Apollo health city   Center for Blood Pressure Management
 

Hypertension

Elevation in blood pressure (hypertension) is abnormal. It occurs with stiffening of arteries and imbalance in chemicals that are responsible for maintaining blood pressure within normal range.


History

Hypertension was first noticed and described by researchers in late nineteenth century. For the next 60 years, most experts believed that elevated blood pressure was harmless. Some of them even thought, it was healthy to have higher level of blood pressure when the arteries were stiffening with age. They believed higher blood pressure helped perfuse vital organs better.

Dr Hay a physician, wrote in a leading medical journal, “The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try and reduce it” (Hay, Brit Med J. 1931; 2:43-47).

Medical records of President Franklin D. Roosevelt indicate how little physicians knew or cared about hypertension. In 1945, when he was at Yalta Conference, his systolic blood pressure averaged close to 250mmHg.

 
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Few months later, when FDR died, his physician did not even mention long standing uncontrolled hypertension as one of the cause for his death.


It was not until late 1960s when the results of first clinical trial evaluation the effects of blood pressure lowering therapy in patients with hypertension was published which convinced medical fraternity of the importance of treating hypertension. 




 Physiology of Blood Pressure

Getting back to basics, there are two components in our blood pressure reading e.g., 120/70 mmHg. The numerator (120) is systolic blood pressure (SBP) and denominator (70) is the diastolic blood pressure (DBP).


Figure: Pressure is created as blood flows from heart into the narrow arteries ( blood vessels ) 


Every time our heart beats (contracts), there is pressure created by the blood as it flows through the narrow arteries. This is systolic blood pressure.

In between the beats, the heart relaxes; the pressure in the arteries is lower as the forward push from the heart is absent. This is diastolic blood pressure.

We all now agree that elevation in blood pressure is harmful, but the debate continues about the level to which blood pressure should be reduced in order to offer complete protection.

The most recent American guideline on hypertension (JNC7) released in 2003, decided a sustained blood pressure above 139/89 mmHg was hypertension and needed to be treated.

For individuals with no other co-morbid diseases like diabetes or kidney problems, the recommendation was to lower blood pressure to less than 140/90 mmHg.

In those with diabetes and kidney disease who were at higher risk of adverse effects, a lower goal of 130/80 mmHg was suggested as offering better protection.


 HYPERTENSION: THE STORY IN ANIMATION
 






Types of Hypertension

There are two main types of hypertension :

Primary hypertension
 
Secondary hypertension  

Primary or essential hypertension

 It is the most common type of hypertension.  
95% patients with hypertension have primary hypertension.  
The cause of primary hypertension is not known.  
It occurs as the arteries are stiffening and kidneys are not able to maintain optimal blood pressure.  
Patients generally develop primary hypertension with age.  
Its onset is very gradual and is not associated with any symptoms.  

Secondary hypertension


5% patients with hypertension have a clear cut cause for elevation in blood pressure  
Several diseases can cause secondary hypertension.  
In some cases, treatment of underlying disease can cure secondary hypertension  
Clues that indicate presence of secondary hypertension are:  
Onset of hypertension at a very young age  
Sudden worsening of blood pressure in an older individual  
Episodic elevation of blood pressure associated with symptoms like palpitation and sweating  
Common causes for secondary hypertension are tumors like pheochromocytoma, adrenal adenoma, arterial disease like renal artery stenosis and coractation of aorta  
There are specific tests to diagnose these diseases  


 

 
Five Patterns of Blood Pressure


Normal Blood pressure:
Blood pressure is normal when measured in physician office as well as at all other places like home or a pharmacy, or patient's work place.

White Coat Effect:
In some patients first few readings are elevated because of an involuntary 'alerting reaction'. Repeat blood pressure measurement provides a more accurate readings.

White Coat Hypertension:
Blood pressure is always elevated in doctor's office and normal at other places. Repeated readings at doctors office do not lower the blood pressure level.

Sustained Hypertension:
Blood pressure is elevated in the physician office as well as at other places. These patients should be treated.

Masked Hypertension:
Blood pressure is normal in physician office, but elevated at all other places These patients should be treated.


Measuring blood pressure at home accurately will help your physician in identifying your blood pressure pattern and treating you appropriately
A 24 hour ambulatory blood pressure monitor (ABPM) is another way to easily identify these patterns


 

 
Blood Pressure Lowering Therapy


 Three important components of successfull blood pressure lowering therapy are:

Risk factor modification  
Lifestyle changes  
Blood pressure lowering edications  





 

 
Risk factor modification and lifestyle changes


If you are overweight or obese, you should lose weight
Quit smoking
Be more physically active and less sedentary
Eat less salt



 

 
 
Drug Therapy

In late 1960s and early 1970s when treating hypertension became mandatory, there were very few medications that could reduce blood pressure. Since the whole field of hypertension therapy was in its infancy, we did not even know the right dose to effectively lower blood pressure.

Some of the medications (diuretics or ‘water pills') that are still in use now were prescribed at very high doses in those days. Now we know that such high doses did not offer any extra benefit, instead they caused excess adverse effects and were probably harmfull to patients.


Our understanding of anti-hypertensive medications has improved in many ways.

Certain medications were found to be more effective in patients with heart disease; other antihypertensive
medications are more effective in patients with kidney disease.

It is important that the anti-hypertensive regimen is personalized based on patient's history.

Here is a list of medications that should preferably be prescribed in patients with specific diseases.

Uncontrolled hypertension remains a major healthcare problem worldwide. Until recently, only 30% patients with hypertension in United States had blood pressure controlled to goal.

Interestingly, the most common reason for uncontrolled hypertension was found to be inadequate therapy in several studies.

It was found that physicians failed to increase the dose of medication or add a new antihypertensive medication when blood pressure remained elevated.

Second most common reason for uncontrolled hypertension is non-adherence to therapy. Since hypertension is a silent disease patients forget to take medications as prescribed by physician.

  Remember drug therapy to lower blood pressure is not an alternative to non-pharmacological therapy (risk factor modification and lifestyle changes) of hypertension.
  Following a healthy lifestyle will make blood pressure lowering medications more effective and improve blood pressure control.



 

 

 
Blood Pressure Control Targets

Patients with hypertension with no other health problems

Office blood pressure (performed based on expert recommendations) : <140/90 mmHg

Home blood pressure (performed based on expert recommendations): <135/85 mmHg

Mean average of 24 hour ambulatory blood pressure readings: <130/80 mmHg

Patients with hypertension and diabetes or kidney disease

Office blood pressure (performed based on expert recommendations) : <130/80 mmHg

Note:

There is no data yet on the cut-off points for blood pressure control in patients who perform home blood pressure monitoring or who undergo 24 hour ambulatory blood pressure readings. Generally, it is agreed that these values should be lower than those recommended for patients who only have hypertension.

 

Did you know?

Clincal trials have demonstrated that an average of three blood pressure lowering medications are needed to control hypertension.

 




 

 

 Side Effects of Blood Pressure Lowering Medications

Most of the blood pressure lowering medications commonly used now a days are safe and have minimum side effects.

But keep in mind these are chemicals, and like all chemicals have properties that may effect you adversely
.
Make sure that you take only those medications that are prescribed by your physicians.

Ask your doctor what side effects are expected and acceptable.

Ask your doctor if the medication has any life threatening side effect.

Here are some of the side effects of commonly used blood pressure lowering medications:


Common Drug Classes

Medications

Common side effects

Diuretics

Chlorthalidone, hydrochlorthiazide, Indapamide

Increase urination, low sodium, gout

Beta – blockers     

Metoprolol, atenolol,nebivolol

Fatigue, depreassion

Alpha blockers

Prazocin, doxazocin

Low blood pressure , dizziness

Alpha agonists

Clonidine, methyl  dopa

Rebound hypertension if you miss the dose of medication, dry mouth, drowsiness

Calcium channel blockers

Amlodipine, diltiazem

Swelling of feet

Angiotensin converting enzyme inhibitors (ACEI)

Lisinopril, ramipril

Dry cough, increase in blood levels of potassium, swelling of lips and tongue (very serious reaction!!)
Increase in blood levels of potassium

Angiotensin receptor blockers (ARS)

Telmisartan, olmisartan

Increase in blood levels of potassium

Vasodilators

Minoxidil, hydralazine

Swelling of feet,Increased hair growth (Minoxidil)




 
 
 
Resistant Hypertension


If you are on three blood pressure lowering medications and still your blood pressure is not at goal, you probably have
'resistant hypertension'.

If you require four or more medications to control blood pressure, you probably have 'controlled resistant hypertension'.

Before a diagnosis of resistant hypertension is made it is important that your blood pressure lowering medications
are reviewed to make sure you are on appropriate dose.

Secondary hypertension can also lead to resistant hypertension. It is important to investigate these patients for any secondary cause that may be responsible for blood pressure elevation.


 


 
Your Next Physician Office Visit

The next time you visit your physician's office follow these simple recommendations:

If you have hypertension, make sure you check your blood pressure regularly and take home blood pressure reading
records with you.

If your blood pressure is elevated, discuss with your physician, and review your therapy.

Sustained elevated blood pressure effects heart, kidney and brain. It is important for patients with hypertension
to periodically undergo screening test to detect early changes of uncontrolled hypertension on heart and kidneys.

An EKG or an echocardiogram will detect thickening of heart muscle (LVH or left ventricular hypertrophy) and a simple blood test (serum creatinine level) and urine test (for protein) will indicate if kidneys are affected as a result of hypertension. In such situation, it is important to review therapy and plan a more aggressive approach to control blood pressure.



Fig: Normal heart chamber on the left and thick walled hear chamber on the right (LVH)


Fig: Simple blood and urine tests will detect early kidney disease

If you have diabetes, heart or kidney disease, confirm you are on blood pressure lowering medications that provide added protection in these conditions.

 
Non-adherence to Prescribed Antihypertensive Regimens

Did you know ?

Approximately 50 % patients with hypertension do not take medications as prescribed by their physicians

Non-adherence to antihypertensive medications is one of the most common cause of uncontrolled hypertension

The risks of complications related to hypertension are high in patients with elevated blood pressures.



 
     
   Tips to Improve Adherence to Anti-hypertensive Regimens

Improve your knowledge about Hypertension : Learn from patient friendly resources about hypertension and how to control it. It will help you to actively participate with your physician in getting your blood pressure to goal.

Home blood pressure monitoring : Regularly (at least once a week – in the morning and at night) measure your blood pressure at home and keep a record, take it with you to your physician’s office for review.

Simplify your medication regimen : If you are on more than one medication, discuss with your physician if a fixed dose combination medication can be prescribed. If you are on a medication that you have to take several times during the day, ask your physician if a long acting substitute is available for use instead.

Pill box : Arrange your daily medications in a pill box so that it is easily accessible at the time of taking medications.

 

 

High Blood Pressure is Bad: Very Low Blood Pressure is Worse

For those patients with hypertension who are on blood pressure lowering medications, it is important to know when to hold these medications temporarily:

If you are dehydrated because of vomiting or diarrhea, or if you have not eating well because of an illness, talk to your physician and get your blood pressure measured. Based on your blood pressure your physician may reduce the dose or of medications.

Dehydration or starvation can lower your blood pressure. If you continue to take blood pressure lowering medications, it may further lower blood pressure to dangerous levels.

Signs that reflect your blood pressure may be very low:


  Generalized weakness
  Feeling dizzy, giddy, blacking out, passing out with change in posture  (getting out of bed or chair)



 


 
         
 
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