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Clinical Review ABC of hypertension

The pathophysiology of hypertension

BMJ 2001; 322 doi: (Published 14 April 2001) Cite this as: BMJ 2001;322:912
  1. Gareth Beevers,
  2. Gregory Y H Lip,
  3. Eoin O'Brien

    There is still much uncertainty about the pathophysiology of hypertension. A small number of patients (between 2% and 5%) have an underlying renal or adrenal disease as the cause for their raised blood pressure. In the remainder, however, no clear single identifiable cause is found and their condition is labelled “essential hypertension”. A number of physiological mechanisms are involved in the maintenance of normal blood pressure, and their derangement may play a part in the development of essential hypertension.

    This article has been adapted from the newly published 4th edition of ABC of Hypertension. The book is available from the BMJ bookshop and at

    The relative frequency of primary and secondary hypertension

    It is probable that a great many interrelated factors contribute to the raised blood pressure in hypertensive patients, and their relative roles may differ between individuals. Among the factors that have been intensively studied are salt intake, obesity and insulin resistance, the renin-angiotensin system, and the sympathetic nervous system. In the past few years, other factors have been evaluated, including genetics, endothelial dysfunction (as manifested by changes in endothelin and nitric oxide), low birth weight and intrauterine nutrition, and neurovascular anomalies.

    Physiological mechanisms involved in development of essential hypertension

    • Cardiac output

    • Peripheral resistance

    • Renin-angiotensin-aldosterone system

    • Autonomic nervous system

    • Other factors:

    • Bradykinin

    • Endothelin

    • EDRF (endothelial derived relaxing factor) or nitric oxide

    • ANP (atrial natriuretic peptide)

    • Ouabain

    Cardiac output and peripheral resistance

    Maintenance of a normal blood pressure is dependent on the balance between the cardiac output and peripheral vascular resistance. Most patients with essential hypertension have a normal cardiac output but a raised peripheral resistance. Peripheral resistance is determined not by large arteries or the capillaries but by small arterioles, the walls of which contain smooth muscle cells. Contraction of smooth muscle cells is thought to be related to a rise in intracellular calcium concentration, which may explain the vasodilatory …

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