HYPERTENSION

INTRODUCTION:
Hypertension is another name for high blood pressure. It is one of the most common
worldwide diseases afflicting humans and is a major risk factor for stroke, myocardial infarction,
vascular disease, and chronic kidney disease. Despite extensive research over the past several
decades, the etiology of most cases of adult hypertension is still unknown, and control of blood
pressure is suboptimal in the general population.

Blood pressure is the force exerted by the blood against the walls of the blood vessels.
The pressure depends on the work being done by the heart and the resistance of the blood
vessels. Medical guidelines define hypertension as a blood pressure higher than 130 over
80 millimeters of mercury (mmHg), according to guidelines issued by the American Heart
Association (AHA) in November 2017.

Hypertension and heart disease are global health concerns. The World Health
Organization (WHO) suggests that the growth of the processed food industry has impacted the
amount of salt in diets worldwide, and that this plays a role in hypertension.

PATHOPHYSIOLOGY:
The pathogenesis of essential hypertension is multifactorial and complex. Multiple factors
modulate the blood pressure (BP) including humoral mediators, vascular reactivity, circulating
blood volume, vascular caliber, blood viscosity, cardiac output, blood vessel elasticity, and
neural stimulation. A possible pathogenesis of essential hypertension has been proposed in which
multiple factors, including genetic predisposition, excess dietary salt intake, and adrenergic tone,
may interact to produce hypertension. Although genetics appears to contribute, the exact
mechanisms underlying essential hypertension have not been established.
Investigations into the pathophysiology of hypertension, both in animals and humans, have
revealed that hypertension may have an immunological basis. Studies have revealed that
hypertension is associated with renal infiltration of immune cells and that pharmacologic
immunosuppression (such as with the drug mycophenolate mofetil) or pathologic
immunosuppression (such as occurs with HIV) results in reduced blood pressure in animals and
humans. Evidence suggests that T lymphocytes and T-cell derived cytokines (eg, interleukin 17,
tumor necrosis factor alpha) play an important role in hypertension.
One hypothesis is that prehypertension results in oxidation of lipids such as arachidonic acid that
leads to the formation of isoketals or isolevuglandins, which function as neoantigens, which are
then presented to T cells, leading to T-cell activation and infiltration of critical organs (eg,
kidney, vasculature). [16] This results in persistent or severe hypertension and end organ damage.
Sympathetic nervous system activation and noradrenergic stimuli have also been shown to
promote T-lymphocyte activation and infiltration and contribute to the pathophysiology of
hypertension. [17, 18, 19]
The natural history of essential hypertension evolves from occasional to established
hypertension. After a long invariable asymptomatic period, persistent hypertension develops into
complicated hypertension, in which end-organ damage to the aorta and small arteries, heart,
kidneys, retina, and central nervous system is evident.
The progression of essential hypertension is as follows:
1. Prehypertension in persons aged 10-30 years (by increased cardiac output)
2. Early hypertension in persons aged 20-40 years (in which increased peripheral resistance is
prominent)
3. Established hypertension in persons aged 30-50 years
4. Complicated hypertension in persons aged 40-60 years
As evident from the above, younger individuals may present with hypertension associated with
an elevated cardiac output (high-output hypertension). High-output hypertension results from
volume and sodium retention by the kidney, leading to increased stroke volume and, often, with
cardiac stimulation by adrenergic hyperactivity. Systemic vascular resistance is generally not
increased at such earlier stages of hypertension. As hypertension is sustained, however, vascular
adaptations including remodeling, vasoconstriction, and vascular rarefaction occur, leading to
increased systemic vascular resistance. In this situation, cardiac output is generally normal or
slightly reduced, and circulating blood volume is normal.
Cortisol reactivity, an index of hypothalamic-pituitary-adrenal function, may be another
mechanism by which psychosocial stress is associated with future hypertension. [20] In a
prospective sub-study of the Whitehall II cohort, with 3 years follow-up of an occupational
cohort in previously healthy patients, investigators reported 15.9% of the patient sample
developed hypertension in response to laboratory-induced mental stressors and found an
association between cortisol stress reactivity and incident hypertension.
ALGORITHM:
SIGNS AND SYMPTOMS:
Signs

Blood pressure can be measured by a sphygmomanometer, or blood pressure monitor.

Having high blood pressure for a short time can be a normal response to many situations. Acute
stress and intense exercise, for example, can briefly elevate blood pressure in a healthy person.

For this reason, a diagnosis of hypertension normally requires several readings that show high
blood pressure over time.

The systolic reading of 130 mmHg refers to the pressure as the heart pumps blood around the
body. The diastolic reading of 80 mmHg refers to the pressure as the heart relaxes and refills
with blood.

The AHA 2017 guidelines define the following ranges of blood pressure:

Systolic (mmHg) Diastolic (mmHg)

Normal blood pressure Less than 120 Less than 80

Elevated Between 120 and 129 Less than 80

Stage 1 hypertension Between 130 and 139 Between 80 and 89

Stage 2 hypertension At least 140 At least 90

 Hypertensive crisis Over 180 Over 120

If the reading shows a hypertensive crisis when taking blood pressure, wait 2 or 3 minutes and
then repeat the test.

If the reading is the same or higher, this is a medical emergency. The person should seek
immediate attention at the nearest hospital.

Symptoms

A person with hypertension may not notice any symptoms, and it is often called the
"silent killer." While undetected, it can cause damage to the cardiovascular system and internal
organs, such as the kidneys.

Regularly checking your blood pressure is vital, as there will usually be no

symptoms to make you aware of the condition. It is maintained that high blood pressure
causes sweating, anxiety, sleeping problems, and blushing. However, in most cases, there will
be no symptoms at all. If blood pressure reaches the level of a hypertensive crisis, a person may
experience headaches and nosebleeds.

Treatment.
While blood pressure is best regulated through the diet before it reaches the stage of
hypertension, there is a range of treatment options. Lifestyle adjustments are the standard first-
line treatment for hypertension.

Regular physical exercise

Doctors recommend that patients with hypertension engage in 30 minutes of moderate-intensity,

dynamic, aerobic exercise. This can include walking, jogging, cycling, or swimming on 5 to 7
days of the week.
Stress reduction

Avoiding stress, or developing strategies for managing unavoidable stress, can help with blood
pressure control.

Using alcohol, drugs, smoking, and unhealthy eating to cope with stress will add to hypertensive
problems. These should be avoided.

Smoking can raise blood pressure. Giving up smoking reduces the risk of hypertension, heart
conditions, and other health issues.

HEALTH EDUCATION
High blood pressure isn't a problem that you can treat and then ignore. It's a condition you need
to manage for the rest of your life. To keep your blood pressure under control:

 Take your medications properly. If side effects or costs pose problems, don't stop taking
your medications. Ask your doctor about other options.

 Schedule regular doctor visits. It takes a team effort to treat high blood pressure
successfully. Your doctor can't do it alone, and neither can you. Work with your doctor to
bring your blood pressure to a safe level, and keep it there.

 Adopt healthy habits. Eat healthy foods, lose excess weight and get regular physical
activity. Limit alcohol. If you smoke, quit.

 Manage stress. Say no to extra tasks, release negative thoughts, maintain good
relationships, and remain patient and optimistic.

Sticking to lifestyle changes can be difficult, especially if you don't see or feel any symptoms of
high blood pressure. If you need motivation, remember the risks associated with uncontrolled
high blood pressure. It may help to enlist the support of your family and friends as well.
REFERENCES:
1. Benjamin EJ, Blaha MJ, Chiuve SE, et al, for the American Heart Association Statistics
Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2017
update: a report from the American Heart Association. Circulation. 2017 Mar 7. 135 (10):e146-
e603.

2. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh
report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. Hypertension. 2003 Dec. 42(6):1206-52.
3. Institute for Clinical Systems Improvement (ICSI). Hypertension diagnosis and treatment.
Bloomington, Minn: Institute for Clinical Systems Improvement (ICSI); 2010.

4. Katakam R, Brukamp K, Townsend RR. What is the proper workup of a patient with
hypertension?. Cleve Clin J Med. 2008 Sep. 75(9):663-72.