Hypertension
A sustained rise in systemic arterial pressure that is usually clinically silent because vessels adapt gradually with no acute pain signal, so screening and end-organ assessment (not symptoms) drive both diagnosis and the urgency of treatment.
In a nutshell
Hypertension is a rise in cardiac output × resistance with no single cause and no acute pain signal, so it is silent until end-organ damage or a hypertensive emergency reveals it. Diagnosis rests on ambulatory confirmation, and first-line drug choice follows the dominant physiological driver by age and ethnicity.
Classic presentation
An asymptomatic adult found to have a persistently raised blood pressure on routine screening, confirmed by ambulatory monitoring, with no symptoms at all.
Key points
- Hypertension is usually asymptomatic because vessels adapt gradually and there is no nociceptive signal for sustained pressure: diagnosis depends on measurement, not symptoms.
- A single clinic reading is not diagnostic; ABPM or HBPM confirms sustained elevation and avoids white-coat overdiagnosis.
- End-organ damage follows the vasculature of each organ: retinopathy in the eye, nephrosclerosis in the kidney, lacunar infarcts in the brain, and LVH in the heart.
- First-line drug choice depends on the dominant physiological driver: ACE inhibitor/ARB for younger or non-Black patients (renin-driven), calcium channel blocker for those over 55 or of Black African/Caribbean origin (renin-independent).
- Severe hypertension with papilloedema or retinal haemorrhage (accelerated/malignant hypertension) is a same-day emergency, unlike routine essential hypertension.
First-line investigation
Ambulatory or home blood pressure monitoring: it confirms sustained elevation rather than a single potentially white-coat-affected clinic reading.
First-line management
Confirm diagnosis with ABPM/HBPM, advise lifestyle modification, then start stepwise antihypertensive therapy chosen by age and ethnicity.
Exam traps
- A single high clinic reading is not diagnostic: the exam expects ABPM/HBPM confirmation before labelling hypertension.
- First-line drug choice is determined by age and ethnicity, not simply prescribed in a fixed order for everyone.
- Asymptomatic severe hypertension without papilloedema or acute end-organ damage does not require emergency admission: accelerated hypertension with retinal signs does.
- Secondary causes (renal artery stenosis, Conn's syndrome, phaeochromocytoma) should be suspected with resistant hypertension or an atypical age of onset, not assumed in every patient.
Educational content pending clinical review. Not medical advice.