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Hypertension
Classification and external resources

Automated arm blood pressure meter showing arterial hypertension (shown a systolic blood pressure 158 mmHg, diastolic blood pressure 99 mmHg and heart rate of 80 beats per minute).
ICD-9 401.x
OMIM 145500
DiseasesDB 6330
MedlinePlus 000468
eMedicine med/1106 ped/1097 emerg/267
MeSH D006973

Hypertension is a chronic medical condition in which the blood pressure is elevated. It is also referred to as high blood pressure or shortened to HT, HTN or HPN. The word "hypertension", by itself, normally refers to systemic, arterial hypertension.[1]

Hypertension can be classified as either essential (primary) or secondary. Essential or primary hypertension means that no medical cause can be found to explain the raised blood pressure and represents about 90-95% of hypertension cases.[2][3][4][5] Secondary hypertension indicates that the high blood pressure is a result of (i.e., secondary to) another condition, such as kidney disease or tumours (adrenal adenoma or pheochromocytoma).

Persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysm, and is a leading cause of chronic renal failure.[6] Even moderate elevation of arterial blood pressure leads to shortened life expectancy. At severely high pressures, defined as mean arterial pressures 50% or more above average, a person can expect to live no more than a few years unless appropriately treated.[7] Beginning at a systolic pressure (which is peak pressure in the arteries, which occurs near the end of the cardiac cycle when the ventricles are contracting) of 115 mmHg and diastolic pressure (which is minimum pressure in the arteries, which occurs near the beginning of the cardiac cycle when the ventricles are filled with blood) of 75 mmHg (commonly written as 115/75 mmHg), cardiovascular disease (CVD) risk doubles for each increment of 20/10 mmHg.[8]

Contents

Classification

The variation in pressure in the left ventricle (blue line) and the aorta (red line) over two cardiac cycles ("heart beats"), showing the definitions of systolic and diastolic pressure.

A recent classification recommends blood pressure criteria for defining normal blood pressure, prehypertension, hypertension (stages I and II), and isolated systolic hypertension, which is a common occurrence among the elderly. These readings are based on the average of seated blood pressure readings that were properly measured during 2 or more office visits. In individuals older than 50 years, hypertension is considered to be present when a person's blood pressure is consistently at least 140 mmHg systolic or 90 mmHg diastolic. Patients with blood pressures over 130/80 mmHg along with Type 1 or Type 2 diabetes, or kidney disease require further treatment.[8]

Classification Systolic pressure Diastolic pressure
mmHg kPa mmHg kPa
Normal 90–119 12–15.9 60–79 8.0–10.5
Prehypertension 120–139 16.0–18.5 80–89 10.7–11.9
Stage 1 140–159 18.7–21.2 90–99 12.0–13.2
Stage 2 ≥160 ≥21.3 ≥100 ≥13.3
Isolated systolic
hypertension
≥140 ≥18.7 <90 <12.0
Source: American Heart Association (2003).[8]

Resistant hypertension is defined as the failure to reduce blood pressure to the appropriate level after taking a three-drug regimen (include thiazide diuretic).[8] Guidelines for treating resistant hypertension have been published in the UK,[9] and US.[10]

Excessive elevation in blood pressure during exercise is called exercise hypertension.[11][12][13] The upper normal systolic values during exercise reach levels between 200 and 230 mm Hg.[14] Exercise hypertension may be regarded as a precursor to established hypertension at rest.[13][14]

Signs and symptoms

Mild to moderate essential hypertension is usually asymptomatic.[15][16][17][18][19] Accelerated hypertension is associated with headache, somnolence, confusion, visual disturbances, and nausea and vomiting (hypertensive encephalopathy). Retinas are affected with narrowing of arterial diameter to less than 50% of venous diameter, copper or silver wire appearance, exudates, hemorrhages, or papilledema.[20] Some signs and symptoms are especially important in infants and neonates such as failure to thrive, seizure, irritability or lethargy, and respiratory distress.[21] While in children hypertension may cause headache, fatigue, blurred vision, epistaxis, and bell palsy.[21]

Some signs and symptoms are especially important in suggesting a secondary medical cause of chronic hypertension, such as centripetal obesity, "buffalo hump," and/or wide purple abdominal striae and maybe a recent onset of diabetes suggest glucocorticoid excess either due to Cushing's syndrome or other causes. Hypertension due to other secondary endocrine diseases such as hyperthyroidism, hypothyroidism, or growth hormone excess show symptoms specific to these disease such as in hyperthyrodism there may be weight loss, tremor, tachycardia or atrial arrhythmia, palmar erythema and sweating.[22] Signs and symptoms associated with growth hormone excess such as coarsening of facial features, prognathism, macroglossia,[23] hypertrichosis, hyperpigmentation, and hyperhidrosis may occur in these patients.[24]:499. Other endocrine causes such as hyperaldosteronism may cause less specific symptoms such as numbness, polyuria, polydipsia, hypernatraemia, and metabolic alkalosis.[25] A systolic bruit heard over the abdomen or in the flanks suggests renal artery stenosis. Also radio femoral delay or diminished pulses in lower versus upper extremities suggests coarctation of the aorta. Hypertension in patients with pheochromocytomas is usually sustained but may be episodic. The typical attack lasts from minutes to hours and is associated with headache, anxiety, palpitation, profuse perspiration, pallor, tremor, and nausea and vomiting. Blood pressure is markedly elevated, and angina or acute pulmonary edema may occur. In primary aldosteronism, patients may have muscular weakness, polyuria, and nocturia due to hypokalemia. Chronic hypertension often leads to left ventricular hypertrophy, which can present with exertional and paroxysmal nocturnal dyspnea. Cerebral involvement causes stroke due to thrombosis or hemorrhage from microaneurysms of small penetrating intracranial arteries. Hypertensive encephalopathy is probably caused by acute capillary congestion and exudation with cerebral edema, which is reversible.[20]

Signs and symptoms associated with pre-eclampsia and eclampsia, can be proteinuria, edema, and hallmark of eclampsia which is convulsions, Other cerebral signs may precede the convulsion such as nausea, vomiting, headaches, and blindness.[26]

Causes

Essential hypertension

While one of the most common disorders, essential hypertension, by definition idiopathic, has an unknown cause . It is the most prevalent hypertension type, affecting 90-95% of hypertensive patients.[2][3][4][5] Although no direct cause has identified itself, there are many factors such as sedentary lifestyle,[27] Stress, visceral obesity, potassium deficiency (hypokalemia) [28] obesity[29][30][31][32][33] (more than 85% of cases occur in those with a body mass index greater than 25),[33] salt (sodium) sensitivity,[34][35][36][37] alcohol intake,[38][39] and vitamin D deficiency.[40][41][42] Risk also increases with aging,[43] some inherited genetic mutations[44][45][46][47][48][49] and family history.[50][51] An elevation of Renin, an enzyme secreted by the kidney, is another risk factor,[30][52] as is sympathetic nervous system overactivity.[32][53][54][55][56] Insulin resistance which is a component of syndrome X, or the metabolic syndrome is also thought to contribute to hypertension.[30][53][57] Recent studies have implicated low birth weight as a risk factor for adult essential hypertension.[31][58]

Secondary hypertension

Secondary hypertension by definition results from an identifiable cause. This type is important to recognize since it's treated differently than essential type by treating the underlying cause.

Many secondary causes can cause hypertension, some are common and well recognized secondary causes such as Cushing's syndrome,[59] which is a condition where both adrenal glands can overproduce the hormone cortisol. Hypertension results from the interplay of several pathophysiological mechanisms regulating plasma volume, peripheral vascular resistance and cardiac output, all of which may be increased. More than 80% of patients with Cushing's syndrome have hypertension.[59] Another important cause is the congenital abnormality coarctation of the aorta.

Adrenal

A variety of adrenal cortical abnormalities can cause hypertension, In primary aldosteronism there is a clear relationship between the aldosterone-induced sodium retention and the hypertension.[60] Another related disorder that causes hypertension is apparent mineralocorticoid excess syndrome which is an autosomal recessive disorder results from mutations in gene encoding 11β-hydroxysteroid dehydrogenase which normal patient inactivates circulating cortisol to the less-active metabolite cortisone.[61] Cortisol at high concentrations can cross-react and activate the mineralocorticoid receptor, leading to aldosterone-like effects in the kidney, causing hypertension.[62] This effect can also be produced by prolonged ingestion of liquorice(which can be of potent strength in liquorice candy), can result in inhibition of the 11β-hydroxysteroid dehydrogenase enzyme and cause secondary apparent mineralocorticoid excess syndrome.[63][64][65] Frequently, if liquorice is the cause of the high blood pressure, a low blood level of potassium will also be present.[64] Yet another related disorder causing hypertension is glucocorticoid remediable aldosteronism, which is an autosomal dominant disorder in which the increase in aldosterone secretion produced by ACTH is no longer transient, causing of primary hyperaldosteronism, the Gene mutated will result in an aldosterone synthase that is ACTH-sensitive, which is normally not.[66][67][68][69][70] GRA appears to be the most common monogenic form of human hypertension.[71] Compare these effects to those seen in Conn's disease, an adrenocortical tumor which causes excess release of aldosterone,[72] that leads to hypertension.[73][74][75]

Another adrenal related cause is Cushing's syndrome which is a disorder caused by high levels of cortisol. Cortisol is a hormone secreted by the cortex of the adrenal glands. Cushing's syndrome can be caused by taking glucocorticoid drugs, or by tumors that produce cortisol or adrenocorticotropic hormone (ACTH).[76] More than 80% of patients with Cushing's syndrome develop hypertension.[59], which is accompanied by distinct symptoms of the syndrome, such as central obesity, buffalo hump, moon face, sweating, hirsutism and anxiety.[77]

Kidney

Other well known causes include diseases of the kidney. This includes diseases such as polycystic kidney disease which is a cystic genetic disorder of the kidneys, PKD is characterized by the presence of multiple cysts (hence, "polycystic") in both kidneys, can also damage the liver, pancreas, and rarely, the heart and brain.[78][79][80][81] It can be autosomal dominant or autosomal recessive, with the autosomal dominant form being more common and characterized by progressive cyst development and bilaterally enlarged kidneys with multiple cysts, with concurrent development of hypertension, renal insufficiency and renal pain.[82] Or chronic glomerulonephritis which is a disease characterized by inflammation of the glomeruli, or small blood vessels in the kidneys.[83][84][85] Hypertension can also be produced by diseases of the renal arteries supplying the kidney. This is known as renovascular hypertension; it is thought that decreased perfusion of renal tissue due to stenosis of a main or branch renal artery activates the renin-angiotensin system.[86][87][88] also some renal tumors can cause hypertension. The differential diagnosis of a renal tumor in a young patient with hypertension includes Juxtaglomerular cell tumor, Wilms' tumor, and renal cell carcinoma, all of which may produce renin.[89]

Neuroendocrine tumors are also a well known cause of secondary hypertension. Pheochromocytoma[90] (most often located in the adrenal medulla) increases secretion of catecholamines such as epinephrine and norepinephrine, causing excessive stimulation of adrenergic receptors, which results in peripheral vasoconstriction and cardiac stimulation. This diagnosis is confirmed by demonstrating increased urinary excretion of epinephrine and norepinephrine and/or their metabolites (vanillylmandelic acid).

Medication side effects

Certain medications, especially NSAIDs (Motrin/Ibuprofen) and steroids can cause hypertension.[91][92][93][94][95] High blood pressure that is associated with the sudden withdrawal of various antihypertensive medications is called rebound hypertension.[96][97][98][99][100][101][102] The increases in blood pressure may result in blood pressures greater than when the medication was initiated. Depending on the severity of the increase in blood pressure, rebound hypertension may result in a hypertensive emergency. Rebound hypertension is avoided by gradually reducing the dose (also known as "dose tapering"), thereby giving the body enough time to adjust to reduction in dose. Medications commonly associated with rebound hypertension include centrally-acting antihypertensive agents, such as clonidine[103] and beta-blockers.[102]

Pregnancy

Few women of childbearing age have high blood pressure, up to 11% develop hypertension of pregnancy.[104] While generally benign, it may herald three complications of pregnancy: pre-eclampsia, HELLP syndrome and eclampsia. Follow-up and control with medication is therefore often necessary.[105][106]

Sleep disturbances

Another common and under-recognized sign of hypertension is sleep apnea,[107][108] which is often best treated with nocturnal nasal continuous positive airway pressure (CPAP), but other approaches include the Mandibular advancement splint (MAS), UPPP, tonsillectomy, adenoidectomy, septoplasty, or weight loss. Another cause is an exceptionally rare neurological disease called Binswanger's disease, causing dementia; it is a rare form of multi-infarct dementia, and is one of the neurological syndromes associated with hypertension.[109]

Arsenic exposure

Because of the ubiquity of arsenic in ground water supplies and its effect on cardiovascular health, low dose arsenic poisoning should be inferred as a part of the pathogenesis of idiopathic hypertension. Idiopathic and essential are both somewhat synonymous with primary hypertension. Arsenic exposure has also many of the same signs of primary hypertension such as headache, somnolence, [110] confusion, proteinuria [111] visual disturbances, and nausea and vomiting [112]

Potassium deficiency

Due to the role of intracellular potassium in regulation of cellular pressures related to sodium, establishing potassium balance has been show to reverse hypertension. [113]

Pathophysiology

A diagram explaining factors affecting arterial pressure

Most of the mechanisms associated with secondary hypertension are generally fully understood. However, those associated with essential (primary) hypertension are far less understood. What is known is that cardiac output is raised early in the disease course, with total peripheral resistance (TPR) normal; over time cardiac output drops to normal levels but TPR is increased. Three theories have been proposed to explain this:

It is also known that hypertension is highly heritable and polygenic (caused by more than one gene) and a few candidate genes have been postulated in the etiology of this condition.[124][125][126]

Recently, work related to the association between essential hypertension and sustained endothelial damage has gained popularity among hypertension scientists. It remains unclear however whether endothelial changes precede the development of hypertension or whether such changes are mainly due to long standing elevated blood pressures.

Diagnosis

Initial assessment of the hypertensive patient should include a complete history and physical examination to confirm a diagnosis of hypertension. Most patients with hypertension have no specific symptoms referable to their blood pressure elevation. Although popularly considered a symptom of elevated arterial pressure, headache generally occurs only in patients with severe hypertension. Characteristically, a "hypertensive headache" occurs in the morning and is localized to the occipital region. Other nonspecific symptoms that may be related to elevated blood pressure include dizziness, palpitations, easy fatiguability, and impotence.[21]

Measuring blood pressure

Conventional (mechanical) sphygmomanometer with aneroid manometer and stethoscope, used to measure blood pressure

Diagnosis of hypertension is generally on the basis of a persistently high blood pressure. Usually this requires three separate measurements at least one week apart. Exceptionally, if the elevation is extreme, or end-organ damage is present then the diagnosis may be applied and treatment commenced immediately.

Obtaining reliable blood pressure measurements relies on following several rules and understanding the many factors that influence blood pressure reading.[127]

For instance, measurements in control of hypertension should be at least 1 hour after caffeine, 30 minutes after smoking or strenuous exercise and without any stress. Cuff size is also important. The bladder should encircle and cover two-thirds of the length of the (upper) arm. The patient should be sitting upright in a chair with both feet flat on the floor for a minimum of five minutes prior to taking a reading. The patient should not be on any adrenergic stimulants, such as those found in many cold medications.

When taking manual measurements, the person taking the measurement should be careful to inflate the cuff suitably above anticipated systolic pressure. The person should inflate the cuff to 200 mmHg and then slowly release the air while palpating the radial pulse. After one minute, the cuff should be reinflated to 30 mmHg higher than the pressure at which the radial pulse was no longer palpable. A stethoscope should be placed lightly over the brachial artery. The cuff should be at the level of the heart and the cuff should be deflated at a rate of 2 to 3 mmHg/s. Systolic pressure is the pressure reading at the onset of the sounds described by Korotkoff (Phase one). Diastolic pressure is then recorded as the pressure at which the sounds disappear (K5) or sometimes the K4 point, where the sound is abruptly muffled. Two measurements should be made at least 5 minutes apart, and, if there is a discrepancy of more than 5 mmHg, a third reading should be done. The readings should then be averaged. An initial measurement should include both arms. In elderly patients who particularly when treated may show orthostatic hypotension, measuring lying sitting and standing BP may be useful. The BP should at some time have been measured in each arm, and the higher pressure arm preferred for subsequent measurements.

BP varies with time of day, as may the effectiveness of treatment, and archetypes used to record the data should include the time taken. Analysis of this is rare at present.

Automated machines are commonly used and reduce the variability in manually collected readings.[128] Routine measurements done in medical offices of patients with known hypertension may incorrectly diagnose 20% of patients with uncontrolled hypertension.[129]

Home blood pressure monitoring can provide a measurement of a person's blood pressure at different times throughout the day and in different environments, such as at home and at work.[130] Home monitoring may assist in the diagnosis of high or low blood pressure. It may also be used to monitor the effects of medication or lifestyle changes taken to lower or regulate blood pressure levels. Home monitoring of blood pressure can also assist in the diagnosis of white coat hypertension. The American Heart Association[131] states, "You may have what's called 'white coat hypertension'; that means your blood pressure goes up when you're at the doctor's office. Monitoring at home will help you measure your true blood pressure and can provide your doctor with a log of blood pressure measurements over time. This is helpful in diagnosing and preventing potential health problems."

Some home blood pressure monitoring devices also make use of blood pressure charting software. These charting methods provide printouts for the patient's physician and reminders to take a blood pressure reading. However, a simple and cheap way is simply to manually record values with pen and paper, which can then be inspected by a doctor.

Systolic hypertension is defined as an elevated systolic blood pressure. If systolic blood pressure is elevated with a normal diastolic blood pressure, it is called isolated systolic hypertension. Systolic hypertension may be due to reduced compliance of the aorta with increasing age.[132]

Laboratory tests

Once the diagnosis of hypertension has been made it is important to attempt to exclude or identify reversible (secondary) causes. Secondary hypertension is more common in preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension.[50] Tests are undertaken to identify possible causes of secondary hypertension, and seek evidence for end-organ damage to the heart itself or the eyes (retina) and kidneys. Diabetes and raised cholesterol levels being additional risk factors for the development of cardiovascular disease are also tested for as they will also require management.[2] Tests done are classified as follows:

System Tests
Renal Microscopic urinalysis, proteinuria, serum BUN (blood urea nitrogen) and/or creatinine
Endocrine Serum sodium, potassium, calcium, TSH (thyroid-stimulating hormone).
Metabolic Fasting blood glucose, total cholesterol, HDL and LDL cholesterol, triglycerides
Other Hematocrit, electrocardiogram, and Chest X-ray
Sources: Harrison's principles of internal medicine[51] others[133][134][135][136][137][138]

Creatinine (renal function) testing is done to identify both the underlying renal disease as a cause of hypertension and, conversely, hypertension causing the onset of kidney damage. It is a baseline for monitoring the possible side-effects of certain antihypertensive drugs later. Glucose testing is done to identify diabetes mellitus. Additionally, testing of urine samples for proteinuria detection is used to pick up an underlying kidney disease or evidence of hypertensive renal damage. Electrocardiogram (EKG/ECG) testing is done to check for evidence of the heart being under strain from working against a high blood pressure. It may also show a resulting thickening of the heart muscle (left ventricular hypertrophy) or of the occurrence of a previously silent cardiac disease (either a subtle electrical conduction disruption or even a myocardial infarction). A chest X-ray might be used to observe signs of cardiac enlargement or evidence of cardiac failure.

Prevention

The degree to which hypertension can be prevented depends on a number of features including: current blood pressure level, sodium/potassium balance, detection and omission of environmental toxins, changes in end/target organs (retina, kidney, heart - among others), risk factors for cardiovascular diseases and the age at presentation. Unless the presenting patient has very severe hypertension, there should be a relatively prolonged assessment period within which repeated measurements of blood pressure should be taken. Following this, lifestyle advice and non-pharmacological options should be offered to the patient, before any initiation of drug therapy.

The process of managing hypertension according the guidelines of the British Hypertension Society suggest that non-pharmacological options should be explored in all patients who are hypertensive or pre-hypertensive. These measures include;

  • Weight reduction and regular aerobic exercise (e.g., walking) are recommended as the first steps in treating mild to moderate hypertension. Regular exercise improves blood flow and helps to reduce resting heart rate and blood pressure.[139] Several studies indicate that low intensity exercise may be more effective in lowering blood pressure than higher intensity exercise.[140] These steps are highly effective in reducing blood pressure, although drug therapy is still necessary for many patients with moderate or severe hypertension to bring their blood pressure down to a safe level.
  • Reducing dietary sugar intake.
  • Reducing sodium (salt) in the diet may be effective: It decreases blood pressure in about 33% of people (see above). Many people use a salt substitute to reduce their salt intake.[141]
  • Additional dietary changes beneficial to reducing blood pressure include the DASH diet (dietary approaches to stop hypertension) which is rich in fruits and vegetables and low-fat or fat-free dairy foods. This diet has been shown to be effective based on research sponsored by the National Heart, Lung, and Blood Institute.[142] In addition, an increase in dietary potassium, which offsets the effect of sodium has been shown to be highly effective in reducing blood pressure.

[143]

  • Discontinuing tobacco use and alcohol consumption has been shown to lower blood pressure. The exact mechanisms are not fully understood, but blood pressure (especially systolic) always transiently increases following alcohol or nicotine consumption. Besides, abstention from cigarette smoking is important for people with hypertension because it reduces the risk of many dangerous outcomes of hypertension, such as stroke and heart attack. Note that coffee drinking (caffeine ingestion) also increases blood pressure transiently but does not produce chronic hypertension.[citation needed]
  • Reducing stress, for example with relaxation therapy, such as meditation and other mindbody relaxation techniques,[144] by reducing environmental stress such as high sound levels and over-illumination can be an additional method of ameliorating hypertension. Jacobson's Progressive Muscle Relaxation and biofeedback are also used,[145] particularly, device-guided paced breathing,[146][147] although meta-analysis suggests it is not effective unless combined with other relaxation techniques.[148]

Treatment

Lifestyle modifications

Lifestyle changes such as the DASH diet, physical exercise, and weight loss have been shown to significantly reduced blood pressure in people with high blood pressure.[149] If hypertension is high enough to justify immediate use of medications, lifestyle changes are initiated concomitantly.

A series of UK guidelines advocate treatment initiation thresholds and desirable targets to be reached as set out in the following table. Of particular note is that for patients with blood pressures between 140-159/80-99 and without additional factors, that only lifestyle actions and regular blood pressure and risk-factor review is proposed.

UK Hypertension guidelines[9]
Thresholds for starting treatment Group Target of treatment
>160/100 all those with such persisting readings <140/90
>140/90 If also:[9] Cardiovascular risk >20% per 10 years
Or have established cardiovascular disease
Or have evidence end organ damage
Or chronic kidney disease without high levels albuminuria[150]
<140/90
>130/80 Type 2 Diabetes alone[151] <130/80
>135/85 Type 1 Diabetes alone[152] <130/80
>130/80 Type 1 Diabetes with microalbuminuria[152]
Or Type 2 Diabetes with kidney, eye or cerebrovascular damage[153]
<130/80
>130/80 chronic kidney disease with high levels albuminuria[150] <125/75

Biofeedback

Biofeedback devices can be used alone or in conjunction with lifestyle changes or medications to monitor and possibly reduce hypertension. One example is Resperate, a portable, battery-operated personal therapeutic medical device, sold over the counter (OTC) in the United States. However, claims of efficacy are not supported by scientific studies. Testimonials are used to promote such products, while no real evidence exists that the use of resperate like devices lowers any morbidity associated with hypertension.

Medications

There are many classes of medications for treating hypertension, together called antihypertensives, which — by varying means — act by lowering blood pressure. Evidence suggests that reduction of the blood pressure by 5–6 mmHg can decrease the risk of stroke by 40%, of coronary heart disease by 15–20%, and reduces the likelihood of dementia, heart failure, and mortality from vascular disease.

The aim of treatment should be blood pressure control to <140/90 mmHg for most patients, and lower in certain contexts such as diabetes or kidney disease (some medical professionals recommend keeping levels below 120/80 mmHg).[154] Each added drug may reduce the systolic blood pressure by 5–10 mmHg, so often multiple drugs are often necessary to achieve blood pressure control.

Commonly used drugs include the typical groups of:[9]

Other additionally used groups include:

Finally several agents may be given simultaneously:

  • Combination products (which usually contain HCTZ and one other drug). The advantage of fixed combinations resides in the fact that they increase compliance with treatment by reducing the number of pills taken by the patients. A fixed combination of the ACE inhibitor perindopril and the calcium channel blocker amlodipine, recently been proved to be very effective even in patients with additional impaired glucose tolerance and in patients with the metabolic syndrome.[159]

Choice of initial medication

For mild blood pressure elevation, consensus guidelines call for medically-supervised lifestyle changes and observation before recommending initiation of drug therapy. However, according to the American Hypertension Association, evidence of sustained damage to the body may be present even prior to observed elevation of blood pressure. Therefore the use of hypertensive medications may be started in individuals with apparent normal blood pressures but who show evidence of hypertension related nephropathy, proteinuria, atherosclerotic vascular disease, as well as other other evidence of hypertension related organ damage.

If lifestyle changes are ineffective, then drug therapy is initiated, often requiring more than one agent to effectively lower hypertension. Which type of many medications should be used initially for hypertension has been the subject of several large studies and various national guidelines.

The largest study, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), concluded that thiazide-type diuretics are better and cheaper than other major classes of drugs at preventing cardiovascular disease, and should be preferred as the starting drug. ALLHAT used the thiazide diuretic chlorthalidone.[160] (ALLHAT showed that doxazosin, an alpha-adrenergic receptor blocker, had a higher incidence of heart failure events, and the doxazosin arm of the study was stopped.)

A subsequent smaller study (ANBP2) did not show the slight advantages in thiazide diuretic outcomes observed in the ALLHAT study, and actually showed slightly better outcomes for ACE-inhibitors in older white male patients.[161]

Thiazide diuretics are effective, recommended as the best first-line drug for hypertension by many experts, and are much more affordable than other therapies, yet they are not prescribed as often as some newer drugs. Hydrochlorothiazide is perhaps the safest and most inexpensive agent commonly used in this class and is very frequently combined with other agents in a single pill. Doses in excess of 25 milligrams per day of this agent incur an unacceptable risk of low potassium or Hypokalemia. Patients with an exaggerated hypokalemic response to a low dose of a thiazide diuretic should be suspected to have Hyperaldosteronism, a common cause of secondary hypertension.

Other drugs have a role in treating hypertension. Adverse effects of thiazide diuretics include hypercholesterolemia, and impaired glucose tolerance with increased risk of developing Diabetes mellitus type 2. The thiazide diuretics also deplete circulating potassium unless combined with a potassium-sparing diuretic or supplemental potassium. Some authors have challenged thiazides as first line treatment.[162][163][164] However as the Merck Manual of Geriatrics notes, "thiazide-type diuretics are especially safe and effective in the elderly."[165]

Current UK guidelines suggest starting patients over the age of 55 years and all those of African/Afrocaribbean ethnicity firstly on calcium channel blockers or thiazide diuretics, whilst younger patients of other ethnic groups should be started on ACE-inhibitors. Subsequently if dual therapy is required to use ACE-inhibitor in combination with either a calcium channel blocker or a (thiazide) diuretic. Triple therapy is then of all three groups and should the need arise then to add in a fourth agent, to consider either a further diuretic (e.g. spironolactone or furosemide), an alpha-blocker or a beta-blocker.[9] Prior to the demotion of beta-blockers as first line agents, the UK sequence of combination therapy used the first letter of the drug classes and was known as the "ABCD rule".[9][166]

Prognosis

Diagram illustrating the main complications of persistent high blood pressure.

It is based upon several factors including genetics, dietary habits, and overall lifestyle choices. If individuals conscious of their condition take the necessary preventive measures to lower their blood pressure, they are more likely to have a much better outcome than those who do not.

Complications

Hypertension is a risk factor for all clinical manifestations of atherosclerosis since it is a risk factor for atherosclerosis itself.[167][168][169][170][171] It is an independent predisposing factor for heart failure,[115][172] coronary artery disease,[173][174][175] stroke,[92] renal disease,[176][177][178] and peripheral arterial disease.[179][180][181] it is the most important risk factor for cardiovascular morbidity and mortality in industrialized countries.[182] The risk is increased for:

Epidemiology

Graph showing, prevalence of awareness, treatment and control of hypertension compared between the four studies of NHANES[210]

It is estimated that nearly one billion people are affected by hypertension worldwide, and this figure is predicted to increase to 1.5 billion by 2025.[211] The level of blood pressure regarded as deleterious has been revised down during years of epidemiological studies. A widely quoted and important series of such studies is the Framingham Heart Study carried out in an American town: Framingham, Massachusetts.[212] The results from Framingham and of similar work in Busselton, Western Australia have been widely applied. To the extent that people are similar this seems reasonable, but there are known to be genetic variations in the most effective drugs for particular sub-populations. Recently (2004), the Framingham figures have been found to overestimate risks for the UK population considerably. The reasons are unclear. Nevertheless the Framingham work has been an important element of UK health policy.

Over 90-95% of adult hypertension is of the essential hypertension type.[2][3][4][5] It is estimated that 43 million people in the United States have hypertension or are taking antihypertensive medication, which is almost 24% of the adult population.[213] This proportion changes with race, being higher in blacks and lower in whites and Mexican Americans ; second it changes with age, because in industrialized countries systolic BP rises throughout life, whereas diastolic BP rises until age 55 to 60 years and thus the greater increase in prevalence of hypertension among the elderly is mainly due to systolic hypertension; also geographic patterns, because hypertension is more prevalent in the southeastern United States; another important one is gender, because hypertension is more prevalent in men (though menopause tends to abolish this difference); and finally socioeconomic status, which is an indicator of lifestyle attributes and is inversely related to the prevalence, morbidity, and mortality rates of hypertension.[2] A series of studies and surveys conducted by National Health and Nutrition Examination Survey (NHANES) between 1976 and 2004 to assess the trends in hypertension prevalence, blood pressure distributions and mean levels, and hypertension awareness, treatment, and control among US adults, aged more than 18 years, showed that there is an increasing pattern of awareness, control and treatment of hypertension, and that prevalence of hypertension is increasing reaching 28.9% as of 2004, with the largest increases among non-Hispanic women.[210][214]

For the secondary hypertension its known that primary aldosteronism is the most frequent endocrine form of secondary hypertension.[134] The incidence of exercise hypertension is reported to range from 1 to 10% of the total population.[14]

Hypertension often is part of the metabolic "syndrome X" its co-occurring with other components of the syndrome. The other components are, diabetes mellitus, combined hyperlipidemia, and central obesity.[116][215][216][217] This is especially occurring among women.[116] And this co-occurrence will increase the risk of cardiovascular disease and cardiovascular events.[217]

Children and adolescents

As with adults, blood pressure is a variable parameter in children. It varies between individuals and within individuals from day to day and at various times of the day. And the population prevalence of high blood pressure in the young is increasing.[218] The epidemic of childhood obesity,[53] the risk of developing left ventricular hypertrophy, and evidence of the early development of atherosclerosis in children would make the detection of and intervention in childhood hypertension important to reduce long-term health risks.[218] Most childhood hypertension, particularly in preadolescents, is secondary to an underlying disorder. Renal parenchymal disease is the most common (60 to 70%) cause of hypertension. Adolescents usually have primary or essential hypertension, making up 85 to 95% of cases.[219]. Medical students commonly suffer from hypertension especially mature students.

History

Some cite the writings of Sushruta in the 6th century BC as being the first mention of symptoms like those of hypertension.[220]

Our modern understanding of hypertension began with the work of physician William Harvey (1578–1657). It was then recognized as a disease a century later by Richard Bright (physician) in (1789–1858). The first ever elevated blood pressure in a patient without kidney disease was reported by Frederick Mahomed (1849–1884).[221]

Society and culture

Economics

The National Heart, Lung, and Blood Institute (NHLBI) estimated in 2002 that hypertension cost the United States $47.2 billion dollars.[222]

High blood pressure is the most common chronic medical problem prompting visits to primary health care providers, yet it is estimated that only 34% of the 50 million American adults with hypertension have their blood pressure controlled to a level of <140/90 mm Hg. Thus, about two thirds of Americans with hypertension are at increased risk for cardiovascular events. The medical, economic, and human costs of untreated and inadequately controlled high blood pressure are enormous. Adequate management of hypertension can be hampered by inadequacies in the diagnosis, treatment, and/or control of high blood pressure.[223] Health care providers face many obstacles to achieving blood pressure control among their patients, including a limited ability to adequately lower blood pressure with monotherapy and a typical reluctance to increase therapy (either in dose or number of medications) to achieve blood pressure goals. Patients also face important challenges in adhering to multidrug regimens and accepting the need for therapeutic lifestyle changes. Nonetheless, the achievement of blood pressure goals is possible, and, most importantly, lowering blood pressure significantly reduces cardiovascular morbidity and mortality, as proved in clinical trials[citation needed]. The medical and human costs of treating preventable conditions such as stroke, heart failure, and end-stage renal disease can be reduced by antihypertensive treatment[citation needed]. The recurrent and chronic morbidities associated with hypertension are costly to treat. Pharmacotherapy for hypertension therefore offers a substantial potential for cost savings.[224] Recent studies proved that the use of angiotensin receptor blockers for treatment of hypertension is cost-saving and cost-effective treatment compared with other conventional treatment.[225][226]

Awareness

The World Health Organization attributes hypertension, or high blood pressure, as the leading cause of cardiovascular mortality. The World Hypertension League (WHL), an umbrella organization of 85 national hypertension societies and leagues, recognized that more than 50% of the hypertensive population worldwide are unaware of their condition.[227] To address this problem, the WHL initiated a global awareness campaign on hypertension in 2005 and dedicated May 17 of each year as World Hypertension Day (WHD). Over the past three years, more national societies have been engaging in WHD and have been innovative in their activities to get the message to the public. In 2007, there was record participation from 47 member countries of the WHL. During the week of WHD, all these countries – in partnership with their local governments, professional societies, nongovernmental organizations and private industries – promoted hypertension awareness among the public through several media and public rallies. Using mass media such as Internet and television, the message reached more than 250 million people. As the momentum picks up year after year, the WHL is confident that almost all the estimated 1.5 billion people affected by elevated blood pressure can be reached.[228]

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Further reading

External links

Hypertension at the Open Directory Project


Study guide

Up to date as of January 14, 2010

From Wikiversity

This page is under construction

Hypertension is a multi-system disease whose hallmark is elevated blood pressure.

Contents

Definitions

Etiologies

Natural History

Treatment


Simple English

Hypertension, also called High blood pressure, HTN, or HPN, is a disease where your blood pressure is always above average.

Contents

Details

There is no fixed point when blood pressure is considered "high". Generally speaking, if someone's blood pressure stays at 140/90 torr (a unit of pressure) or above in both arms, they are said to have high blood pressure. A recent report has defined blood pressure 120/80 torr to 139/89 torr as "prehypertension." Prehypertension is not a disease, but means that a person has a high chance of developing hypertension. In patients with diabetes mellitus or kidney disease, studies have shown that blood pressure over 130/80 torr should be considered a risk factor and may need treatment. A number of factors increase the risk of developing hypertension, including high salt use, being overweight, occupation, drinking alcohol, family size, too much noise and crowding. High salt use has received the greatest attention. About 60% of hypertension patients are affected by salt use.

Hypertension is one of the most common complex inherited disorders. More than 50 genes have been examined in studies of hypertension, and the number is constantly growing. Renal Hypertension is caused by renal disease. What it does is decreases perfusion of renal tissue due to stenosis of a main or branch renal artery activates the renin-angiotensin system.

While high elevated blood pressure alone is not an illness, it often requires treatment due to its short- and long-term effects on many organs. The risk is increased for strokes, heart attack, heart failure, damage to the eye, and renal failure.

Although few women of childbearing age have high blood pressure, up to 10% develop hypertension of pregnancy.

Diagnosis

File:Automatische bloeddrukmeter (0).jpg
Machine to measure blood pressure

Diagnosis of hypertension is generally on the basis of a persistently high blood pressure. Usually this needs three separate measurements at least one week apart. Obtaining correct blood pressure measurements depends on following several rules and understanding the many factors that influence blood pressure readings. For instance, measurements in control of hypertension should be at least one hour after caffeine, 30 minutes after smoking and without any stress. Cuff size is also important. The cuff should go right around and cover two-thirds of the length of the upper arm. You should be sitting for at least five minutes.

Treatment

Doctors recommend weight loss and regular exercise as the first steps in treating mild to moderate hypertension. These steps are highly effective in reducing blood pressure, but easier to suggest than to achieve, and most patients with moderate or severe hypertension end up requiring indefinite drug therapy to bring their blood pressure down to a safe level. Stopping smoking, does not directly reduce blood pressure, but it is very important for people with hypertension because it reduces the risk of many dangerous outcomes of hypertension, such as stroke and/or heart attack. Mild hypertension can usually be treated by diet, exercise, and improved physical fitness. A diet rich in fruits, vegetables, fat-free dairy foods, and foods low in fat and salt lowers blood pressure in people with hypertension. Regular mild exercise improves blood flow, and helps to lower blood pressure. Reduction of environmental stressors such as high sound levels and over-illumination can be an additional method of ameliorating hypertension.

There are many medications for treating hypertension, called antihypertensives, which lower blood pressure. Reducing blood pressure by 5-6 torr can decrease the risk of stroke by 40%, reduce coronary heart disease by 15-20%, and reduce the likelihood of heart failure. Commonly used drugs include beta blockers such as metoprolol, atenolol, labetalol, carvedilol, ACE inhibitors such as lisinopril, quinapril, fosinopril, captopril, enalapril, ramipril; angiotensin receptor blockers (ARBs) such as losartan, valsartan, irbesartan; calcium channel blockers such as amlodipine, verapamil; diuretics, such as chlortalidone, hydrochlorothiazide (HCTZ), combination products (usually contains HCTZ and another drug), and alpha blockers such as terazosin and prazosin.

The aim of treatment should be blood pressure control (<140/90 torr for most patients, and lower in certain contexts such as diabetes or kidney disease. Each added drug may reduce the systolic blood pressure by 5-10 torr, so often many drugs are necessary to control blood pressure.

See Also








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