
- Uncontrolled hypertension damages the heart, brain, kidneys, and eyes.
- Secondary hypertension accounts for about 5–10% of cases.
- Hypertension increases the risk of atrial fibrillation.
- Good control allows you to live a normal and healthy life.
- What is the target blood pressure I should aim for?
- Should I monitor my blood pressure at home, and how often?
- Which lifestyle changes will make the biggest difference for me?
- Do I need medication now, or can we try lifestyle changes first?
- Which medication is best for my condition and why?
- What side effects should I watch for with my medication?
- How will we assess whether my treatment is working?
- Could my high blood pressure be caused by another condition?
- What symptoms should prompt urgent medical attention?
- How can I reduce my long-term risk of heart attack or stroke?
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