Hypertension does not cause symptoms in most people.1-4 There is a common misbelief among patients that hypertension always causes symptoms, but most people with hypertension have no symptoms.3,4 This lack of significant symptoms and the fact that hypertension is the biggest risk factor for cardiovascular disease is why it has become known worldwide as “The Silent Killer.”3,5,6
It should be noted this PALS article is discussing mild and moderate hypertension, not hypertensive crisis. People experiencing a hypertensive crisis have dangerously high blood pressure (above 180/120 mm Hg) and clinical signs or symptoms of serious organ damage.7
The World Health Organization (WHO) states that most people with hypertension have no symptoms.3 However, they follow this statement with the acknowledgement that sometimes people can have symptoms, such as headache, dizziness, shortness of breath, nose bleeds, chest pain, and heart palpitations. The WHO also states that these symptoms cannot be relied on to identify people with hypertension.
Studies have tried to determine whether symptoms are caused by high blood pressure and whether symptoms can help identify people for diagnosis. Many studies found no significant correlation between high blood pressure and epistaxis.8-11 However, one meta-analysis did find an association between high blood pressure and epistaxis.9 Regardless, most studies agree that symptoms are not reliable indicators of blood pressure status.
Hypertension and Epistaxis Study Details
In 1972, Weiss et al. reviewed data from the 1960 to 1962 Health Examination Survey of adults. They analyzed a self-administered medical history form and the blood pressure of 6,672 adults.8 They found no correlation between headache, epistaxis, and tinnitus with high blood pressure. Dizziness was found more often only in people with a very high diastolic pressure (>110 mm Hg), and fainting occurred less often in people with higher blood pressure.
A 2017 systematic review and meta-analysis of the association between hypertension and epistaxis was performed on 10 studies with 9,574 participants total.9 Min et al. found a significantly increased risk of epistaxis for hypertensive patients (odds ratio [OR] 1.532, 95% CI [1.181 – 1.986], p=0.038). However, the analysis could not prove a causal relationship between hypertension and epistaxis due to limitations in the available studies and because hypertensive patients did not have a sign of increased increased risk for epistaxis in cohort studies, but did in the case-control studies.
Symptoms Due to Secondary Hypertension
Up to 10% of hypertension is caused by an underlying condition.12-15 This is called secondary hypertension. These conditions often cause symptoms. Causes of secondary high blood pressure include:7
Condition
|
Signs and Symptoms
|
Renal disease
|
Urinary frequency, nocturia, hematuria, urinary tract infections, fatigue, dizziness, weakness, shortness of breath, confusion, nausea, vomiting, and swelling of feet, hands, or face
|
Primary aldosteronism
|
Headache, fatigue, leg cramps, weakness, constipation
|
Obstructive sleep apnea
|
Fitful sleep, daytime sleepiness, snoring, morning headache
|
Drug- or alcohol-induced
|
Fine tremor, racing heartbeat, sweating, headache, dizziness, nausea, vomiting
|
Pheochromocytoma
|
Headache, sweating, palpitations, pallor
|
Cushing’s syndrome
|
Weight gain, stretch marks, easy bruising, proximal muscle weakness, fatigue, headache, emotional lability, depression, hirsutism (women)
|
Hypothyroidism
|
Dry skin, cold intolerance, constipation, hoarseness, weight gain, coarse skin
|
Hyperthyroidism
|
Heat intolerance, nervousness, tremor, weight loss, insomnia, diarrhea, proximal muscle weakness
|
Aortic coarctation
|
Headache, leg cramps, chest pain, nosebleeds, muscle weakness
|
Acromegaly
|
Headache, visual disturbance, polydipsia, polyuria, enlarged hands, feet, or facial features
|
Primary hyperparathyroidism
|
Excessive thirst, frequent urination, nausea, vomiting, constipation, bone pain, muscle weakness, confusion, fatigue, palpitations
|
Congenital adrenal hyperplasia
|
Early pubic hair, rapid growth in childhood, severe acne, hypokalemia (fatigue, leg cramps, weakness, constipation)
Women only: hirsutism, deep voice, absent or irregular periods
|
Mineralocorticoid excess syndromes
|
Hypokalemia (fatigue, leg cramps, weakness, constipation)
|
References
- Ohler WR. The signs and symptoms of hypertension. Am Heart J 1927; 2 (6): 609-612.
- Page IH. Hypertension: a symptomless but dangerous disease. N Engl J Med 1972; 287 (13): 665-666.
- A global brief on hypertension: silent killer, global health crisis. Geneva, Switzerland: World Health Organization; 2013.
- Siu AL. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2015; 163 (10): 778-786.
- Bell K, Twiggs J, Olin BR, Date IR. Hypertension: The silent killer: updated JNC-8 guideline recommendations. Ala Pharm Assoc 2015: 1-8.
- Sawicka K, Szczyrek M, Jastrzebska I, Prasal M, Zwolak A, Daniluk J. Hypertension–the silent killer. JPPCR 2011; 5 (2).
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2017.
- Weiss NS. Relation of high blood pressure to headache, epistaxis, and selected other symptoms. The United States Health Examination Survey of Adults. N Engl J Med 1972; 287 (13): 631-633.
- Min HJ, Kang H, Choi GJ, Kim KS. Association between hypertension and epistaxis: systematic review and meta-analysis. Otolaryngol Head Neck Surg 2017; 157 (6): 921-927.
- Kikidis D, Tsioufis K, Papanikolaou V, Zerva K, Hantzakos A. Is epistaxis associated with arterial hypertension? A systematic review of the literature. Eur Arch Otorhinolaryngol 2014; 271 (2): 237-243.
- Knopfholz J, Lima-Junior E, Precoma-Neto D, Faria-Neto JR. Association between epistaxis and hypertension: a one year follow-up after an index episode of nose bleeding in hypertensive patients. Int J Cardiol 2009; 134 (3): e107-109.
- Pullalarevu R, Akbar G, Teehan G. Secondary hypertension, issues in diagnosis and treatment. Prim Care 2014; 41 (4): 749-764.
- Omura M, Saito J, Yamaguchi K, Kakuta Y, Nishikawa T. Prospective study on the prevalence of secondary hypertension among hypertensive patients visiting a general outpatient clinic in Japan. Hypertens Res 2004; 27 (3): 193-202.
- Anderson GH, Jr., Blakeman N, Streeten DH. The effect of age on prevalence of secondary forms of hypertension in 4429 consecutively referred patients. J Hypertens 1994; 12 (5): 609-615.
- Sinclair AM, Isles CG, Brown I, Cameron H, Murray GD, Robertson JW. Secondary hypertension in a blood pressure clinic. Arch Intern Med 1987; 147 (7): 1289-1293.