Hypertension

Getting the diagnosis right

A single high reading in a clinic is not hypertension. Blood pressure should be measured correctly — seated, rested, correct cuff size, arm supported — and confirmed either with home readings over a week or with 24-hour ambulatory monitoring.

Ambulatory monitoring also identifies the two patterns that clinic readings miss entirely: white-coat hypertension, where treating on clinic readings alone leads to over-medication, and masked hypertension, where normal clinic readings conceal genuinely elevated pressure and real risk.

Treatment

Most patients require more than one agent to reach target, and starting with a low-dose combination is generally more effective and better tolerated than pushing a single drug to its maximum. The target depends on age, diabetes status, kidney function and overall cardiovascular risk.

Salt reduction, weight loss, alcohol moderation and regular aerobic exercise each produce measurable reductions and are not optional adjuncts to the drugs.

When it will not come down

Blood pressure that remains above target on three agents including a diuretic warrants a search for a cause rather than a fourth drug. Adherence, salt intake and interfering medications come first. Beyond that: primary aldosteronism, which is far more common than historically believed; renal artery stenosis; obstructive sleep apnoea; thyroid and kidney disease.

Hypertensive emergency

A severe, abrupt rise in blood pressure accompanied by chest pain, severe headache, visual disturbance, breathlessness, weakness on one side or confusion is a medical emergency and requires immediate hospital assessment — not an increased dose at home.

Severe readings without any of these features still need urgent review, but lowering pressure too quickly can itself cause harm, which is why this is managed rather than corrected on the spot.