The Tension behind Hypertension

Hypertension (high blood pressure) is the most prevalent modifiable risk factor for cardiovascular disease worldwide. It contributes significantly to heart attacks, stroke, chronic kidney disease, and heart failure. Despite its impact, hypertension is frequently underdiagnosed and undertreated in primary care.

In Ireland, nearly 1 in 3 adults has high blood pressure, yet an estimated 50% are unaware of their condition. In the UK, over 14 million people are affected, with similar gaps in diagnosis and management. As many as 1 in 3 diagnosed patients do not achieve adequate blood pressure control.

Risk Factors and Diagnosis

Hypertension is influenced by a combination of genetic, environmental, and lifestyle factors. Common risk factors include:

• Age over 55
• Obesity or overweight
• Sedentary lifestyle
• High salt intake
• Excessive alcohol consumption
• Family history of hypertension

Diagnosis requires repeated elevated readings (typically >140/90 mmHg in clinic settings) or use of ambulatory blood pressure monitoring (ABPM) for confirmation. White-coat hypertension and masked hypertension complicate the diagnostic process, making out-of-office measurements increasingly important.

Clinical Consequences

Uncontrolled hypertension increases the risk of:

• Ischaemic heart disease
• Stroke (both haemorrhagic and ischaemic)
• Left ventricular hypertrophy and heart failure
• Chronic kidney disease and end-stage renal failure
• Atrial fibrillation and vascular dementia

The World Health Organization estimates that hypertension contributes to more than 7.5 million deaths globally each year — about 12.8% of total deaths.

Treatment and Targets

First-line treatment includes lifestyle modification:

• Salt reduction (<5 g/day)
• Weight loss
• Regular physical activity
• Limiting alcohol intake
• Smoking cessation

Pharmacological treatment typically starts with:

• ACE inhibitors or ARBs
• Calcium channel blockers
• Thiazide-like diuretics

National guidelines recommend a treatment goal of <140/90 mmHg for most patients, with stricter targets (<130/80 mmHg) for those at high cardiovascular risk.

Missed Opportunities in Primary Care

Despite the availability of effective treatments, many patients remain undiagnosed or inadequately controlled due to:

• Infrequent screening, particularly in younger adults
• Poor follow-up after initial elevated readings
• Lack of access to ABPM or home monitoring
• Low medication adherence

Improving hypertension detection and control in primary care requires:

• Systematic screening of all adults over age 40
• Use of digital alerts and reminders for follow-up
• Integration of ABPM and home BP readings into health records
• Patient education on adherence and risk reduction

Conclusion

Hypertension is a silent but preventable contributor to some of the most serious health conditions seen in primary care. Strengthening early identification and sustained control of blood pressure can yield significant population-level health benefits.

Primary care remains the most strategic setting for improvement — but it needs the right tools, time, and systems to act early and consistently.

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