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Hypertension

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The heart pumps oxygen-rich blood to various parts of the body via major blood vessels known as arteries. Blood pressure (BP) is the force applied by the blood on the walls of the arteries. BP is composed of two numbers: systolic BP and diastolic BP. The first number, systolic BP, is the BP while your heart is beating. The second number, called the diastolic BP, is the BP while your heart rests between the two beats. The normal reading of systolic and diastolic BP is 120/80 mmHg; hypertension is diagnosed when the systolic and diastolic reading is greater than or equal to 140 mmHg and 90 mmHg, respectively.

Globally, one in four people has hypertension. Around 3.5 billion people have BP levels greater than 110–115 mmHg, and 874 million people have systolic BP greater than 140 mmHg. There are >200 million hypertension patients in India. In India, hypertension is present in 25%–30% of the urban population and 10%–20% of the rural population.

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Types

Normal BP is lower than or equal to 120/80 mmHg. People with BP readings between 120/80 and 129/89 mmHg are considered as pre-hypertensives; these people do not have BP as low as it should be but are not considered to have hypertension.

There are two stages of hypertension:


  • Stage I: When the BP reading is 130/80 mmHg.

  • Stage II: When the BP reading is greater than or equal to 130/80 mmHg.


A BP reading of greater than 180/110 mmHg is considered “hypertensive crises,” and patients require immediate medical attention.

Symptoms

Hypertension is known as a “silent killer,” and BP must be regularly measured because hypertension does not have any warning symptoms or signs, and many people do not realize they have high BP. Certain patients may develop heart or kidney problems without even knowing they have hypertension.

Few symptoms associated with hypertension include:


  • Headache

  • Nosebleeds

  • Vision problem

  • Increased heart rate

  • Chest pain

  • Buzzing in the ears

  • Vomiting

  • Confusion

  • Anxiety

  • Muscle tremors

Causes And Risk Factors

Causes

Secondary hypertension can be caused by an existing medical condition such as


  • Chronic kidney disease

  • Diabetes

  • Blocked arteries

  • Cushing’s syndrome

  • Thyroid problems

  • Sleep disorders

  • Pregnancy

  • Narrowed blood vessel that supplies blood to the kidney


Certain medications such as decongestants, antidepressants, birth control pills, and painkillers can make it difficult for the body to control BP.

Risk Factors

Several known factors increase your risk of hypertension.

Modifiable risk factors include:

  • An unhealthy diet comprising excessive Na and not enough K, high fats, and low intake of fruits and vegetables.

  • Obese or overweight

  • Lack of exercise

  • Too much consumption of caffeine, alcohol, and tobacco.

  • Use of illegal drugs such as cocaine and methamphetamine.

  • Lack of sleep.


Non-modifiable risk factors include:

  • Age: Blood vessels thicken with age, which leads to an increase in BP. Middle-aged men possibly develop high BP than women, whereas, in older adults, women are more likely to develop high BP.



  • A family history of hypertension and genetics.

  • Stress

Prevention

Most people can prevent hypertension by making simple lifestyle changes such as


  • Simple exercise such as brisk walking, which is good for the heart.

  • Maintain healthy body weight.

  • Include foods that are rich in potassium and fibre.

  • Include foods lower in fats such as fruits, vegetables, and whole grains.

  • Maintain a salt intake lower than 1500 mg per day.

  • Drink plenty of water.

  • Limit alcohol intake up to two drinks per day in men and one drink per day in women.

  • Avoid smoking.

  • Manage stress with the help of yoga, meditation, music, and exercise.

  • Monitor BP at regular intervals.

Diagnosis

Usually, primary hypertension is symptomless; hence, it is advised to verify BP at regular intervals. For diagnosing hypertension, the doctor checks BP using a sphygmomanometer and a stethoscope. Nowadays, electrical sensors are available to verify BP. Moreover, the doctor verifies the family history, eating pattern, and physical activity of the patient. Patients are diagnosed with hypertension if they have consistent high BP in two or more readings at separate appointments. In addition to BP, patients with hypertension are verified for other factors. Blood tests are performed to verify whether kidney damage, high cholesterol, diabetes and thyroid problems may have caused raised BP.

A correct diagnosis of hypertension leads to a cure or considerable improvement in BP and reduces risks associated with hypertension.

Treatment

Hypertension treatment aims to reduce BP that will ultimately decrease the risk of associated health problems. Before recommending any treatment, the doctor will consider various factors such as age, existing disease conditions, existing medications, and possible side effects.


  • In pre-hypertensives, lifestyle changes are suggested to lower BP.

  • In stage I hypertension, lifestyle changes are recommended if there are no diseases or risk factors. Along with lifestyle changes, if BP remains between 130/80 to 140/90 mmHg, medications are prescribed to lower the BP.

  • In stage II hypertension, lifestyle changes and two medicines, one of which is a diuretic, are recommended.


Mostly, a single medicine cannot control severe hypertension. Two or more medications are combined to achieve an “add-on” effect. However, medicines are added only if required to achieve the target BP. Combining two or more drugs in low doses helps to achieve an “add-on” effect and produce fewer side effects. The recommendations for using the various class of antihypertensive medication are as follows:

For patients with no concomitant disease the following is preferred.

  • Angiotensin Receptor blockers (ARBs) are preferred as first line treatments for hypertension under the age of 60 years.

  • ARBs in combination with calcium channel blockers (CCBs) is preferred as first line combination therapy. Diuretics may pe prescribed as a third drug in combination therapy.

  • For hypertensive patients above 60 years of age, CCBs and diuretics are preferred as first line treatment.

  • In younger individuals with high renin hypertension, ARBs or newer beta blockers are drug of choice.

  • In younger individuals with low renin hypertension, diuretics or CCBs are preferred drugs.


For a patient with associated disease conditions such as diabetes, kidney disease, or heart disease; one of the following therapies is preferred:

  • Hypertensive patients with diabetes are given ACE inhibitors with or without calcium channel blockers or diuretics.

  • Hypertensive patients with heart failure are given ACE inhibitors/ARBs, diuretics, and beta-blockers.

  • Hypertensive patients with coronary artery disease are given beta-blockers, ACE inhibitors, or calcium channel blockers.

  • Hypertensive patients with ischemic heart disease beta blockers are preferred as first line drugs.


In pregnant women, alpha-methyl dopa or labetalol is indicated for high BP.

Lifestyle/management

Simple lifestyle changes may prevent and improve hypertension and decrease the requirement for antihypertensive medicines.


  • A reduction in sodium intake to 1500 mg per day and an increase in potassium intake to 4.7 g per day can lower the systolic BP by 2–4 mmHg. Rather than taking potassium supplements, consume fruits and vegetables rich in potassium.

  • Generally, obese or overweight patients with hypertension are recommended low-calorie diets and exercise.

  • Regular exercise as simple as brisk walking reduces BP in patients with hypertension.

  • Reduce mental stress by doing yoga, meditation, exercise, listening to music, or any activity that calms down a patient.

  • Ensure regular checking of BP.

  • Treat BP with prescribed medications.

  • Manage other medical conditions present, along with hypertension.

Treatment Of Hypertension

The treatment of hypertension includes lifestyle modifications through a healthy diet and regular exercise and medications to tame your blood pressure levels. If an underlying health condition is the cause behind hypertension, your prescription will also need to include medicines for it alongside blood pressure drugs. Common medications for hypertension include:

Beta-blockers

They work by bringing down the speed and force of your heart beats and impairing the functions of certain hormones that can increase your blood pressure levels.

Diuretics

High volume of sodium and excessive fluid in the body escalates the blood pressure level. Diuretics help in eliminating both.

ACE inhibitors

Chemicals known as angiotensin narrow down and tighten your arterial walls. ACE inhibitors prevents the synthesis of this chemical in the body.

Calcium channel blockers

These drugs prevent calcium from sneaking into your cardiac muscles, which, in turn, reduces the force of your heartbeat. This process brings down blood pressure levels.

Prognosis And Complications

Prognosis

Patients can easily control BP by making certain lifestyle changes and taking proper medications. The prognosis for hypertension depends on the duration and severity of hypertension and other existing conditions such as diabetes. Failure to control BP can increase patients’ risk for:


  • Heart attack or heart failure

  • Vision problems

  • Stroke

  • Insufficient blood supply to the legs, abdomen and pelvis


 

Complications

As mentioned earlier, uncontrolled BP is a silent killer. High BP can cause severe damage to the heart. Prolonged hypertension leads to the hardening of arteries, leading to a decreased blood and oxygen supply to the heart. Major complications associated with hypertension are:

  • Chest pain

  • A heart attack that occurs because of restricted blood flow and oxygen supply to the heart.

  • Heart failure that occurs when your heart muscles cannot pump enough blood and fail to supply enough oxygen to the vital organs.

  • Irregular heartbeat

  • Vision problems

  • Stroke that occurs when arteries carrying blood and oxygen to the brain burst or are blocked

  • Kidney failure

  • Sudden death

  • High blood pressure in pregnant women may increase the risk of cardiac problems in both mother and the child in their later years

Alternative Treatments

A popular option among patients is the use of complementary and alternative medicines for treating hypertension. However, it is always better to consult a medicinal practitioner before starting any treatment for hypertension.

Few alternative treatments for hypertension are as follows:

Dark chocolate

Dark chocolate derived from cacao bean is rich in flavonoids and polyphenols. The consumption of small quantities of dark chocolate can cause a reduction in BP and improve blood function.

Approaches to reduce stress


  • Various mind-body practices are suggested for lowering stress, which is one of the mediators for hypertension in patients.

  • Qigong is a traditional approach that incorporates breathing, meditation and movement.

  • Slow breathing technique.

  • Transcendental meditation in which a person sits twice a day and repeat mantras with closed eyes.


 

References

  1. World Health Organization. Available at: https://www.who.int/news-room/fact-sheets/detail/hypertension. Accessed on: Mar 3, 2021. (https://www.who.int/news-room/fact-sheets/detail/hypertension)

  2. High blood pressure. NIH. Available at: https://www.nhlbi.nih.gov/health-topics/high-blood-pressure. Accessed on: Mar 3, 2021. (https://www.nhlbi.nih.gov/health-topics/high-blood-pressure)

  3. Oparil S, et al. Nat Rev Dis Primers. 2018; 4:18014.

  4. Gupta R, et al. Curr Opin Cardiol. 2019;34(4):331-341.

  5. High blood pressure. Medline Plus. Available at: https://medlineplus.gov/highbloodpressure.html. Accessed on: Mar 3, 2021. (https://medlineplus.gov/highbloodpressure.html)

  6. M Naranjo M and M Paul. Malignant hypertension. Treasure Island: StatPearls Publishing. 2018.

  7. Yaxley JP, et al. J Family Med Prim Care. 2015;4(2):193-9.

  8. High blood pressure–Understanding the silent killer. FDA. Available at: https://www.fda.gov/drugs/special-features/high-blood-pressure-understanding-silent-killer. Accessed on: Mar 3, 2021. (https://www.fda.gov/drugs/special-features/high-blood-pressure-understanding-silent-killer)

  9. High blood pressure – adults. Medline Plus. Available at: https://medlineplus.gov/ency/article/000468.htm. Accessed on: Mar 3, 2021. (https://medlineplus.gov/ency/article/000468.htm)

  10. How to prevent high blood pressure. Medline Plus. Available at: https://medlineplus.gov/howtopreventhighbloodpressure.html. Accessed on Mar 3, 2021. (https://medlineplus.gov/ency/article/000468.htm)

  11. Standard treatment guidelines. Hypertension. Ministry of Health & Family Welfare Government of India. Available at: https://nhm.gov.in/images/pdf/guidelines/nrhm-guidelines/stg/Hypertension_full.pdf. Accessed on: Mar 3, 2021. (https://nhm.gov.in/images/pdf/guidelines/nrhm-guidelines/stg/Hypertension_full.pdf)

  12. Shah SN. et al. J HumHypertens. 2020;34:745-758.

  13. Rosendorff C. Circulation. 2015;131(19):e435–e470.

  14. High blood pressure (Hypertension). Harvard. Available at: https://www.health.harvard.edu/a_to_z/high-blood-pressure-hypertension-a-to-z. Accessed on: Mar 3, 2021. (https://www.health.harvard.edu/a_to_z/high-blood-pressure-hypertension-a-to-z)

  15. Nahas R. Can Fam Physician. 2008;54(11):1529-33.


 

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