HYPERTENSION

BACKGROUND

Hypertension, more commonly known as high blood pressure, occurs when the blood forces or pushes against the blood vessels instead of flowing normally. This can cause damage to the vessels, the heart, the kidneys and other organs.

An individual's blood pressure is defined by two measurements:

• Systolic pressure is the pressure in the arteries produced when the heart contracts (at the time of a heart beat)
• Diastolic pressure refers the pressure in the arteries during relaxation of the heart between heart beats.

Blood pressure is reported as the systolic pressure over diastolic pressure (e.g. 120/70 or 120 over 70).

NORMAL BLOOD PRESSURE: — Less than 120 over less than 80

PREHYPERTENSION: — 121 to 139 over 81 to 89

People with prehypertension are at increased risk of developing hypertension and cardiovascular complications, but drugs used to lower blood pressure are not known to be beneficial in people with prehypertension.

HYPERTENSION:

• Stage 1: 140 to 159 over 90 to 99
• Stage 2: greater than 160 over greater than 100

DISEASE OCCURRENCE IN POPULATION:

According to Pakistan National Health Survey (1990-94) survey, 17.9% of the population over the age of 15 years and 33% over the age of 45years were labeled as hypertensive (>140 / 90 mmHg). A similar prevalence (15% over the age of 18 years and 36% over the age of 45years) was reported by another survey conducted in the Northern Areas of Pakistan.

RISK FACTORS:

High blood pressure has many risk factors, including:

• Age: The risk of high blood pressure increases as you age. Through early middle age, or about age 45, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
• Race: High blood pressure is particularly common among blacks, 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 blacks.
• Family history: High blood pressure tends to run in families.
• Being overweight or obese: 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.
• Not being physically active: 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.
• Using tobacco: 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, increasing your blood pressure. Secondhand smoke also can increase your blood pressure.
• Too much salt (sodium) in your diet: Too much sodium in your diet can cause your body to retain fluid, which increases blood pressure.
• Too little potassium in your diet: Potassium helps balance the amount of sodium in your cells. If you don't get enough potassium in your diet or retain enough potassium, you may accumulate too much sodium in your blood.
• Too little vitamin D in your diet: It's uncertain if having too little vitamin D in your diet can lead to high blood pressure. Vitamin D may affect an enzyme produced by your kidneys that affects your blood pressure.
• Drinking too much alcohol: Over time, heavy drinking can damage your heart. Having more than two drinks a day for men and more than one drink a day for women may affect your blood pressure.
• High levels of stress can lead to a temporary increase in blood pressure. If you try to relax by eating more, using tobacco or drinking alcohol, you may only increase problems with high blood pressure.
• Certain chronic conditions. Certain chronic conditions also may increase your risk of high blood pressure, such as kidney disease, diabetes and sleep apnea.

Sometimes pregnancy contributes to high blood pressure, as well.

SIGN AND SYMPTOMS:

High blood pressure does not usually cause any symptoms. If symptoms do appear they may include:

• Headaches
• Dizziness
• Loss of vision
• Chest pain
• Abdominal pain
• Difficulty in breathing
• Nausea and vomiting

DIAGNOSTIC TEST:

Blood pressure can be easily tested with a simple, painless procedure using an inflatable arm cuff and a pressure-measuring device. You will not be diagnosed with hypertension after one reading. If the blood pressure is high for three consecutive visits to the doctor, you may suffer from hypertension. For accuracy, your blood pressure may be measured several times during a single visit. You would be required to get regular measurements of your blood pressure as per the doctor’s directive or every six months. To determine if the hypertension is caused by an underlying medical disorder, you may be subjected to the following tests:

• Blood test to measure the blood sugar, kidney function and blood cell counts

• Urinalysis in which you may be asked to collect your urine samples over the period of twenty-four hours for an accurate result
• Echocardiogram in which sound waves are used to produce images of the heart. The doctor studies the images to see if the heart chambers are enlarged, if there is any abnormality in the blood flow and to identify any other heart defects
• Ultrasound of your kidney, in which sound waves and a sensor is used to create an image on the computer to be studied by the doctor. Sound waves are sent by a handheld device that is moved across the abdomen

TREATMENT OPTIONS:

LIFESTYLE CHANGES: Treatment of hypertension usually begins with lifestyle changes. Making these lifestyle changes involves little or no risk. Recommended changes often include:

• Reduce the amount of salt in your diet
• Lose weight if you are overweight or obese
• Avoid drinking too much alcohol
• Stop smoking
• Exercise at least 30 minutes per day most days of the week

TREATMENT: Having high blood pressure puts you at risk for heart attack, stroke, kidney damage, and other serious problems. The medicines your doctor or nurse prescribes to treat high blood pressure can help reduce the risk of these problems and even help you live longer.

If your medicines cause unpleasant side effects, or if you can't afford your medicines, talk to your doctor or nurse. There are often ways to deal with these problems. The first step is to let your doctor or nurse know.

MEDICINES: Below is a list of the most common types of medicine given to people with high blood pressure:

• Medicines called "diuretics"
• Medicines called "angiotensin-converting enzyme inhibitors" ("ACE inhibitors") or "angiotensin receptor blockers" ("ARBs")
• Medicines called "calcium channel blockers"
• Medicines called "beta blockers"

DIURETICS: Diuretics are sometimes called "water pills," because they make you urinate more than usual. Some examples of diuretics include chlorthalidone, indapamide, hydrochlorothiazide (also known as HCTZ), and furosemide.

ACE INHIBITORS AND ARBS: ACE inhibitors and ARBs are often grouped together, because they work in similar ways. These medicines can help prevent kidney disease. Doctors often prescribe them for people with diabetes, because people with diabetes have a higher-than-average risk of kidney disease. Some examples of ACE inhibitors include enalapril, captopril, and lisinopril. Some examples of ARBs include candesartan and valsartan.

CALCIUM CHANNEL BLOCKERS: Some examples of calcium channel blockers include amlodipine, felodipine, and diltiazem. These medicines also help prevent chest pain caused by heart disease.

BETA BLOCKERS: Besides lowering blood pressure, beta blockers help reduce the amount of work the heart has to do. When people first start taking beta-blockers, they sometimes feel tired. That is just while the body gets used to the medicine. But once the body gets used to beta blockers, the medicines can really help. If your doctor prescribes a beta blocker, give it a little time to start working. Some examples of beta blockers include atenolol, metoprolol and propranolol.

PRECAUTIONS:

LOSE WEIGHT: When people think about losing weight, they sometimes make it more complicated than it really is. To lose weight, you have to either eat less or move more. If you do both of those things, it's even better. But there is no single weight-loss diet or activity that's better than any other. When it comes to weight loss, the most effective plan is the one that you'll stick with.

IMPROVE YOUR DIET: There is no single diet that is right for everyone. But in general, a healthy diet can include:

• Lots of fruits, vegetables, and whole grains
• Some beans, peas, lentils, chickpeas, and similar foods
• Some nuts, such as walnuts, almonds, and peanuts
• Fat-free or low-fat milk and milk products
• Some fish

To have a healthy diet, it's also important to limit or avoid sugar, sweets, meats, and refined grains. (Refined grains are found in white bread, white rice, most forms of pasta, and most packaged "snack" foods.)

REDUCE SALT: The most important thing you can do to cut down on sodium is to eat less processed food. That means that you should avoid most foods that are sold in cans, boxes, jars, and bags. You should also eat in restaurants less often.

To reduce the amount of sodium you get, buy fresh or fresh-frozen fruits, vegetables, and meats. (Fresh-frozen foods have had nothing added to them before freezing.) Then you can make meals at home, from scratch, with these ingredients.

BECOME MORE ACTIVE: If you want to be more active, you don't have to go to the gym or get all sweaty. It is possible to increase your activity level while doing everyday things you enjoy. Walking, gardening, and dancing are just a few of the things that you might try. If you don't do any activity now, start by walking for just a few minutes every other day. Do that for a few weeks. If you stick with it, try doing it for longer. But if you find that you don't like walking, try a different activity.

DRINK LESS ALCOHOL: If you are a woman, do not have more than 1 "standard drink" of alcohol a day. If you are a man, do not have more than 2.

REFERENCES:

• Shah SM, Luby S, Rahbar M, Khan AW, McCormick JB. Hypertension and its Determinants amongAdults in High Mountain Villages of the NorthernAreas of Pakistan. J Hum Hypertens 2001;15(2):107-12
• https://www.ucsfhealth.org/education/risk_factors_for_high_blood_pressure/index.html
• Webb AJ, Fischer U, Mehta Z, Rothwell PM. Effects of antihypertensivedrug class on interindividual variation in blood pressure and risk of stroke: a systematic review and metaanalysis. Lancet 2010; 375:906.
• Wald DS, Law M, Morris JK, et al. Combination therapy versus monotherapy in reducing blood pressure: metaanalysis on 11,000 participants from 42 trials. Am J Med 2009; 122:290.
• James PA, Oparil S, Carter BL, et al. 2014 evidence based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014; 311:507.n techniques.