Hypertension

Hypertension
From Wikipedia, the free encyclopedia Jump to: navigation, search This article is about arterial hypertension. For other forms of hypertension, see Hypertension (disambiguation).
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). I10.,I11.,I12., ICD-10 I13.,I15. ICD-9 401 OMIM 145500 DiseasesDB 6330 MedlinePlus 000468 eMedicine med/1106 ped/1097 emerg/267 D006973 MeSH Hypertension (HTN) or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. It is the opposite of hypotension. Hypertension is classified as either primary (essential) hypertension or secondary hypertension; About 9095% of cases are categorized as "primary hypertension," which means high blood pressure with no obvious medical causes.The remaining 510% of cases (Secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart or endocrine system. Persistent hypertension is one of the risk factors for stroke, myocardial infarction, heart failure and arterial aneurysm, and is a leading cause of chronic kidney failure. Moderate elevation of arterial blood pressure leads to shortened life expectancy. Dietary and lifestyle changes can improve blood pressure control and decrease the risk of associated health complications, although drug treatment may prove necessary in patients for whom lifestyle changes prove ineffective or insufficient.
Contents
1 Classification 2 Signs and symptoms

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2.1 Accelerated hypertension 2.2 Secondary hypertension 2.3 In pregnancy 2.4 In children 3.1 Essential hypertension 3.2 Secondary hypertension
3 Causes
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4 Pathophysiology 5 Diagnosis 6 Prevention 7 Treatment

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7.1 Lifestyle modifications 7.2 Medications 7.3 In the elderly 7.4 Resistant
8 Complications 9 Epidemiology
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9.1 In children
10 History 11 Society and culture

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11.1 Economics 11.2 Awareness
12 References 13 Further reading 14 External links
[edit] 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 Systolic pressure Diastolic pressure Classification mmHg kPa mmHg kPa Normal 90119 1215.9 6079 8.010.5 Prehypertension 120139 16.018.5 8089 10.711.9 Stage 1 140159 18.721.2 9099 12.013.2 Stage 2 160 21.3 100 13.3 Isolated systolic 140 18.7 <90 <12.0 hypertension Source: American Heart Association (2003).[5] Blood pressure is usually classified based on the systolic and diastolic blood pressures. Systolic blood pressure is the blood pressure in vessels during a heart beat. Diastolic blood pressure is the pressure between heartbeats. A systolic or the diastolic blood pressure measurement higher than the accepted normal values for the age of the individual is classified as prehypertension or hypertension. Hypertension[6] has several sub-classifications including, hypertension stage I, hypertension stage II, and isolated systolic hypertension. Isolated systolic hypertension refers to elevated systolic pressure with normal diastolic pressure and is common in the elderly. These classifications are made after averaging a patient's resting blood pressure readings taken on two or more office visits. Individuals older than 50 years are classified as having hypertension if their blood pressure is consistently at least 140 mmHg systolic or 90 mmHg diastolic. Patients with blood pressures higher than 130/80 mmHg with concomitant presence of diabetes mellitus or kidney disease require further treatment.[5] Hypertension is also classified as resistant if medications do not reduce blood pressure to normal levels.[5] Exercise hypertension is an excessively high elevation in blood pressure during exercise.[7][8][9] The range considered normal for systolic values during exercise is between 200 and 230 mm Hg.[10] Exercise hypertension may indicate that an individual is at risk for developing hypertension at rest.
[9][10]
[edit] Signs and symptoms

Mild to moderate essential hypertension is usually asymptomatic.[11]
[edit] Accelerated hypertension

Accelerated hypertension is associated with headache, drowsiness, confusion, vision disorders, nausea, and vomiting. These symptoms are collectively called hypertensive encephalopathy.[12] Hypertensive encephalopathy is caused by severe small blood vessel congestion and brain swelling, which is reversible if blood pressure is lowered.[13]
[edit] Secondary hypertension

Main article: Secondary hypertension
Some additional signs and symptoms suggest that the hypertension is caused by disorders in hormone regulation. Hypertension combined with obesity distributed on the trunk of the body, accumulated fat on the back of the neck ('buffalo hump'), wide purple marks on the abdomen (abdominal striae), or the recent onset of diabetes suggests that an individual has a hormone disorder known as Cushing's syndrome. Hypertension caused by other hormone disorders such as hyperthyroidism, hypothyroidism, or growth hormone excess will be accompanied by additional symptoms specific to these disorders. For example, hyperthyrodism can cause weight loss, tremors, heart rate abnormalities, reddening of the palms, and increased sweating.[14] Signs and symptoms associated with growth hormone excess include coarsening of facial features, protrusion of the lower jaw, enlargement of the tongue,[15] excessive hair growth, darkening of the skin color, and excessive sweating.[16]:499. Other hormone disorders like hyperaldosteronism may cause less specific symptoms such as numbness, excessive urination, excessive sweating, electrolyte imbalances and dehydration, and elevated blood alkalinity.[17] and also cause of mental pressure.
[edit] In pregnancy
Hypertension in pregnant women is one symptom of pre-eclampsia. Pre-eclampsia can progress to a life-threatening condition called eclampsia, which is the development of protein in the urine, generalized swelling, and severe seizures. Other symptoms indicating that brain function is becoming impaired may precede these seizures such as nausea, vomiting, headaches, and vision loss.[18] In addition, the systemic vascular resistance and blood pressure decrease during pregnancy. The body must compensate by increasing cardiac output and blood volume to provide sufficient circulation in the utero-placental arterial bed.[19]
[edit] In children
Some signs and symptoms are especially important in newborns and infants such as failure to thrive, seizures, irritability, lack of energy, and difficulty breathing.[20] In children, hypertension can cause headache, fatigue, blurred vision, nosebleeds, and facial paralysis.[20] Even with the above clinical symptoms, the true incidence of pediatric hypertension is not known. In adults, hypertension has been defined due to the adverse effects caused by hypertension. However, in children, similar studies have not been performed thoroughly to link any adverse effects with the increase in blood pressure. Therefore, the prevalence of pediatric hypertension remains unknown due to the lack of scientific knowledge.[21]
[edit] Causes
[edit] Essential hypertension
Main article: Essential hypertension Essential hypertension is the most prevalent hypertension type, affecting 9095% of hypertensive patients.[1] Although no direct cause has been identified, there are many factors such as sedentary lifestyle,[22] smoking, stress, visceral obesity, potassium deficiency (hypokalemia),[22] obesity[23] (more than 85% of cases occur in those with a body mass index greater than 25),[24] salt (sodium) sensitivity,[25] alcohol intake,[26] and vitamin D deficiency that increase the risk of developing hypertension.[27][28] Risk also increases with aging,[29] some inherited genetic mutations,[30] and having a family history of hypertension.[31] An elevated level of renin, a hormone secreted by the kidney, is another risk factor,[32] as is sympathetic nervous system overactivity.[33] Insulin resistance,
which is a component of syndrome X (or the metabolic syndrome), is also thought to contribute to hypertension.[32][34] Recent studies have implicated low birth weight as a risk factor for adult essential hypertension.[35]
[edit] Secondary hypertension

Main article: Secondary hypertension Secondary hypertension by definition results from an identifiable cause. This type is important to recognize since it's treated differently to essential hypertension, by treating the underlying cause of the elevated blood pressure. Hypertension results in the compromise or imbalance of the pathophysiological mechanisms, such as the hormone-regulating endocrine system, that regulate blood plasma volume and heart function. Many conditions cause hypertension. Some are common, well-recognized secondary causes such as Cushing's syndrome,[36] which is a condition where the adrenal glands overproduce the hormone cortisol.[36] Hypertension is also caused by other conditions that cause hormone changes, such as hyperthyroidism, hypothyroidism (citation needed), and certain tumors of the adrenal medulla (e.g., pheochromocytoma). Other common causes of secondary hypertension include kidney disease, obesity/metabolic disorder, preeclampsia during pregnancy, the congenital defect known as coarctation of the aorta, and certain prescription and illegal drugs.
[edit] Pathophysiology
Main article: Pathophysiology of hypertension
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:
Inability of the kidneys to excrete sodium, resulting in natriuretic factors such as Atrial Natriuretic Factor being secreted to promote salt excretion with the side effect of raising total peripheral resistance. An overactive Renin-angiotensin system leads to vasoconstriction and retention of sodium and water. The increase in blood volume plus vasoconstriction leads to hypertension.[37] An overactive sympathetic nervous system, leading to increased stress responses.[38]
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.[39] 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.
[edit] Diagnosis
Hypertension is generally diagnosed on the basis of a persistently high blood pressure. Usually this requires three separate sphygmomanometer (see figure) measurements at least one week apart. Often, this entails three separate visits to the physician's office. Initial assessment of the hypertensive patient should include a complete history and physical examination. Exceptionally, if the elevation is extreme, or if symptoms of organ damage are present then the diagnosis may be given and treatment started immediately. Once the diagnosis of hypertension has been made, physicians will attempt to identify the underlying cause based on risk factors and other symptoms, if present. 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.[31] Laboratory tests can also be performed to identify possible causes of secondary hypertension, and determine if hypertension has caused damage to the heart, eyes, and kidneys. Additional tests for Diabetes and high cholesterol levels are also usually performed because they are additional risk factors for the development of heart disease require treatment.[1] Tests typically performed 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 radiograph Sources: Harrison's principles of internal medicine[40] others[41][42][43][44][45][46] Creatinine (renal function) testing is done to determine if kidney disease is present, which can be either the cause or result of hypertension. In addition, it provides a baseline measurement of kidney function that can be used to monitor for side-effects of certain antihypertensive drugs on kidney function. Additionally, testing of urine samples for protein is used as a secondary indicator of kidney disease. Glucose testing is done to determine if diabetes mellitus is present. Electrocardiogram (EKG/ECG) testing is done to check for evidence of the heart being under strain from high blood pressure. It may also show if there is thickening of the heart muscle (left ventricular hypertrophy) or has experienced a prior minor heart disturbance such as a silent heart attack. A chest X-ray may be performed to look for signs of heart enlargement or damage to heart tissue.
[edit] 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 diagnosis of prehypertension or at risk for hypertension. A prolonged assessment that involves repeated blood pressure measurements provides the most accurate blood pressure level assessment. Following this, lifestyle changes are recommended to lower blood pressure, before the initiation of prescription drug therapy. The process of managing prehypertension according the guidelines of the British Hypertension Society suggest the following lifestyle changes:

Weight reduction and regular aerobic exercise (e.g., walking): Regular exercise improves blood flow and helps to reduce the resting heart rate and blood pressure.[47] Reduce dietary sugar Reduce sodium (salt) in the body by disuse of condiment sodium and the adoption of a high potassium diet which rids the renal system of excess sodium. Many people use potassium chloride[48]salt substitute to reduce their salt intake.[49] 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 products. Research sponsored by the National Heart, Lung, and Blood Institute.[50] showed this diet to be effective. In addition, an increase in dietary potassium, which offsets the effect of sodium has been shown highly effective in reducing blood pressure.[51] 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. Abstaining from cigarette smoking reduces the risks of stroke and heart attack associated with hypertension.[52] Vasodialators such as niacin. Limiting alcohol intake to less than 2 standard drinks per day can reduce systolic blood pressure by between 2-4mmHg.[53] Reducing stress, for example with relaxation therapy, such as meditation and other mindbody relaxation techniques,[54] by reducing environmental stress such as high sound levels and over-illumination can also lower blood pressure. Jacobson's Progressive Muscle Relaxation and biofeedback are also beneficial,[55] such as device-guided paced breathing, [56][57] although meta-analysis suggests it is not effective unless combined with other relaxation techniques.[58] Increasing omega 3 fatty acids can help lower hypertension. Fish oil is shown to lower blood pressure in hypertensive individuals. The fish oil may increase sodium and water excretion.[59]
Treatment
Lifestyle modifications
The first line of treatment for hypertensionwhich are the same as the recommended preventative lifestyle changes[53] include:
Dietary changes
Physical exercise Weight loss
These have all been shown to significantly reduce blood pressure in people with hypertension.[60] If hypertension is high enough to justify immediate use of medications, lifestyle changes are still recommended in conjunction with medication. Drug prescription should take into account the patient's absolute cardiovascular risk (including risk of myocardial infarction and stroke) as well as blood pressure readings, in order to gain a more accurate picture of the patient's cardiovascular profile.[4] Different programs aimed to reduce psychological stress such as biofeedback, relaxation or meditation are advertised to reduce hypertension. However, in general claims of efficacy are not supported by scientific studies, which have been in general of low quality.[61][62][63] Regarding dietary changes, a low sodium diet is beneficial; A Cochrane review published in 2008 concluded that a long term (more than 4 weeks) low sodium diet in Caucasians has a useful effect to reduce blood pressure, both in people with hypertension and in people with normal blood pressure.[64] Also, the DASH diet (Dietary Approaches to Stop Hypertension) is a diet promoted by the National Heart, Lung, and Blood Institute (part of the NIH, a United States government organization) to control hypertension. A major feature of the plan is limiting intake of sodium,[65] and it also generally encourages the consumption of nuts, whole grains, fish, poultry, fruits and vegetables while lowering the consumption of red meats, sweets, and sugar. It is also "rich in potassium, magnesium, and calcium, as well as protein".
Medications
Several classes of medications, collectively referred to as antihypertensive drugs, are currently available for treating hypertension. Reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34%, of ischaemic heart disease by 21%, and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease.[66] The aim of treatment should be reduce blood pressure to <140/90 mmHg for most individuals, and lower for individuals with diabetes or kidney disease (some medical professionals recommend keeping levels below 120/80 mmHg).[67] If the blood pressure goal is not met, a change in treatment should be made as therapeutic inertia is a clear impediment to blood pressure control.[68] Comorbidity also plays a role in determining target blood pressure, with lower BP targets applying to patients with end-organ damage or proteinuria.[4] The first line antihypertensive supported by the best evidence is a low dose thiazide-based diuretic.
[69]
Often multiple medications in combined are needed to achieve the goal blood pressure. Commonly used prescription drugs include:[70]ACE inhibitors, alpha blockers, angiotensin II receptor antagonists , beta blockers , calcium channel blockers, diuretics (e.g. hydrochlorothiazide), direct renin inhibitors. Some examples of common combined prescription drug treatments include:
A fixed combination of an ACE inhibitor and a calcium channel blocker. One example of this is the combination of perindopril and amlodipine, the efficacy of which has been demonstrated in individuals with glucose intolerance or metabolic syndrome.[71] A fixed combination of a diuretic and an ARB.
Combinations of an ACE inhibitor or angiotensin IIreceptor antagonist, a diuretic and an NSAID (including selective COX-2 inhibitors and non-prescribed drugs such as ibuprofen) should be
avoided whenever possible due to a high documented risk of acute renal failure. The combination is known colloquially as a "triple whammy" in the Australian health industry.[53]
In the elderly
Treating moderate to severe high blood pressure decreases death rates in those under 80 years of age.[72] In those over 80 years old there was a decrease in morbidity but no decrease in mortality.[72] The recommended BP goal is <140/90 mm Hg with thiazide diuretics being the first line medication.[73]
Resistant
Guidelines for treating resistant hypertension have been published in the UK[70] and US.[74]
Complications
Complications of hypertension
Diagram illustrating the main complications of persistent high blood pressure. Hypertension is the most important risk factor for death in industrialized countries.[75] It increases hardening of the arteries[76] thus predisposes individuals to heart disease,[77] peripheral vascular disease,[78] and strokes.[79] Types of heart disease that may occur include: myocardial infarction,[79] heart failure,[80] and left ventricular hypertrophy[81] Other complications include:

Hypertensive retinopathy[82] Hypertensive nephropathy[83] If blood pressure is very high hypertensive encephalopathy may result. Silent stroke is a type of stroke (infarct) that does not have any outward symptoms (asymptomatic), and the patient is typically unaware they have suffered a stroke. Despite not causing identifiable symptoms a silent stroke still causes damage to the brain, and places the patient at increased risk for a major stroke in the future. Hypertension is the major treatable risk factor associated with silent stokes.
Epidemiology
In the year 2000 it is estimated that nearly one billion people or ~26% of the adult population had hypertension worldwide.[85] It was common in both developed (333 million ) and undeveloped (639
million) countries.[85] However rates vary markedly in different regions with rates as low as 3.4% (men) and 6.8% (women) in rural India and as high as 68.9% (men) and 72.5% (women) in Poland.[86] In 1995 it is estimated that 43 million people in the United States had hypertension or were taking antihypertensive medication, almost 24% of the adult population.[87] The prevalence of hypertension in the United States is increasing and reached 29% in 2004.[88][89] It is more common in blacks and native Americans and less in whites and Mexican Americans, rates increase with age, and is greater in the southeastern United States. Hypertension is more prevalent in men (though menopause tends to decrease this difference) and those of low socioeconomic status.[1] Over 9095% of adult hypertension is essential hypertension.[1] The most common cause of secondary hypertension is primary aldosteronism.[42] The incidence of exercise hypertension is reported to range from 110%.[10]
[edit] In children
The prevalence of high blood pressure in the young is increasing.[90] Most childhood hypertension, particularly in preadolescents, is secondary to an underlying disorder. Kidney disease is the most common (6070%) cause of hypertension in children. Adolescents usually have primary or essential hypertension, which accounts for 8595% of cases.[91]
[edit] History
Image of veins from Harvey's Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus Some cite the writings of Sushruta in the 6th century BC as being the first mention of symptoms like those of hypertension.[92] Others propose even earlier descriptions dating as far as 2600 BCE. Main treatment for what was called the "hard pulse disease" consisted in reducing the quantity of blood in a subject by the sectioning of veins or the application of leeches.[93] Well known individuals such as The Yellow Emperor of China, Cornelius Celsus, Galen, and Hipocrates advocated such treatments.[93] Our modern understanding of hypertension began with the work of physician William Harvey (15781657), who was the first to describe correctly the systemic circulation of blood being pumped around the body by the heart in his book "De motu cordis". The basis for measuring blood pressure were established by Stephen Hales in 1733.[93] Initial descriptions of hypertension as a disease came among others from Thomas Young in 1808 and specially Richard Bright in 1836.[93] The first ever elevated blood pressure in a patient without kidney disease was reported by Frederick Mahomed (18491884).[94] It was not until 1904 that sodium restriction was advocated while a rice diet was popularized around 1940.[93]
Studies in the 1920s demonstrated the public health impact of untreated high blood pressure; treatment options were limited at the time, and deaths from malignant hypertension and its complications were common. A prominent victim of severe hypertension leading to cerebral hemorrhage was Franklin D. Roosevelt (18821945). The Framingham Heart Study added to the epidemiological understanding of hypertension and its relationship with coronary artery disease. The National Institutes of Health also sponsored other population studies, which additionally showed that African Americans had a higher burden of hypertension and its complications.[95] Before pharmacological treatment for hypertension became possible, three treatment modalities were used, all with numerous side-effects: strict sodium restriction, sympathectomy (surgical ablation of parts of the sympathetic nervous system), and pyrogen therapy (injection of substances that caused a fever, indirectly reducing blood pressure).[93][95] The first chemical for hypertension, sodium thiocyanate, was used in 1900 but had many side effects and was unpopular.[93] Several other agents were developed after the Second World War, the most popular and reasonably effective of which were tetramethylammonium chloride and its derivative hexamethonium, hydralazine and reserpine (derived from the medicinal plant Rauwolfia serpentina). A randomized controlled trial sponsored by the Veterans Administration using these drugs had to be stopped early because those not receiving treatment were developing more complications and it was deemed unethical to withhold treatment from them. These studies prompted public health campaigns to increase public awareness of hypertension and the advice to get blood pressure measured and treated. These measures appear to have contributed at least in part of the observed 50% fall in stroke and ischemic heart disease between 1972 and 1994.[95] A major breakthrough was achieved with the discovery of the first well-tolerated orally available agents. The first was chlorothiazide, the first thiazide and developed from the antibiotic sulfanilamide, which became available in 1958;[93][96] it increased salt excretion while preventing fluid accumulation. In 1975, the Lasker Special Public Health Award was awarded to the team that developed chlorothiazide.[95] The British physician James W. Black developed beta blockers in the early 1960s;[97] these were initially used for angina, but turned out to lower blood pressure. Black received the 1976 Lasker Award and in 1988 the Nobel Prize in Physiology or Medicine for his discovery.[95] The next class of antihypertensives to be discovered was that of the calcium channel blockers. The first member was verapamil, a derivative of papaverine that was initially thought to be a beta blocker and used for angina, but then turned out to have a different mode of action and was shown to lower blood pressure.[95] ACE inhibitors were developed through rational drug design; the renin-angiotensin system was known to play an important role in blood pressure regulation, and snake venom from Bothrops jararaca could lower blood pressure through inhibition of ACE. In 1977 captopril, an orally active agent, was described;[98] this led to the development of a number of other ACE inhibitors.
Society and culture

Economics
The National Heart, Lung, and Blood Institute (NHLBI) estimated in 2002 that hypertension cost the United States $47.2 billion.[99] 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.[100] Thus, about two thirds of Americans with hypertension are at increased risk for heart disease. 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.[101] Health care providers face many obstacles to achieving blood pressure control from their patients, including resistance to taking multiple medications to reach blood pressure goals. Patients also face the challenges of adhering to medicine schedules and making lifestyle changes. Nonetheless, the achievement of blood pressure goals is possible, and most importantly, lowering blood pressure significantly reduces the risk of death due to heart disease, the development of other debilitating conditions, and the cost associated with advanced medical care.,[102][103]
Awareness
Graph showing, prevalence of awareness, treatment and control of hypertension compared between the four studies of NHANES[88] 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.[104] 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.
High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body. High blood pressure does not mean excessive emotional tension, although emotional tension and stress can temporarily increase blood pressure. Normal blood pressure is below 120/80; blood pressure between
120/80 and 139/89 is called "pre-hypertension", and a blood pressure of 140/90 or above is considered high. The top number, the systolic blood pressure, corresponds to the pressure in the arteries as the heart contracts and pumps blood forward into the arteries. The bottom number, the diastolic pressure, represents the pressure in the arteries as the heart relaxes after the contraction. The diastolic pressure reflects the lowest pressure to which the arteries are exposed. An elevation of the systolic and/or diastolic blood pressure increases the risk of developing heart (cardiac) disease, kidney (renal) disease, hardening of the arteries (atherosclerosis or arteriosclerosis), eye damage, and stroke (brain damage). These complications of hypertension are often referred to as end-organ damage because damage to these organs is the end result of chronic (long duration) high blood pressure. For that reason, the diagnosis of high blood pressure is important so efforts can be made to normalize blood pressure and prevent complications. It was previously thought that rises in diastolic blood pressure were a more important risk factor than systolic elevations, but it is now known that in people 50 years or older systolic hypertension represents a greater risk. The American Heart Association estimates high blood pressure affects approximately one in three adults in the United States - 73 million people. High blood pressure is also estimated to affect about two million American teens and children, and the Journal of the American Medical Association reports that many are under-diagnosed. Hypertension is clearly a major public health problem.
High Blood Pressure Guidelines What Should My Blood Pressure Be? High blood pressure is often called the silent killer because in the initial stages it presents with no symptoms. It is only after an organ in the body is irritated or damaged, that the consequences of high blood pressure are realized. The blood pressure recording, measures pressures within the arteries at two different times. The first reading, the systolic pressure, measures the pressure when the heart is pumping blood to the body through the arteries. The second reading, the diastolic pressure, measures the pressure within the arteries when the heart is receiving blood returning from the body.
Blood pressure measurement is listed with two numbers with normal being less than 120/80, with 120 being the systolic blood pressure when the heart is pushing blood through the arterial system; and 80 being the diastolic blood pressure when the arteries are at rest and the heart is refilling. How is the blood pressure measured? The blood pressure usually is measured with a small, portable instrument called a blood pressure cuff (sphygmomanometer). (Sphygmo is Greek for pulse, and a manometer measures pressure.) The blood pressure cuff consists of an air pump, a pressure gauge, and a rubber cuff. The instrument measures the blood pressure in units called millimeters of mercury (mm Hg). The cuff is placed around the upper arm and inflated with an air pump to a pressure that blocks the flow of blood in the main artery (brachial artery) that travels through the arm. The arm is then extended at the side of the body at the level of the heart, and the pressure of the cuff on the arm and artery is gradually released. As the pressure in the cuff decreases, a health practitioner listens with a stethoscope over the artery at the front of the elbow. The pressure at which the practitioner first hears a pulsation from the artery is the systolic pressure (the top number). As the cuff pressure decreases further, the pressure at which the pulsation finally stops is the diastolic pressure (the bottom number).
How is high blood pressure defined? Blood pressure can be affected by several factors, so it is important to standardize the environment when blood pressure is measured. For at least one hour before blood pressure is taken, avoid eating, strenuous exercise (which can lower blood pressure), smoking, and caffeine intake. Other stresses may alter the blood pressure and need to be considered when blood pressure is measured. Even though most insurance companies consider high blood pressure to be 140/90 and higher for the general population, these levels may not be appropriate cut-offs for all individuals. Many experts in the field of hypertension view blood pressure levels as
a range, from lower levels to higher levels. Such a range implies there are no clear or precise cut-off values to separate normal blood pressure from high blood pressure. Individuals with so-called pre-hypertension (defined as a blood pressure between 120/80 and 139/89) may benefit from lowering of blood pressure by life style modification and possibly medication especially if there are other risk factors for endorgan damage such as diabetes or kidney disease (life style changes are discussed below). For some people, blood pressure readings lower than 140/90 may be a more appropriate normal cut-off level. For example, in certain situations, such as in patients with long duration (chronic) kidney diseases that spill (lose) protein into the urine (proteinuria), the blood pressure is ideally kept at 130/80, or even lower. The purpose of reducing the blood pressure to this level in these patients is to slow the progression of kidney damage. Patients with diabetes (diabetes mellitus) may also benefit from blood pressure that is maintained at a level lower than 130/80. In addition, African Americans, who have an increased risk for developing the complications of hypertension, may decrease this risk by reducing their systolic blood pressure to less than 135 and the diastolic blood pressure to 80 mm Hg or less. In line with the thinking that the risk of end-organ damage from high blood pressure represents a continuum, statistical analysis reveals that beginning at a blood pressure of 115/75 the risk of cardiovascular disease doubles with each increase in blood pressure of 20/10. This type of analysis has led to an ongoing "rethinking" in regard to who should be treated for hypertension, and what the goals of treatment should be Isolated systolic high blood pressure Remember that the systolic blood pressure is the top number in the blood pressure reading and represents the pressure in the arteries as the heart contracts and pumps blood into the arteries. A systolic blood pressure that is persistently higher than 140 mm Hg is usually considered elevated, especially when associated with an elevated diastolic pressure (over 90). Isolated systolic hypertension, however, is defined as a systolic pressure that is above 140 mm Hg with a diastolic pressure that still is below 90. This disorder primarily affects older people and is characterized by an increased (wide) pulse pressure. The pulse pressure is the difference between the systolic and diastolic blood pressures. An elevation of the systolic pressure without an elevation of the diastolic pressure, as in isolated systolic hypertension, therefore, increases the pulse pressure. Stiffening of the arteries contributes to this widening of the pulse pressure. Once considered to be harmless, a high pulse pressure is now considered an important precursor or indicator of health problems and potential end-organ damage. Isolated systolic hypertension is associated with a two to four times increased future risk of an enlarged heart, a heart attack (myocardial infarction), a stroke (brain damage), and death from heart disease or a stroke. Clinical studies in patients with
isolated systolic hypertension have indicated that a reduction in systolic blood pressure by at least 20 mm to a level below 160 mm Hg reduces these increased risks. White coat high blood pressure A single elevated blood pressure reading in the doctor's office can be misleading because the elevation may be only temporary. It may be caused by a patient's anxiety related to the stress of the examination and fear that something will be wrong with his or her health. The initial visit to the physician's office is often the cause of an artificially high blood pressure that may disappear with repeated testing after rest and with follow-up visits and blood pressure checks. One out of four people that are thought to have mild hypertension actually may have normal blood pressure when they are outside the physician's office. An increase in blood pressure noted only in the doctor's office is called 'white coat hypertension.' The name suggests that the physician's white coat induces the patient's anxiety and a brief increase in blood pressure. A diagnosis of white coat hypertension might imply that it is not a clinically important or dangerous finding. However, caution is warranted in assessing white coat hypertension. An elevated blood pressure brought on by the stress and anxiety of a visit to the doctor may not necessarily always be a harmless finding since other stresses in a patient's life may also cause elevations in the blood pressure that are not ordinarily being measured. Monitoring blood pressure at home by blood pressure cuff or continuous monitoring equipment or at a pharmacy can help estimate the frequency and consistency of higher blood pressure readings. Additionally, conducting appropriate tests to search for any complications of hypertension can help evaluate the significance of variable blood pressure readings. Borderline high blood pressure Borderline hypertension is defined as mildly elevated blood pressure higher than 140/90 mm Hg at some times, and lower than that at other times. As in the case of white coat hypertension, patients with borderline hypertension need to have their blood pressure taken on several occasions and their end-organ damage assessed in order to establish whether their hypertension is significant. People with borderline hypertension may have a tendency as they get older to develop more sustained or higher elevations of blood pressure. They have a modestly increased risk of developing heart-related (cardiovascular) disease. Therefore, even if the hypertension does not appear to be significant initially, people with borderline hypertension should have continuing follow-up of their blood pressure and monitoring for the complications of hypertension. If, during the follow-up of a patient with borderline hypertension, the blood pressure becomes persistently higher than 140/ 90 mm Hg, an anti-hypertensive medication is
usually started. Even if the diastolic pressure remains at a borderline level (usually under 90 mm Hg, yet persistently above 85) treatment may be started in certain circumstances. What causes high blood pressure? Two forms of high blood pressure have been described: essential (or primary) hypertension and secondary hypertension. Essential hypertension is a far more common condition and accounts for 95% of hypertension. The cause of essential hypertension is multifactorial, that is, there are several factors whose combined effects produce hypertension. In secondary hypertension, which accounts for 5% of hypertension, the high blood pressure is secondary to (caused by) a specific abnormality in one of the organs or systems of the body. (Secondary hypertension is discussed further in a separate section later.) Essential hypertension affects approximately 72 million Americans, yet its basic causes or underlying defects are not always known. Nevertheless, certain associations have been recognized in people with essential hypertension. For example, essential hypertension develops only in groups or societies that have a fairly high intake of salt, exceeding 5.8 grams daily. Salt intake may be a particularly important factor in relation to essential hypertension in several situations, and excess salt may be involved in the hypertension that is associated with advancing age, African American background, obesity, hereditary (genetic) susceptibility, and kidney failure (renal insufficiency). The Institute of Medicine of the National Academies recommends healthy 19 to 50-year-old adults consume only 3.8 grams of salt to replace the average amount lost daily through perspiration and to achieve a diet that provides sufficient amounts of other essential nutrients. Genetic factors are thought to play a prominent role in the development of essential hypertension. However, the genes for hypertension have not yet been identified. (Genes are tiny portions of chromosomes that produce the proteins that determine the characteristics of individuals.) The current research in this area is focused on the genetic factors that affect the renin-angiotensin-aldosterone system. This system helps to regulate blood pressure by controlling salt balance and the tone (state of elasticity) of the arteries. Approximately 30% of cases of essential hypertension are attributable to genetic factors. For example, in the United States, the incidence of high blood pressure is greater among African Americans than among Caucasians or Asians. Also, in individuals who have one or two parents with hypertension, high blood pressure is twice as common as in the general population. Rarely, certain unusual genetic disorders affecting the hormones of the adrenal glands may lead to hypertension. (These identified genetic disorders are considered secondary hypertension.) The vast majority of patients with essential hypertension have in common a particular abnormality of the arteries: an increased resistance (stiffness or lack of elasticity) in
the tiny arteries that are most distant from the heart (peripheral arteries or arterioles). The arterioles supply oxygen-containing blood and nutrients to all of the tissues of the body. The arterioles are connected by capillaries in the tissues to the veins (the venous system), which returns the blood to the heart and lungs. Just what makes the peripheral arteries become stiff is not known. Yet, this increased peripheral arteriolar stiffness is present in those individuals whose essential hypertension is associated with genetic factors, obesity, lack of exercise, overuse of salt, and aging. Inflammation also may play a role in hypertension since a predictor of the development of hypertension is the presence of an elevated C reactive protein level (a blood test marker of inflammation) in some individuals What are the causes of secondary high blood pressure? As mentioned previously, 5% of people with hypertension have what is called secondary hypertension. This means that the hypertension in these individuals is secondary to (caused by) a specific disorder of a particular organ or blood vessel, such as the kidney, adrenal gland, or aortic artery. Renal (kidney) hypertension Diseases of the kidneys can cause secondary hypertension. This type of secondary hypertension is called renal hypertension because it is caused by a problem in the kidneys. One important cause of renal hypertension is narrowing (stenosis) of the artery that supplies blood to the kidneys (renal artery). In younger individuals, usually women, the narrowing is caused by a thickening of the muscular wall of the arteries going to the kidney (fibromuscular hyperplasia). In older individuals, the narrowing generally is due to hard, fat-containing (atherosclerotic) plaques that are blocking the renal artery. How does narrowing of the renal artery cause hypertension? First, the narrowed renal artery impairs the circulation of blood to the affected kidney. This deprivation of blood then stimulates the kidney to produce the hormones, renin and angiotensin. These hormones, along with aldosterone from the adrenal gland, cause a constriction and increased stiffness (resistance) in the peripheral arteries throughout the body, which results in high blood pressure. Renal hypertension is usually first suspected when high blood pressure is found in a young individual or a new onset of high blood pressure is discovered in an older person. Screening for renal artery narrowing then may include renal isotope (radioactive) imaging, ultrasonographic (sound wave) imaging, or magnetic resonance imaging (MRI) of the renal arteries. The purpose of these tests is to determine whether there is a restricted blood flow to the kidney and whether angioplasty (removal of the restriction in the renal arteries) is likely to be beneficial. However, if the ultrasonic assessment indicates a high resistive index within the kidney (high resistance to blood flow), angioplasty may not improve the blood pressure because chronic damage in the kidney from long-standing hypertension
already exists. If any of these tests are abnormal or the doctor's suspicion of renal artery narrowing is high enough, renal angiography (an X-ray study in which dye is injected into the renal artery) is done. Angiography is the ultimate test to actually visualize the narrowed renal artery. A narrowing of the renal artery may be treated by balloon angioplasty. In this procedure, the physician threads a long narrow tube (catheter) into the renal artery. Once the catheter is there, the renal artery is widened by inflating a balloon at the end of the catheter and placing a permanent stent (a device that stretches the narrowing) in the artery at the site of the narrowing. This procedure usually results in an improved blood flow to the kidneys and lower blood pressure. Moreover, the procedure also preserves the function of the kidney that was partially deprived of its normal blood supply. Only rarely is surgery needed these days to open up the narrowing of the renal artery. Any of the other types of chronic kidney disease that reduces the function of the kidneys can also cause hypertension due to hormonal disturbances and/or retention of salt. It is important to remember that not only can kidney disease cause hypertension, but hypertension can also cause kidney disease. Therefore, all patients with high blood pressure should be evaluated for the presence of kidney disease so they can be treated appropriately. Adrenal gland tumors Two rare types of tumors of the adrenal glands are less common, secondary causes of hypertension. The adrenal glands sit right on top of the kidneys. Both of these tumors produce excessive amounts of adrenal hormones that cause high blood pressure. These tumors can be diagnosed from blood tests, urine tests, and imaging studies of the adrenal glands. Surgery is often required to remove these tumors or the adrenal gland (adrenalectomy), which usually relieves the hypertension. One of the types of adrenal tumors causes a condition that is called primary hyperaldosteronism because the tumor produces excessive amounts of the hormone aldosterone. In addition to the hypertension, this condition causes the loss of excessive amounts of potassium from the body into the urine, which results in a low level of potassium in the blood. Hyperaldosteronism is generally first suspected in a person with hypertension when low potassium is also found in the blood. (Also, certain rare genetic disorders affecting the hormones of the adrenal gland can cause secondary hypertension.) The other type of adrenal tumor that can cause secondary hypertension is called a pheochromocytoma. This tumor produces excessive catecholamines, which include several adrenaline-related hormones. The diagnosis of a pheochromocytoma is suspected in individuals who have sudden and recurrent episodes of hypertension
that are associated with flushing of the skin, rapid heart beating (palpitations), and sweating, in addition to the symptoms associated with high blood pressure. Coarctation of the aorta Coarctation of the aorta is a rare hereditary disorder that is one of the most common causes of hypertension in children. This condition is characterized by a narrowing of a segment of the aorta, the main large artery coming from the heart. The aorta delivers blood to the arteries that supply all of the body's organs, including the kidneys. The narrowed segment (coarctation) of the aorta generally occurs above the renal arteries, which causes a reduced blood flow to the kidneys. This lack of blood to the kidneys prompts the renin-angiotensin-aldosterone hormonal system to elevate the blood pressure. Treatment of the coarctation is usually the surgical correction of the narrowed segment of the aorta. Sometimes, balloon angioplasty (as described above for renal artery stenosis) can be used to widen (dilate) the coarctation of the aorta. The metabolic syndrome and obesity Genetic factors play a role in the constellation of findings that make up the "metabolic syndrome." Individuals with the metabolic syndrome have insulin resistance and a tendency to have type 2 diabetes mellitus (non-insulin-dependent diabetes). Obesity, especially associated with a marked increase in abdominal girth, leads to high blood sugar (hyperglycemia), elevated blood lipids (fats), vascular inflammation, endothelial dysfunction (abnormal reactivity of the blood vessels), and hypertension all leading to premature atherosclerotic vascular disease. The American Obesity Association states the risk of developing hypertension is five to six times greater in obese Americans, age 20 to 45, compared to non-obese individuals of the same age. The American Journal of Clinical Nutrition reported in 2005 that waist size was a better predictor of a person's blood pressure than body mass index (BMI). Men should strive for a waist size of 35 inches or under and women 33 inches or under. The epidemic of obesity in the United States contributes to hypertension in children, adolescents, and adults. What are the symptoms of high blood pressure? Uncomplicated high blood pressure usually occurs without any symptoms (silently) and so hypertension has been labeled "the silent killer." It is called this because the disease can progress to finally develop any one or more of the several potentially fatal complications of hypertension such as heart attacks or strokes. Uncomplicated hypertension may be present and remain unnoticed for many years, or even decades. This happens when there are no symptoms, and those affected fail to undergo periodic blood pressure screening. Some people with uncomplicated hypertension, however, may experience symptoms such as headache, dizziness, shortness of breath, and blurred vision. The presence of
symptoms can be a good thing in that they can prompt people to consult a doctor for treatment and make them more compliant in taking their medications. Often, however, a person's first contact with a physician may be after significant damage to the end-organs has occurred. In many cases, a person visits or is brought to the doctor or an emergency room with a heart attack, stroke, kidney failure, or impaired vision (due to damage to the back part of the retina). Greater public awareness and frequent blood pressure screening may help to identify patients with undiagnosed high blood pressure before significant complications have developed. About one out of every 100 (1%) people with hypertension is diagnosed with severe high blood pressure (accelerated or malignant hypertension) at their first visit to the doctor. In these patients, the diastolic blood pressure (the minimum pressure) exceeds 140 mm Hg! Affected persons often experience severe headache, nausea, visual symptoms, dizziness, and sometimes kidney failure. Malignant hypertension is a medical emergency and requires urgent treatment to prevent a stroke (brain damage). How is end-organ damage assessed in the patient with high blood pressure? Damage of organs fed by the circulatory system due to uncontrolled hypertension is called end-organ damage. As already mentioned, chronic high blood pressure can lead to an enlarged heart, kidney failure, brain or neurological damage, and changes in the retina at the back of the eyes. Examination of the eyes in patients with severe hypertension may reveal damage; narrowing of the small arteries, small hemorrhages (leaking of blood) in the retina, and swelling of the eye nerve. From the amount of damage, the doctor can gauge the severity of the hypertension. People with high blood pressure have an increased stiffness, or resistance, in the peripheral arteries throughout the tissues of the body. This increased resistance causes the heart muscle to work harder to pump the blood through these blood vessels. The increased workload can put a strain on the heart, which can lead to heart abnormalities that are usually first seen as enlarged heart muscle. Enlargement of the heart can be evaluated by chest X-ray, electrocardiogram, and most accurately by echocardiography (an ultrasound examination of the heart). Echocardiography is especially useful in determining the thickness (enlargement) of the left side (the main pumping side) of the heart. Heart enlargement may be a forerunner of heart failure, coronary (heart) artery disease, and abnormal heart rate or rhythms (cardiac arrhythmias). Proper treatment of the high blood pressure and its complications can reverse some of these heart abnormalities. Blood and urine tests may be helpful in detecting kidney abnormalities in people with high blood pressure. (Remember that kidney damage can be the cause or the result of hypertension.) Measuring the serum creatinine in a blood test can assess how well the kidneys are functioning. An elevated level of serum creatinine indicates damage to the kidney. In addition, the presence of protein in the urine (proteinuria) may reflect
chronic kidney damage from hypertension, even if the kidney function (as represented by the blood creatinine level) is normal. Protein in the urine alone signals the risk of deterioration in kidney function if the blood pressure is not controlled. Even small amounts of protein (microalbuminuria) may be a signal of impending kidney failure and other vascular complications from uncontrolled hypertension. African American patients with poorly controlled hypertension are at a higher risk than Caucasians for most end-organ damage and particularly kidney damage. Uncontrolled hypertension can cause strokes, which can lead to brain or neurological damage. The strokes are usually due to a hemorrhage (leaking blood) or a blood clot (thrombosis) of the blood vessels that supply blood to the brain. The patient's symptoms and signs (findings on physical examination) are evaluated to assess the neurological damage. A stroke can cause weakness, tingling, or paralysis of the arms or legs and difficulties with speech or vision. Multiple small strokes can lead to dementia (impaired intellectual capacity). The best prevention for this complication of hypertension or, for that matter, for any of the complications, is control of the blood pressure. Recent studies have also suggested the angiotensin receptor blocking drugs may offer an additional protective effect against strokes above and beyond control of blood pressure High Blood Pressure (Hypertension) At A Glance
High blood pressure (hypertension) is designated as either essential (primary) hypertension or secondary hypertension and is defined as a consistently elevated blood pressure exceeding 140/90 mm Hg. In essential hypertension (95% of people with hypertension), no specific cause is found, while secondary hypertension (5% of people with hypertension) is caused by an abnormality somewhere in the body, such as in the kidney, adrenal gland, or aortic artery. Essential hypertension may run in some families and occurs more often in the African American population, although the genes for essential hypertension have not yet been identified. High salt intake, obesity, lack of regular exercise, excessive alcohol or coffee intake, and smoking may all adversely affect the outlook for the health of an individual with hypertension. High blood pressure is called "the silent killer" because it often causes no symptoms for many years, even decades, until it finally damages certain critical organs. Poorly controlled hypertension ultimately can cause damage to blood vessels in the eye, thickening of the heart muscle and heart attacks, hardening of the arteries (arteriosclerosis), kidney failure, and strokes.
Heightened public awareness and screening of the population are necessary to detect hypertension early enough so it can be treated before critical organs are damaged. Lifestyle adjustments in diet and exercise and compliance with medication regimes are important factors in determining the outcome for people with hypertension. Several classes of anti-hypertensive medications are available, including ACE inhibitors, ARB drugs, beta-blockers, diuretics, calcium channel blockers, alphablockers, and peripheral vasodilators. Most antihypertensive medications can be used alone or in combination: some are used only in combination; some are preferred over others in certain specific medical situations; and some are not to be used (contraindicated) in other situations. The goal of therapy for hypertension is to bring the blood pressure down to 140/85 in the general population and to even lower levels in diabetics, African Americans, and people with certain chronic kidney diseases. Screening, diagnosing, treating, and controlling hypertension early in its course can significantly reduce the risk of developing strokes, heart attacks, or kidney failure
Management of Hypertension
Hypertension is a major risk factor for cardiovascular disease (CVD - cerebrovascular event (CVE) and ischaemic heart disease (IHD)) and, as such, is one of the most important preventable causes of premature morbidity and mortality in developed and developing countries. Yet studies still show that hypertension remains underdiagnosed, undertreated and poorly controlled in the UK.1 The benefits of antihypertensive therapy in reducing the incidence of CVD depend largely on blood pressure (BP) lowering - so achieving stated BP targets is important. Taking a measurement

Measure BP in a relaxed environment - the patient should be sitting with arm outstretched, and supported. Ensure BP equipment is regularly validated and maintained. If initial BP >140/90 mm Hg (or target), repeat later in the consultation if possible. If BP is different in both arms - take the higher reading as the reference in future and, if there are postural symptoms, take a standing BP to measure postural drop. Routine use of home monitoring devices or ambulatory BP devices is not recommended. Diagnosis - ideally this should require BP >140/90 mm Hg on at least 3 occasions.
Decision to treat hypertension Drug treatment is recommended:
In patients with sustained systolic BP (SBP) 160 mm Hg or sustained diastolic BP (DBP) 100 mm Hg. In patients with sustained SBP in the range 140-159 mm Hg, and/or DBP in the range 9099 mm Hg with known CVD, diabetes, target organ damage (i.e. renal impairment); or, in patients with an estimated CVD risk of 20% over the next 10 years, using risk charts or calculator. Patients with isolated SBP or aged >80 years should not be treated differently. Always take account of comorbidity and other medications (prescribed or otherwise). BP treatment targets - titrate the doses of medication to the following targets, adding more drugs as necessary until further treatment is inappropriate or declined:
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NB:

BP 140/85 mm Hg (the National Institute for Health and Clinical Excellence (NICE) says140/90 mm Hg2 - audit standard <150/90 mm Hg). BP 130/80 mm Hg in patients with established CVD, chronic renal failure or diabetes (strive for optimal glycaemic control - HbA1c <7) (NICE says 130/75 mm Hg - audit standard <140/80 mm Hg).
Treatment summary Based on Joint British Societies' (JBS2) Guidelines 20053 and NICE.2Advise lifestyle measures in hypertensive, borderline hypertensive and patients with high normal BP (130-139/85-89 mm Hg). Inform about any local initiatives, and supplement advice with leaflets or audiovisual information.

Patients should stop smoking (offer help nicotine replacement therapy). Weight reduction should be suggested if necessary, to maintain ideal body mass index (BMI) of 20-25 kg/m2. Offer a diet sheet and/or dietetic appointment. Dietary self-help, e.g. dieting clubs, may be appropriate. Reduce their salt, total fat, saturated fat and cholesterol intake, while increasing consumption of polyunsaturated, monosaturated fats and oily fish. Encourage fruit, vegetables, legumes and whole grains; and low-fat (or zero-fat) dairy, poultry meat, fish and shellfish products - as in the Dietary Approaches to Stop Hypertension (DASH) eating plan.4 Cut alcohol intake to no more than 21 units (male) or 14 units (female) of alcohol per week. Encourage regular dynamic exercise tailored to the age and capabilities of the patient. This may mean three vigorous training sessions per week for a young adult, or brisk walking for 30 minutes most days for the older individuals. Do not offer supplements of calcium, magnesium or potassium to reduce BP.5 Relaxation therapy can help (PCTs are not recommended to provide them routinely). As well as the targets above, strive for a happy, well-informed patient. Remember to look for and treat any underlying cause in your initial assessment (see separate article Hypertension).
Antihypertensive therapy choices
In the absence of contra-indications or compelling indications for other antihypertensive drugs (see table below), follow the guideline algorithm as follows: NB: black only refers to patients of African or Caribbean descent, not mixed-race, Asian or Chinese3 Initial Drug Choices2 If the patient is young (<55) and non-black, start with:

(A) Angiotensin-converting enzyme (ACE) inhibitor or Angiotensin-II receptor antagonist. (C) Calcium-channel blocker or (D) Diuretic (thiazide). Second Drug Choices
If the patient is black or aged 55 years, use:
(A+C) ACE inhibitor or Angiotensin II receptor antagonist with Calcium-channel blocker or (A+D) ACE inhibitor or Angiotensin II receptor antagonist with Diuretic (thiazide). Third Drug Choices
(A+C+D) ACE inhibitor or Angiotensin II receptor antagonist and Calcium channel blocker and Diuretic (thiazide). Most hypertensives will need a combination of 2 or 3 drugs to achieve satisfactory control. Explain the need for long-term treatment: "hypertension treatment should be continued until further notice - usually lifelong", and if the patient agrees, enlist the spouse's help with diet and medication. Give clear verbal and written advice, and stress the importance of regular BP checks ( blood tests) and follow-up - including annual review (e.g. in a 'birthday month'). Remember that most drugs take 4-8 weeks to produce their maximum effect and don't assess efficacy on the basis of a single clinic BP measurement. Betablockers are no longer recommended by NICE as first-line therapy, as they may be less effective in reducing major cardiovascular events, particularly stroke, than other drug combinations.6
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They may be appropriate in younger individuals who cannot tolerate ACE inhibitors or angiotensin-II receptor antagonists.7 Co-prescribing betablocker with a calcium-channel blocker is better than a betablocker with a thiazide because of increased risk of developing diabetes. If this combination is unavoidable, consider screening for diabetes regularly. When hypertensive patients on betablockers are reviewed, the drug should be continued if there is a compelling indication for their use. If the BP is being controlled on betablockers there is no absolute reason to stop them.6 If the BP is not being controlled, the dose should be stepped down and stopped gradually, and replaced with a more appropriate drug as per the algorithm above.
Drug Indications and Contra-indications

Drug ClassIndications (compelling and possible)Cautions and Contra-indicationsACE inhibitorsCompelling indications:

Heart failure.8 Left ventricular (LV) dysfunction. Type 1 diabetes with nephropathy. IHD post myocardial infarction (MI). Previous stroke/CVE. Proteinuria and nondiabetic nephropathy. Chronic renal diseasea. Type 2 diabetic nephropathy. Pregnancy. Renovascular disease. Hyperkalaemia Renal impairmenta. PVDb.
Possible indications:
Contra-indications:
Possible cautions:
Angiotensin-II receptor antagonists (angiotensin receptor blockers (ARBs))Compelling indications:

Cough on ACE inhibitor. Left ventricular hypertrophy (LVH). Heart failure9 intolerant of ACEs. Type 2 diabetic nephropathy. Diabetic microalbuminuria. proteinuria. Pregnancy. Renovascular disease. Hyperkalaemia. Renal impairment.
Contra-indications:
Possible cautions:
PVDb. Symptomatic angina.10 Post MI. Tachyarrhythmias. Pregnancy. Patients with evidence of increased sympathetic drive.6 Asthma/COPD. Heart block. Heart failurec. Diabetes (except if CHD). Athletes and physically active patients. PVDb.
BetablockersCompelling indications:
Possible Indications
Contra-indications:
Possible cautions:
Calcium-channel blockers (dihydropyridine) (e.g. nifedipine S/R)Compelling indications:

Elderly ISH. Raynaud's. Elderly angina. Tachyarrythmias. Congestive cardiac failure.
Possible indications: Possible cautions:
Other calcium-channel blockers (rate limiting)Compelling indications:

Angina. MI. Heart block. Heart failure.
Possible indications: Contra-indications:
Possible cautions:
Combination with betablockers. Elderly including ISH. Hypertensives of African origin. Heart failure. Previous stroke. Gout. Pregnancy. Congestive cardiac failure (CCF). Post MI. Renal failure. Hyperkalaemia. Prostatic hyperplasia (BPH). Hyperlipidaemia. Urinary incontinence. Orthostatic hypotension. Congestive heart failured. caution; close supervision and specialist advice are needed when there is established and significant renal impairment.
ThiazidesCompelling indications:
Contra-indications: Possible cautions: Diuretics (anti-aldosterone)Compelling indications:
Contra-indications:
Alpha-blockersCompelling indications:
Contra-indications: Possible cautions:
a. ACE inhibitors may be beneficial in chronic renal failure but should only be used with
b. Caution with ACE inhibitors and angiotensin-II receptor antagonists in peripheral vascular
disease because of association with renovascular disease.

c. Betablockers may worsen heart failure, but in specialist hands may be used to treat heart
failure (titrate dose carefully).

d. When used as monotherapy.
Adapted from Williams B et al; BMJ. 2004 Mar 13;328(7440):634-40.11 CVE = Cerebrovascular event; COPD = chronic obstructive pulmonary disease; ISH = isolated systolic hypertension; PVD = peripheral vascular disease.
Drug Indications and Contra-indications
Drug Class Indications (compelling and possible) Cautions and Contra-indications ACE inhibitors
Compelling indications:

Heart failure.8 Left ventricular (LV) dysfunction. Type 1 diabetes with nephropathy. IHD post myocardial infarction (MI). Previous stroke/CVE. Proteinuria and nondiabetic nephropathy. Chronic renal diseasea. Type 2 diabetic nephropathy.

Contra-indications:

Pregnancy. Renovascular disease. Hyperkalaemia Renal impairmenta. PVDb.
Possible cautions:

Angiotensin-II receptor antagonists (angiotensin receptor blockers (ARBs))
Cough on ACE inhibitor.
Left ventricular hypertrophy (LVH). Heart failure9 intolerant of ACEs. Type 2 diabetic nephropathy. Diabetic microalbuminuria. proteinuria.

Contra-indications:

Pregnancy. Renovascular disease. Hyperkalaemia. Renal impairment. PVDb.
Possible cautions:

Betablockers

Symptomatic angina.10 Post MI. Tachyarrhythmias. Pregnancy. Patients with evidence of increased sympathetic drive.6
Possible Indications

Contra-indications:

Asthma/COPD. Heart block. Heart failurec. Diabetes (except if CHD).
Possible cautions:

Athletes and physically active patients. PVDb.
Calcium-channel blockers (dihydropyridine) (e.g. nifedipine S/R)

Elderly ISH. Raynaud's. Elderly angina.
Possible cautions:

Tachyarrythmias. Congestive cardiac failure.
Other calcium-channel blockers (rate limiting)
Angina. MI.
Contra-indications:

Heart block. Heart failure. Combination with betablockers.
Possible cautions:
Thiazides Compelling indications:
Elderly including ISH. Hypertensives of African origin. Heart failure. Previous stroke.
Contra-indications:
Gout. Pregnancy.
Possible cautions:
Diuretics (anti-aldosterone)

Congestive cardiac failure (CCF). Post MI.
Contra-indications:

Renal failure. Hyperkalaemia.
Alpha-blockers

Prostatic hyperplasia (BPH). Hyperlipidaem
Contra-indications:
Urinary incontinence.
Possible cautions:
Orthostatic hypotension. Congestive heart failured.
a. ACE inhibitors may be beneficial in chronic renal failure but should only be used with
caution; close supervision and specialist advice are needed when there is established and significant renal impairment.
b. Caution with ACE inhibitors and angiotensin-II receptor antagonists in peripheral vascular
disease because of association with renovascular disease.

c. Betablockers may worsen heart failure, but in specialist hands may be used to treat heart
failure (titrate dose carefully).

d. When used as monotherapy.
Adapted from Williams B et al; BMJ. 2004 Mar 13;328(7440):634-40.11 CVE = Cerebrovascular event; COPD = chronic obstructive pulmonary disease; ISH = isolated systolic hypertension; PVD = peripheral vascular disease. Drugs to further reduce cardiovascular disease risk
Unless contra-indicated, the guideline suggests prescribing a statin for all people with ischaemic heart disease, and hypertensive patients aged >50 years who have a 10-year CVD risk 20% once BP is under control.3 Aim (in this group) to lower total cholesterol by 25% or LDL-cholesterol by 30% or achieve a total cholesterol of <4.0 mmol/L or LDL-cholesterol of <2.0 mmol/L, whichever is the greatest reduction.3
NB: aspirin is not recommended for primary prevention of ischaemic heart disease. Special circumstances
Hypertension in the elderly: the absolute benefit of treatment is greater in the elderly. Patients tolerate BP treatment as well as younger age groups, so studies suggest optimum BP levels should be similar.
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Beware that older people show greater BP variability so more readings may be necessary (including standing BP) and titrate therapy to standing levels. Isolated systolic hypertension should certainly be treated, although in borderline cases (140-159/<90 mm Hg) without cardiovascular or target organ damage, resource and quality of life issues come to the fore. Follow the drug choices as above, starting with calcium-channel blocker or thiazide.
Benefits in those aged >80 years have not been proven, but this is the subject of a current research (HYpertension in the Very Elderly Trial (HYVET) trial).
Hypertension in the young: always consider a secondary cause for hypertension (e.g. renal artery stenosis), particularly if difficult to control (consider consultant referral). Framingham risk data are not valid <32 years, and it is extremely unlikely that their CVD 10-year risk will be 20%. Balance long-term risk with inconvenience of early treatment. Idiopathic hypertension in pregnancy: methyldopa remains the first-line choice, with calcium antagonists (nifedipine) and hydralazine commonly used as second-line. Labetolol is often used for resistant third trimester hypertension. Avoid ACE-inhibitors and thiazides.12 Hypertension and oral contraceptives: generally, patients with OCP-induced hypertension or pre-existing hypertension should use non-hormonal contraception, especially if there is co-existent migraine or CVD. If this is unacceptable, switching to the progestogen-only pill (POP) with careful BP monitoring is recommended. HRT and hypertension: HRT use is not generally associated with increasing BP, and HRT should not be denied to hypertensive women as long as BP can be controlled. Hypertension and ethnic groups: black African-Caribbeans frequently have severe hypertension which often responds to salt restriction. They are sensitive to diuretics and calcium antagonists, but ACEs and betablockers are often ineffective as monotherapy unless used with diuretics, calcium-channel blockers or alpha-blockers.5,11 At least every 6 months, frequency of visits depending on degree of control, complexity of therapy and compliance. Annual urinalysis for protein, blood for glucose, creatinine and electrolytes ( total and HDL-cholesterol) and evaluation of CHD/CVD risk recommended: with routine visits to measure weight, BP and to enquire about general health, side-effects, treatment problems and to reinforce nondrug measures. A robust call/recall system is essential. It may be possible to titrate down gradually or to stop medication in patients who successfully modify their lifestyle (as long as appropriate BP and other targets are achieved, in patients with low cardiovascular risk).
Follow-up
The poorly controlled hypertensive In the young a secondary cause for hypertension (e.g. renal artery stenosis) should be considered, particularly if difficult to control. Consider compliance; it is estimated that between 50-80% of patients with hypertension do not take all of their prescribed medication. Are they intolerant to the drug or does the frequency of dosing pose problems? Diuretics may cause problems for patients with poor bladder control. If compliance is assured on a maximum dose (or the largest that can be tolerated): add drugs in a stepwise manner according to the 'ACD' approach to the treatment of hypertension. If the person is already taking three antihypertensive drugs, consider increasing the dose of a thiazide-type diuretic or adding another diuretic (for example, spironolactone), an alpha-blocker, or a betablocker. When opting for another diuretic, the choice is complicated and will be influenced by a variety of
factors, including the antihypertensive drugs the person is currently taking. Prescribers unfamiliar with these issues might wish to consult a colleague or a specialist in these circumstances. If the target BP cannot be reached, aim to reduce the BP as far as possible while not exceeding the person's ability to tolerate the treatment. In trials aiming to reduce BP to below 140/90 mm Hg using stepped medication regimes, 50-75% of patients achieve target BP. Many patients may need 2 or 3 drugs to control their BP adequately. Implementation procedures
In order to improve the effectiveness of healthcare, most GP practices now have 'practice protocols' for hypertension, asthma, diabetes, etc. Local adaption and hence 'ownership' of these is essential for their full implementation and effectiveness. All of the primary healthcare team should be involved in the initial design, with review dates and regular audits built in Guidelines should act as a catalyst for the practice's individual protocol.
Audit Hypertensive care lends itself well to audit. The Quality and Outcomes Framework (QOF) quality indicators for hypertension are currently as follows (2006-7):
Reference BP 1. Criterion The practice can produce a register of patients with established hypertension. The percentage of patients with hypertension in whom there is a record of the BP in the previous nine months. The percentage of patients with hypertension in whom the last BP (measured in the previous nine months) is 150/90 or less. 40-90% Target
BP 2.
BP 3.
40-70%
Two new indicators were added for QOF 2009-10:
Primary prevention (PP) 1: in those patients with a new diagnosis of hypertension, the percentage of patients who have had a face-to-face cardiovascular risk assessment at the outset of diagnosis using an agreed risk assessment treatment tool. PP 2: the percentage of people diagnosed with hypertension diagnosed after 1st April 2009 who were given lifestyle advice in the previous 15 months.
Hypertension (high blood pressure) is a disease of vascular regulation resulting from malfunction of arterial pressure control mechanisms (central nervous system, renninangiotensinaldosterone system, extracellular fluid volume.) the cause is unknown, and there is no cure. The basic explanation is that blood pressure is elevated when there is increased cardiac output plus increased peripheral vascular resistance. The two major types of hypertension are primary (essential) hypertension, in which diastrolic pressure is 90 mm Hg or higher and systolic pressure is 140 mm Hg or
higher in absence of other causes of hypertension (approximately 95 % of patients); and Secondary hypertension, which results primarily from renal disease, endocrine disorders, and coarctation of the aorta. Either of these conditions may give rise to accelerated hypertension a medical emergency in which blood pressure elevates very rapidly to threaten one or more of the target organs: the brain, kidney, or the heart. Hypertension is one of the most prevalent chronic diseases for which treatment is available; however, most patients with hypertension are unaware, untreated, or inadequately treated. Risk factors for hypertension are age between 30 and 70; black; overweight; sleep apnea; family history; cigarette smoking; sedentary lifestyle; and diabetes mellitus. Because hypertension presents no over symptoms, it is termed the silent killer. The untreated disease may progress to retinopathy, renal failure, coronary artery disease, heart failure, and stroke. Hypertension in children is defined as the average systolic or diastolic blood pressure greater than or equal to the 95th percentile for age and sex with measurement on at lease three occasions. The incidence of hypertension in children is low, but it is increasingly being recognized in adolescents; and it may occur in neonates, infants, and young children with secondary causes.
Hypertension refers to a state where a persons blood pressure remains at an elevated level at all times. This condition is formally known as arterial hypertension and is popularly called high blood pressure. Two types of hypertension:
1. Primary Hypertension when a patients chronically elevated blood pressure does not have
a specific medical cause that can be identified

2. Secondary Hypertension When high blood pressure is caused by other health conditions
like tumors of the adrenal gland, kidney disease of other problems. Hypertension is a dangerous condition because it can lead to serious complications. Chronically elevated blood pressure increases the risk of developing heart failure, heart attacks, arterial aneurysm and strokes. Many cases of chronic renal failure have been linked to high blood pressure. Signs and Symptoms:
Undiagnosed high blood pressure can lead to
many physical problems including damage to major organs over a period of time. The symptoms of hypertension, if ignored, can lead to deterioration in kidney / liver function and cardiac problems. Hypertension can also damage vision, cause strokes and more. Here are some of the common hypertension symptoms to be aware of.

Recurrent / persistent headaches Vision problems including blurring of vision Giddiness Convulsions Tremors in the hands or other body parts Walking difficulties (formally called ataxia)
INTRODUCTION Hypertension is one of the most common worldwide diseases afflicting humans. Because of the associated morbidity and mortality and the cost to society, hypertension is an important public health challenge. Over the past several decades, extensive research, widespread patient education, and a concerted effort on the part of health care professionals have led to decreased mortality and morbidity rates from the multiple organ damage arising from years of untreated hypertension. Hypertension is the most important modifiable risk factor for coronary heart disease (the leading cause of death in North America), stroke (the third leading cause), congestive heart failure, endstage renal disease, and peripheral vascular disease. Therefore, health care professionals must not only identify and treat patients with hypertension but also promote a healthy lifestyle and preventive strategies to decrease the prevalence of hypertension in the general population. Pre-hypertension Systolic blood pressure (SBP) 120-139 or diastolic blood pressure(DBP) 80-89 Stage I HTN SBP 140-159 or DBP 90-99 Stage II HTN SBP >160 or DBP >100 Hypertensive crises encompass a spectrum of clinical presentations where uncontrolled BPs leads to progressive or impending target organ dysfunction (TOD). The clinical distinction between
hypertensive emergencies and hypertensive urgencies depends on the presence of acute TOD and not on the absolute level of the BP. Hypertensive emergencies represent severe HTN with acute impairment of an organ system (eg, central nervous system [CNS], cardiovascular, renal). In these conditions, the BP should be lowered aggressively over minutes to hours. Hypertensive urgency is defined as a severe elevation of BP, without evidence of progressive target organ dysfunction. These patients require BP control over several days to weeks. Causes The most common hypertensive urgency is a rapid unexplained rise in BP in a patient with chronic essential HTN. Other causes:

Renal parenchymal disease Chronic pyelonephritis, primary glomerulonephritis, tubulointerstitial nephritis (accounts for 80% of all secondary causes) Systemic disorders with renal involvement Systemic lupus erythematosus, systemic sclerosis, vasculitides Renovascular disease Atherosclerotic disease, fibromuscular dysplasia, polyarteritis nodosa Endocrine Pheochromocytoma, Cushing syndrome, primary hyperaldosteronism Drugs Cocaine, amphetamines, cyclosporin, clonidine withdrawal, phencyclidine, diet pills, oral contraceptive pills Drug interactions Monoamine oxidase inhibitors with tricyclic antidepressants, antihistamines, or tyramine-containing food CNS CNS trauma or spinal cord disorders, such as Guillain-Barr syndrome Coarctation of the aorta Preeclampsia/eclampsia Postoperative hypertension
Physical Vitals

BP should be measured in both the supine position and the standing position (assess volume depletion). BP should also be measured in both arms (a significant difference suggests an aortic dissection).
ENT: The presence of new retinal hemorrhages, exudates, or papilledema suggests a hypertensive urgency. Cardiovascular Evaluate for the presence of heart failure.

Jugular venous distension Crackles Peripheral edema
Abdomen Abdominal masses or bruits CNS

Level of consciousness Visual fields Focal neurologic signs
Takayasu arteritis is a granulomatous vasculitis of unknown etiology that commonly affects the thoracic and abdominal aorta. It causes intimal fibroproliferation of the aorta, great vessels, pulmonary arteries, and renal arteries and results in segmental stenosis, occlusion, dilatation, and aneurysmal formation in these vessels. Takayasu arteritis is the only form of aortitis that causes stenosis and occlusion of the aorta. Takayasu disease has also been referred to as pulseless disease and aortic arch syndrome. During the acute inflammatory stage, Takayasu disease causes a low-grade temperature, tachycardia, pain adjacent to the inflamed arteries (eg, carotodynia), and easy fatigability in 50% of patients. Carotid and clavicular bruits, asymmetric upper-extremity blood pressures, hypertension, diminished or absent upper-extremity pulses, and ischemic symptoms can suggest the diagnosis ANATOMY & PHYSIOLOGY Central Nervous System Medulla Oblongata; relays motor and sensory impulses between other parts of the brain and the spinal cord. Reticular formation (also in pons, midbrain, and diencephalon) functions in consciousness and arousal. Vital centers regulate heartbeat, breathing (together with pons) and blood vessel diameter. Hypothalamus; controls and intergrates activities of the autonomic nervous system and pituitary gland. Regulates emotional and behavioral patterns and circadian rhythms. Controls body temperature and regulates eating and drinking behavior. Helps maintain the waking state and establishes patterns of sleep. Produces the hormones oxytocin and antidiuretic hormone. Cardiovascular System Baroreceptor, pressure-sensitive sensory receptors, are located in the aorta, internal carotid arteries, and other large arteries in the neck and chest. They send impulses to the cardiovascular center in the medulla oblongata to help regulate blood pressure. The two most important baroreceptor reflexes are the carotid sinus reflex and the aortic reflex. Chemoreceptors, sensory receptors that monitor the xhemical composition of blood, are located close to the baroreceptors of the carotid sinus and the arch of the aorta in small structures called carotid bodies and aortic bodies, respectively. These chemoreceptors detect changes in blood level of O2, CO2, and H+. Renal System Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to the kidneys decreases, juxtaglomerular cells in the kidneys secrete renin into the bloodstream. In sequence, renin and angiotensin converting enzyme (ACE) act on their substrates to produce the active hormone angiotensin II, which raises blood pressure in two ways. First, angiotensin II is a potent vasoconstrictor; it raises blood pressure by increasing systemic vascular resistance. Second, it
stimulates secretion of aldosterone, which increases reabsorption of sodium ions and water by the kidneys. The water reabsorption increases total blood volume, which increases blood pressure. Antidiuretic hormone. ADH is produced by the hypothalamus and released from the posterior pituitary in response to dehydration or decreased blood volume. Among other actions, ADH causes vasoconstriction, which increases blood pressure. Atrial Natriuretic Peptide. Released by cells in the atria of the heart, ANP lowers blood pressure by causing vasodilation and by promoting the loss of salt and water in the urine, which reduces blood volume. NURSING ASSESSMENT Present Health History The present health history started 7 days prior to confinement at PCMC when the patient, experienced general body weakness, vomiting and elevated blood pressure. She was admitted at Duques Clinic for 3 days but no BP monitoring was done. After 3 days, she was transferred to Cabiao General Hospital. Chest x-ray was done and the result implies cardiomegaly. She stayed at the said institution for 2 days and was treated as a case of hypertension. The patient was referred to Nueva Ecija Doctors last April 10, she had undergone ultrasound of her abdomen. She was given furosemide, nifedipine, mefenamic acid and ranitidine as her medication. Last April 12, 2007 at 12:55am she was admitted at the Philippine Childrens Medical Center with a diagnosis of Hypertensive Urgency secondary to Takayasu disease. Past Health History Prior to her hospitalization , she denies in having any record or medical history of being admitted due to trauma, accident and disease. She also denies having allergies to food and drugs. Family Health History The patient has family health history of hypertension on her mothers side. Demographic Data/Physical Assessment & General Appearance Review of Systems ? Psychosocial Being the second among three children, she considers herself as an active individual who is fond of interacting with other people. She considers herself as friendly even at home and at work. She excels in her subjects especially in Mathematics. ? Elimination Her elimination pattern has somehow deviated from her usual urine and stool elimination. Before her confinement, she usually urinates for 7 times a day and defecates at least 2 times per day. During her confinement, she now urinates 4 times a day and defecates once a day. According to her the variation from her elimination pattern is due to change in appetite and setting. ? Rest & Activity A typical day to her would be waking up at around 7:00 am to eat breakfast and play with her siblings. She had is fond of playing in their neighborhood and running around their house. Her usual sleeping hours is at 8:00 pm. During her confinement, she was not able to rest and have enough sleep as well. During her leisure time before confinement, she loves to watch television.
? Safety She usually stays at home and around their vicinity when playing. There is no physical threat for her safety. ? Oxygenation According to her, before and during her confinement she had no difficulty in breathing and ventilation. ? Nutrition According to her mother, she has a good appetite. She prefers to eat fish and vegetables rather than meat. She also adds that her daughter prefers to drink water. PATHOPHYSIOLOGY LABORATORY DIAGNOSIS MEDICAL & SURGICAL MANAGEMENT There are three clinical indications for selecting a patient with a hemodynamically significant renal artery stenosis (RAS) for treatment. The first is hypertension that is poorly controlled on adequate (two or three drugs) medical therapy, or in a patient intolerant of hypertensive medications. The second is renal insufficiency, and the third is a cardiac disturbance syndrome, such as flash pulmonary edema. The treating physician should have a high clinical suspicion that the target RAS is causally related to the clinical symptoms. The procedural risks, potential benefits, and alternative therapies must be considered for each patient. Generally, a RAS of <50% does not require revascularization, while a symptomatic patient with a stenosis ?70% generally merits revascularization. Absolute criteria for determining lesion severity have not been established; however, a systolic translesional pressure gradient of ?20 mm Hg or a mean gradient of ?10 mm Hg is generally accepted as representing significant renal artery obstruction in symptomatic patients. Stents are superior to balloons for both procedural success and long-term patency, due to scaffolding of the arterial lumen. The single, randomized, controlled trial comparing stents to balloons in renovascular hypertension demonstrated procedural superiority, better patency rates, and cost-effectiveness for primary stent placement. Despite a uniformly high (?95%) technical success rate for renal artery stent placement, very few patients will be cured of hypertension. However, the majority of hypertensive patients will benefit by improved blood pressure control and/or the need for fewer medications. Patients with the highest pretreatment systolic blood pressures have the greatest decrease in systolic pressure. A multivariate logistic regression analysis demonstrated that bilateral RAS and mean arterial pressure >110 mm Hg predicted a better blood pressure response following stent placement. Studies comparing the results in elderly (?75 years) versus younger (<75 years) patients or in females versus males have failed to show any difference in response to renal stent placement. The suggestion that a high level of resistance in the segmental renal arteries (resistance index ?80), determined by noninvasive Doppler measurement, predicted a poor response to revascularization has been challenged by more recent data that suggested that patients with increased resistance respond favorably to renal intervention. The benefits of renal stent placement include reperfusion of the ischemic kidney(s), resulting in a reduction in the stimulus to renin production, which decreases angiotensin and aldosterone
production, thereby decreasing peripheral arterial vasoconstriction and intravascular volume. Improving renal perfusion enhances glomerular filtration, thus natriuresis. Finally, in patients with a solitary kidney or bilateral RAS, the administration of angiotensin antagonists is facilitated by revascularization.
What Are the Different Types of Hypertension?

X
Amber Keefer Amber Keefer has more than 25 years of experience working in the fields of human services and health care administration. Writing professionally since 1997, she has written articles covering health, fitness and women's issues published in "Family Digest Magazine," "Chicago Parent" and "Woman's Touch." Keefer holds a B.A. from Bloomsburg University of Pennsylvania and an M.B.A. in health care management from Baker College. By Amber Keefer, eHow Contributor Hypertension, more commonly known as high blood pressure, occurs when blood pressure remains consistently high. Hypertension is the major cause of stroke but can also cause damage to the kidneys, coronary arteries and eyes. For this reason, it is important to identify among the different types of hypertension, the causes and the treatment. To control hypertension successfully in individual patients, health care professionals must first diagnose a particular case based on its characteristics and causes.
1.
Primary Hypertension
o
Individuals typically suffer primary hypertension as a result of poor lifestyle habits. While this type of hypertension accounts for most of the cases diagnosed by doctors, the exact cause is unknown. However, some theories have suggested that in some people, a problem with the kidneys may cause the body to retain an increased amount of sodium, which, in turn, increases blood volume and pressure in the vessels. While medication may be required, dietary changes, stress management and physical activity are essential elements of treatment. Sodium intake is a primary factor responsible for high blood pressure in many individuals, particularly the elderly and people who are obese. Fruits and vegetables are excellent sources of potassium, which, if consumed in adequate amounts, can help to decrease blood pressure.
Secondary Hypertension
o
Secondary hypertension is the symptom of an underlying medical condition such as kidney disease, problems with the liver, congestive heart failure, stress, sleep apnea or an endocrine disorder such as hyperthyroidism or Cushing's syndrome, which produce
elevated levels of hormones. Renal artery stenosis is a frequent cause of secondary hypertension. Problems occur when the artery supplying the kidney with blood narrows. Treatment of secondary hypertension involves controlling the underlying medical condition or disease in addition to prescribing antihypertensive drugs.
Alcohol-Induced Hypertension
o
On average, 30 to 50 percent of alcoholics have hypertension. The condition is more likely to occur in women who abuse alcohol than in men. In fact, heavy drinking of alcohol may be one of the most common causes of secondary hypertension. Numerous studies of alcoholics have shown that, in most cases, blood pressure returns to normal once alcohol is out of the person's system, and he continues to abstain. However, if a person begins to drink again, blood pressure rises. Consuming too much caffeine can also cause a temporary increase in blood pressure. Caffeine stimulates the release of cortisol and adrenaline. Because most caffeine addicts develop a tolerance over time, the question remains whether caffeine adversely affects blood pressure in the long term.
Isolated Systolic Hypertension

o
Isolated systolic hypertension occurs in people as they grow older. Build up of plaque in the arteries makes it more difficult for blood to flow through. A common form of high blood pressure in individuals older than 60, medication appears to reduce the risk of heart attack and stroke. Research supported by both the National Institute of Aging and the National Heart, Lung, and Blood Institute found that treating the elderly with diuretics not only decreases the risk of developing cardiovascular disease but may also reduce the risk of dementia and related depression.
Pregnancy-Induced Hypertension
o
Some otherwise healthy women begin to suffer from hypertension after the twentieth week of pregnancy. In the majority of cases, these women are overweight or obese. The condition can be mild or rather severe. Other symptoms include retaining water and protein in the urine. The condition normally goes away within a few weeks following delivery. Pregnancy-induced hypertension may be due to preexisting hypertension, diabetes, kidney disease or carrying multiple fetuses. Women who are diagnosed with pregnancy-induced hypertension are at greater risk of preeclampsia during pregnancy. Symptoms may include headache, dizziness, swelling of the hands and face, nausea, vomiting and pain in the abdomen. The condition usually affects pregnant women who are younger than 25 years old or older than 40 years of age. It is more likely to occur during a first pregnancy or in women who had hypertension before becoming pregnant.
Medication-Induced Hypertension
o
Certain prescription drugs and over-the-counter (OTC) medications can either cause or worsen hypertension. Nonsteroidal anti-inflammatory drugs (NSAIDs), decongestants and weight loss supplements are common OTC drugs that can cause an increase in blood pressure. Cortocosteroids, immunosuppressive and cancer drugs are among the prescription medications for which high blood pressure can be a side effect. These drugs constrict blood vessels and can cause kidney problems.
Malignant Hypertension
o
Malignant hypertension is considered to be a medical emergency as the blood pressure can suddenly rise to dangerous levels. A person can experience shortness of breath, chest pain, an excruciating headache, seizures or even loss of consciousness as the blood pressure rises. Vomiting, blurred vision or blindness can occur as well. Although the condition can be life threatening if not treated immediately, these symptoms are sometimes the first sign that an individual has high blood pressure. Because blood pressure quickly rises so high, a person is at risk for suffering stroke, heart attack, kidney damage or aneurysm causing bleeding in the brain.
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Diet and Hypertension by J. Anderson, L. Young and E. Long1 (Revised 8/08) Quick Facts...

Calories and body weight go hand in hand. Excess body fat leads to an increased risk of health problems. Potassium has an important role in blood pressure treatment. Low calcium intake may increase risk of hypertension. Excessive sodium intake is linked with high blood pressure or hypertension in some people. Dietary recommendations suggest avoiding too much sodium. The suggested range is 1,100 to 3,300 mg per day. Table salt is 40 percent sodium. One teaspoon has about 2,000 mg sodium.
Hypertension (high blood pressure) affects one in four adults in the United States. Another 25 percent of adults have blood pressure readings considered to be on the high end of normal. Your blood pressure is the force exerted on your artery walls by the blood flowing through your body. A blood pressure reading provides two measures, systolic pressure and diastolic pressure, which are expressed as millimeters of mercury (mm Hg), or how high the pressure of blood would raise a column of mercury. Systolic pressure is measured as the heart pumps. Diastolic pressure is measured between beats, as blood flows back into the heart. High blood pressure is often called the silent killer because it has no symtoms and can go undetected for years. It is important to have your blood pressure checked regularly. Table 1 below shows how to classify blood pressure readings. Table 1: Know Your Numbers.
SYSTOLIC (MM HG) Normal Prehypertension HYPERTENSION Stage 1 Stage 2 140 159
160
DIASTOLIC (MM HG) and or <80 80 89
<120 120 139
or or
90 99
100
Based on two readings taken 5 minutes apart with a confirmation reading in the contralateral arm.
Hypertension cannot be cured, but it can be controlled through lifestyle changes and prescriptive medication. While medications to treat hypertension are available, research has shown that modest lifestyle and dietary changes can help treat and often delay or prevent high blood pressure. People trying to control hypertension often are advised to decrease sodium, increase potassium, watch their calories, and maintain a reasonable weight. For sodium-sensitive people, reducing sodium is a prudent approach to reducing the risk of hypertension. The recommendation for daily sodium intake is 1,500 to 2,300 mg a day. The amount of potassium in the diet is also important. Potassium works with sodium to regulate the bodys water balance. Research has shown that the more potassium and less sodium a person has in his/her diet, the greater the likelihood that the person will maintain normal blood pressure. However, the evidence does not suggest that people with high blood pressure should take potassium supplements. Instead, potassium rich foods should be eaten everyday. A newer area of interest is the relationship between calcium and high blood pressure. People with a low calcium intake seem to be at increased risk for hypertension. Everyone should meet the Dietary Reference Intake (DRI) for calcium every day. For adults, this is 1,000 mg per day. For adults over 50, 1,200 mg is recommended. Maintaining a reasonable weight is important to minimize the risk of several major diseases, including hypertension. For people who are overweight, even a small weight loss can dramatically reduce or even prevent high blood pressure. Use Table 2 to assess sodium, calorie, calcium and potassium content of foods. Learn to read labels to identify differences between brands of food. Be a wise shopper.
Untreated hypertension causes damage to the blood vessels over time. This can lead to other health complications such as strokes, kidney failure, impaired vision, heart attack, and heart failure. The DASH Diet A landmark study called DASH (Dietary Approaches to Stop Hypertension) looked at the effects of an overall eating plan in adults with normal to high blood pressure. Researchers found that in just eight weeks, people following the DASH diet saw their blood pressure decrease. A subsequent study called DASH 2 looked at the effect of following the DASH diet and restricting salt intake to 1500 mg per day. Under the DASH 2 diet, people with Stage 1 hypertension had their blood pressure decrease as much or more than any anti-hypertensive medication had been able to lower it.(See fact sheet, 9.374, DASHing to Lower Blood Pressure.) Recommended by the American Heart Association and the National Cancer Institute, the DASH diet is an overall eating plan that focuses on what people should eat, rather than what not to eat. Rick in rich in fruits, vegetables, complex carbohydrates and low-fat dairy products, the DASH diet is lower in fat, saturated fat, cholesterol, and sodium, and higher in potassium, magnesium, and calcium than the typical American diet. The high levels of potassium, magnesium, and calcium in the DASH diet are thought to be at least partially responsible for its results. Table 3 below outlines the DASH eating plan. Table 3: The DASH Diet. Food Group Grains and grain products Vegetables Fruits Daily Servings Significance to the DASH Diet 78 45 45 Carbohydrates and fiber Potassium, magnesium and fiber Potassium, magnesium and fiber Calcium, protein, potassium and magnesium Protein and magnesium Magnesium, potassium, protein and fiber
Low-fat or fat free milk or milk 23 products Meats, poultry and fish Nuts, seeds and beans 2 or less 4 5 a week
Source: A Clinical Trial of the Effects of Dietary Patterns on Blood Pressure. New England Journal of Medicine. 1997.336:1117-1124.
Table 2: Sodium, calorie, calcium and potassium content of foods. Food energ Potass y Sodiu ium Amou Kcalor m (Na) (K) nt ies mg mg BEVERAGES Fruit drinks, dehydrated, reconstituted: Lemon ade 1 cup 102 115 13 12 33 49 71 61
Food
Calcium (Ca) mg
Orange 1 cup
Fruit juices, unsweetened: Apple 1 cup cider or juice Grapefr 1 cup uit juice Orange 1 cup juice Grape 1 cup juice, bottled Prune juice 1 cup 117 5 250 15
75
360
32
120 159
5 8
498 279
25 27
192 110
5 232
588 176
35 107
Cocoa 1 cup mix, water added (Carnat ion) Coffee, 1 cup freezedried
166
(using 2 tsp.) DAIRY PRODUCTS Natural cheese: Chedda 1 r ounce Colby 1 ounce 112 110 120 176 171 457 23 35 260 211 192 108
Cottag 1/2 cup e, 4 1/2% milk fat Cream 1 ounce
99 105 72
84 152 132
34 23 24
23 209 183
Monter 1 ey Jack ounce Mozzar 1 ella, ounce part skim milk Cream, 1 sour tablesp oon Milk: Skim Whole 1 cup 1 cup
26
17
14
89 149
126 120
406 370
296 290
Ice Cream: Vanilla Yogurt: Regular plain 1 cup 152 105 323 272 1 cup 290 112 193 208
Fruit flavored with nonfat milk solids
1 cup
231
133
442
345
EGGS, FISH, MEAT, POULTRY AND RELATED PRODUCTS Eggs, whole (boiled) Fish: Salmon, broiled Sardines, canned Trout, brook, raw Tuna, canned in water Shellfish: Clams, raw, hard Crab, canned Lobster, boiled (northern) Scallops, steamed Shrimp, canned Meat: Beef, lean hamburger, cooked Pork: Bacon, cooked Ham Poultry: Chicken, roasted, breast without skin Turkey, roasted, breast with skin 1/2 breast 3 1/2 ounces FRUITS 142 189 63 67 220 289 13 21 2 strips 3 ounces 96 298 274 1,114 34 284 2 4 1 patty 140 55 480 14 3 ounces 3 ounces 3 ounces 3 ounces 3 ounces 68 86 80 95 324 174 425 212 225 1,955 264 94 153 405 122 58 38 55 98 9 3 ounces 3 ounces 3 ounces 3 ounces 156 174 86 108 99 552 67 288 378 501 319 237 127 372 12 14 1 78 59 62 26
Apples, medium (2 1/2 inches in diameter) Apricots Avocado, raw, peeled Banana, raw, medium Strawberries, raw Cherries, raw, sweet Grapefruit, pink, raw, medium Oranges, raw Grapes Cantaloupe Peaches, raw Pears, raw Pineapple, raw Plums, raw Raisins Watermelon
1 apple 3 apricots 1 1 1 cup 1 cup 1/2 1 10 1/2 melon 1 1 1 cup 1 1 cup 1/16 melon
87 51 167 127 55 82 40 71 31 60 38 122 69 33 462 152
2 1 22 2 2 150 1 1 1 24 1 1 1 1 17 10
165 281 604 550 244 223 135 311 72 502 202 260 195 150 1,221 560
10 17 10 12 31 26 16 65 7 28 9 16 23 9 99 38
GRAIN PRODUCTS Bread: White Whole Wheat Cereals: Cream of Wheat, regular Oatmeal Crackers: 3/4 cup 3/4 cup 100 111 3 1 17 98 10 16 1 slice 1 slice 62 56 114 132 24 63 20 23
Graham Saltine Whole wheat Macaroni, cooked, no salt Muffin, English (Wonder) Noodles, egg, cooked, no salt Rice, brown, cooked, no salt Snacks: Corn chips, Fritos Popcorn with oil and salt Potato chips Pretzel sticks, Frito Lay
1 2 1 1 cup 1 medium 1 cup 1 cup
27 28 16 151 131 200 178
48 70 30 2 293 2 10
27 7 120 85 N.L. 70 105
3 1 1 11 80 16 18
1 ounce 1 cup 10 3
154 41 114 324
231 175 200 17
23 256 226 99
35 1 8 21
DESSERTS AND SWEETS Cookies: Brownies, iced, frozen Chocolate chip (commercial) Oatmeal and raisins Sandwich type (round) Sugar Doughnut, cake (plain) Cakes, from mix: Angel White Pies, frozen: 1/12 1/12 121 187 134 238 40 38 4 31 1 2 cookies 2 2 1 1 126 104 126 99 89 125 69 69 55 96 108 160 54 30 104 8 15 29 12 8 6 5 16 13
Apple Cherry
1/8 of pie 1/8 of pie
160 100
208 169
76 82
13 12
LEGUMES AND NUTS Almonds, roasted and salted Beans, baked, no pork Beans and peas, dry, cooked: Northern Blackeye, cooked Pinto, calico, raw Split, cooked Kidney, canned Cashews, roasted Peanuts: Dry, roasted, salted Unsalted Peanut butter Pecans Pistachios Walnuts, English 1 cup 1 cup 1 tablespoon 1 cup 1 cup 1 cup 838 838 86 696 594 781 986 8 81 1 6 3 1,009 1,009 123 420 972 540 104 104 11 74 131 119 1 cup 1 cup 1/2 cup 1 cup 1 cup 1 cup 118 178 349 208 225 561 5 12 4 5 844 1,200 416 625 984 536 660 464 50 40 135 20 72 38 1 cup 1 cup 984 236 311 606 1,214 832 369 100
VEGETABLES Asparagus, canned Snap beans, canned Beets, cooked, fresh Broccoli, raw 4 spears 1 cup 1 cup 1 stalk 14 43 54 32 298 326 73 23 127 227 344 382 14 81 24 103
Cabbage, green, raw Carrots, raw, grated Cauliflower, raw, flower pieces Celery, raw Corn: Cooked, fresh Frozen Cream style, regular, canned Cucumber Lettuce, iceberg, chopped Mushrooms, raw Onions Peas: Cooked Frozen, regular Potatoes: Baked or boiled without skin French fried Mashed with milk and salt Pumpkin, canned Spinach: Raw, chopped Frozen, chopped, cooked Squash, summer, cooked
1 cup 1 cup 1 cup 1 stalk (outer)
24 46 27 8
8 34 17 25
233 375 295 170
49 41 25 20
1 ear 1 cup 1 cup 7 slices 1 cup 1 cup 1 medium
70 130 210 4 7 20 38
1 7 671 2 4 7 10
151 304 248 45 96 290 157
2 5 8 7 11 4 27
1 cup 3 ounces
106 58
2 80
294 116
34 16
1 medium 10 strips 1 cup 1 cup
139 137 137 76
5 15 632 12
755 427 548 552
14 8 50 58
1 cup 1/2 cup 1 cup
14 23 28
49 65 5
259 333 282
51 113 50
Squash, winter, baked, mashed Sweet potatoes: Baked or boiled Canned, solid packed Tomato, raw Tomato paste Tomato sauce
1 cup
126
922
56
1 sm. potato 1 sm. potato 1 med. tomato 1 cup 1 cup
141 108 33 215 97
20 48 14 77 1,498
300 200 366 2,237 1,060
40 25 20 71 32
CONDIMENTS, FATS AND OILS Catsup Mustard, prepared, yellow Olives, green, large Pickles, dill Sauces: A-1 Barbecue Worcestershire Butter, regular Margarine Salad dressing: 1 tablespoon 1 tablespoon 1 tablespoon 1 tablespoon 1 tablespoon 12 15 12 108 108 275 130 206 116 140 51 28 120 4 3 3 3 15 4 3 1 tablespoon 1 teaspoon 4 olives 1 lg. pickle 16 4 18 11 156 65 323 928 55 7 8 200 3 4 10 26
Blue cheese French, bottled Italian, bottled Mayonnaise Thousand Island
1 tablespoon 1 tablespoon 1 tablespoon 1 tablespoon 1 tablespoon
71 57 77 61 70
153 214 116 78 109
5 11 2 1 16
11 2 2 2 2

Hypertension

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Hypertension

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Hypertension

1 Classification 2 Signs and symptoms

4 Pathophysiology 5 Diagnosis 6 Prevention 7 Treatment

10 History 11 Society and culture

11.1 Economics 11.2 Awareness

12 References 13 Further reading 14 External links

[edit] Signs and symptoms

[edit] Accelerated hypertension

[edit] Secondary hypertension

[edit] Secondary hypertension

Physical exercise Weight loss

Society and culture

Decision to treat hypertension Drug treatment is recommended:

Antihypertensive therapy choices

If the patient is black or aged 55 years, use:

Drug Indications and Contra-indications

Angiotensin-II receptor antagonists (angiotensin receptor blockers (ARBs))Compelling indications:

Calcium-channel blockers (dihydropyridine) (e.g. nifedipine S/R)Compelling indications:

Elderly ISH. Raynaud's. Elderly angina. Tachyarrythmias. Congestive cardiac failure.

Possible indications: Possible cautions:

Other calcium-channel blockers (rate limiting)Compelling indications:

Angina. MI. Heart block. Heart failure.

Possible indications: Contra-indications:

Contra-indications: Possible cautions: Diuretics (anti-aldosterone)Compelling indications:

Contra-indications: Possible cautions:

disease because of association with renovascular disease.

failure (titrate dose carefully).

Drug Indications and Contra-indications

Pregnancy. Renovascular disease. Hyperkalaemia Renal impairmenta. PVDb.

Angiotensin-II receptor antagonists (angiotensin receptor blockers (ARBs))

Cough on ACE inhibitor.

Pregnancy. Renovascular disease. Hyperkalaemia. Renal impairment. PVDb.

Asthma/COPD. Heart block. Heart failurec. Diabetes (except if CHD).

Athletes and physically active patients. PVDb.

Calcium-channel blockers (dihydropyridine) (e.g. nifedipine S/R)

Elderly ISH. Raynaud's. Elderly angina.

Tachyarrythmias. Congestive cardiac failure.

Other calcium-channel blockers (rate limiting)

Heart block. Heart failure. Combination with betablockers.

Thiazides Compelling indications:

Congestive cardiac failure (CCF). Post MI.

Renal failure. Hyperkalaemia.

Prostatic hyperplasia (BPH). Hyperlipidaem

Orthostatic hypotension. Congestive heart failured.

disease because of association with renovascular disease.

failure (titrate dose carefully).

Two new indicators were added for QOF 2009-10:

a specific medical cause that can be identified

Undiagnosed high blood pressure can lead to

Jugular venous distension Crackles Peripheral edema

Abdomen Abdominal masses or bruits CNS

Level of consciousness Visual fields Focal neurologic signs

What Are the Different Types of Hypertension?

Isolated Systolic Hypertension

DIASTOLIC (MM HG) and or <80 80 89

<120 120 139

Cottag 1/2 cup e, 4 1/2% milk fat Cream 1 ounce

Fruit flavored with nonfat milk solids

87 51 167 127 55 82 40 71 31 60 38 122 69 33 462 152

1 2 1 1 cup 1 medium 1 cup 1 cup

27 28 16 151 131 200 178

27 7 120 85 N.L. 70 105

154 41 114 324