Hypertension

9/7/2014 Hypertension - Wikipedia, the free encyclopedia
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Hypertension
Classification and external resources
Automated arm blood pressure meter showing arterial hypertension (shown a
systolic blood pressure 158 mmHg, diastolic blood pressure 99 mmHg and heart
rate of 80 beats per minute)
ICD-10 I10
(http://apps.who.int/classifications/icd10/browse/2010/en#/I10),I11
(http://apps.who.int/classifications/icd10/browse/2010/en#/I12),
I13
(http://apps.who.int/classifications/icd10/browse/2010/en#/I15)
ICD-9 401 (http://www.icd9data.com/getICD9Code.ashx?icd9=401)
OMIM 145500 (http://omim.org/entry/145500)
DiseasesDB 6330 (http://www.diseasesdatabase.com/ddb6330.htm)
MedlinePlus 000468
(http://www.nlm.nih.gov/medlineplus/ency/article/000468.htm)
eMedicine med/1106 (http://www.emedicine.com/med/topic1106.htm)
ped/1097 (http://www.emedicine.com/ped/topic1097.htm#)
emerg/267 (http://www.emedicine.com/emerg/topic267.htm#)
Patient UK Hypertension (http://www.patient.co.uk/doctor/hypertension)
MeSH D006973 (https://www.nlm.nih.gov/cgi/mesh/2014/MB_cgi?
field=uid&term=D006973)
Hypertension
From Wikipedia, the free encyclopedia
Hypertension (HTN) or
high blood pressure,
sometimes called arterial
hypertension, is a chronic
medical condition in which the
blood pressure in the arteries
is elevated. Blood pressure is
summarised by two
measurements, systolic and
diastolic, which depend on
whether the heart muscle is
contracting (systole) or
relaxed between beats
(diastole). This equals the
maximum and minimum
pressure, respectively.
Normal blood pressure at rest
is within the range of 100
140mmHg systolic (top
reading) and 6090mmHg
diastolic (bottom reading).
High blood pressure is said to
be present if it is often at or
above 140/90 mmHg.
Hypertension is classified as
either primary (essential)
hypertension or secondary
hypertension; about 9095%
of cases are categorized as
"primary hypertension" which
means high blood pressure
with no obvious underlying
medical cause.
[1]
The
remaining 510% of cases
(secondary hypertension) are
caused by other conditions
that affect the kidneys,
arteries, heart or endocrine system.
Hypertension puts strain on the heart, leading to hypertensive heart disease and coronary artery disease if not
treated. Hypertension is also a major risk factor for stroke, aneurysms of the arteries (e.g. aortic aneurysm),
peripheral arterial disease and is a cause of chronic kidney disease. A moderately high arterial blood pressure is
The Scoop (Celebritychef)
associated with a shortened life expectancy while mild elevation is not. Dietary and lifestyle changes can improve
blood pressure control and decrease the risk of health complications, although drug treatment is still often
necessary in people for whom lifestyle changes are not enough or not effective.
Contents
1 Signs and symptoms
1.1 Secondary hypertension
1.2 Hypertensive crisis
1.3 Pregnancy
1.4 Children
2 Cause
2.1 Primary hypertension
2.2 Secondary hypertension
3 Pathophysiology
4 Diagnosis
4.1 Adults
4.2 Children
5 Prevention
6 Management
6.1 Lifestyle modifications
6.2 Medications
6.3 Elderly
6.4 Resistant hypertension
7 Epidemiology
7.1 Children
8 Prognosis
9 History
10 Society and culture
10.1 Awareness
10.2 Economics
11 Research
12 References
13 Further reading
14 External links
Signs and symptoms
Hypertension is rarely accompanied by any symptoms, and its identification is usually through screening, or when
seeking healthcare for an unrelated problem. A proportion of people with high blood pressure report headaches
(particularly at the back of the head and in the morning), as well as lightheadedness, vertigo, tinnitus (buzzing or
hissing in the ears), altered vision or fainting episodes.
[2]
These symptoms, however, might be related to
associated anxiety rather than the high blood pressure itself.
[3]
On physical examination, hypertension may be suspected on the basis of the presence of hypertensive
retinopathy detected by examination of the optic fundus found in the back of the eye using ophthalmoscopy.
[4]
Classically, the severity of the hypertensive retinopathy changes is graded from grade IIV, although the milder
types may be difficult to distinguish from each other.
[4]
Ophthalmoscopy findings may also give some indication
as to how long a person has been hypertensive.
[2]
Secondary hypertension
Some additional signs and symptoms may suggest secondary hypertension, i.e. hypertension due to an
identifiable cause such as kidney diseases or endocrine diseases. For example, truncal obesity, glucose
intolerance, moon face, a hump of fat behind the neck/shoulder, and purple stretch marks suggest Cushing's
syndrome.
[5]
Thyroid disease and acromegaly can also cause hypertension and have characteristic symptoms
and signs.
[5]
An abdominal bruit may be an indicator of renal artery stenosis (a narrowing of the arteries
supplying the kidneys), while decreased blood pressure in the lower extremities and/or delayed or absent
femoral arterial pulses may indicate aortic coarctation (a narrowing of the aorta shortly after it leaves the heart).
Labile or paroxysmal hypertension accompanied by headache, palpitations, pallor, and perspiration should
prompt suspicions of pheochromocytoma.
[5]
Hypertensive crisis
Severely elevated blood pressure (equal to or greater than a systolic 180 or diastolic of 110sometimes
termed malignant or accelerated hypertension) is referred to as a "hypertensive crisis", as blood pressure at this
level confers a high risk of complications. People with blood pressures in this range may have no symptoms, but
are more likely to report headaches (22% of cases)
[6]
and dizziness than the general population.
[2]
Other
symptoms accompanying a hypertensive crisis may include visual deterioration or breathlessness due to
heart failure or a general feeling of malaise due to renal failure.
[5]
Most people with a hypertensive crisis are
known to have elevated blood pressure, but additional triggers may have led to a sudden rise.
[7]
A "hypertensive emergency", previously "malignant hypertension", is diagnosed when there is evidence of direct
damage to one or more organs as a result of severely elevated blood pressure greater than 180 systolic or 120
diastolic.
[8]
This may include hypertensive encephalopathy, caused by brain swelling and dysfunction, and
characterized by headaches and an altered level of consciousness (confusion or drowsiness). Retinal
papilloedema and/or fundal hemorrhages and exudates are another sign of target organ damage. Chest pain may
indicate heart muscle damage (which may progress to myocardial infarction) or sometimes aortic dissection, the
tearing of the inner wall of the aorta. Breathlessness, cough, and the expectoration of blood-stained sputum are
characteristic signs of pulmonary edema, the swelling of lung tissue due to left ventricular failure an inability of the
left ventricle of the heart to adequately pump blood from the lungs into the arterial system.
[7]
Rapid deterioration
of kidney function (acute kidney injury) and microangiopathic hemolytic anemia (destruction of blood cells) may
also occur.
[7]
In these situations, rapid reduction of the blood pressure is mandated to stop ongoing organ
damage.
[7]
In contrast there is no evidence that blood pressure needs to be lowered rapidly in hypertensive
urgencies where there is no evidence of target organ damage and over aggressive reduction of blood pressure is
not without risks.
[5]
Use of oral medications to lower the BP gradually over 24 to 48h is advocated in
hypertensive urgencies.
[7]
Pregnancy
Hypertension occurs in approximately 810% of pregnancies.
[5]
Two blood pressure measurements six hours
apart of greater than 140/90 mm Hg is considered diagnostic of hypertension in pregnancy.
[9]
Most women with
hypertension in pregnancy have pre-existing primary hypertension, but high blood pressure in pregnancy may be
the first sign of pre-eclampsia, a serious condition of the second half of pregnancy and puerperium.
[5]
Pre-
eclampsia is characterised by increased blood pressure and the presence of protein in the urine.
[5]
It occurs in
about 5% of pregnancies and is responsible for approximately 16% of all maternal deaths globally.
[5]
Pre-
eclampsia also doubles the risk of perinatal mortality.
[5]
Usually there are no symptoms in pre-eclampsia and it is
detected by routine screening. When symptoms of pre-eclampsia occur the most common are headache, visual
disturbance (often "flashing lights"), vomiting, epigastric pain, and edema. Pre-eclampsia can occasionally
progress to a life-threatening condition called eclampsia, which is a hypertensive emergency and has several
serious complications including vision loss, cerebral edema, seizures or convulsions, renal failure, pulmonary
edema, and disseminated intravascular coagulation (a blood clotting disorder).
[5][10]
Children
Failure to thrive, seizures, irritability, lack of energy, and difficulty breathing
[11]
can be associated with
hypertension in neonates and young infants. In older infants and children, hypertension can cause headache,
unexplained irritability, fatigue, failure to thrive, blurred vision, nosebleeds, and facial paralysis.
[11][12]
Cause
Primary hypertension
Primary (essential) hypertension is the most common form of hypertension, accounting for 9095% of all cases
of hypertension.
[1]
In almost all contemporary societies, blood pressure rises with aging and the risk of
becoming hypertensive in later life is considerable.
[13]
Hypertension results from a complex interaction of genes
and environmental factors. Numerous common genetic variants with small effects on blood pressure have been
identified
[14]
as well as some rare genetic variants with large effects on blood pressure
[15]
but the genetic basis
of hypertension is still poorly understood. Several environmental factors influence blood pressure. Lifestyle
factors that lower blood pressure include reduced dietary salt intake,
[16][17]
increased consumption of fruits and
low fat products (Dietary Approaches to Stop Hypertension (DASH diet)), exercise,
[18]
weight loss
[19]
and
reduced alcohol intake.
[20]
Stress appears to play a minor role
[3]
with specific relaxation techniques not
supported by the evidence.
[21][22]
The possible role of other factors such as caffeine consumption,
[23]
and
vitamin D deficiency
[24]
are less clear cut. Insulin resistance, which is common in obesity and is a component of
syndrome X (or the metabolic syndrome), is also thought to contribute to hypertension.
[25]
Recent studies have
also implicated events in early life (for example low birth weight, maternal smoking and lack of breast feeding) as
risk factors for adult essential hypertension,
[26]
although the mechanisms linking these exposures to adult
hypertension remain obscure.
[26]
A diagram explaining factors affecting arterial pressure
Illustration depicting the effects of
high blood pressure
Secondary hypertension
Secondary hypertension results from an identifiable cause. Renal disease is the most common secondary cause
of hypertension.
[5]
Hypertension can also be caused by endocrine conditions, such as Cushing's syndrome,
hyperthyroidism, hypothyroidism, acromegaly, Conn's syndrome or hyperaldosteronism, hyperparathyroidism
and pheochromocytoma.
[5][27]
Other causes of secondary hypertension include obesity, sleep apnea,
pregnancy, coarctation of the aorta, excessive liquorice consumption and certain prescription medicines, herbal
remedies and illegal drugs.
[5][28]
Pathophysiology
In most people with established essential
(primary) hypertension, increased resistance to
blood flow (total peripheral resistance) accounts
for the high pressure while cardiac output
remains normal.
[29]
There is evidence that some
younger people with prehypertension or
'borderline hypertension' have high cardiac
output, an elevated heart rate and normal
peripheral resistance, termed hyperkinetic
borderline hypertension.
[30]
These individuals
develop the typical features of established essential hypertension in
later life as their cardiac output falls and peripheral resistance rises
with age.
[30]
Whether this pattern is typical of all people who
ultimately develop hypertension is disputed.
[31]
The increased
peripheral resistance in established hypertension is mainly attributable
to structural narrowing of small arteries and arterioles,
[32]
although a
reduction in the number or density of capillaries may also
contribute.
[33]
Hypertension is also associated with decreased
peripheral venous compliance
[34]
which may increase venous return,
increase cardiac preload and, ultimately, cause diastolic dysfunction.
Whether increased active vasoconstriction plays a role in established
essential hypertension is unclear.
[35]
Pulse pressure (the difference between systolic and diastolic blood
pressure) is frequently increased in older people with hypertension.
This can mean that systolic pressure is abnormally high, but diastolic
pressure may be normal or low a condition termed isolated
systolic hypertension.
[36]
The high pulse pressure in elderly people with hypertension or isolated systolic
hypertension is explained by increased arterial stiffness, which typically accompanies aging and may be
exacerbated by high blood pressure.
[37]
Many mechanisms have been proposed to account for the rise in peripheral resistance in hypertension. Most
evidence implicates either disturbances in renal salt and water handling (particularly abnormalities in the intrarenal
renin-angiotensin system)
[38]
and/or abnormalities of the sympathetic nervous system.
[39]
These mechanisms are
not mutually exclusive and it is likely that both contribute to some extent in most cases of essential hypertension.
It has also been suggested that endothelial dysfunction and vascular inflammation may also contribute to
Typical tests performed
System Tests
Renal Microscopic urinalysis, proteinuria, BUN and/or creatinine
Endocrine Serum sodium, potassium, calcium, TSH
Metabolic Fasting blood glucose, HDL, LDL, and total cholesterol, triglycerides
Other Hematocrit, electrocardiogram, and chest radiograph
Sources: Harrison's principles of internal medicine
[43]
others
[44][45][46][47][48]
increased peripheral resistance and vascular damage in hypertension.
[40][41]
Interleukin 17 has garnered interest
for its role in increasing the production of several other immune system chemical signals thought to be involved in
hypertension such as tumor necrosis factor alpha, interleukin 1, interleukin 6, and interleukin 8.
[42]
Diagnosis
Hypertension is diagnosed
on the basis of a persistent
high blood pressure.
Traditionally, the National
Institute of Clinical
Excellence recommends
three separate
sphygmomanometer
measurements at one
monthly intervals.
[49][50]
The American Heart
Association recommends at
least three measurements on at least two separate health care visits.
[51]
An exception to this is those with very
high blood pressure readings especially when there is poor organ function.
[50]
Initial assessment of the
hypertensive people should include a complete history and physical examination. With the availability of 24-hour
ambulatory blood pressure monitors and home blood pressure machines, the importance of not wrongly
diagnosing those who have white coat hypertension has led to a change in protocols. In the United Kingdom,
current best practice is to follow up a single raised clinic reading with ambulatory measurement, or less ideally
with home blood pressure monitoring over the course of 7 days.
[50]
Pseudohypertension in the elderly or
noncompressibility artery syndrome may also require consideration. This condition is believed to be due to
calcification of the arteries resulting in abnormally high blood pressure readings with a blood pressure cuff while
intra arterial measurements of blood pressure are normal.
[52]
Orthostatic hypertension is when blood pressure
increases upon standing.
[53]
Once the diagnosis of hypertension has been made, physicians will attempt to identify the underlying cause
based on risk factors and other symptoms, if present. Secondary hypertension is more common in
preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more
common in adolescents and has multiple risk factors, including obesity and a family history of hypertension.
[54]
Laboratory tests can also be performed to identify possible causes of secondary hypertension, and to determine
whether hypertension has caused damage to the heart, eyes, and kidneys. Additional tests for diabetes and high
cholesterol levels are usually performed because these conditions are additional risk factors for the development
of heart disease and may require treatment.
[1]
Serum creatinine is measured to assess for the presence of kidney disease, which can be either the cause or the
result of hypertension. Serum creatinine alone may overestimate glomerular filtration rate and recent guidelines
advocate the use of predictive equations such as the Modification of Diet in Renal Disease (MDRD) formula to
estimate glomerular filtration rate (eGFR).
[55]
eGFR can also provide a baseline measurement of kidney function
that can be used to monitor for side effects of certain antihypertensive drugs on kidney function. Additionally,
testing of urine samples for protein is used as a secondary indicator of kidney disease. Electrocardiogram
(EKG/ECG) testing is done to check for evidence that the heart is under strain from high blood pressure. It may
Classification (JNC7)
[55]
Systolic pressure Diastolic pressure
mmHg kPa mmHg kPa
Normal 90119 1215.9 6079 8.010.5
High normal
[56]
or prehypertension
120139 16.018.5 8089 10.711.9
Stage 1 hypertension 140159 18.721.2 9099 12.013.2
Stage 2 hypertension 160 21.3 100 13.3
Isolated systolic
hypertension
140 18.7 <90 <12.0
also show whether there is thickening of the heart muscle (left ventricular hypertrophy) or whether the heart has
experienced a prior minor disturbance such as a silent heart attack. A chest X-ray or an echocardiogram may
also be performed to look for signs of heart enlargement or damage to the heart.
[5]
Adults
In people aged 18 years or
older hypertension is defined
as a systolic and/or a
diastolic blood pressure
measurement consistently
higher than an accepted
normal value (currently
139 mmHg systolic,
89 mmHg diastolic: see table
Classification (JNC7)).
Lower thresholds are used
(135 mmHg systolic or
85 mmHg diastolic) if
measurements are derived from 24-hour ambulatory or home monitoring.
[50]
Recent international hypertension
guidelines have also created categories below the hypertensive range to indicate a continuum of risk with higher
blood pressures in the normal range. JNC7 (2003)
[55]
uses the term prehypertension for blood pressure in the
range 120-139 mmHg systolic and/or 80-89 mmHg diastolic, while ESH-ESC Guidelines (2007)
[57]
and BHS
IV (2004)
[58]
use optimal, normal and high normal categories to subdivide pressures below 140 mmHg systolic
and 90 mmHg diastolic. Hypertension is also sub-classified: JNC7 distinguishes hypertension stage I,
hypertension stage II, and isolated systolic hypertension. Isolated systolic hypertension refers to elevated systolic
pressure with normal diastolic pressure and is common in the elderly.
[55]
The ESH-ESC Guidelines (2007)
[57]
and BHS IV (2004),
[58]
additionally define a third stage (stage III hypertension) for people with systolic blood
pressure exceeding 179 mmHg or a diastolic pressure over 109 mmHg. Hypertension is classified as "resistant"
if medications do not reduce blood pressure to normal levels.
[55]
Children
Hypertension in neonates is rare, occurring in around 0.2 to 3% of neonates, and blood pressure is not
measured routinely in the healthy newborn.
[12]
Hypertension is more common in high risk newborns. A variety
of factors, such as gestational age, postconceptional age and birth weight needs to be taken into account when
deciding if a blood pressure is normal in a neonate.
[12]
Hypertension occurs quite commonly in children over the age of 3 years and adolescents (2-9% depending on
age, sex and ethnicity)
[59]
and is associated with long term risks of ill-health.
[60]
Blood pressure rises with age in
childhood and, in children, hypertension is defined as an average systolic or diastolic blood pressure on three or
more occasions equal or higher than the 95th percentile appropriate for the sex, age and height of the child. High
blood pressure must be confirmed on repeated visits however before characterizing a child as having
hypertension.
[60]
Prehypertension in children has been defined as average systolic or diastolic blood pressure
that is greater than or equal to the 90th percentile, but less than the 95th percentile.
[60]
In adolescents, it has
been proposed that hypertension and pre-hypertension are diagnosed and classified using the same criteria as in
adults.
[60]
The value of routine screening for hypertension in children over the age of 3 years is debated.
[61][62]
In 2004 the
National High Blood Pressure Education Program recommended that children aged 3 years and older have
blood pressure measurement at least once at every health care visit
[60]
and the National Heart, Lung, Blood
Institutes and American Academy of Pediatrics made a similar recommendation.
[63]
However the American
Academy of Family Physicians
[64]
support the view of the U.S. preventive Services Task Force that evidence is
insufficient to determine the balance of benefits and harms of screening for hypertension in children and
adolescents who do not have symptoms.
[65]
Prevention
Much of the disease burden of high blood pressure is experienced by people who are not labelled as
hypertensive.
[58]
Consequently, population strategies are required to reduce the consequences of high blood
pressure and reduce the need for antihypertensive drug therapy. Lifestyle changes are recommended to lower
blood pressure, before starting drug therapy. The 2004 British Hypertension Society guidelines
[58]
proposed the
following lifestyle changes consistent with those outlined by the US National High BP Education Program in
2002
[66]
for the primary prevention of hypertension:
maintain normal body weight for adults (e.g. body mass index 2025 kg/m
2
)
reduce dietary sodium intake to <100 mmol/ day (<6 g of sodium chloride or <2.4 g of sodium per day)
engage in regular aerobic physical activity such as brisk walking (30 min per day, most days of the
week)
limit alcohol consumption to no more than 3 units/day in men and no more than 2 units/day in women
consume a diet rich in fruit and vegetables (e.g. at least five portions per day);
Effective lifestyle modification may lower blood pressure as much as an individual antihypertensive drug.
Combinations of two or more lifestyle modifications can achieve even better results.
[58]
Management
Lifestyle modifications
The first line of treatment for hypertension is identical to the recommended preventive lifestyle changes
[67]
and
includes dietary changes,
[68]
physical exercise, and weight loss. These have all been shown to significantly
reduce blood pressure in people with hypertension.
[69]
Their potential effectiveness is similar to and at times
exceeds a single medication.
[56]
If hypertension is high enough to justify immediate use of medications, lifestyle
changes are still recommended in conjunction with medication.
Dietary change such as a low sodium diet is beneficial. A long term (more than 4 weeks) low sodium diet is
effective in reducing blood pressure, both in people with hypertension and in people with normal blood
pressure.
[70]
Also, the DASH diet, a diet rich in nuts, whole grains, fish, poultry, fruits and vegetables lowers
blood pressure. A major feature of the plan is limiting intake of sodium, although the diet is also rich in
potassium, magnesium, calcium, as well as protein.
[71]
Some programs aimed to reduce psychological stress
such as biofeedback or transcendental meditation may be reasonable add-ons to other treatment to reduce
hypertension. However several techniques such as yoga, relaxation and other forms of meditation do not appear
to reduce blood pressure,
[72]
and, of the techniques with supportive evidence, there is limited information on
whether the modest reduction in blood pressure results in prevention of cardiovascular disease.
[72]
Several exercise regimesincluding isometric resistance exercise, aerobic exercise, resistance exercise and
device-guided breathingmay be useful in reducing blood pressure.
[72]
Medications
Several classes of medications, collectively referred to as antihypertensive drugs, are currently available for
treating hypertension. Use should take into account the person's cardiovascular risk (including risk of myocardial
infarction and stroke) as well as blood pressure readings, in order to gain a more accurate picture of the
person's cardiovascular profile.
[73]
Benefit is related to a person's cardiac disease risk.
[74]
Evidence in those
with mild hypertension (SBP less than 160 mmHg and /or DBP less than 100 mmHg) and no other health
problems does not support a reduction in the risk of death or rate of health complications from medication
treatment.
[75]
Medications are not recommended for people with prehypertension or high normal blood
pressure.
[56]
If drug treatment is initiated the Joint National Committee on High Blood Pressure (JNC-7)
[55]
recommends
that the physician not only monitor for response to treatment but should also assess for any side effects resulting
from the medication. Reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34%, of
ischaemic heart disease by 21%, and reduce the likelihood of dementia, heart failure, and mortality from
cardiovascular disease.
[76]
For most people, recommendations are to reduce blood pressure to less than or
equal to somewhere between 140/90 mmHg to 160/100 mmHg.
[73][77]
Attempting to achieve lower levels have
not been shown to improve outcomes
[77]
while there is evidence that it increases side effects.
[78]
In those with
diabetes or kidney disease some recommend levels below 120/80 mmHg;
[73][79]
however, evidence does not
support these lower levels.
[77][80]
If the blood pressure goal is not met, a change in treatment should be made as
therapeutic inertia is a clear impediment to blood pressure control.
[81]
The best first line agent is disputed.
[82]
The Cochrane collaboration, World Health Organization and the United
States guidelines supports low dose thiazide-based diuretic as first line treatment.
[69][82][83][84]
The UK
guidelines emphasise calcium channel blockers (CCB) in preference for people over the age of 55 years or if of
African or Caribbean family origin, with angiotensin converting enzyme inhibitors (ACE-I) used first line for
younger people.
[85]
In Japan starting with any one of six classes of medications including: CCB, ACEI/ARB,
thiazide diuretics, beta-blockers, and alpha-blockers is deemed reasonable, while in Canada and Europe all of
these but alpha-blockers are recommended as options.
[56][82]
When compared to placebo and other anti-
hypertensive drugs as first-line therapy for hypertension, beta-blockers have greater benefit in stroke reduction,
but no difference on coronary heart disease or all-cause mortality.
[86]
However, three-quarters of active beta-
blocker treatment in the randomised controlled trials included in the review were with atenolol and none with the
newer vasodilating beta-blockers.
[87]
Drug combinations
The majority of people require more than one drug to control their hypertension. In those with a systolic blood
pressure greater than 160 mmHg or a diastolic blood pressure greater than 100 mmHg the American Heart
Association recommends starting both a thiazide and an ACEI, ARB or CCB.
[69]
An ACEI and CCB
combination can be used as well.
[69]
Unacceptable combinations are non-dihydropyridine calcium blockers (such as verapamil or diltiazem) and
beta-blockers, dual reninangiotensin system blockade (e.g. angiotensin converting enzyme inhibitor +
angiotensin receptor blocker), reninangiotensin system blockers and beta-blockers, beta-blockers and
centrally acting agents.
[88]
Combinations of an ACE-inhibitor or angiotensin IIreceptor antagonist, a diuretic
and an NSAID (including selective COX-2 inhibitors and non-prescribed drugs such as ibuprofen) should be
avoided whenever possible due to a high documented risk of acute renal failure. The combination is known
colloquially as a "triple whammy" in the Australian health industry.
[67]
Tablets containing fixed combinations of
two classes of drugs are available and while convenient for the people, may be best reserved for those who
have been established on the individual components.
[89]
Elderly
Treating moderate to severe hypertension decreases death rates and cardiovascular morbidity and mortality in
people aged 60 and older.
[90]
There are limited studies of people over 80 years old but a recent review
concluded that antihypertensive treatment reduced cardiovascular deaths and disease, but did not significantly
reduce total death rates.
[90]
The recommended BP goal is advised as <150/90 mm Hg with thiazide diuretic,
CCB, ACEI, or ARB being the first line medication in the United States,
[91]
and in the revised UK guidelines
calcium-channel blockers are advocated as first line with targets of clinic readings <150/90, or <145/85 on
ambulatory or home blood pressure monitoring.
[85]
Resistant hypertension
Resistant hypertension is defined as hypertension that remains above goal blood pressure in spite of using, at
once, three antihypertensive agents belonging to different drug classes. Guidelines for treating resistant
hypertension have been published in the UK
[92]
and US.
[93]
It has been proposed that a proportion of resistant
hypertension may be the result of chronic high activity of the autonomic nervous system; this concept is known
as "neurogenic hypertension".
[94]
Low adherence to treatment is an important causes of resistant
hypertension.
[95]
Epidemiology
As of 2000, nearly one billion people or ~26% of the adult population of the world had hypertension.
[97]
It was
common in both developed (333 million) and undeveloped (639 million) countries.
[97]
However rates vary
markedly in different regions with rates as low as 3.4% (men) and 6.8% (women) in rural India and as high as
68.9% (men) and 72.5% (women) in Poland.
[98]
In Europe hypertension occurs in about 30-45% of people as
of 2013.
[56]
In 1995 it was estimated that 43 million people in the United States had hypertension or were taking
antihypertensive medication, almost 24% of the adult United States population.
[99]
The prevalence of
hypertension in the United States is increasing and reached 29% in 2004.
[100][101]
As of 2006 hypertension
affects 76 million US adults (34% of the population) and African American adults have among the highest rates
of hypertension in the world at 44%.
[102]
It is more common in blacks, Filipinos, and Native Americans and less
Disability-adjusted life year for
hypertensive heart disease per
100,000 inhabitants in 2004.
[96]
no data
<110
110-220
220-330
330-440
440-550
550-660
660-770
770-880
880-990
990-1100
1100-1600
>1600
Diagram illustrating the main
complications of persistent high blood
pressure
Image of veins from Harvey's
Exercitatio Anatomica de Motu Cordis
et Sanguinis in Animalibus
in whites and Mexican Americans, rates increase with age, and is
greater in the southeastern United States.
[1][103]
Hypertension is
more common in men (though menopause tends to decrease this
difference) and in those of low socioeconomic status.
[1]
Children
Rates of high blood pressure in children and adolescent have
increased in the last 20 years in the United States.
[104]
Most
childhood hypertension, particularly in preadolescents, is secondary
to an underlying disorder. Aside from obesity, kidney disease is the
most common (6070%) cause of hypertension in children.
Adolescents usually have primary or essential hypertension, which
accounts for 8595% of cases.
[105]
Prognosis
Hypertension is the most important preventable risk factor for
premature death worldwide.
[106]
It increases the risk of ischemic
heart disease
[107]
strokes,
[5]
peripheral vascular disease,
[108]
and
other cardiovascular diseases, including heart failure, aortic
aneurysms, diffuse atherosclerosis, and pulmonary embolism.
[5]
Hypertension is also a risk factor for cognitive impairment and
dementia, and chronic kidney disease.
[5]
Other complications include
hypertensive retinopathy and hypertensive nephropathy.
[55]
History
Modern understanding of
the cardiovascular system
began with the work of
physician William Harvey
(15781657), who described the circulation of blood in his book "De
motu cordis". The English clergyman Stephen Hales made the first
published measurement of blood pressure in 1733.
[109][110]
Descriptions of hypertension as a disease came among others from
Thomas Young in 1808 and especially Richard Bright in 1836.
[109]
The first report of elevated blood pressure in a person without
evidence of kidney disease was made by Frederick Akbar Mahomed
(18491884).
[111]
However hypertension as a clinical entity came
into being in 1896 with the invention of the cuff-based
sphygmomanometer by Scipione Riva-Rocci in 1896.
[112]
This allowed the measurement of blood pressure in
the clinic. In 1905, Nikolai Korotkoff improved the technique by describing the Korotkoff sounds that are heard
when the artery is ausculated with a stethoscope while the sphygmomanometer cuff is deflated.
[110]
Graph showing, prevalence of
awareness, treatment and control of
hypertension compared between the
four studies of NHANES
[100]
Historically the treatment for what was called the "hard pulse disease" consisted in reducing the quantity of blood
by bloodletting or the application of leeches.
[109]
This was advocated by The Yellow Emperor of China,
Cornelius Celsus, Galen, and Hippocrates.
[109]
In the 19th and 20th centuries, before effective pharmacological
treatment for hypertension became possible, three treatment modalities were used, all with numerous side-
effects: strict sodium restriction (for example the rice diet
[109]
), sympathectomy (surgical ablation of parts of the
sympathetic nervous system), and pyrogen therapy (injection of substances that caused a fever, indirectly
reducing blood pressure).
[109][113]
The first chemical for hypertension, sodium thiocyanate, was used in 1900
but had many side effects and was unpopular.
[109]
Several other agents were developed after the Second World
War, the most popular and reasonably effective of which were tetramethylammonium chloride and its derivative
hexamethonium, hydralazine and reserpine (derived from the medicinal plant Rauwolfia serpentina). A major
breakthrough was achieved with the discovery of the first well-tolerated orally available agents. The first was
chlorothiazide, the first thiazide diuretic and developed from the antibiotic sulfanilamide, which became available
in 1958.
[109][114]
Subsequently beta blockers, calcium channel blockers, angiotensin converting enzyme (ACE)
inhibitors, angiotensin receptor blockers and renin inhibitors were developed as antihypertensive agents.
Society and culture
Awareness
The World Health Organization has identified hypertension, or high
blood pressure, as the leading cause of cardiovascular mortality. The
World Hypertension League (WHL), an umbrella organization of 85
national hypertension societies and leagues, recognized that more than
50% of the hypertensive population worldwide are unaware of their
condition.
[115]
To address this problem, the WHL initiated a global
awareness campaign on hypertension in 2005 and dedicated May 17
of each year as World Hypertension Day (WHD). Over the past
three years, more national societies have been engaging in WHD and
have been innovative in their activities to get the message to the
public. In 2007, there was record participation from 47 member
countries of the WHL. During the week of WHD, all these countries
in partnership with their local governments, professional societies,
nongovernmental organizations and private industries promoted
hypertension awareness among the public through several media and public rallies. Using mass media such as
Internet and television, the message reached more than 250 million people. As the momentum picks up year
after year, the WHL is confident that almost all the estimated 1.5 billion people affected by elevated blood
pressure can be reached.
[116]
Economics
High blood pressure is the most common chronic medical problem prompting visits to primary health care
providers in USA. The American Heart Association estimated the direct and indirect costs of high blood
pressure in 2010 as $76.6 billion.
[102]
In the US 80% of people with hypertension are aware of their condition,
71% take some antihypertensive medication, but only 48% of people aware that they have hypertension
adequately control it.
[102]
Adequate management of hypertension can be hampered by inadequacies in the
diagnosis, treatment, and/or control of high blood pressure.
[117]
Health care providers face many obstacles to
achieving blood pressure control, including resistance to taking multiple medications to reach blood pressure
goals. People also face the challenges of adhering to medicine schedules and making lifestyle changes.
Nonetheless, the achievement of blood pressure goals is possible, and most importantly, lowering blood
pressure significantly reduces the risk of death due to heart disease and stroke, the development of other
debilitating conditions, and the cost associated with advanced medical care.
[118][119]
Research
Selective radiofrequency ablation of the nerves supplying the kidneys, which employs a catheter-based device to
cause thermal injury to the nerves surrounding the renal artery without affecting other sympathetic nerves, may
lower blood pressure.
[120]
So far, major side effects have been relatively infrequent, although cases of renal
artery dissection, femoral artery pseudoaneurysm, excessive decreases in blood pressure and heart rate are
among the reported adverse effects.
[120]
It has been suggested that renal nerve ablation may have a role in the
management of resistant hypertension but its long term efficacy and safety have not been evaluated.
[120]
However, a 2014 trial failed to confirm a beneficial effect.
[121]
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James, Paul A.; Oparil, Suzanne; Carter, Barry L.; Cushman, William C.; Dennison-Himmelfarb, Cheryl;
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Olugbenga; Smith, Sidney C.; Svetkey, Laura P.; Taler, Sandra J.; Townsend, Raymond R.; Wright,
Jackson T.; Narva, Andrew S.; Ortiz, Eduardo (18 December 2013). "2014 Evidence-Based Guideline
for the Management of High Blood Pressure in Adults". JAMA 311 (5): 50720.
doi:10.1001/jama.2013.284427 (http://dx.doi.org/10.1001%2Fjama.2013.284427). PMID 24352797
External links
Hypertension
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c
Gulati, V.; White, WB. (August 2013). "Review of the state of renal nerve ablation for patients with
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