INTRODUCTION higher will be blood pressure.[4] The pressure that

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Last updated: December 3, 2019

INTRODUCTION1.

1 HypertensionThroughoutmost of the world till this day, “hypertension” is defined as long-lastingrisein Blood Pressure equal to or greater than 140/90 mmHg. For diabetes andchronic kidney disease, blood pressure should be maintained at levels<130/80 mm Hg. Not all the professional experts are agreed to this but it isa significant monitoring in these types of patients.123 Thenormal physiology of cardiovascular system is thatblood is carried from heartto all other organs of the body through the vessels.With every heartbeat, itpumps blood into the vessels which are arteries, the vessels which carryoxygenated blood, and, the veins which bring back deoxygenated blood to theheart. Blood pressure is created by the force of blood pushing against thewalls of blood vessels (arteries) as it is pumped and pushed by the heart.

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Thehigher the pressure the harder the heart has to pump the blood and the higherwill be blood pressure.4 Thepressure that is set at normal for evaluating hypertensive & normotensivesituations is 120/80 mmHg systolic & diastolic respectively. Systolic bloodpressure is the pressure generated by blood against the walls of arteries whenthe heart contracts while diastolic blood pressure is the pressure when heartis in rest phase between two consecutive beats.5The WHO describeshigh blood pressure exists when the systolic pressure is at least 140 mmHg orgreater and the diastolic blood pressure exceeds at least 90 mmHg. In thisdefinition, temporary increases in blood pressure by, for example, physicalexertion, pregnancy or drugs, is not included. 6In2015, cardiovascular diseases (CVDs) were leading cause of death with approximately18 million deaths worldwide that is 31% of all global death.

7In2010, hypertension was among the two leading risk factors for global diseaseburden with 7% of global disability-adjusted life years and, the second wastobacco smoking.8Heart has its central function in running thebody all the time throughout the life which makes it the most vital of all theorgans of the body. It beats approximately 2.5 billion times on average in lifewhere it supplies necessary nutrients and oxygen to all the cells of the bodythrough circulation of blood. It also drains the deoxygenated blood back fromcells which includes metabolic wastes also and thus helps the body to get ridof wastes accumulation in the cells.

Heart catches different types ofabnormalities either at birth known as congenital or in life known as acquiredcardiovascular disorders. Hypertension is one of the acquired diseases mainly affectingthe vessels primarily and the heart later on.Asper World Health Organization report, in 2008, about 40% of populationhavingage above than 25 years had hypertension.

9The prevalence ofhypertension in adults is expected to grow from 26.4% (in 2000) to 29.2% in2025.10Around the globe, 7.6 million premature deaths (about 13.5%of the total deaths worldwide) were attributed to raise blood pressure.

About54% of stroke and 47% of ischemic heart disease worldwide were attributable tohypertension.11The worldwide prevalence of hypertension is 40% withvariation in ratios among different demographic regions of the world. It isalso known as silent killer.

Hypertension is the leading but preventable causeof death worldwide. 1.2 Classification of Hypertension:Hypertensionis classified on various bases. We discuss them one by one1.2.1 Essential hypertension:Itis also known as primary hypertension. This type is diagnosed after a doctorobserves that blood pressure of a patient is high on three or more visits and excludesall other causes of hypertension. Patients are symptomless, but may experience numerousheadaches, fatigue, light-headedness, or nose bleeds.

Even though the specificcause is unidentified yet, researchers do know that obesity; smoking, alcohol,diet, and genetics all play role in developing essential hypertension.1.2.

2 Secondary hypertension:Themost common cause of secondary hypertension is an abnormality in the arteriessupplying blood to the kidneys. Other causes include airway obstruction duringsleep, diseases and tumours of the adrenal glands, hormone defects, thyroiddisease, and too much salt intake or alcohol use. The good sign is that if the reasonis known, hypertension may be treated.

AdditionalHypertension Types: Isolated Systolic, Malignant, and ResistantIsolatedsystolic hypertension, malignant hypertension, and resistant hypertension areall recognized hypertension types with specific diagnostic criteria.1.2.3 Isolated systolic hypertension:Inisolated systolic hypertension, the systolic pressure rises above 140, whilethe lower number stays near the normal range, below 90 mmHg. This type is mostcommon in older people above age of 65 years and is caused by the loss ofelasticity in the arteries.

1.2.4 Malignant hypertension:Thistype takes place in only about 1% of people with hypertension. It is morecommon in younger adult population, African-American men, and women who havepregnancy toxaemia. Malignant hypertension occurs when blood pressure rises veryrapidly.If diastolic pressure exceeds 130 mmHg, it may be malignant hypertension. Thisis a medical emergency and needs quick treatment in a hospital.

Symptomsinclude numbness in the arms and legs, blurred vision, confusion, chest pain,and headache.  1.2.5 Resistant hypertension:If a patient is on three different typesantihypertensive medications and the blood pressure is still too high, itspossibly resistant hypertension. This type is more common in people who areolder, obese, female, African American, or have an underlying illness, such asdiabetes or kidney disease.Gene’s involvement is also consideredas associatedrisk factor.12As the aging process of the people progress with arise in the obesity, the global burden of hypertension increases with everypassing year.

About 10% of patients who have hypertension diagnosed on clinicalbasis exhibit presence of resistant hypertension, defined as a SBP of 140 mm Hgor abovein spite oftaking at least three different classes of maximallytolerated doses of antihypertensive medications as their treatment, which alsoinclude a drug belongs to diuretic class in a suitable dose.13, 14, 15,161.2.6 White coat hypertension:Generallyknown as white coat syndrome, a phenomenon in which patients have a bloodpressure level above the normal range, when they visit a clinical setup, thoughthey don’t show this rise in normal routine settings.

It is assumed that the occurrenceof this rise of blood pressure in a clinical visit is due to anxiety that is experiencedduring visit to clinic.17 Daytime blood pressure is used as a referencein this case as it takes into account ordinary levels of daily stress. Theterm “masked hypertension” can be used to describe the contrasting occurrence,where a patient’s blood pressure is above the normal range during daily living,although it isn’t above the normal range when the patient is in a clinicsetting. 181.3 Classification on basis of severity:Thebasic blood pressure stages in the WG-ASH (writing group American Society ofHypertension) definition/classification taken from JNC7.

19(JointNational Committee on Detection, Evaluation and treatment of High BloodPressure) Normal·        Resting blood pressureusually <120/80 mm Hg, although may be occasionally elevated·        No identifiable riskfactors for cardiovascular disease·        No identifiable earlymarkers of cardiovascular disease  Stage 1 (Pre-hypertension JNC7)·        Early signs offunctional or structural changes in the heart and small arteries·        Blood pressure usually120/80-139/89 mm Hg, although values ?140/90 mm Hg may be occasionally orintermittently observed·        Includes individualswith multiple cardiovascular risk factors and early disease markers but noevidence of target organ damage  Stage 2 (Hypertension-I JNC7)·        Progressive diseaseresulting from persistent functional and structural changes in blood pressurecontrol mechanisms and in the heart and vasculature·        Resting blood pressurefrequently ?140/90 mm Hg and much higher with physiologic or psychologicalstressors·        Identifiable orwidespread disease markers of evidence of early target-organ damage may bepresent regardless of blood pressure levels Stage 3 (Hypertension-II JNC7)·        All clinical evidenceof target-organ damage or overt cardiovascular disease, regardless of bloodpressure levels. ·        Sustained resting bloodpressure may be ?140/90 mm Hg even when treated (>160/100 mm Hg notuncommon)·        Cardiovascular eventsmay have already occurred·        Aging and persistenceof other identifiable risk factors continue to exacerbate the risk of morbidityand mortality Classification  Systolic BP (mm Hg)    Diastolic BP (mm Hg)  Normal  <120  AND  <80  Pre-hypertension  120–139  OR  80–89  Hypertension Stage I  140–159  OR  90–99  Hypertension  Stage II ?160  OR  ?100       JNC 7:Classification of hypertension JNC; Joint National Committee on Detection,Evaluation, and Treatment of High Blood Pressure. 19 1.4 Risk Factors for hypertension:Itis evident from a number of studies that anyone can develop hypertensionbecause the pathology of primary hypertension is not established yet; however,age, race or ethnicity, overweight or obesity, gender, lifestyle, and a familyhistory of high blood pressure can put a person in risk for developing highblood pressure. Some disease conditions can also lead to develop hypertensionin the body which is termed as secondary hypertension.

1.4.1AgeBloodpressure has a tendency to rise as people become older with age. It is becausethe vessels lose their flexibility that is a particular property to adjust the volumeof blood passing through them. However, the risk of pre-hypertension andhypertensionisincreasing in children and teens also, possibly due to the rise in the number ofoverweight children and teens because of sedentary lifestyle.Hypertension andpre-hypertension have been observed to increase among children and adolescentssince 1990s. 20, 21In the years 2003 to 2006, children andadolescents aged 8–17 years, the prevalence of pre-hypertension wasapproximately 14% in boys and 6% in girls, and the prevalence of hypertensionwas estimated to be 3%–4% in this age group in various studies.

20, 22,231.4.2Race/EthnicityHighblood pressure is more common in some races/ethnic groups while other have lessor no prevalence of hypertension.Blacks develop high blood pressure more oftenthan whites, Hispanics, Asians, Pacific Islanders, American Indians, or AlaskaNatives.

Black population also tends to develop hypertension in earlier life ascompared to other races. 241.4.3OverweightYouare more likely to develop pre-hypertension or high blood pressure ifyou’re overweight or obese. The terms “overweight” and “obese” refer tobody weight that is greater than what is considered healthy for a certainheight.1.4.4GenderBeforeage 55, men are more likely than women to develop high blood pressure.

Afterage 55, women are more likely than men to develop high blood pressure.Kearneyet al in his research in 2000 reported that the overall prevalence ofhypertension was estimated to be 26.4% of the total world’s population, out ofwhich 26.6% were male and 26.1% were female. 25 This elicit thatmale gender is slightly at high risk of becoming hypertensive.

1.4.5Lifestyle HabitsRoutinelifestyle habits can affect blood pressure. Some of them include: Eating too much sodium (> 1500mg/day)  or too little potassium Lack of physical activity Drinking too much alcohol Stress Smoking and Tobacco use  1.4.6Family HistoryAfamily history of high blood pressure increases the risk of developing pre-hypertensionor hypertension.

People having hypertension in their family are at risk ofgetting it as compared to others who don`t have a family history. Some peoplehave a high sensitivity to sodium and salt, which may increase their risk forhigh blood pressure and may run in families.1.4.7 DiabetesDiabetes,a disorder of the endocrine system in which body is either unable to produceInsulin or it cannot utilize insulin despite production. Insulin is a hormonesecreted by Pancreas that regulates sugar levels in the blood under differentcircumstances according to needs of the body.

Diabetes also increases the riskof cardiovascular diseases, in which hypertension is one of them. Diabetesincreases levels of sugar in the blood to rise abnormally.About 60% of diabeticpatients have hypertension. 261.5 Causes of High Blood PressureChanges,either from genes or the environment, in the body’s normal functionsmay cause high blood pressure.

Some known causes are discussed below:1.5.1Biology and High Blood PressureItis being studied through ongoing researches that how internal changes in normalbody functions cause high blood pressure. The significant factors which areconsidered to be affected in high blood pressure include:KidneyFluid and Salt BalancesThekidneys usuallycontrol the levels of salt in the body by retaining sodium andwater and expelling unwanted amount ofpotassium. Imbalance in this function ofthe kidney can expand circulating blood volumes, which can lead to rise in bloodpressure.

27Renin-Angiotensin-AldosteroneSystemThissystem of the body makes two different hormones, angiotensin and aldosterone.Angiotensin constricts blood vessels, which develops the pressure of blood inthese vessels. Aldosterone is responsible for regulation of fluid and saltlevels by the kidneys. Increased levels or action of aldosterone may affectthis function of kidney, leading to increased blood volumes and ultimately highblood pressure.SympatheticNervous System ActivityThesympathetic nervous system has a central role in blood pressure regulation,including heart rate, blood pressure, and breathing rate. It is under studiesto observe the relation of SNS with increase in blood pressure. Althoughuncertain, but the case is strong that in hypertension, we are now on the edgeof successful “mechanisms to management” shift, with the use of catheter-basedrenal sympathetic nerve ablation for treating drug-resistant hypertension.

28BloodVessel Structure and FunctionChangesin the internal structure and endothelial function of small and large arteriesmay contribute to high blood pressure. In up to date researches, it has becomeclear that structural changes inside arteries, referred to as remodelling, canbe the reason for losing flexibility found in arterial walls which cancontribute in the development of hypertension. 29,301.5.2Genetic Causes of High Blood PressureMostof the understandings that body internal functions are involved in the increaseof blood pressure have come from genetic studies. Hypertension is more commonin patients having a family history of it.

Large numbers of studies have identifiedmany genes and mutations in them associated with hypertension, some of themexist in the renal salt regulatory and renin-angiotensin-aldosterone pathways. 31However, these known genetic factors only responsible for 2-3% of allcases. Recent studies suggest involvement ofcertain changes in DNA duringembryological stages inside motherbody also may cause the development of hypertensionlater in life. 1.5.3Other Medical Causes of High Blood PressureCertainother known medical conditions which can cause hypertensionare chronic kidneydisease, sleep apnea, thyroid problems, or certain tumours. This happensbecause these conditions change the activity of body for example, sodium andwater regulation, hormones levels in the blood, which also contribute incausing secondary hypertension.1.

6 Signs and SymptomsMyth:People with hypertension will pass through symptoms, such as nervousness,sweating, and trouble in sleeping or cheek redness. Truth:Hypertension is symptomless, in most of the cases best termed as a “silentkiller.” If persistent high blood pressure values are neglected and the appearanceof symptoms is waited then it becomes a life threatening condition.

1.7 Investigations32 Hypertension: Investigation of all patients Urinalysis for blood, protein and glucose Blood urea, electrolytes and creatinine N.B. Hypokalaemic alkalosis may indicate primary hyperaldosteronism but is usually due to diuretic therapy Blood glucose Serum total and HDL cholesterol Thyroid function tests 12-lead ECG (left ventricular hypertrophy, coronary artery disease)  1.8 Treatment32Optimal target blood pressures 1                                           Age     Clinic BP Ambulatory/ home BP 2 <80 yrs <140/90 mmHg <135/85 mmHg ? 80 yrs           < 150/90 mmHg <140/85 mmHg 1Bothsystolic and diastolic values should be attained2AverageBP during waking hours  1.

8.1 Pharmacological treatment:Manytypes of medications, collectively called as antihypertensive drugs, arecommonly used for treating hypertension. The first line therapy is disputed.33The Cochrane collaboration, WHO, and the US guidelines suggest low dosethiazide diuretic as first line treatment.33343536 The UKguidelines recommends calcium channel blockers (CCB) in preference for peopleabove 55 years, and angiotensin converting enzyme inhibitors (ACE-I) used firstline for younger people.37 In Japan starting with any one of sixclasses of medications including: CCB, ACEI/ARB, thiazide diuretics,beta-blockers, and alpha-blockers areacceptable, while in Canada and Europe allof these but alpha-blockers are recommended as options.

3833 Whencompared to placebo group, beta-blockers are considered successful in strokereduction, but have no well established effect on coronary artery disease.39Someof the medications used to treat hypertension include:Beta-blockers:Theyslow heart rate and heart beats with less force. This decrease the volume ofblood pushed in the arteries, which lowers blood pressure.Diuretics:Thevolume of blood is also increased by high levels of sodium and fluid in thebody. This high volume can also increase blood pressure.

Diuretics, also knownas water pills, act on kidneys and make them excrete excess sodium from yourbody. As the sodium level goes down, fluid volume decreases, which ultimatelylower blood pressure.ACE inhibitors:Angiotensin is an enzyme that causes constriction in blood vessels.

ACE(angiotensin converting enzyme) inhibitors prevent the formation of angiotensinwhich helpswalls of blood vessels remain relax and blood pressure does notincrease.Angiotensin II receptor blockers (ARBs):This drug prevents angiotensin from binding with its receptors. It has someadditional benefits in avoiding adverse effects of ACEI.Calcium channel blockers:Excess amount of calcium in the smooth muscles of heart results in harderforceful heartbeats. If we reduce these levels then the force of the heartbeatswill also decrease which will help in lowering blood pressure.Alpha-2 agonists:Itreduces nerve impulses coming from brain to the vessels which are responsiblefor increase tone of smooth muscles in the arteries. This helps smooth musclesof vessels remain relax and blood pressure is reduced.1.

8.2 Combination TherapyThemajority of people need more than one type of medication to lower their bloodpressure.For example, people with blood pressure greater than 160/100 mmHg,American Heart Association recommend initial therapy with one type fromthiazide class and the other from ACEI, ARB or CCB. An ACEI and CCB combine treatmentcan also be used.

40Insome situations combination drug therapy should be avoided keeping the consequentialeffects on the body in mind. Such drug therapy can worsen the body condition bycausing other organs deteriorate from their normal function. Some unacceptabledrug combination includes use of Verapamil or Diltiazem (CCB) withbeta-blockers or dual renin–angiotensin system blockade (ACEI+ ARB),renin–angiotensin system blockers and beta-blockers, beta-blockers andcentrally acting medications.41   1.

9 Prevention of high blood pressure Byliving a healthy lifestyle, blood pressure can be kept in a healthy range thatcan lower risk for other heart diseases and stroke. A healthy lifestyleincludes:Eating a healthy dietMaintaining a healthy weightGetting enough physical activityNot smoking.Limiting alcohol useHealthyDietChoosinghealthy dietcan help in avoiding high blood pressure and its complications.Make sure to eat plenty of fresh fruits and vegetables.Eatingfoods low in salt (sodium) and high in potassium can lower your blood pressure.The DASH (Dietary Approaches to Stop Hypertension) eating plan is one healthydiet that is proven to help people lower their blood pressure.

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