Hypertension

Submitted by: Patrick D. delos Santos

Batch 6

Submitted to: Mr. Jonathan Cuevas

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What is high blood pressure?

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.

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).

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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
end-organ 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

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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

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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.

Causes

Blood pressure measurements are the result of the force of the blood produced by
the heart and the size and condition of the arteries.

Many factors can affect blood pressure, including:

• How much water and salt you have in your body

• The condition of your kidneys, nervous system, or blood vessels
• The levels of different body hormones

High blood pressure can affect all types of people. You have a higher risk of high
blood pressure if you have a family history of the disease. High blood pressure is
more common in African Americans than Caucasians. Smoking, obesity, and diabetes
are all risk factors for hypertension.

Most of the time, no cause is identified. This is called essential hypertension.

High blood pressure that results from a specific condition, habit, or medication is
called secondary hypertension. Too much salt in your diet can lead to high blood
pressure. Secondary hypertension may also be due to:

• Adrenal gland tumor

• Alcohol abuse
• Anxiety and stress
• Arteriosclerosis
• Birth control pills
• Coarctation of the aorta
• Cocaine use
• Cushing syndrome
• Diabetes
• Kidney disease, including:
o Glomerulonephritis (inflammation of kidneys)
o Kidney failure
o Renal artery stenosis
o Renal vascular obstruction or narrowing
• Medications
o Appetite suppressants
o Certain cold medications
o Corticosteroids
o Migraine medications
• Hemolytic-uremic syndrome

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 • Henoch-Schonlein purpura
• Obesity
• Pain
• Periarteritis nodosa
• Pheochromocytoma
• Pregnancy (called gestational hypertension)
• Primary hyperaldosteronism
• Renal artery stenosis
• Retroperitoneal fibrosis
• Wilms' tumor

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.

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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.

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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

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a medical emergency and requires urgent treatment to prevent a stroke (brain
damage).

Exams and Tests

Your health care provider will perform a physical exam and check your blood
pressure. If the measurement is high, your doctor may think you have high blood
pressure. The measurements need to be repeated over time, so that the diagnosis
can be confirmed.

If you monitor your blood pressure at home, you may be asked the following
questions:

• What was your most recent blood pressure reading?

• What was the previous blood pressure reading?
• What is the average systolic (top number) and diastolic (bottom number)
reading?
• Has your blood pressure increased recently?

Other tests may be done to look for blood in the urine or heart failure. Your doctor
will look for signs of complications to your heart, kidneys, eyes, and other organs in
your body.

These tests may include:

• Chem-20
• Echocardiogram
• Urinalysis
• Ultrasound of the kidneys

Treatment

the goal of treatment is to reduce blood pressure so that you have a lower risk of
complications.

There are many different medicines that can be used to treat high blood pressure,
including:

• Alpha blockers
• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin receptor blockers (ARBs)
• Beta-blockers
• Calcium channel blockers
• Central alpha agonists
• Diuretics
• Renin inhibitors, including aliskiren (Tekturna)
• Vasodilators

Your doctor may also tell you to exercise, lose weight, and follow a healthier diet. If
you have pre-hypertension, your doctor will recommend the same lifestyle changes
to bring your blood pressure down to a normal range.

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Often, a single blood pressure drug may not be enough to control your blood
pressure, and you may need to take two or more drugs. It is very important that you
take the medications prescribed to you. If you have side effects, your health care
provider can substitute a different medication.

Possible Complications

• Aortic dissection
• Blood vessel damage (arteriosclerosis)
• Brain damage
• Congestive heart failure
• Kidney damage
• Kidney failure
• Heart attack
• Hypertensive heart disease
• Stroke
• Vision loss

Prevention

Adults over 18 should have their blood pressure checked routinely.

Lifestyle changes may help control your blood pressure:

• Lose weight if you are overweight. Excess weight adds to strain on the heart.
In some cases, weight loss may be the only treatment needed.
• Exercise regularly. If possible, exercise for 30 minutes on most days.
• Eat a diet rich in fruits, vegetables, and low-fat dairy products while reducing
total and saturated fat intake (the DASH diet is one way of achieving this kind
of dietary plan). (See: Heart disease and diet)
• Avoid smoking. (See: Nicotine withdrawal)
• If you have diabetes, keep your blood sugar under control.
• Do not consume more than 1 or 2 alcoholic drinks per day.
• Try to manage your stress.

Follow your health care provider's recommendations to modify, treat, or control

possible causes of secondary hypertension.

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