DR ABDUL GHANI WASEEM

INTRODUCTION

High blood pressure (hypertension) is a common condition in which the long-term

force of the blood against the artery walls is high enough that it may eventually cause
health problems, such as heart disease.

Blood pressure is determined both by the amount of blood the heart pumps and the
amount of resistance to blood flow in the arteries.
The more blood the heart pumps and the narrower the arteries, the higher the blood
pressure. A blood pressure reading is given in millimeters of mercury (mm Hg).

It has two numbers, for example

120/80 mmHg.
Top number (systolic pressure). 
Bottom number (diastolic pressure).
Hypertension Classification
 Categories of Blood pressure measurements
Hypertensive crisis. 
A blood pressure measurement higher than 180/120 mm Hg is an emergency
situation that requires urgent medical care.
Causes

There are two types of high blood pressure.

Primary (essential) hypertension

Secondary hypertension
Primary (essential) hypertension
Causes

For most adults, there's no identifiable cause of high blood pressure.

This type of high blood pressure, called primary (essential) hypertension, tends to
develop gradually over many years.
What is blood pressure and how is it measured?

The heart supplies the organs and tissues of the body with blood. With every beat, it pumps blood into the large blood
vessels of the circulatory system. As the blood moves around the body, it puts pressure on the walls of the vessels.
Blood pressure readings are made up of two values:

Systolic blood pressure is the pressure when the heart beats – while the heart muscle is contracting (squeezing) and
pumping oxygen-rich blood into the blood vessels.
Diastolic blood pressure is the pressure on the blood vessels when the heart muscle relaxes. The diastolic pressure is
always lower than the systolic pressure.

Blood pressure is measured in units of millimeters of mercury (mmHg).

The readings are always given in pairs, with the upper (systolic) value first, followed by the lower (diastolic) value.

So someone who has a reading of 136/94 mmHg (often spoken “136 over 94”) has a
Systolic blood pressure of 136 mmHg,
Diastolic blood pressure of 94 mmHg.
What is normal blood pressure, and when
is blood pressure considered to be high
Blood pressure is always measured on a number of different days and when the patient is at rest. If several of
these measurements are too high, thev patient is said to have high blood pressure, even if only one of the two
– either the systolic or the diastolic one – is high.

The medical term for high blood pressure is hypertension.

In adults, blood pressure is considered to be normal under a systolic value of 120 mmHg and under a
diastolic value of 80 mmHg.

When taking your blood pressure for the first time, it makes sense to measure the blood pressure in both
arms, because it's sometimes high on only one side. The values that are higher are always the ones used for
assessing blood pressure. After that it is enough to measure the blood pressure only in the arm that produced
the higher reading. A person is considered to have high blood pressure if the systolic value is over 140
mmHg, the diastolic value is over 90 mmHg, or if both are higher than these readings.

High blood pressure itself usually goes unnoticed. Only if it is extremely high can it sometimes result in
symptoms like dizziness or trouble seeing. Over the long term, high blood pressure increases the risk of
cardiovascular problems like heart attacks, strokes, and heart and kidney failure.
Measurement of blood pressure

It's important to measure blood pressure more than once because it fluctuates over the course of the day. It can
also change due to things like physical exertion, stress, pain, or extreme heat or cold. But this kind of increase in
blood pressure is only temporary and it soon returns to normal.

So, if blood pressure is measured just once and found to be high, it doesn't necessarily mean that it's always too
high. A blood pressure reading taken at the doctor’s office can also be misleading: Going to the doctor makes
some people so nervous that their blood pressure goes up.

So to get reliable readings, blood pressure is measured on several different days and while you are resting. This
means sitting down and relaxing on a chair, and waiting about three minutes before taking a measurement so that
your circulatory system comes to rest. The upper arm that is being used for the measurement should rest on a
table, at about the same height as the heart, while the reading is being done.
You can measure your blood pressure on your own using a digital blood pressure monitor for automated readings
or an instrument called a sphygmomanometer for manual readings.
Measurement of blood pressure

Digital blood pressure monitors

Digital blood pressure monitors are often used on the wrist, but they can also be placed on the
finger or upper arm and are activated simply by pressing a button. They read the blood
pressure automatically based on variations in the volume of blood in the arteries. When taking
blood pressure measurements on the wrist, it's important to keep the hand level with the heart.
Otherwise it can affect the readings.
Digital meters can sometimes be inaccurate and produce unreliable readings anyway –
especially in people with certain heart rhythm problems or arteries that have hardened due to
arteriosclerosis.
Go to:
Measuring blood pressure with a sphygmomanometer

A sphygmomanometer has three parts:

a cuff that can be inflated with air,
a pressure meter (manometer) for measuring air pressure in the cuff, and
a stethoscope for listening to the sound the blood makes as it flows through the brachial artery (the major artery found in your
upper arm).

The scale of the pressure meter ranges from 0 to 300 mmHg. The pressure meter has a rubber pump on it for inflating the cuff
and a button for letting the air out.

To measure blood pressure, the cuff is placed around the bare and stretched out upper arm, and inflated until no blood can flow
through the brachial artery. Then the air is slowly let out of the cuff.
As soon as the air pressure in the cuff falls below the systolic blood pressure in the brachial artery, blood will start to flow
through the arm once again. This creates a pounding sound when the arteries close again and the walls of the vessels hit each
other after a heart beat. The sound can be heard by placing the stethoscope close to the elbow. Right when you start to hear this
pounding for the first time you can read your systolic blood pressure off the pressure meter.
The pounding sound stops when the air pressure in the cuff falls below the diastolic blood pressure in the brachial artery. Then
the blood vessels remain open. Right when the pounding stops, you can read the diastolic blood pressure off the pressure meter.
 Blood pressure is typically measured with an inflatable cuff that is placed around your arm.
When taking your blood pressure, your healthcare provider is looking for two
measurements:
 Systolic blood pressure: Blood vessel pressure during a heart beat
 Diastolic blood pressure: Blood vessel pressure between heart beats
 The two measurements are listed together, systolic on top of diastolic. A normal blood
pressure measurement is less than 120/80. Once your blood pressure rises above this
measurement, your healthcare provider will start to monitor you for high blood pressure.
It’s a condition that can be treated.
Causes
Secondary hypertension
Some people have high blood pressure caused by an underlying condition. This type of high blood pressure, called secondary hypertension.
Chemical substances and causing high blood pressure

 Alcohol, amphetamines, ecstasy (MDMA and derivatives), and cocaine.

 Angiogenesis inhibitors (including tyrosine kinase inhibitors and monoclonal antibodies)

 Antidepressants (including venlafaxine, bupropion, and desipramine)

Risk factors

High blood pressure has many risk factors, including:

Age. The risk of high blood pressure increases with age.

Race. High blood pressure is particularly common among people of African heritage, often developing at an earlier age than it does in
whites. Serious complications, such as stroke, heart attack and kidney failure, also are more common in people of African heritage.

Family history. High blood pressure tends to run in families.

Overweight or obese. The more the patient weigh, the more blood , needed to supply oxygen and nutrients to y the
tissues. As the amount of blood blow through your blood vessels increases, so does the pressure on your artery walls.

Lack of exercise. People who are inactive tend to have higher heart rates. The higher your heart rate, the harder your heart must work with
each contraction and the stronger the force on the arteries. Lack of physical activity also increases the risk of being overweight.

Smoking  Not only does smoking or chewing tobacco immediately raise the blood pressure temporarily, but the chemicals in
tobacco can damage the lining of the artery walls. This can cause the arteries to narrow and increase the risk of heart disease.

Too much salt (sodium) in diet. Too much sodium in the diet can cause the body to retain
fluid, which increases blood pressure.
CLINICAL FEATURES

Most people with high blood pressure have no signs or symptoms, even if blood
pressure readings reach dangerously high levels.

A few people with high blood pressure may have:

 Headaches.

 Shortness of breath.

 Nosebleeds.

But these signs and symptoms aren't specific and usually don't occur until high blood
pressure has reached a severe or life-threatening stage.
Complications

Uncontrolled high blood pressure can lead to complications including:

Myocardial Infarction or stroke

High blood pressure can cause hardening and thickening of the arteries (atherosclerosis), which can
lead to a heart attack, stroke or other complications.

Aneurysm
 Increased blood pressure can cause the blood vessels to weaken and bulge, forming an aneurysm. If
an aneurysm ruptures, it can be life-threatening.

Heart failure. To pump blood against the higher pressure in the vessels, the heart has to work harder.
This causes the walls of the heart's pumping chamber to thicken (left ventricular hypertrophy).
Eventually, the thickened muscle may have a hard time pumping enough blood to meet thebody's
needs, which can lead to heart failure.
ANEURYSM
Complications

.
Weakened and narrowed blood vessels in the kidneys. This can prevent these
organs from functioning normally.

Thickened, narrowed or torn blood vessels in the eyes. This can result in vision
loss.
INVESTIGATIONS

Ambulatory monitoring. This 24-hour blood pressure monitoring test is used to confirm

if the patient have high blood pressure. The device used for this test measures the blood
pressure at regular intervals over a 24-hour period and provides a more accurate picture
of blood pressure changes over an average day and night. However, these devices
aren't available in all medical centers, and they may not be reimbursed.
Lab tests. Your doctor may recommend a urine test (urinalysis) and blood tests,
including a cholesterol test.
Electrocardiogram (ECG or EKG). This quick and painless test measures the heart's
electrical activity.
Echocardiogram. Depending on the signs and symptoms and test results, your doctor
may order an echocardiogram to check for more signs of heart disease. An
echocardiogram uses sound waves to produce images of the heart.
Electrocardiogram (ECG or EKG)
Echocardiogram
Treatment of hypertension
Treatment
Lifestyle modifications

Changing the lifestyle can help control and manage high blood pressure.

Lifestyle changes include:

Regular physical activity.

Maintaining a healthy weight..

Less salt Intake.

Stop smoking.

Stop the alcohol Intake.

But sometimes lifestyle changes aren't enough.

If diet and exercise don't help, then recommend medication to lower your blood pressure.
DRUG TREATMENT OF HYPERTENSION
Diuretics. 

Angiotensin-converting enzyme (ACE) inhibitors. 

Angiotensin II receptor blockers (ARBs). 

Calcium channel blockers. 

Alpha blockers. 

Alpha-beta blockers.

Beta blockers. 

Vasodilators. 

Central-acting agents.
Mechanism of action
Treatment

Diuretics. Diuretics, sometimes called water pills, are medications that help the kidneys
eliminate sodium and water from the body.

These drugs are often the first medications tried to treat high blood pressure.

There are 5 different classes of diuretics including:

 Thiazides and thiazide-like diuretics
 Loop diuretics
 Carbonic anhydrase inhibitors
 Potassium-sparing diuretics
 Osmotic diuretics.

A common side effect of diuretics is increased urination, which could reduce potassium
levels.
Treatment
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin has a powerful narrowing effect on the blood vessels, which increases the  blood pressure. 
ACE inhibitors inhibit or limit this enzyme, making the blood vessels relax and widen. This, in turn, lowers the blood pressure and
improves blood flow to the heart muscle.
 These medications — such as:
 Captopril
 Lisinopril (prinivil, zestril)
 Benazepril (lotensin)

Angiotensin II receptor blockers (ARBs). 

Angiotensin II receptor blockers (ARBs) are medications that block the action of angiotensin II by preventing angiotensin II from
binding to angiotensin II receptors on the muscles surrounding blood vessels. As a result, blood vessels enlarge (dilate) and blood
pressure is reduced

 ARBs include :
Losartan (cozaar)
Candesartan (Atacand)
 Side effects
 Dry cough.
 Increased potassium levels in the blood (hyperkalemia)
 Postural Drop.
 Headaches.
Treatment

.
Calcium channel blockers. 
Calcium channel blockers lower the blood pressure by preventing calcium from entering
the cells of the heart and arteries.
 Calcium causes the heart and arteries to contract more strongly. By
blocking calcium, calcium channel blockers allow blood vessels to relax and open.

Some slow your heart rate. Calcium channel blockers may work better for older
people and people of African heritage than do ACE inhibitors alone.

These medications — including amlodipine (Norvasc), diltiazem (Cardizem, Tiazac,

others) and others.
Treatment

Beta blockers. 

Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. 
Beta blockers cause the heart to beat more slowly and with less force, which lowers blood
pressure. Beta blockers also help open up the veins and arteries to improve blood flow.
Beta blockers include acebutolol, atenolol (Tenormin) and others.

Side effects
 Side effects commonly reported by people taking beta blockers include:
 feeling tired, dizzy or lightheaded (these can be signs of a slow heart rate)
 cold fingers or toes (beta blockers may affect the blood supply to your hands and feet)
 difficulties sleeping or nightmares.
Treatment

Alpha blockers. These medications reduce nerve signals to blood vessels, lowering

the effects of natural chemicals that narrow blood vessels. Alpha blockers include
doxazosin (Cardura), prazosin (Minipress) and others.

Alpha-beta blockers. Alpha-beta blockers block nerve signals to blood vessels and

slow the heartbeat to reduce the amount of blood that must be pumped through the
vessels. Alpha-beta blockers include carvedilol (Coreg) and labetalol (Trandate).
Treatment

.
Aldosterone antagonists. These drugs also are considered diuretics.
Examples are spironolactone and eplerenone (Inspra). These drugs block the effect
of a natural chemical that can lead to salt and fluid buildup, which can contribute to
high blood pressure. They may be used to treat resistant hypertension.
Treatment
Treating resistant hypertension
If the blood pressure remains stubbornly high despite taking at least three different types of high blood pressure drugs, one of which usually should
be a diuretic, the patient may have resistant hypertension.

, the patient may have resistant hypertension, if he have controlled high blood pressure but are taking four different types of medications at the
same time to achieve that control. If you do, your doctor should investigate the possibility of a secondary cause of the high blood pressure.

Having resistant hypertension doesn't mean that blood pressure will never get lower. If you and your doctor can determine the cause, a more
effective treatment plan can be created to help you meet your goal blood pressure.

Treating resistant hypertension may involve many steps, including:

Changing your high blood pressure medications to determine which combinations and doses work best

Reviewing all the medications you take, including those that you take for other conditions or buy without a prescription

Monitoring your blood pressure at home to see if going to the doctor causes your blood pressure to increase (white coat hypertension)

Making healthy lifestyle changes, such as eating a healthy diet with less salt, maintaining a healthy weight and limiting alcohol

You should always take blood pressure medications as prescribed.

Never skip a dose or abruptly stop taking your blood pressure medication. Suddenly stopping certain blood pressure drugs, such as beta blockers,
can cause a sharp increase in blood pressure (rebound hypertension).

If you skip doses because you can't afford the medications, because you have side effects or because you simply forget to take your medications,
talk to your doctor about solutions. Don't change your treatment without your doctor's guidance.