High BP is called the “silent killer” because many people do not realize that they have a problem until HTN puts them at risk for heart disease, stroke, chronic renal failure, peripheral vascular disease, and retinopathy.12

The diagnosis of primary HTN is based on evidence of elevated SBP and/or DBP in the absence of secondary causes. The Seventh Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (JNC-7) provides a classification of BP for adults aged 18 or older (Figure 3).12 When SBP and DBP fall into different categories, the higher category is used to determine treatment strategies. The classification includes the category of “prehypertension” for those individuals with BP ranging from 120/80 to 139/89 mmHg. Prehypertension is not a disease category.12 Rather, it is a designation intended to identify individuals who require health-promoting lifestyle modifications to reduce their risk of developing HTN.

Figure 3. Classification of blood pressure for adults aged 18 or older.12
Classification of blood pressure for adults aged 18 or older

The basic evaluation recommended for patients with elevated BP includes a review of the medical history, physical examination, and routine laboratory testing.12 The medical evaluation of patients with documented elevated BP has 3 objectives:

  1. To assess lifestyle and identify other cardiovascular risk factors or other concomitant disorders that may affect prognosis or treatment strategies (Table 2).
  2. To discover identifiable causes of high BP (Table 1).
  3. To assess the presence or absence of target-organ damage (Table 2).12
Table 2. Lifestyle and Cardiovascular Risk Factors and Target-organ Damage.
Lifestyle and Cardiovascular Risk FactorsTarget-organ Damage
  • Hypertension
  • Age, i.e., men >55 years, women >65 years
  • Diabetes mellitus
  • High LDL or low HDL cholesterol
  • Estimated GFR < 60 mL/min
  • Family history of CVD, i.e., men < 55 years of age, women < 65 years of age
  • Microalbuminuria
  • Obesity, i.e., BMI ≥30 kg/m2
  • Physical inactivity
  • Tobacco usage, particularly cigarettes
  • Heart
    • Left ventricular hypertrophy
    • Angina/prior MI
    • Prior coronary revascularization
    • Heart failure
  • Brain
    • Stroke, transient ischemic attack
    • Dementia
  • Chronic kidney disease
  • Peripheral arterial disease
  • Retinopathy