Category Archives: Hypertension
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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What Are The Symptoms And Ways Of Diagnosis Of High Blood Pressure (hypertension)
Hypertension is often called a silent killer, because the condition remains asymptomatic in most people till great damage is done to other systems of the body. Though some symptoms may be present, such as a flushed face, frequent headaches, tiredness and dizziness and bleeding from nose, which are usually considered to be symptoms associated with hypertension, they often do not get the required attention. This is due to the fact that people without hypertension also may have the same symptoms, resulting from some other conditions.
The damage caused by uncontrolled hypertension may be far reaching, severe and progressive in nature as it affects almost all other systems of the body and cause irreversible damage to kidneys, heart, brain and eyes. These damages often become apparent from the symptoms they produce, such as shortness of breath, fatigue, vomiting, nausea and severe headache. Swelling of retina and bleeding caused by very high blood pressure, in those who have malignant hypertension, results in blurring of vision or blindness. This condition requires immediate medical attention as it is fatal, if not treated. Hypertensive encephalopathy is another potentially fatal condition, in which the brain swells due to extreme high pressure, resulting in symptoms such as severe headache that steadily worsens, drowsiness, sleepiness, confusion, nausea and vomiting. It can also cause seizures and the patient may drift into a coma and eventually death, unless emergency medical care is provided.
Since the tumor pheochromocytoma results in overproduction of the fight or flight hormones of the adrenal glands namely, epinephrine and norepinephrine, the secondary hypertension resulting from that condition has characteristic symptoms such as a racing heart, palpitations, tremors, excessive sweating and anxiety.
Hypertension Diagnosis
Diagnosis of hypertension is based on several readings taken at the doctor’s clinic at various intervals. The first reading is taken after a short period of rest either in a sitting position or lying down. After standing up for a short while, the next reading is taken. Blood pressure above 140/90 mm Hg in several readings, may be diagnosed as hypertension. But, if there is a lot of variation between the readings, a few more readings on the same day, of on separate occasions, are taken into consideration before final diagnosis is given.
If the diagnosis still seems inconclusive, a wearable battery-operated blood pressure monitor is worn for 24-hours to take readings throughout the period. The device is attached to the hip and it is connected to a cuff on the arm that reads the blood pressure. It can determine the presence as well as the severity of the condition.
Pseudohypertension is a misdiagnosed hypertension in people who have stiff arteries that do not yield to the pressure applied on the artery by the blood pressure cuff, resulting in a false reading of hypertension. This occurs in older people who are more likely to have stiff arteries.
After hypertension is diagnosed, an effort is made to determine its cause, such as hormonal imbalances or specific disorders of the heart or the kidneys, to see if they can be treated to reduce the blood pressure. Possible damage caused by the high blood pressure to various internal organs may be assessed too. Generally, a thorough physical examination of the heart and the kidneys, including checking for tenderness over the location of the kidneys and listening for bruit (the characteristic sound of blood passing through an artery narrowed by stenosis) in the renal arteries through a stethoscope. It is followed by blood and urine tests to determine kidney function and blood chemistry. Electrocardiography may be done to assess the damage to the heart.
An ophthalmoscope helps doctors to see the damage caused by hypertension to the fine arterioles of the retina, and it is taken as an evidence of similar damage caused to other arteries and arterioles in other organs in the body which cannot be viewed directly. The damage to the retina is termed retinopathy and the severity of hypertension is usually determined on the basis of the extent of retinopathy.
Abnormal heart sounds, resulting from structural changes brought about in the chambers of the heart due to prolonged hypertension, can be detected by a stethoscope placed on the chest. A characteristic sound, termed fourth heart sound, is an indication of the enlargement of the left ventricle which pumps out oxygenated blood to the rest of the body except the lungs. When the left ventricle is enlarged and has become stiff due to the effect of high blood pressure, its elasticity is reduced, and it does not get filled with adequate amount of blood between contractions. To compensate for this, the left atrium contracts harder to fill the left ventricle, producing the typical fourth heart sound.
Electrocardiography can help detect the effects of the damage caused to the heart by hypertension, especially hypertrophy of myocardium or thickening of the heart muscle as well as the enlargement of the chambers of the heart. Echocardiography can provide ultrasound pictures of the heart, to show the exact change in size of the chambers as well as the thickness of the walls.
When hypertension causes kidney damage, it can be detected by urine tests and blood sample tests for kidney function. If a blood protein called albumin is excreted in the urine, it is often an early indication of kidney damage. So is the presence of blood in the urine. Since the other symptoms of kidney damage such as loss of appetite, weakness and lethargy, appear only after about three fourths of kidney function is lost, the urine and blood tests help to take remedial action much earlier.
Diagnosis of Cause: The search and diagnosis of the exact cause of hypertension is of more significance in younger people with hypertension. Detailed investigations including radionuclide imaging of the renal arteries and the kidneys and measurement of blood levels of adrenal gland hormones as well as cortisol are done in addition to ultrasonography and x-rays. But many routine tests also may help in identifying the cause. For example, bruit in the renal arteries point to stenosis of renal arteries. Excess levels of adrenal hormones adrenalin and norepinephrine, may be diagnosed by the usual symptoms they produce. The occurrence of a tumor in the adrenal gland called pheochromocytoma, is detected from the urine tests which show traces of the substances formed on the breakdown of the adrenal hormones. Measuring the levels of potassium in the blood may be helpful in detecting hyperaldosteronism or the excessive production of the hormone aldosterone. It may not be always possible to detect the exact cause, in spite of all these tests as hypertension can result from subtle changes involving several systems of the body and hereditary factors also play a role.
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What Are The Causes Of High Blood Pressure (Hypertension)
Primary Hypertension: around 90% people with high blood pressure have no identifiable cause for their hypertension. They are said to be having primary hypertension, which was previously referred to as essential hypertension. The actual cause of their hypertension may be a combination of inherited or acquired disorders of the heart or the blood vessels. It can range from an increase in cardiac output due to a fast heart rate, to narrowing of blood vessels which offer resistance to blood flow. An increase in the volume of circulating blood due to fluid retention also may be the cause of hypertension. The factors causing abnormality in the constriction and dilatation of arterioles may be either inherited or may be due to reduction in the chemical substances which bring about these changes. It may also be resulting from excess salt accumulation in the cells interfering with the body’s mechanisms of homeostasis.
Secondary Hypertension: .Around 15% of people with hypertension has an identifiable cause for their condition, such as kidney or endocrine disorders, and they are said to be having secondary hypertension. Since kidneys play an important part in the control of blood pressure, any of the disorders of the kidneys, have a direct impact on blood pressure regulation. Damage caused to the kidneys by infections or inflammations reduce their ability to regulate the circulating volume of blood, to reduce high blood pressure. Stenosis or narrowing of the renal arteries, either due to injury or atherosclerosis or due to some other disorders of the blood vessels, is a major contributor of high blood pressure. Existing hormonal disorders or hormonal imbalance caused by the use of drugs, such as oral contraceptives may precipitate hypertension. Hyperthyroidism due to an overactive thyroid gland and sometimes hyperaldosteronism caused by a tumor in one of the adrenal glands which produces the hormone aldosterone, are known to cause secondary hypertension. People with Cushing’s syndrome, which causes high levels of the hormone cortisol and those with a tumor in the adrenal glands called pheochromocytoma, which causes high levels of epinephrine and norepinephrine, also develop secondary hypertension.
Hardening of arteries due to Arteriosclerosis interferes with the body’s mechanism of controlling blood pressure, thus increasing the risk of hypertension. It is due to the fact that the stiff arterial walls offer resistance to body’s attempts to dilate the vessels to bring down the blood pressure to normal levels.
Risk Factors For Hypertension: When people already have a hereditary factor that predisposes them to developing high blood pressure, additional risk factors such as stress, smoking, excessive alcohol consumption, obesity and inactivity may accelerate the process. Emotional stress results in temporary rising of blood pressure but the homeostatic mechanisms of the body soon manage to bring it down to normal levels. Some people who have normal blood pressure at all times, may give a high blood pressure reading at the doctors’ clinic due to the stress of visiting a doctor. This may repeat every time they visit the doctor and this condition is termed as “white coat hypertension”. Even though individual incidences of sudden rising of blood pressure due to a stressful experience is not harmful in itself, repeated incidents may have a cumulative effect which culminates in the development of permanent hypertension. However, this is not a proven fact but a general assumption only.
Complications Of Hypertension
Damage to the heart and blood vessels due to hypertension may be either structural or functional or both. When the arterial pressure remains very high for an extended period of time, it causes enlargement of the heart. The muscular walls thicken, to help the heart pump with more force against the higher pressure prevailing in the arteries. But the thickening of the walls affect the elasticity of the heart, and after every contraction, the heart does not return to its original size and does not fill up with enough blood. It further increases the load on the heart, as it has to beat more frequently to pump the same quantity of blood, and fast arrhythmias may develop. When the heart’s capacity to pump enough blood to meet the requirement of the body is compromised, heart failure develops.
Atherosclerosis is often a consequence of hypertension, causing thickening and eventually hardening of the arterial walls and narrowing of the main arteries impeding the blood flow to vital organs. This condition predisposes people to kidney failure, heart attack and stroke.
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How Do Our Bodies Control Blood Pressure
In this article i will try to focus on understanding blood pressure and the role of our bodies in controlling it. Our body has its own defense mechanisms to maintain the blood pressure within range. By changing the total circulatory volume of blood in the body, by controlling the volume of blood pumped by the heart or by adjusting the diameter of arteries, the body can control blood pressure. When the rate of contractions as well as the force of each contraction is lowered, it results in reducing the amount of blood pumped into the arteries, lowering the pressure in them. By removing some of the fluid from the body through excretion, the blood pressure can be lowered. Vasodilatation or the widening of the smaller arterioles and veins can reduce the blood pressure in the arteries, even when the volume of blood remains the same. On the other hand, by increasing the rate of heart beat as well as the force with which the heart pumps blood, the body can raise the blood pressure in the arteries. Extra fluid released into the blood stream can increase the total circulating volume of blood, thus raising blood pressure. Constriction or narrowing of the arterioles (smaller arteries) and veins can also raise the blood pressure without the addition of fluid into the blood stream.
The sympathetic nervous system and parasympathetic nervous system which are parts of the autonomous nervous system, are responsible for the body’s maintenance of normality or homeostasis by reacting to stress in a variety of ways. Adrenal glands are stimulated by the sympathetic system, to release the fight or flight hormones adrenaline, also called epinephrine and its counterpart noradrenaline or norepinephrine. These hormones increase the heart rate, to help it pump more blood, when required. They also cause the constriction of arterioles in most parts of the body and at the same time, dilating the vessels in those parts which are involved in the fight or flight response, such as the musculoskeletal system. The regulation of salt movement across cell membranes help to keep the chemical balance of the cells, as excess salt inside the cells make them more vulnerable to overstimulation by the sympathetic nervous system. The kidneys are also stimulated by the sympathetic nervous system, to reduce the removal of water from the body so as to maintain extra volume of blood circulating in the body.
The kidneys have a direct role to play in the regulation of blood pressure. When blood pressure is raised, kidneys react to it by removing a portion of the fluid from the blood, by increasing the production of urine and eliminating salt and water from the body. The decrease in the volume of blood brings down the blood pressure in the arteries. When the blood pressure is lowered below the normal limits, the kidneys reduce urine production and hold salt and water within the body, causing the blood volume to increase till blood pressure is restored to normal levels. An enzyme called renin is secreted by the kidneys to help with elevation of blood pressure. The enzyme rennin induces the production of angiotensin II, a hormone that triggers the sympathetic nervous system, to increase the blood pressure by the constriction of the smaller arteries (arterioles). The arterioles in the kidneys dilate to compensate for the constriction of the arterioles elsewhere in the body. Angiotensin II also causes the release of hormones aldosterone and vasopressin, acting on the kidneys to retain water in the body.
Any temporary change in the blood pressure caused by stress or exertion is immediately counteracted by the body’s defense mechanisms to bring it back to normal. When the heart is forced to pump extra blood, to keep up with the demand of the body, during additional physical activity, the blood pressure temporarily increases in the arteries. This elevated pressure is brought down by reducing the volume of blood through the increased production of urine by the kidneys. If the blood vessels dilate to accommodate the extra amount of blood pumped by the heart, then also the blood pressure is brought back to normal level.
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What Is a High Blood Pressure (Hypertension)
High blood pressure (hypertension) is a condition in which the pressure in the arteries is higher than the normal range.
- Disorders of the kidneys or the endocrine system may be the underlying cause of high blood pressure but not necessarily so. Often, no identifiable cause can be found.
- Some people may be inherently predisposed to developing high blood pressure. For them, additional risk factors such as stress, smoking, excessive alcohol consumption, inactivity, obesity and excess salt intake can accelerate the development of high blood pressure.
- Lifestyle changes recommended include regular exercise, diet low in fats and salt, and weight loss.
- Drug therapy consists of drugs that help bring down the blood pressure called anti hypertensive drugs.
The medical term hypertension, when used to refer to high blood pressure, many people assume that it is about the increase in the mental tension or excess stress. But medically, it is a physical condition characterized by the high pressure prevailing in the arteries which may eventually lead to the damage of vital organs. Unless kept under control, by either lifestyle changes or through appropriate medication, hypertension can have far reaching consequences such as heart failure leading to heart attack, aneurysms of the arteries, kidney failure and even stroke.
Incidence of hypertension is quite high in the general population, with around 65 million Americans alone, having this condition. Blacks and people of Asian origin are more prone to developing hypertension. While 23% incidence is seen in whites and people of American origin, it is much higher at 32% in blacks. The other disorders resulting from the condition are also more severe in them.
Older people are more prone to hypertension; 75% women and 65% men above the age of 75 having this condition, while it occurs only in 25% of people below 75years. In addition to age, obesity also makes people prone to high blood pressure, the incidence of hypertension in them being almost twice of that in non-obese people.
Not all cases of hypertension are diagnosed, mainly due to the lack of symptoms. In the United States, only less than three fourths of the existing cases are clinically diagnosed and over three fourths of known cases undergo treatment. Even among those who are treated, only just over 50% achieve proper control over hypertension.
Blood pressure is expressed in two numbers, as in a fraction, the upper number standing for systolic pressure and the lower number, which incidentally is of lower value too, representing diastolic pressure. Systole is the contraction of the heart and during this time, the pressure is highest in the arteries. After every contraction, a period of relaxation follows, during which blood pours into the heart from the rest of the body; this is termed diastole and blood pressure in the arteries decreases at this time. Arteries have the lowest pressure right before the next contraction. The higher systolic pressure is expressed over the lower diastolic pressure like this -120/80 mm Hg- and it is read as 120 over 80, which incidentally is the normal reading for blood pressure.
What does high blood pressure mean ? When a few, subsequent, blood pressure readings present values higher than the normal range, the person is diagnosed as having hypertension. A systolic pressure above 140 mm Hg and diastolic reading above 90 mm Hg fall in this category. Within the range generally considered normal too, the lower the readings are, the lesser the risk of damage to other organs. In people with hypertension, either one of the readings or both, could be high. When hypertension appears early in life, systolic pressure as well as diastolic pressure are found to be high. But isolated systolic hypertension is usually found among older people with high blood pressure, in which, the systolic pressure is very high, while the blood pressure at the time of diastole remains within range.
Blood pressure readings above 180/120 mm Hg indicates a condition called hypertensive urgency, but it may often go unnoticed because organ damage due to this condition may not have become severe enough to bring it to the notice of doctors. Though asymptomatic, this condition steadily worsens and silently precipitates a variety of disorders, in several internal organs, including the kidneys and the heart.
Malignant hypertension is a potentially fatal form of hypertensive emergency, which can severely damage eyes and occasionally kidneys too. Unless diagnosed in time and treated immediately, malignant hypertension results in death within 6 months from the onset of symptoms. The incidence of this dangerous condition is reported in one out of every two hundred people with hypertension, but it is more common among economically weaker sections of society than in those of higher economic status and blacks, when compared to whites and men, compared to women.