Normal† - < 120/80

Prehypertension: 120-139/80-99

Stage 1: < 140-159/90-99

Stage 2:  ≥ 160/100


*Based on the average of 2 or more readings taken at each of 2 or more visits after initial screening

†Normal blood pressure with respect to cardiovascular risk is less than 120/80 mm Hg. However, unusually low readings should be evaluated for clinical significance.

Prehypertension, a new category designated in the JNC VII report, emphasizes that patients with prehypertension are at risk for progression to hypertension and that lifestyle modifications are important preventive strategies.

Hypertension may be either essential or secondary. Essential hypertension is diagnosed in the absence of an identifiable secondary cause. Approximately 95% of American adults have essential hypertension, while secondary hypertension accounts for fewer than 5% of the cases.



Target organ damage


left atrial enlargement
aortic root dilatation
atrial and ventricular arrhythmias
systolic and diastolic heart failure, and
ischemic heart disease

LVH is associated with an increased risk of premature death and morbidity. A higher frequency of cardiac atrial and ventricular dysrhythmias and sudden cardiac death may exist. Possibly, increased coronary arteriolar resistance leads to reduced blood flow to the hypertrophied myocardium, resulting in angina despite clean coronary arteries. Hypertension, along with reduced oxygen supply and other risk factors, accelerates the process of atherogenesis, thereby further reducing oxygen delivery to the myocardium.

Hypertension remains the most common cause of congestive heart failure.


atheroembolic stroke
hypertensive hemorrhage
hypertensive encephalopathy
lacunar-type infarctions

Both the high systolic and diastolic pressures are harmful; a diastolic pressure of more than 100 mm Hg and a systolic pressure of more than 160 mm Hg have led to a significant incidence of strokes. Other cerebrovascular manifestations of complicated hypertension include


end-stage renal disease

A reduction in renal blood flow in conjunction with elevated afferent glomerular arteriolar resistance increases glomerular hydrostatic pressure secondary to efferent glomerular arteriolar constriction. The result is glomerular hyperfiltration, followed by development of glomerulosclerosis and further impairment of renal function.



Secondary causes
(account for 2-10%; essential/primary make up the rest)

Renal (2.5-6%)

Renovascular hypertension (0.2-4%)


Endocrine (1-2%) - Oral contraceptives


Hyperthyroidism and hypothyroidism





Pregnancy-induced hypertension

Drugs and toxins: alcohol, cocaine, cyclosporine, EPO, Adrenergic medications



JNC VII recommendations to lower blood pressure and decrease cardiovascular disease risk include the following:

Initial therapy based on the JNC VII report recommendations is as follows:

Considerations in the Individualization of Antihypertensive Therapy

Risk Factor/Disease Preferred Therapy Alternative Therapy Avoid Therapy
Uncomplicated hypertension (<60 y) Low-dose thiazidelike diuretics, beta-blockers, ACE inhibitors, or long-acting dihydropyridine calcium channel blockers Combinations of first-line drugs …
Uncomplicated hypertension (³60 y) Low-dose thiazidelike diuretics, ACE inhibitors, or long-acting dihydropyridine calcium channel blockers Combinations of first-line drugs …
Dyslipidemia As for uncomplicated hypertension … …
Diabetes mellitus with nephropathy ACE inhibitors Angiotensin II receptor blockers High-dose diuretics and centrally acting agents (in the setting of autonomic neuropathy)
Diabetes mellitus without nephropathy ACE inhibitors or beta-blockers … …
Diabetes mellitus without nephropathy, with systolic hypertension Low-dose thiazidelike diuretics or long-acting dihydropyridine calcium channel blockers … …
Angina Beta-blockers (ACE inhibitors as add-on therapy) Long-acting calcium channel blockers …
Prior myocardial infarction Beta-blockers, ACE inhibitors … …
Systolic dysfunction ACE inhibitors (thiazide or loop diuretics, beta-blockers, spironolactone is additive therapy) Angiotensin II receptor blockers, hydralazine/isosorbide dinitrate, amlodipine Nondihydropyridine calcium channel blockers (diltiazem, verapamil)
Left ventricular hypertrophy Most antihypertensives reduce LVH … Hydralazine, minoxidil
Peripheral arterial disease As for uncomplicated hypertension As for uncomplicated hypertension Beta-blockers (with severe disease)
Renal disease ACE inhibitors (diuretics as additive therapy) Dihydropyridine calcium channel blockers ACE inhibitors in cases of bilateral renal artery stenosis




Key messages of the JNC VII: