Hypertension; Causes, Symptoms, Diagnosis, Treatment


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Hypertension is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high blood pressure, however, is a major risk factor for coronary artery disease, stroke, heart failure, atrial fibrillation, peripheral vascular disease, vision loss, chronic kidney disease, and dementia. High blood pressure is classified as either primary (essential) high blood pressure or secondary high blood pressure. About 90–95% of cases are primary, defined as high blood pressure due to nonspecific lifestyle and genetic factors.

Blood pressure is expressed by two measurements, the systolic and diastolic pressures, which are the maximum and minimum pressures, respectively. For most adults, normal blood pressure at rest is within the range of 100–130 millimeters mercury (mmHg) systolic and 60–80 mmHg diastolic. For most adults, high blood pressure is present if the resting blood pressure is persistently at or above 130/90 or 140/90 mmHg. Different numbers apply to children. Ambulatory blood pressure monitoring over a 24-hour period appears more accurate than office-based blood pressure measurement.


Hypertension is a chronic elevation of blood pressure that, in the long-term, causes end-organ damage and results in increased morbidity and mortality. Blood pressure is the product of cardiac output and systemic vascular resistance. It follows that patients with arterial hypertension may have an increase in cardiac output, an increase in systemic vascular resistance, or both. In the younger age group, the cardiac output is often elevated, while in older patients increased systemic vascular resistance and increased the stiffness of the vasculature play a dominant role. The vascular tone may be elevated because of increased α-adrenoceptor stimulation or increased release of peptides such as angiotensin or endothelins. The final pathway is an increase in cytosolic calcium in vascular smooth muscle causing vasoconstriction. Several growth factors, including angiotensin and endothelins, cause an increase in vascular smooth muscle mass termed vascular remodeling. Both an increase in systemic vascular resistance and an increase in vascular stiffness augment the load imposed on the left ventricle; this induces left ventricular hypertrophy and left ventricular diastolic dysfunction.


Causes: Common Secondary Hypertension by age

  • Age under 18 years
  • Renal parenchymal disease (most common in underage <12 years)
  • Vesicoureteral Reflux Nephropathy
  •  Glomerulonephritis
  • Aortic Coarctation

3.  Age 19 to 39 years

  • Renal Artery Stenosis due to fibromuscular dysplasia
  • Thyroid Disease

4.  Age 40 to 64 years

  • Hyperaldosteronism
  • Thyroid Disease
  • Obstructive Sleep Apnea
  • Cushing Syndrome
  • Pheochromocytoma

5.  Age over 65 years

  • Renal Artery Stenosis due to atherosclerotic disease
  • Chronic Kidney Disease
  • Hypothyroidism

 Causes: Secondary Hypertension in AdultsEndocrine Causes

  • Chest Pain
  • Primary Aldosteronism
    1. Most common treatable secondary cause of Hypertension
    2. Evaluate as cause in Refractory Hypertension where Hypokalemia or borderline low Potassium
  •  Pheochromocytoma
  • Cushing’s Disease
  • Hyperparathyroidism
  • Thyroid Disease
  • Hyperthyroidism causes systolic Hypertension
  • Hypothyroidism causes diastolic Hypertension

Vascular Causes

  • Aortic Coarctation
  • Renal Artery Stenosis

Medications or substances

  • Antihypertensive Withdrawal
  • Alcohol Withdrawal
  • Cocaine or another stimulant
  • Serotonin Syndrome
  • Anticholinergic Syndrome
  • Malignant Hyperthermia

Miscellaneous Causes

  • Obstructive Sleep Apnea
  • Renal parenchymal disease
  • Preeclampsia
  • Cerebrovascular Accident

Causes: Secondary Hypertension in age <18 years old

  • Renal parenchymal disease (Most common cause in children under age 12 years – up to 70%)
    1. Glomerulonephritis
    2. Vesicoureteral Reflux Nephropathy
  • Renal Artery Stenosis (due to fibromuscular dysplasia)
  • Aortic Coarctation
  • Endocrine conditions
    1. Metabolic Syndrome
    2. Pheochromocytoma
    3. Hyperthyroidism
  • Essential Hypertension
    1. Rare in age <10 years
    2. Most common cause in adolescents and adults

Medication Causes of Hypertension

Causes:Sodium retaining agents

  • Oral Contraceptives (occurs in 5% of users)
  • Estrogen Replacement Therapy
  • Licorice
  • High Sodium Antacids
  • Mineralocorticoids
  • Glucocorticoids or Corticosteroids
  • Anabolic Steroids

Causes: Miscellaneous agents

  • Nonsteroidal Antiinflammatory Drugs (NSAIDs)
  • Cyclooxygenase-2 Inhibitors (COX-2 Inhibitors such as Celebrex)
  • Cyclosporine (significantly raises Blood Pressure)
  • Levothyroxine (excessive dosing)
  • Erythropoietin
  • Growth Hormone

Neurologic and psychiatric agents

  • Venlafaxine (Effexor)
  • Fluoxetine (Prozac)
  • Bupropion (Wellbutrin)
  • Tricyclic Antidepressants
  • Monoamine Oxidase Inhibitors (MAO inhibitors)
  • Lithium
  • Clozapine (Clozaril)
  • Carbamazepine (Tegretol)

Causes: Stimulants (Sympathomimetics)

  • Ergonomic aids (e.g. Anabolic Steroids)
  • Cocaine
  • Amphetamines
  • Caffeine
  • Dietary supplements (e.g. Ephedra)
  • Appetite Suppressants (e.g. Sibutramine)
  • Decongestants (e.g. Pseudoephedrine, Afrin)

Image result for homeopathic treatment of high blood pressure

Causes: Herbals

  • Aniseed
  • St. Johns Wort
  • Capsicum
  • Cola alkaloids
  • Blue Cohosh
  • Vervain
  • Agnus cactus
  • Calamus amines
  • Broom alkaloids
  • Bayberry
  • Licorice
  • Genung
  • Ginseng
  • Guarana
  • Ma Huang (Ephedra)
  • Pau de Arco
  • Coltsfoot
  • Gentian
  • Ginger

Causes Medication-Related Syndromes

  • Antihypertensive Withdrawal
  • Alcohol Withdrawal
  • Serotonin Syndrome
  • Anticholinergic Syndrome
  • Malignant Hyperthermia

Risk Factor of Hypertension

 Risk Group A – Low Cardiovascular Risk

a. Criteria

  • No Cardiovascular Risks (See Risk Group B)
  • Target organ damage or Cardiovascular Disease
  • Prehypertension (120-139 / 80-89)
  • Lifestyle Modification in Hypertension

Stage 1 Hypertension (140-159 / 90-99)

  • Lifestyle Modification in Hypertension
  • Consider Antihypertensive after up to 6-12 months
  • Hydrochlorothiazide first choice in most patients

Stage 2 Hypertension or greater (>159/99)

  • Lifestyle Modification in Hypertension
  • Hypertension Combination Therapy

Risk Group B – Moderate Cardiovascular Risk


  • Tobacco Abuse
  • Dyslipidemia
  • Renal Insufficiency
  • Patient age over 60 years
  • Male gender of postmenopausal women
  • Cardiovascular Family History
  • No Diabetes Mellitus
  • No Target organ damage or Cardiovascular Disease

Prehypertension (120-139 / 80-89)

  • Alcohol Withdrawal
  • Lifestyle Modification in Hypertension

Stage 1 Hypertension (140-159 / 90-99)

  • Lifestyle Modification in Hypertension
  • Antihypertensive (e.g. Hydrochlorothiazide)

Stage 2 Hypertension or greater (>159/99)

  • Lifestyle Modification in Hypertension
  • Hypertension Combination Therapy

 Risk Group C -High Cardiovascular Risk


Target organ damage or Cardiovascular Disease

  • Left Ventricular Hypertrophy
  • Angina or prior Myocardial Infarction
  • Prior coronary revascularization
  • Cerebrovascular Accident (Stroke or CVA)
  • Transient Ischemic Attack (TIA)
  • Nephropathy or Chronic Kidney Disease
  • Peripheral Vascular Disease
  • Retinopathy

Prehypertension (120-139 / 80-89) or greater

  • Lifestyle Modification in Hypertension
  • Antihypertensive
  • Hypertension Combination Therapy if >20/10 over goal

Symptoms of Hypertension  

  • Blood in the Urine
  • Blurred Vision
  • Chest Pain
  • Decreased Urine Output
  • Dizziness
  • Headache
  • Leg Swelling
  • Nosebleeds
  • Pounding Sensation in the Neck, Chest, or Ears
  • Shortness of Breath
  • Other inconclusively related symptoms – A variety of symptoms may be indirectly related to but are not always caused by, high blood pressure, such as:
  • Blood spots in the eyes – blood spots in the eyes (subconjunctival hemorrhage) are more common in people with diabetes or high blood pressure, but neither condition causes the blood spots. Floaters in the eyes are also not related to high blood pressure. However, an eye doctor (ophthalmologist) may be able to detect damage to the optic nerve caused by untreated high blood pressure.
  • Facial flushing – Facial flushing occurs when blood vessels in the face dilate. It can occur unpredictably or in response to certain triggers such as sun exposure, cold weather, spicy foods, wind, hot drinks, and skin-care products. Facial flushing can also occur with emotional stress, exposure to heat or hot water, alcohol consumption and exercise — all of which can raise blood pressure temporarily. While facial flushing may occur while your blood pressure is higher than usual, high blood pressure is not the cause of facial flushing.
  • Dizziness – While dizziness can be a side effect of some blood pressure medications, it is not caused by high blood pressure. However, dizziness should not be ignored, especially if the onset is sudden. Sudden dizziness, loss of balance or coordination and trouble walking are all warning signs of a stroke. High blood pressure is a leading risk factor for stroke.

People often do not seek medical care until they have symptoms arising from the organ damage caused by chronic (ongoing, long-term) high blood pressure. The following types of organ damage are commonly seen in chronic high blood pressure:

  • Heart attack
  • Heart failure
  • Stroke or transient ischemic attack(TIA)
  • Kidney failure
  • Eye damage with progressive vision loss
  • Peripheral arterial disease causing leg pain with walking (claudication)
  • Outpouchings of the aorta called aneurysms

About 1% of people with high blood pressure do not seek medical care until high blood pressure is very severe, a condition known as malignant hypertension.

  • In malignant hypertension, the diastolic blood pressure (the lower number) often exceeds 140 mm Hg.
  • Malignant hypertension may be associated with headache, lightheadedness, nausea, vomiting, and stroke-like symptoms
  • Malignant hypertension requires emergency intervention and lowering of blood pressure to prevent brain hemorrhage or stroke

Criteria: Hypertension in Adults

JNC-8 Blood Pressures goals (modified as of 2014)

  • Renal Insufficiency: <140/90 mmHg
  • Diabetes Mellitus: <140/90 mmHg > ADA recommends <140/80 mmHg, Age >80 years: <150/90 mmHg
  • No Diabetes Mellitus or renal disease
  • Age <60 years: <140/90 mmHg
  • Age >60 years: <150/90 mmHg

Goal Blood Pressures for Hypertensive Patients (JNC-7 Guidelines)

  • Hypertension without Co-morbidity: <140/90
  • Diabetes Mellitus: <130/80
  • Congestive Heart Failure: <130/80
  • Renal Insufficiency: <130/80
  • Renal Failure and >1g Proteinuria/24 hours: <125/75

JNC-7 Blood Pressure definitions

  • Optimal Blood Pressure: <115/80
  • Normal Blood Pressure: <120/80
  • Pre-Hypertension: 120-139/80-89
  • Stage 1 Hypertension: 140-159/90-99
  • Stage 2 Hypertension: >160/100

Stages eliminated in JNC-7

  • Stage 3 Hypertension: 180-209/110-119
  • Stage 4 Hypertension: >210/120

Isolated Systolic Hypertension

  • Systolic Blood Pressure: >140 mmHg
  • Diastolic Blood Pressure: <90 mmHg

Criteria: Hypertension in Children and Adolescents (based on age, height, gender over at least 3 values)

Normal Blood Pressur

  • Blood Pressure <90% for age, height, gender


  • Blood Pressure 90% to 95% for age, height, gender or
  • Blood Pressure >120/80

Stage I Hypertension

  • Blood Pressure 95 to 99% plus 5 mm Hg for age, height, gender

Stage II Hypertension

  • Blood Pressure >99% plus 5 mm Hg for age, height, gender

Criteria: Hypertension in Adolescents

Age 16-18 years

  • Significant Hypertension: BP> 142/92
  • Severe Hypertension: BP> 150/98

Age: 13-15 years

  • Significant Hypertension: BP> 136/86
  • Severe Hypertension: BP> 144/92

Criteria: Hypertension in Children

Age 10-12 years

  • Significant Hypertension: BP> 126/82
  • Severe Hypertension: BP> 134/90

Age 6-9 years

  • Significant Hypertension: BP> 122/78
  • Severe Hypertension: BP> 130/86

Age 3-5 years

  • Significant Hypertension: BP> 116/76
  • Severe Hypertension: BP> 124/84

Age 1 month to 2 years

  • Significant Hypertension: BP> 112/74
  • Severe Hypertension: BP> 118/82
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Age 8-30 days

  • Alcohol Withdrawal
  • Significant Hypertension: SBP> 104
  • Severe Hypertension: SBP> 110

Age <7 day old

  • Significant Hypertension: SBP> 96
  • Severe Hypertension: SBP> 106

Exam: Vitals

  • BP Examination >Consider arm to leg systolic BP measurements (difference >20 mmHg suggests Aortic Coarctation)
  • Pulse

Assess for Obesity

  • Weight and Height
  • Ideal Body Weight or BMI
  • Waist Circumference (assess for Metabolic Syndrome)

Exam: Head

  • Retinal Exam
  • Mouth Exam > Mallampati Score increased in Sleep Apnea

Exam: Neck

  • Thyroid exam
  • Carotid Bruits
  • Neck vein exam

Exam: Chest

  • Congestive Heart Failure signs
  • Palpable intercostal pulses

Exam: Cardiovascular

  • S4 Gallop rhythm (decreased LV compliance)
  • Tachycardia
  • Accentuated S2 Heart Sound
  • Aortic Insufficiency murmur
  • Abnormal EKG or Echocardiogram
  • Prior Angiography results

Exam: Abdomen

  • Renal artery bruit  > May be present in Renal Artery Stenosis
  • Abdominal Aortic Aneurysm
  • Enlarged or tender Kidneys (CVA pain)

Exam: Genitourinary

  • Abnormal Sexual Development
  • Enlarged Prostate

Exam: Peripheral Vascular Disease

  • Femoral bruits
  • Femoral pulses > Delayed or absent in Aortic Coarctation
  • Symmetrical pulses
  • Lower extremity shin Hair Loss

 Exam: Neurologic

  • Peripheral Neuropathy

 Exam: Skin

  • Stigmata of Cirrhosis
  • Neurofibromata
  • Chloasma

Signs of Cushing’s Disease

  • Striae
  • Acne Vulgaris
  • Hirsutism
typical physical examination to evaluate hypertension includes:
  • medical and family history
  • physical examination
  • ophthalmoscopy: Examination of the blood vessels in the eye
  • chest x-ray
  • electrocardiograph (ECG)
  • blood and urine tests.
The medical and family history help the physician determine if the patient has any conditions or disorders that might contribute to or cause hypertension. A family history of hypertension might suggest a genetic predisposition for hypertension.
The physical exam may include several blood pressure readings at different times and in different positions. The physician uses a stethoscope to listen to sounds made by the heart and blood flowing through the arteries. The pulse, reflexes, and height and weight are checked and recorded.


Lifestyle changes are important for both treatment and prevention of high blood pressure, and they can be as effective as a drug treatment. These lifestyle changes can also have wider benefits for heart health and overall health. So the first choice is diuretics. It helps the kidneys eliminate excess salt and water from the body’s tissues and blood.

Loop diuretics

  • bumetanide
  • ethacrynic acid
  • furosemide
  • torsemide

Thiazide diuretics

  • epitizide
  • hydrochlorothiazide and chlorothiazide
  • bendroflumethiazide
  • methyclothiazide
  • polythiazide

Thiazide-like diuretics

  • indapamide
  • chlorthalidone
  • metolazone

Potassium-sparing diuretics

  • amiloride
  • triamterene
  • spironolactone
  • eplerenone

Calcium channel blockers

Calcium channel blockers block the entry of calcium into muscle cells in artery walls.


  • amlodipine
  • cilnidipine
  • clevidipine
  • felodipine
  • isradipine
  • lercanidipine
  • levamlodipine
  • nicardipine
  • nifedipine
  • nimodipine
  • nisoldipine
  • nitrendipine


  • diltiazem
  • verapamil

JNC8 recommends calcium channel blockers to be a first-line treatment either as monotherapy or in combination with thiazide-type diuretics, ACE inhibitors, or angiotensin II receptor antagonists for all patients regardless of age or race.

ACE inhibitors

Captopril, the prototypical ACE inhibitor

ACE inhibitors inhibit the activity of the angiotensin-converting enzyme (ACE), an enzyme responsible for the conversion of angiotensin I into angiotensin II, a potent vasoconstrictor.

  • captopril
  • enalapril
  • fosinopril
  • lisinopril
  • moexipril
  • perindopril
  • quinapril
  • ramipril
  • trandolapril
  • benazepril

A systematic review of 63 trials with over 35,000 participants indicated ACE inhibitors significantly reduced doubling of serum creatinine levels compared to other drugs (ARBs, α blockers, β blockers, etc.), and the authors suggested this as the first line of defense. The AASK trial showed that ACE inhibitors are more effective at slowing down the decline of kidney function compared to calcium channel blockers and beta-blockers. As such, ACE inhibitors should be the drug treatment of choice for patients with chronic kidney disease regardless of race or diabetic status.

ACE inhibitors (and angiotensin II receptor antagonists) – should not be a first-line treatment for black hypertensives without chronic kidney disease. Results from the ALLHAT trial showed that thiazide-type diuretics and calcium channel blockers were both more effective as monotherapy in improving cardiovascular outcomes compared to ACE inhibitors for this subgroup. Furthermore, ACE inhibitors were less effective in reducing blood pressure and had a 51% higher risk of stroke in black hypertensives when used as initial therapy compared to a calcium channel blocker. There are fixed-dose combination drugs, such as ACE inhibitor and thiazide combinations.

Notable side effects of ACE inhibitors include dry cough, hyperkalemia, fatigue, dizziness, headaches, loss of taste and a risk for angioedema.

Angiotensin II receptor antagonists

Valsartan, an angiotensin II receptor antagonist

Angiotensin II receptor antagonists work by antagonizing the activation of angiotensin receptors.

  • azilsartan
  • candesartan
  • eprosartan
  • irbesartan
  • losartan
  • olmesartan
  • telmisartan
  • valsartan
  • Fimasartan

Whether angiotensin receptor blockers may or may not increase the risk of myocardial infarction (heart attack) was announced in BMJ and was debated in 2006 in the medical journal of the American Heart Association. To date, there is no consensus on whether ARBs have a tendency to increase MI, but there is also no substantive evidence to indicate that ARBs are able to reduce MI.

In the VALUE trial, the angiotensin II receptor blocker valsartan produced a statistically significant 19% (p=0.02) relative increase in the prespecified secondary endpoint of myocardial infarction (fatal and non-fatal) compared with amlodipine.

The CHARM-alternative trial showed a significant +52% (p=0.025) increase in myocardial infarction with candesartan (versus placebo) despite a reduction in blood pressure.

Indeed, as a consequence of AT1 blockade, ARBs increase Angiotensin II levels several-fold above baseline by uncoupling a negative-feedback loop. Increased levels of circulating Angiotensin II result in unopposed stimulation of the AT2 receptors, which are, in addition, upregulated. Unfortunately, recent data suggest that AT2 receptor stimulation may be less beneficial than previously proposed and may even be harmful under certain circumstances through the mediation of growth promotion, fibrosis, and hypertrophy, as well as proatherogenic and proinflammatory effects.

Adrenergic receptor antagonists

Propranolol, the first beta-blocker to be successfully developed
  • atenolol
  • bisoprolol
  • betaxolol
  • carteolol
  • carvedilol
  • labetalol
  • metoprolol
  • nadolol
  • nebivolol
  • oxprenolol
  • penbutolol
  • pindolol
  • propranolol
  • timolol


  • doxazosin
  • phentolamine
  • indoramin
  • phenoxybenzamine
  • prazosin
  • terazosin
  • tolazoline

Mixed Alpha + Beta-blockers

  • bucindolol
  • carvedilol
  • labetalol

Despite lowering blood pressure, alpha-blockers have significantly poorer endpoint outcomes than other antihypertensives and are no longer recommended as a first-line choice in the treatment of hypertension. However, they may be useful for some men with symptoms of prostate disease.


Vasodilators act directly on the smooth muscle of arteries to relax their walls so blood can move more easily through them; they are only used in hypertensive emergencies or when other drugs have failed, and even so are rarely given alone.

Sodium nitroprusside, a very potent, short-acting vasodilator, is most commonly used for the quick, temporary reduction of blood pressure in emergencies (such as malignant hypertension or aortic dissection). Hydralazine and its derivatives are also used in the treatment of severe hypertension, although they should be avoided in emergencies. They are no longer indicated as first-line therapy for high blood pressure due to side effects and safety concerns, but hydralazine remains a drug of choice in gestational hypertension.


Although controversial over this off-label purpose, benzodiazepines may play a role in lowering blood pressure. They work as an agonist of the GABA-a receptors in the brain, thus slowing down neurotransmission and dilating blood vessels. GABA is an abbreviation for gamma-aminobutyric acid. It is an inhibitory neurotransmitter among others (glycine, adenosine, etc.) GABA-a receptors are ion channels that are the primary target for benzodiazepines. When an agonist binds to this receptor site, the protein channel opens, allowing negative chloride ions entering the channel and penetrating the voltage-gated ion site. Thus, giving negative feedback in neurotransmission and easing stress, anxiety and tension in patients that can be associated with elevated blood pressure. In addition to GABA, benzodiazepines inhibit the re-uptake of a nucleoside chemical called Adenosine, which serves as an inhibitory chemical mentioned above. It also serves as a coronary vasodilator, allowing the cardiac muscle to relax and dilating cardiac arteries. However, long-term use of benzodiazepines are associated with dependence and tolerance, which is likely the result of GABA-a receptor downregulation. Therefore, withdrawal symptoms include hypertension, even in healthy individuals

Renin Inhibitors

Renin comes one level higher than angiotensin-converting enzyme (ACE) in the renin-angiotensin system. Inhibitors of renin can therefore effectively reduce hypertension. Aliskiren (developed by Novartis) is a renin inhibitor which has been approved by the U.S. FDA for the treatment of hypertension.

Aldosterone receptor antagonists

Aldosterone receptor antagonists

  • eplerenone
  • spironolactone

Aldosterone receptor antagonists are not recommended as first-line agents for blood pressure, but spironolactone and eplerenone are both used in the treatment of heart failure and resistant hypertension.

Alpha-2 adrenergic receptor agonists

Central alpha agonists lower blood pressure by stimulating alpha-receptors in the brain which open peripheral arteries easing blood flow. These alpha 2 receptors are known as autoreceptors which provide negative feedback in neurotransmission (in this case, the vasoconstriction effects of adrenaline). Central alpha agonists, such as clonidine, are usually prescribed when all other anti-hypertensive medications have failed. For treating hypertension, these drugs are usually administered in combination with a diuretic.

  • clonidine
  • guanabenz
  • guanfacine
  • methyldopa
  • moxonidine

Adverse effects of this class of drugs include sedation, drying of the nasal mucosa and rebound hypertension.

Some indirect anti-adrenergic are rarely used in treatment-resistant hypertension

  • guanethidine – replaces norepinephrine in vesicles, decreasing its tonic release
  • mecamylamine – antinicotinic and ganglion blocker
  • reserpine – indirect via irreversible VMAT inhibition

For the most resistant and severe disease, oral minoxidil (Loniten) in combination with diuretic and β-blocker or another sympathetic nervous system suppressant may be used.

Endothelin receptor blockers

Bosentan belongs to a new class of drug and works by blocking the receptors of the hormone endothelin. It is specifically indicated only for the treatment of pulmonary artery hypertension in patients with moderate to severe heart failure.

Future Treatment Options

Blood pressure vaccines

Blood pressure vaccinations are being trialed and may become a treatment option for high blood pressure in the future. CYT006-AngQb was only moderately successful in studies, but similar vaccines are being investigated.

Peripheral adrenergic inhibitors

This group of drugs works to block certain chemical messengers inside the brain, which keeps the smooth muscles from getting the message to constrict. These medications are generally used only if other medications aren’t effective. They include:

  • guanadrel (Hylorel)
  • guanethidine monosulfate (Ismelin)
  • reserpine (Serpasil)


Vasodilators relax the muscles in the walls of blood vessels, especially small arteries (arterioles). This widens the blood vessels and allows blood to flow through them more easily. Blood pressure falls as a result. Hydralazine hydrochloride (Apresoline) and minoxidil (Loniten) are examples of these.

Consider treating immediately if BP in the clinic is ≥180/110 mm Hg; otherwise, consider after results of ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM), blood tests and cardiovascular risk assessment are available.

Diagnose hypertension if the average of ABPM or HBPM readings is ≥135/85 mm Hg, (ignore first-day readings and average the rest – see separate Hypertension article).

  • Stage 1 hypertension – clinic readings ≥140/90 mm Hg and ABPM/HBPM ≥135/85 mm Hg.
  • Stage 2 hypertension – clinic readings ≥160/100 mm Hg and ABPM/HBPM ≥150/95 mm Hg.
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Hypertension treatment should be commenced in people aged under 80 years with stage 1 hypertension plus signs of end-organ damage (known cardiovascular or renal disease), or with diabetes mellitus or a 10-year cardiovascular disease (CVD) risk ≥20%. Treatment in mild hypertension without target-organ damage or cardiovascular risk remains contentious.

The recommendation criteria for long time Treatment

Treatment should be started in all patients (any age) with stage 2 hypertension. Treat isolated systolic hypertension in the same way.

Initial antihypertensive choices
If the patient is young (≤55 years) and non-black, start with:

  • (A) angiotensin-converting enzyme (ACE) inhibitor or low-cost angiotensin-II receptor antagonist (AIIRA) – also called an angiotensin receptor blocker (ARB).
  • A beta-blocker may be appropriate in younger adults if an ACE inhibitor is not tolerated, in women who may become pregnant or if there is evidence of increased sympathetic drive. Beta-blockers were the B in the previous ABCD hypertension advice but are no longer preferred treatment, as evidence suggests they are inferior to other agents in terms of outcome.
If the patient has aged>55 years or a black person of African or Caribbean family origin, use:

  • (C) calcium-channel blocker (CCB).
  • (D) thiazide-like diuretic if CCB not suitable. Chlortalidone (12.5-25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) are specifically recommended choices.
Step 2 choices
  • (A+C) ACE inhibitor or AIIRA with CCB.
  • Use an ACE inhibitor/AIIRA and a thiazide-like diuretic (D) if CCB is not tolerated (or if there is any evidence of heart failure).
  • If initially started on a beta-blocker, add a CCB rather than a thiazide-like diuretic second-line (reduce diabetic risk).
  • Consider an AIIRA rather than an ACE inhibitor with a CCB in black people of African or Caribbean origin.
Step 3 choices
  • (A+C+D) ACE inhibitor or AIIRA and a CCB and a thiazide-like diuretic (chlorthalidone or indapamide).
Step 4 choices
  • Consider a fourth agent or referral for specialist advice.
  • (A+C+D) ACE inhibitor or AIIRA and a CCB and a thiazide-like diuretic plus a further diuretic (higher-dose thiazide-like diuretic or spironolactone, depending on potassium). Monitor renal function and electrolytes.
  • If the higher-dose diuretic is not tolerated, consider an alpha-blocker or a beta-blocker, or seek expert advice.

The combination of an ACE inhibitor with an AIIRA is not recommended for the treatment of hypertension.

The PATHWAY-2 trial, published in 2015, suggested that spironolactone is the most effective fourth-line agent for resistant hypertension. A drug safety update from the Medicines and Healthcare products Regulatory Agency (MHRA) in 2016 warns of the risk of hyperkalemia when an ACE inhibitor or AIIRA is combined with spironolactone. Routine use of this combination is not recommended but where it is, the lowest possible dose should be used and electrolytes monitored closely.

Natural/Ayurvedic & Unani Remedies  High Blood Pressure


blood-pressure-home remedies


  • Garlic is gaining more and more popularity for its use in lowering high blood pressure. This herb also has blood-thinning properties which makes it great for improving overall cardiac health.
  • Garlic is also a natural diuretic — meaning it forces out excess sodium and water from the body, and into your urine. This effect takes the pressure off of an overworked heart and decreases blood pressure.

Method: If the taste of garlic is too strong for you, popular odorless garlic supplements are also available.

  • If you cannot handle eating the entire clove raw, hold a slice of garlic in your mouth and try sucking on the juices for 15 minutes.
  • You can also finely mince 1-2 cloves of garlic, mix it into a glass of water, and drink it.
  • Another method is to take the finely minced pieces, put it on a piece of fruit, and cover it with honey.
  • Tip — try adding a few cloves to your smoothies.



  • Carrots contain high levels of antioxidants beta-carotene, Vitamin A, and Vitamin C. Antioxidants reduce the amount of cancer-causing free radicals in the body. They also protect against damage to blood vessels and cellular death.
  • Carrots are also high in the electrolyte, potassium. Potassium is great at keeping the fluid within the body balanced and normalizing blood pressure. Potassium positively counteracts the effects of sodium. Consumed in large amounts, sodium can negatively affect blood pressure.

Method: Drink 1-3 glasses of carrot juice a day. Make sure to buy organic and do not add any sugar.


  • Tomatoes contain beta-carotene, vitamin E, potassium, and antioxidants — which are all great at lowering high blood pressure.
  • Tomatoes also contain lycopene, a chemical that gives it its rich red color. Lycopene has antioxidant effects that lowers bad cholesterol (LDL) and prevents the build-up of fatty deposits in arteries (atherosclerosis). These buildups can lead to cardiovascular disease.


  • Eat a cup of fresh tomatoes, tomato sauce, or blended tomato juice, everyday. If you do not like the taste of tomatoes, try taking lycopene supplements. Avoid commercial tomato sauce, which contain high levels of sodium.



  • Celery seeds are widely used in the Chinese culture for lowering blood pressure. Specifically, the Chinese use celery seeds to lower high blood pressure of the liver.
  • Celery is a fibrous vegetable that also acts as a diuretic. Diuretics flush out excess water from the heart and the body. This causes a decrease in blood pressure.


  • Pomegranates not only are dense in nutrients but are also high in antioxidants — specifically in tannins and anthocyanins. Pomegranates are fruits that have a hard shell and edible juicy red seeds.
  • Pomegranates contain phytochemicals, flavonoids, polyphenols, and punicalagin. Phytochemicals naturally occur in plant foods that act as antioxidants and prevent damage to our cells. Antioxidants such as flavonoids and polyphenols fight against heart disease and cancers.
  • Punicalagin is a compound that is mostly responsible for the health benefits in pomegranates. It improves the functions of the heart and blood vessels, lowers bad (LDL) cholesterol, raises good (HDL) cholesterol, lowers high blood pressure, and reverses the effects of arterial blockage (atherosclerosis).

Pomegranates contain more antioxidants than red wine, berries, or even green tea.

Method: Add pomegranate seeds to your salad, or juice the seeds into a tasty drink.


Method: Mix celery seeds into your tea, your cooking, or drink fresh celery juice — 3 times a day.

Beets & Radishes


  • Beets & radishes are under-appreciated and overcooked vegetables. Both beets and radishes are high in nitrates, which are great at lowering high blood pressure, by improving vasodilation.
  • Nitrates change into vasodilator nitric oxide after being ingested. Nitric acid dilates blood vessels, regulates blood pressure, decreases endothelial inflammation, and platelet aggregation.
  • Both the leaves and the roots of the radish lowers elevated blood pressures.


  • Juice made out of beets or radishes is the best form of the vegetables, in lowering blood pressure. Drink a glass of blended beets or radishes juice, daily. Also, add fresh beets and radishes to any dish!



  • Sesame oil contains omega-6s, polyunsaturated fatty acids (PUFA), Vitamin E, and sesamin, which are great for lowering blood pressure, cardiovascular disease, and diabetes.
  • Sesamin is a lignan compound in sesame oil that has been shown to reduce blood pressure levels. Sesame lignans reduce the absorption of cholesterol in the body.
  • PUFA and sesamin work together to relax the arterial wall and reduce blood pressure.

Method: Incorporate 1 ounce of sesame seeds or oil into your daily cooking, for at least 2 months.


  • Ginger has been used for centuries in Asian and Indian cultures, especially for its numerous health benefits. Ginger is great for preventing heart conditions, such as lowering blood pressure, decreasing cholesterol, and preventing blood clots.
  • Ginger decreases bad cholesterol (Low-Density Lipoproteins), by preventing plaque build-up on arterial walls, that can lead to increased blood pressure.

Method: Add fresh ginger to your smoothies and juices, and try to incorporate ginger into your daily cooking.

Coconut Water


  • Coconut water is filled with potassium and magnesium electrolytes, which are good for the heart muscle.
  • Coconut water lowers blood pressure by acting as a potassium-sparing diuretic. This removes the excess water from the body while retaining vital potassium. Coconut water is best when it is organic and bottled in its raw form.


  • Drink 8 ounces of organic coconut water, 1-3 times a day. The effects are weight-based, so if you are on the heavier side, drink more coconut water (3 times a day).

Cayenne Pepper (Capsaicin)


  • Cayenne pepper is a known vasodilator. It quickly expands blood vessels, which improves the flow of blood. Faster and more efficient flow takes the pressure off of the arteries, thus decreasing your blood pressure. Capsaicin is one of the major ingredients in red peppers. The spicier the pepper, the more capsaicin it contains.
  • Cayenne pepper helps to create new red blood cells, improves blood structure, and aids in detoxing the blood. During detoxification, cayenne pepper is thought to also remove some plaque build-up off of the arterial walls. Cayenne pepper is also known to stop bleeding fast. If you have a cut, try sprinkling some cayenne pepper over it.


  • The recommended dosage is 1 teaspoon of organic cayenne pepper a day, and slowly work your way up to one teaspoon, 3 times a day. If the taste is too spicy for you, try taking capsaicin supplements.

Dark Chocolate (Caca0)


  • Dark chocolate is made from the seeds of the cocoa tree (Theobroma cacao) and is loaded with antioxidants (cancer-fighting) — including polyphenols, flavonoids, catechins.
  • The cocoa tree seeds contain flavonoids, but more importantly, it is exceptionally high in its levels of flavanols.
  • Flavanols (Flavan-3-ol) are phytonutrients, which is known as plant-based nutrients. Not many other foods come close to the number of flavanols that are found in cocoa seeds.
  • Activated nitric oxide dilates blood vessels, making it easier for the blood to circulate throughout the body. NO is absolutely necessary for maintaining a healthy body.
  • By keeping the blood vessels open, it allows the blood to efficiently carry vital oxygen and nutrients to all parts of the body. Dilated blood vessels decrease stress in the body. This in turn, lowers blood pressure and reduces the risk of stroke or a heart attack.


  • Make sure your dark chocolates or cocoa powders contain at least 50-80% of cocoa to reap the benefits of the flavanols. Just remember that the more cocoa content your chocolate contains, the more nutritious it is.



  • Cardamom is a spice that has been used for thousands of years in Ayurveda medicine. It is widely used for cardiac disorders, gastrointestinal disorders, renal problems, heartburn, and respiratory disorders.
  • Cardamom is also known for its antioxidant, gastroprotective, anti-spasmodic, antibacterial, anti-platelet aggregation, and anti-cancer properties.
  • Cardamom causes vasodilation (dilation of blood vessels) and allows blood to flow more easily, thus lowering blood pressure.
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  •  Mix 1 teaspoon of cardamom powder with raw organic honey in a cup of warm filtered water. Drink twice a day.

Hibiscus Tea


  • Hibiscus is widely used around the world to manage blood pressure.
  • Hibiscus acts as a diuretic and flushes out all the excess fluid that is in your heart and in your tissues. This decreases the pressure on the arterial walls. Vessel walls are relaxed and blood volume is decreased, thus lowering your blood pressure.
  • A study performed in 2008 shows that 3 cups of hibiscus tea daily lowers systolic blood pressure (SBP) by 7 mm Hg, after only 6 weeks.


  • Seep dried hibiscus leaves into a cup of hot filtered water. Add raw organic honey and lemon for taste



  • For centuries, hawthorn has been used for cardiac, circulatory, and respiratory disorders. The berries of the plant has been specifically used to treat high blood pressure, irregular heartbeats, chest pain, atherosclerosis, and heart failure.
  • Hawthorn also contains flavonoids, which are antioxidants that destroy free radicals. Flavonoids help dilate blood vessels, improve the flow of blood, and protect against blood vessel damage.


  • Drink hawthorn tea 1-3 times a day.

Cat’s Claw


  • Cat’s claw (uncaria tomentosa) is a popular herb in China, South America, and Central America. It is widely used in China for the treatment of high blood pressure. Cat’s claw lowers blood pressure by inducing vasodilation. Dilated blood vessels allow the blood to flow more easily. It also acts as a mild diuretic and rids the body of harmful excess
  • Activated NO dilates blood vessels, making it easier for the blood to circulate throughout the body.
  • By keeping the blood vessels open, blood is able to efficiently carry vital oxygen and nutrients all over the body. Dilated blood vessels decrease stress in the body, ultimately lowering blood pressure and reduces the risk of stroke and heart attacks.


  • A typical daily dose of cat’s claw is 350 milligrams. Cat’s claw tea is also a good alternative.



  • Mistletoe is not the first thing that may come to one’s mind when thinking about lowering elevated blood pressures. There is a lot more to this plant than just being a beautiful holiday decoration.
  • Mistletoe boosts the immune system, lowers blood pressure, and helps treat cancer and hepatitis. Mistletoe extracts contain an active compound called alkaloids. Alkaloids lower blood pressure by controlling nerve impulses along the heart and arterial walls. The actions of mistletoe are gradual but have a long-lasting effect on blood pressure.


  • Mistletoe can be harmful and poisonous if consumed raw and unprocessed. Always consult with a doctor before taking mistletoe extracts, to avoid hypotension (below normal blood pressure).

Turmeric (Curcumin)


  • Curcumin is the main component of turmeric. Turmeric is one of the most studied spices in the world. It is known to significantly decrease inflammation throughout the body. By reducing inflammation, turmeric improves blood flow and improves cardiovascular function.
  • Turmeric can help remove some of the plaque build-ups off arterial walls. Turmeric is also a natural blood thinner, which improves blood flow and thus, lowers blood pressure.


  •  Add turmeric powder to your favorite tea, and flavor it with ginger and raw organic honey. Turmeric capsules or tinctures are also available.

Omega-3 (Fatty Acids)


  • Omega-3 is great at lowering blood pressure and cholesterol.
  • Fish oil contains Essential Fatty Acids (EFA). EFAs are polyunsaturated fats derived from linolenic (Omega-3), linoleic (Omega-6), and oleic acids. These are essential fats, meaning that our bodies cannot produce them on its own. It is crucial that EFAs are obtained from our diet.
  • The balanced ratio that is needed by our bodies of Omega-6 and Omega-3 is between 2:1-4:1. Due to the American diet, our ratios have become 10:1-30:1. Unfortunately, a large chunk of the population is lacking in Omega-3.
  • Omega-3 is important for decreasing inflammation throughout the body. Decreasing inflammation helps prevent heart disease, autoimmune diseases, stroke, and mental illnesses (inflammation of the brain). It is also well-known that Omega-3s are effective at fighting depression and anger.


  • Fatty fish such as salmon, herring, trout, krill, canned tuna, and sardines contain a good amount of Omega-3. The daily recommended dose of Omega-3 is 1,000 milligrams.

Vitamin D


  • Vitamin D is a “sun vitamin” that regulates over 200 genes. It is also responsible for proper cell growth and development. Usually, 50-90% of vitamin D is absorbed by our bodies, directly from the sun. The remainder comes from our diet. Natural sources of Vitamin D can be found in eggs, fatty fish, fortified dairy and meats.
  • Since people are spending less and less time outdoors, vitamin D deficiency is on the rise and is affecting people worldwide.
  • A study published in 2014 shows that Vitamin D supplementation helps to lower high blood pressure. Vitamin D suppresses the hormone renin, which is similar to the effect of angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors are popularly prescribed antihypertensives.


  • If you are going to take supplements, make sure to get D3 (cholecalciferol), and not D2 (ergocalciferol). Vitamin D3 is the active form that our bodies can use. The recommended daily dose of Vitamin D3 is 2,000 IU.




  • CoQ10 is a naturally occurring enzyme. It contains antioxidants that are good for maintaining cardiac health.
  • CoQ10 has been shown to decrease blood pressure and reduces the thickening of the heart muscle (hypertrophy).
  • There are no known side effects of CoQ10 since it naturally occurs in the body.


  • According to Mayo Clinic, for the treatment of hypertension, take 60-360 milligrams daily for 8-12 weeks.

 French Lavender


  • Lavender is a popular fragrance that is widely used as a relaxer of the mind, body and soul. This herb is also known to help decrease your blood pressure and heart rate.
  • One study shows that aromatherapy with certain essential oils can lower blood pressure. Effective oils include blends of lavender, ylanglang, and bergamot. The recommended usage is once daily, for 4-weeks.


  • Use lavender essential oils, or incorporate lavender into your baked foods and daily cooking.

Relax & Listen to (Classical) Music



  • Surprisingly, stress plays a huge role in cardiovascular disease.
  • Music has a calming effect and can be used as stress-relieving therapy. Music subconsciously affects our mood. The right type of music can have a positively calming effect and has been proven to lower blood pressure.
  • Listening to music for at least 30-minutes a day can lower blood pressure, slow down heart rate, and decrease anxiety.


  • Set aside sometime every day to just relax and listen to some Giuseppe Verdi or Beethoven’s Ninth Symphony.

Exercise – Get Walking


  • Being overweight puts extra pressure on your arterial walls and forces your heart to work harder 24/7. It also puts you at risk for developing other diseases, such as atherosclerosis, which can lead to hypertension, cardiovascular disease, heart attacks, and stroke. A sedentary lifestyle can increase your risk of having high blood pressure by 30 percent. Walking is the best exercise you can do for your entire body.
  • One study shows that light exercising (brisk walking or light jogging) aids in decreasing elevated blood pressure. Walking daily can also help you to go to sleep more easily, and stay asleep.

Homeopathic Remedies to Lower Blood Pressure

  • Belladonna – While good for throbbing and violent conditions that start suddenly, it can be useful for high blood pressure as well. It’s one of the main remedies in a hypertensive crisis, with flushes of heat, pounding headache, an impending stroke.
  • Glonoinum – This one is helpful for high blood pressure that may be accompanied by a pulsating, congestive headache that worsens in the sun. A headache is worse from the sun. Your face is flushed. Along with hypertension, you may have angina that causes a hot sensation in the chest.
  • Nux Vomica – The candidates for Nux are easily angered or upset, and compulsive workaholics. They are chilly in body temperature and tend to complain of gastrointestinal upset (diarrhea, constipation, stomach pain, nausea, etc.). They crave stimulants, such as drugs, caffeine or alcohol. This character profile paves the way toward high blood pressure.
  • Natrum Mur – This is a salty remedy that helps symptoms caused by grief. High blood pressure can return following an emotional event, like the death of a spouse. These people tend not to like sympathy and are emotionally closed off.
  • Baryta Carbonica – Used for hypertension in people who are very shy and have difficulty concentrating. Symptoms are worse when lying on the left side. They can include strong stomach pain that recedes when lying on the stomach.
  • Aurum – A common recommendation for people with hypertension triggered by stress endured over the long term. It’s like it’s burning inside them; this feeling is often linked to their job.
  • Lachesis – This remedy is good for high blood pressure where one’s face is flushed and whose behavior is overactive, and who overall appears primed to explode one day.

Healthy diet to Prevent Hypertension

Advice from NICE includes

  • Weight reduction should be suggested if necessary, to maintain an ideal body mass index (BMI) of 18.5-24.9 kg/m. Offer a diet sheet and/or dietetic appointment. Dietary self-help (eg, dieting clubs, for which there may be local referral options) may be appropriate. Encourage physical activity alongside dietary changes. NICE guidelines for obesity make further recommendations about pharmaceutical and surgical options where appropriate.
  • Use of wholegrain varieties of starchy food (eg, rice, pasta, bread) where possible.
  • Reduction of saturated fats, and increasing monounsaturated fats, using olive or rapeseed oils and spreads.
  • Reduction in sugar intake and that of foods containing refined sugars.
  • Eating at least five portions of fruit and vegetables per day.
  • Eating at least two portions of fish per week, including a portion of oily fish.
  • Eating at least 4-5 portions of unsalted nuts, seeds, and legumes per week
  • Reducing any excessive caffeine consumption.
  • Low dietary salt
  • Keeping alcohol within current national recommended levels. (Currently, no more than 14 units per week for men and women, spread through the week, with at least two days alcohol-free.)
  • Calcium, magnesium or potassium supplements are not recommended.


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