Although the United States has defined hypertension by systolic blood pressure (SBP) ≥ 130 mm Hg and/or diastolic blood pressure (DBP) ≥ 80 mm Hg since 2017, most countries and regions in Europe and Asia continue to use a hypertension threshold of SBP ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg. The most common symptoms of hypertension include headache, dizziness, flushing, and neck and back pain, although many hypertensive patients do not experience any discomfort. However, some individuals have blood pressure (BP) that is elevated and accompanied by the above symptoms, yet does not meet the diagnostic criteria of hypertension. For example, a patient’s baseline BP may be 100/70 mm Hg. When the BP reaches 120/75 mm Hg, the patient may experience symptoms similar to those of hypertension. A diagnosis of hypertension cannot be made, yet the symptoms are caused by elevated BP. To better manage these individuals, a definition is necessary; we believe that “hypertensive-like reaction” is an appropriate term for this condition.
The Rationale for Hypertensive-Like Reaction
The clinical prognosis of this syndrome requires further exploration. In fact, the diagnostic criteria for hypertension are subjective; for example, the United States has adopted diagnostic criteria for hypertension that differ from those used in other countries and regions. However, studies have shown that the relationship between BP levels and the risk of adverse cardiovascular events is continuous and linear. In a meta-analysis by Lewington et al., in people 40–69 years of age, each difference of 20 mm Hg usual SBP (or, approximately equivalently, 10 mm Hg usual DBP) is associated with more than a twofold difference in the stroke death rate, and with twofold differences in the death rates from ischemic heart disease and other vascular causes [1]. In addition, Whelton et al. have found a stepwise increase in the risk of atherosclerotic cardiovascular disease with an increase in SBP ranging from 90 to 129 mmHg. For every 10 mmHg increase in SBP, the risk of atherosclerotic cardiovascular disease is 53% higher [2]. A similar conclusion has been reached in a meta-analysis by Huang et al. [3]. These results suggest that attention should be paid to not only hypertensive patients but also the BP of normotensive individuals, particularly their dynamic changes in BP. Because this special state is associated with not only obvious clinical symptoms but also increased risk of cardiovascular disease [4], we believe that hypertensive-like reaction should be recognized as a separate BP category from asymptomatic normotensive or high normal BP.
Treatment of Hypertensive-Like Reaction
Research indicating whether individuals with hypertensive-like reaction require drug intervention remains lacking. The level of BP leading to hypertensive-like reaction is generally categorized as high normal BP or prehypertension [5]. In the 2017 ACC/AHA hypertension guidelines, the level has been classified as elevated BP or hypertension [6]. To date, the need for medication for prehypertension remains controversial [7, 8], but lifestyle interventions are reasonable strategies for all patients. Therefore, for individuals with hypertensive-like reaction, therapeutic lifestyle modification should be recommended first. Patients with clear causes of BP elevation, should be guided to address the relevant causes. We believe that drug treatment should not be routinely encouraged for these individuals. However, low dose antihypertensive drugs may be considered for patients who have substantial symptoms despite positive lifestyle modifications and are willing to receive drug treatment, although the effects on prognosis remain unclear.