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What is Hypertension ?

Hypertension

Blood flow of hypertensive and non hypertensive patients

High blood pressure (hypertension) is the leading cause of death or disability in the world. In Egypt, data from the Egyptian National hypertension Project (NHP) showed that hypertension is common among Egyptians. In the years from 1991–1993, 26.3% of adult Egyptians had high blood pressure. 1, 2, 3 More than 50% of individuals older than 60 years suffered from hypertension. Important influencers include the autonomic nervous system, renin-angiotensin axis, cardiac function and output, vascular function, and renal salt and water balance.

 

Risk factors

  • The risk of high blood pressure increases as you age. Until about age 64, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
  • 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.
  • The more you weigh the more blood you need to supply oxygen and nutrients to your tissues. As the volume of blood circulated through your blood vessels increases, so does the pressure on your artery walls.
  • Sedentary life. 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 your arteries. Lack of physical activity also increases the risk of being overweight.
  • Excessive smoking. Not only does smoking or chewing tobacco immediately raise your blood pressure temporarily, but the chemicals in tobacco can damage the lining of your artery walls. This can cause your arteries to narrow and increase your risk of heart disease. Secondhand smoke also can increase your heart disease risk.
  • High sodium intake. Too much sodium in your diet can cause your body to retain fluid, which increases blood pressure.
  • High consumption of alcohol. Over time, heavy drinking can damage your heart. Having more than one drink a day for women and more than two drinks a day for men may affect your blood pressure.
  • Stress and anxiety. High levels of stress can lead to a temporary increase in blood pressure.
  • Certain chronic conditions. Certain chronic conditions also may trigger your blood pressure, such as kidney disease, diabetes and sleep apnea.

 

History

  • Duration of hypertension, usual BP level, any sudden change in severity of hypertension, and prior hospitalization or emergency department visit for hypertensive urgency.
  • Use of home monitoring, home BP levels, noting any discrepancy between home and office values
  • History of antihypertensive drug use, reason for changing/stopping therapy, effectiveness, side effects and intolerance
  • Drugs that may cause hypertension
  • Drugs that may interact with antihypertensive drugs (those that induce or inhibit metabolism)
  • Adherence with lifestyle recommendations and drug therapy
  • Family history of hypertension, cardiovascular risk factors and premature cardiovascular disease
  • Personal history of cigarette and alcohol use, usual physical activity, usual diet and sodium intake, current weight and recent weight change, waist circumference, diabetes, and dyslipidemia.
  • Cerebrovascular, cardiac and peripheral vascular symptoms to assess for target organ damage.
  • Symptoms of secondary hypertension, which include, for example, pheochromocytoma (hyperadrenergic symptoms), hyper- and hypothyroidism, Cushing syndrome, renal/urinary symptoms or
  • Past history of renal disease

 

Diagnosis

High blood pressure chart

  • Diagnosis of hypertension is immediate in case of hypertensive emergencies and urgencies.
  • Measurements using a validated electronic device are preferred. Automated office measurement is the preferred method of measuring BP in the office or pharmacy. Measurement can minimize the white coat effect.
  • Hypertension may be diagnosed if the mean BP at the initial office visit is ≥180/110 mm Hg.
  • Diagnosis of hypertension through out-of-office measurement can be done by performing a 24-hour ambulatory BP monitoring study or a home BP series. Ambulatory (continuous) monitoring is preferred and is considered the gold standard of BP measurement. The home BP series comprises 2 readings taken each morning and evening for 7 days (28 total readings).

 

Physical exam

  • Edema and lung fields for signs of heart failure
  • Heart sounds (fourth heart sound), sustained and displaced apex for left ventricular hypertrophy
  • Abdominal mass for polycystic kidneys and aortic aneurysm
  • Neurologic exam for cerebrovascular disease

Initial laboratory testing

  • Serum potassium, Sodium and Creatinine
  • Urinalysis
  • Urinary albumin and/or albumin-creatinine ratio in patients with diabetes
  • Fasting glucose and/or HbA1c
  • Total cholesterol, HDL-C, LDL-C, triglycerides (lipids may be measured in the fasting or nonfasting state)
  • Standard 12-lead ECG

 

Therapeutic Management

 Non pharmacological management  

All individuals should be advised about a healthy lifestyle to prevent or control hypertension and cardiovascular disease.
  • Weight loss of 4 kg or more if overweight. Eat healthy diet which is high in fresh fruits, vegetables, soluble fibers and low-fat dairy products, low in saturated fats and sodium, try DASH eating diet. It will decrease your blood pressure by −7.2/−5.9 mm/hg.
  • Consider decreasing sodium intake. It will decrease your blood pressure by −5.8/−2.5 mm/hg.
  • Increase dietary potassium intake such as fruits, if the patient is not at risk of hyperkalemia. It will decrease your blood pressure by −11.4/−5.5 mm/hg.
  • Try regular moderate-intensity cardiorespiratory physical activity for 30–60 minutes on most days. It will decrease your blood pressure by −10.3/−7.5 mm/hg.
  • Low-risk alcohol consumption (0–2 drinks/day). It will decrease your blood pressure by −4.6/−2.3 mm/hg.
  • Enjoy a smoke-free environment.

 

Pharmacological Management

 Diuretics

Extensive evidence supports low-dose thiazide or related diuretics (e.g., indapamide) as first-line therapy for uncomplicated hypertension. They have proven antihypertensive effectiveness in patients especially the elderly and black patients. Diuretics can cause hypokalemia that may be associated with adverse cardiovascular outcomes. You can also consider using a combination product to minimize the risk of hypokalemia (hydrochlorothiazide plus a potassium-sparing diuretic—spironolactone or amiloride). Loop diuretics can also be used in patients with renal impairment.

 

Beta1-Adrenergic Antagonists

Beta1-adrenergic antagonists (beta-blockers) such as (bisoprolol, carvedilol and misoprolol) are first-line therapy in patients who are younger than 60 years of age, or who have stable angina, heart failure or a history of MI. Beta-blockers are also useful in patients who have migraine headaches, tachycardia or essential tremor. However, beta-blockers are not as effective as ARBs, CCBs or diuretics, as initial therapy for primary prevention of cardiovascular events in patients over 60 years of age.

 

Angiotensin-Converting Enzyme Inhibitors

ACE inhibitors such as (captopril, ramipril and enalapril) are first-line agents for non-black patients with uncomplicated hypertension. In addition, it’s also indicated for patients with diabetes, ischemic heart disease, recent MI, heart failure or chronic kidney disease.

 

Angiotensin II Receptor Blockers

ARBs are valsartan, candesartan, olmesartan, telmisartan and losartan. They are first-line agents for patients with uncomplicated hypertension, diabetes or ischemic heart disease. ARBs are good alternatives when ACE inhibitors are indicated but have intolerable side effects. It’s suitable with patients suffering from asthma and COPD as it doesn’t trigger dry cough like ACE inhibitors.

 

Calcium Channel Blockers

Long-acting dihydropyridine CCBs can be used as first-line agents. Short-acting formulations of these agents (nifedipine) have caused an increase in cardiovascular events. Elderly patients with isolated systolic hypertension and black patients has high response to CCBs.

 

References:

  1. Lim SS, Vos T, Flaxman AD et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010
  2. Mills KT, Bundy JD, Kelly TN et al. Global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries. Circulation 2016;134(6):441-50.
  3. Padwal RS, Bienek A, McAlister FA et al. Epidemiology of hypertension in Canada: an update. Can J Cardiol 2016;32(5):687-94.
  4. https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/symptoms-causes/syc-20373410
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