Exploring 6 Common Types of Hypertensive Disorders, Disease Management

Primary Hypertension

Cleveland Clinic defines essential or primary hypertension as high blood pressure not precipitated by another medical condition. Typically, this type of hypertension is linked to obesity, genetics, or unhealthy nutrition habits.

High arterial pressure can cause damage to blood vessels. Prolonged hypertension has been linked to brain aneurysms, dementia, heart attacks, heart failure, kidney disease, malignant hypertension, stroke, and vision loss.

Multiple factors, including advanced age, diabetes, excessive salt intake, excessive caffeine intake, family history, obesity, alcohol use disorder, sedentary lifestyles, and insomnia, can trigger primary hypertension.

Unlike secondary hypertension, primary hypertension is not a byproduct of a singular condition or medication.

According to the Cleveland Clinic, “Primary and secondary hypertension can co-exist; particularly, when there’s an acute worsening of blood pressure, a new secondary cause should be considered.”

Symptoms of primary hypertension include hematuria, blurred vision, chest pain, shortness of breath, dizziness, lightheadedness, fatigue, mental fog, nosebleeds, and severe headaches.

Before diagnosing a patient with primary hypertension, providers evaluate their medical history to eliminate secondary hypertension. Additionally, they conduct blood pressure checks. If multiple blood pressure checks identify high blood pressure, patients may be asked to participate in 24-hour ambulatory blood pressure monitoring.

There are two primary routes for managing primary hypertension: lifestyle changes and medication.

The most commonly recommended lifestyle changes include increasing physical activity, ceasing alcohol and drug use, consuming a heart-healthy diet, getting enough sleep, and smoking cessation.

The six major medications used to manage primary hypertension include the following:

• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin II receptor blockers (ARBs)
• Beta-blockers
• Calcium channel blockers
• Diuretics
• Vasodilators

Secondary Hypertension

The Mayo Clinic reveals that secondary hypertension is high blood pressure caused by an underlying medical condition. The symptoms and characterization are the same as primary hypertension. The primary difference is that there is a cause.

The most common causes of secondary hypertension are kidney diseases that alter the body’s filtering system, including diabetic nephropathy, polycystic kidney disease, glomerular disease, and renovascular hypertension.

Hormonal disorders, including Cushing syndrome, aldosteronism, pheochromocytoma, thyroid problems, and hyperparathyroidism, can also cause secondary hypertension.

Other factors, such as coarctation of the aorta, sleep apnea, obesity, pregnancy, or medication side effects, can cause secondary hypertension.

Pregnancy-Related Hypertensive Disorders

Three hypertensive disorders can impact pregnancy: chronic hypertension, gestational hypertension, and preeclampsia. Chronic hypertension develops independently of pregnancy; however, it can impact pregnancy outcomes and fetal development.

The American College of Obstetrics and Gynecology (ACOG) categorizes gestational hypertension as a systolic blood pressure greater than 140 mmHg or a diastolic blood pressure greater than 90 mmHg despite having normal blood pressure before pregnancy. It can increase the risk of developing high blood pressure after pregnancy.

ACOG notes that preeclampsia is similar to gestational hypertension, but other physiological changes, such as proteinuria, accompany it.

Resistant Hypertension

Johns Hopkins Medicine defines resistant hypertension as high blood pressure that does not respond to medications. More specifically, providers diagnose resistant hypertension when patients’ blood pressure remains unmanaged even while they are taking three different blood pressure medications at the maximum dose. One of those medications should be a diuretic.

Other criteria include blood pressure over the goal pressure, which may vary between patients but is often 130/80 mmHg. Additionally, even if high blood pressure is managed with four or more medications, it is considered resistant hypertension.

An estimated 20% of hypertensive patients have resistant hypertension. In some cases, the condition may be asymptomatic, but left untreated, it can cause heart attack, stroke, vision impairments, and kidney damage.

Approximately 25% of resistant hypertension cases are types of secondary hypertension. According to Hopkins Medicine, the most common causes of secondary resistant hypertension are structural disorders, including sleep apnea, renal artery stenosis, coarctation of the aorta, or kidney failure, and hormonal disorders, including primary aldosteronism, pheochromocytoma, hyperthyroidism, hypothyroidism, Cushing's disease, or congenital neuroendocrine diseases.

Without managing the underlying condition, it is unlikely that a patient will be able to control their blood pressure, resulting in arterial damage.

The remaining 75% of resistant hypertension patients have an idiopathic cause; however, medication management and lifestyle changes can help improve symptoms.

Malignant Hypertension

Mount Sinai defines malignant hypertension as a sudden onset of very high blood pressure. This condition is more common in young Black male adults.

The risk of malignant hypertension is higher for patients with collagen vascular disorder, including systemic lupus erythematosus, systemic sclerosis, and periarteritis nodosa. Other risk factors include kidney problems and pregnancy-induced high blood pressure.

Lifestyle factors, such as smoking, combined with other conditions, such as kidney failure and renal hypertension resulting from renal artery stenosis, may also increase the risk of malignant hypertension.

Common symptoms of malignant hypertension include blurred vision, cognitive impairment, chest pain, cough, headache, nausea, vomiting, numbness of face or extremities, reduced urine output, seizures, shortness of breath, and fatigue.

Long-term complications of malignant hypertension may include brain damage, heart damage, kidney failure, blindness, and fluid in the lungs.

Malignant hypertension is considered a medical emergency. Physical exams often revealed extremely high blood pressure, foot swelling, and abnormal heart sounds. Additionally, ocular exams may reveal retinal bleeding or narrowing, optic nerve swelling, and other retinal issues triggered by high blood pressure.

Considering it is a medical emergency, patients are often admitted to the hospital and provided intravenous medications to reduce blood pressure. Providers also manage the resulting symptoms and provide oral blood pressure medications to manage the condition and prevent another malignant hypertension case.

Isolated Systolic Hypertension

Isolated systolic hypertension is a systolic blood pressure over 140 mmHg and a diastolic blood pressure less than 90 mmHg. It is the most common form of hypertension in elderly patients, impacting roughly 15% of people over 60.

Isolated systolic hypertension is commonly a form of primary hypertension; however, StatPearls notes that, in rare cases, it can be a secondary hypertensive disorder caused by thyroid conditions, chronic kidney disease, peripheral vascular disease, diabetes mellitus, aortic insufficiency, arteriovenous fistula, anemia, Paget disease, or atherosclerotic renal artery stenosis.

Left untreated, the condition can lead to stroke, myocardial infarction, heart failure, peripheral vascular disease, aneurysm, chronic kidney disease, retinopathy, and erectile dysfunction.

Understanding common hypertensive disorders can help patients and providers understand how to manage the condition through medication and lifestyle changes.