Treatment of High Blood Pressure (Hypertension)
The causes of primary hypertension cannot be determined, hence, there is no possibility of finding a cure for the condition. The treatment focuses on the management of the condition; mainly to reduce damage, and to decrease the chances of complications due to hypertension. In cases of mild hypertension, doctors advise life style changes and the avoidance of any medication that may aggravate the condition. But if high diastolic and systolic readings are detected, around 160/100 or higher, doctors start those people on antihypertensive medication along with other measures to reduce hypertension. People with additional risk factors such as kidney disorders, coronary artery disease, multiple organ damage and diabetes are also started on drugs even when their readings are 120/80mm Hg, as a precaution to avoid further damage.
Obese people who have developed hypertension may greatly benefit from losing weight; often a reduction of 10 pounds (5 kilograms) in weight may considerably lower their blood pressure. If they also have high cholesterol and blood sugar levels, a low-fat diet rich in fruits and vegetables may help reduce the risk of cardiovascular diseases. Quitting tobacco usage and reducing the intake of sodium salts to less than 6 grams, while the other essential minerals such as potassium, magnesium and calcium are taken in sufficient quantities, are favorable measures advised by the doctors. Alcohol consumption should be limited to 2 drinks for men and one for women. It is equivalent to 2 ounces of whiskey or 8 ounces of wine or 24 ounces of beer for men and half that quantity for women.
Regular exercise has a moderating effect on blood pressure. Since exercise also helps to reduce weight, it is beneficial in lowering hypertension. People who have primary hypertension have no contraindications to any form of exercise as long as it helps to lower their blood pressure, but those with secondary hypertension should limit themselves to moderate forms of exercise, keeping in mind the other disorders they have, and an exercise program should be chosen with doctor’s advice. Regular monitoring of blood pressure at home is usually recommended by doctors, as a way of motivating the patients to follow their doctors’ advice regarding the various aspects of treatment such as diet, exercise, and regular intake of drugs.
Drug Therapy: Antihypertensive drugs are designed to lower the blood pressure and maintain it within the normal range. Though there are several drugs available, the medication should be adjusted to suit the individual, often by trial and error. Good communication between the doctor and the patient helps in formulating the ideal treatment for controlling hypertension.
The target blood pressure through treatment is also different for different individuals. Generally the goal is to attain consistent blood pressure readings below 140/90 mm Hg, but if kidney failure, coronary artery disease or diabetes is also present, the aim would be to keep it lower than 130/80 mm Hg. Lowering of diastolic pressure beyond 65mmHg should be avoided in patients who have angina or coronary artery disease. Diastolic pressure should be kept above 65 mmHg in older people also.
The action of the different groups of antihypertensive drugs differs considerably; and doctors use their discretion and vast experience in prescribing a single drug or a combination of drugs which may suit a patient. Depending on further tests and the patient’s feedback, doses are adjusted and combinations are changed by a trial and error method to finally arrive on the drug therapy with maximum blood pressure control and minimum side effects and unpleasantness to the patient. People who have more than 160/ 100 mm Hg, may need more than one drug from the very start.
Several factors are taken into account while prescribing drug therapy for hypertension. They include the severity of hypertension, the age and sex of the person, his race, the coexistence of high cholesterol and blood glucose levels etc. Since side effects vary between drugs and also depending on the reaction of individuals, suitability has to be assessed. The cost of treatment, factoring in the cost of drugs as well as the periodic tests needed to keep track of their side effects, is also a factor in selecting the drugs.
Almost three fourths of those with hypertension, require a combination of drugs to achieve adequate blood pressure control.
Antihypertensive drug therapy is continued for life, with certain adjustments in dosage and drug combinations from time to time. All antihypertensive drugs have side effects. But if the side effects are not tolerable, the patient should inform the doctor so that an alternate drug can be given.
The first drug usually tried in the treatment of hypertension is a thiazide diuretic. Diuretics act in two ways. Dilatation of arterioles to bring down blood pressure is one of them. They also induce kidneys to excrete salt and water, thus reducing the circulating volume of blood and decreasing blood pressure. Thiazide diuretics results in the excretion of potassium salts which may have to be replaced by potassium supplements. Potassium-sparing diuretics are also available but since their action is not as good as that of thiazide diuretics, they have to be taken together. Spironolactone is a potassium-sparing diuretic that may be given alone. Obese people, blacks and older people are especially benefitted from diuretic drugs. Those who have kidney or heart failure also derive benefit from diuretics.
Adrenergic blockers consist of various groups of drugs, including peripherally acting adrenergic blockers, alpha-blockers and beta-blockers. They act by blocking the action of the sympathetic nervous system which reacts to stress stimuli by raising the blood pressure. Beta blockers are very useful for young people and whites as well as for those who have suffered a heart attack but older people may have severe side effects. People with migraines and angina pectoris and those who have fast arrhythmias also benefit from them. Alpha blockers are not found to be useful in reducing the risk of death and peripherally acting adrenergic blockers are used only as a supporting drug with other antihypertensive drugs.
Centrally acting alpha-agonists stimulate receptors in the brain stem, inhibiting the effects of the sympathetic nervous system, to lower blood pressure by a mechanism similar to the action of adrenergic blockers. However, these are seldom used in the treatment of hypertension.
Angiotensin-converting enzyme (ACE) inhibitors help dilate arterioles by inhibiting the formation of angiotensin II, by blocking angiotensin-converting enzyme, that changes angiotensin I in to angiotensin II, which has the property of constricting the arterioles. People with coronary artery disease and heart failure, as well as those who have proteinuria due to diabetic kidney disease or chronic kidney disease, are benefitted from ACE inhibitors. Whites, young men and those with sexual dysfunction due to the use of other antihypertensive drugs also find this drug useful.
Angiotensin II receptor blockers (ARBs) reduce hypertension by a similar mechanism as the one used by ACE inhibitors, but they act by directly blocking the action of angiotensin II. Since the blocking action of ARBs is more direct, side effects are lesser.
Calcium channel blockers which help dilate arterioles are found to be useful, especially for blacks and older people and also for those who suffer from migraines, angina pectoris and certain fast arrhythmias. Calcium channel blockers which are short-acting are not used to treat hypertension due to the perceived risk of them causing heart attacks. But channel blockers who are long acting are not found to increase the risk of heart attack.
Direct vasodilators are used concurrently with another antihypertensive drug, when that drug alone fails to have the desired effect in controlling blood pressure.
A low-dose aspirin a day is often prescribed, though it is not an antihypertensive drug, to reduce the risk of complications due to hypertension.
Treatment of Secondary Hypertension
In the treatment of secondary hypertension, the first focus is on tackling the cause of hypertension. Kidney disease, if present, is treated with the possible outcome of significantly lowering or even normalizing the blood pressure. Renal artery stenosis can be repaired by catheterization with a balloon tipped catheter or by a bypass surgery of the renal artery. Pheochromocytoma and such other tumors that cause excess hormonal production resulting in hypertension can be surgically removed, usually resulting in complete cure.
Treatment of Hypertensive Urgencies and Emergencies
Hypertensive urgencies require that the very high blood pressure present should be brought down without delay. Oral administration of Clonidine, which is an adrenergic blocker or sublingual administration of nifedipine, a calcium channel blocker, is done.
Hypertensive encephalopathy and malignant hypertension are emergencies which necessitate rapid lowering of the blood pressure. Patients are admitted to intensive care units of well equipped hospitals and immediate intravenous administration of nitroprusside or fenoldopam is started. Other antihypertensive drugs such as labetalol or nicardipine can also be given.
Prognosis
Prognosis is good for people who have had their hypertension diagnosed early enough, before severe, irreversible damage has been done to vital organs. Many cardiovascular changes due to hypertension are at least partially reversible with adequate blood pressure management. Hypertension is a major risk factor contributing to several abnormalities of the heart and blood vessels such as heart failure, atherosclerosis and aneurisms as well as kidney failure. But it is also a modifiable risk. Hence good blood pressure control holds the key to better health and reduction of risk of death due to various reasons including heart attack and stroke.
Without adequate control, hypertension has the potential to inflict progressive damage to several systems and organs of the body, which may eventually culminate in death due to any of the complications precipitated by the condition. People who have malignant hypertension rarely survive beyond a year without proper treatment.
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Yasser Elnahas
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