CHAPTER I

INTRODUCTION

1. Background.

Hypertension in the pediatric population is now commonly observed. Hypertension is known to

be a major cause of morbidity and mortality in the United States and in many other countries,
and the long-term health risks to children with hypertension may be substantial. In the United
States, extensive normative data on blood pressure (BP) in children are available.
The Task Force on Blood Pressure Control in Children, commissioned by the National Heart,
Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH), developed
standards for BP by using the results of 11 surveys of more than 83,000 person-visits of infants
and children (including approximately equal numbers of boys and girls). The percentile curves
were first published in 1987 and describe age-specific distributions of systolic and diastolic BP
in infants and children, with corrections for height and weight.[1]
The Third Report of the Task Force, published in 1996, provided further details regarding the
diagnosis and treatment of hypertension in infants and children.[2] In 2004, the Fourth Report
added normative data and adapted the data to growth charts from the Centers for Disease Control
and Prevention (CDC) for 2000.[3] In accordance with the recommendations of the Task Force,
BP is considered normal when the systolic and diastolic values are less than the 90th percentile
for the childs age, sex, and height.
The Fourth Report introduced a new category, prehypertension, which is diagnosed when a
childs average BP is above the 90th percentile but below the 95th. Any adolescent whose BP is
greater than 120/80 mm Hg is also given this diagnosis, even if the BP is below the 90th
percentile. This classification was created to align the categories for children with the categories
for adults from the recommendations of the Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Stage I hypertension is diagnosed if a childs BP is greater than the 95th percentile but less than
or equal to the 99th percentile plus 5 mm Hg. Stage II hypertension is diagnosed if a childs BP
is greater than the 99th percentile plus 5 mm Hg. It may be categorized as prehypertension if the
BP is between 90th to 95th percentile.
If the systolic and diastolic pressures give rise to a discrepancy with respect to classification, the
childs condition should be categorized by using the higher value. Table 1 (see below) serves as a

guide to the practicing physician. Full blood pressure tables for children and adolescents are
available from the NHLBI.
Blood pressure (BP) in newborns depends on various factors, including gestational age, postnatal
age, and birth weight. Hypertension can be observed in various situations in the modern NICU
and is especially common in infants who have undergone umbilical arterial catheterization. A
careful diagnostic evaluation should lead to determination of the underlying cause of
hypertension in most infants. (See Etiology, Presentation, and Workup.)
High blood pressure (HBP) is one of the most important risk factors for cardiovascular-renal
disease, because it has a high prevalence in almost all populations; it has a large impact on
disease incidence, and can be controlled by early detection, and treatment. Between 24.0 and
31.1% of the adult population in the United States has HBP,1 a condition that only in 1998
accounted for $108.0 billions in health-care spending.2 Despite its high health impact, primary
prevention of HBP is partly hampered because of a limited knowledge on risk factors. In this
article, we review the epidemiological and biological evidence of a possible link between chronic
mild inflammation (CMI) and HBP.

2 Destination
a. General purpose.
That students and readers understand about hypertension
b. Special Purpose.
1. What causes high blood pressure?
2. What Is "Normal" Blood Pressure?
3. What Causes High Blood Pressure?

CHAPTER II
THEORETICAL REVIEW
1. Definition

Hypertension (HTN or HT), also known as high blood pressure, is a long term medical
condition in which the blood pressure in the arteries is persistently elevated. Blood pressure is
expressed by two measurements, the systolic and diastolic pressures, which are the maximum
and minimum pressures, respectively, in the arterial system. The systolic pressure occurs when
the left ventricle is most contracted; the diastolic pressure occurs when the left ventricle is most
relaxed prior to the next contraction. Normal blood pressure at rest is within the range of 100
140 millimeters mercury (mmHg) systolic and 6090 mmHg diastolic. Hypertension is present if
the resting blood pressure is persistently at or above 140/90 mmHg for most adults; different
numbers apply to children
Hypertension usually does not cause symptoms initially, but sustained hypertension over time is
a major risk factor for hypertensive heart disease, coronary artery disease stroke, aortic
aneurysm, peripheral artery disease, and chronic kidney disease.
Hypertension is classified as either primary (essential) hypertension or secondary hypertension.
About 9095% of cases are categorized as primary hypertension, defined as high blood pressure
with no obvious underlying cause. The remaining 510% of cases are categorized as secondary
hypertension, defined as hypertension due to an identifiable cause, such as chronic kidney
disease, narrowing of the aorta or kidney arteries, or an endocrine disorder such as
excess aldosterone, cortisol, or catecholamines.
Dietary and lifestyle changes can lower blood pressure and decrease the risk of health
complications, although treatment with medication is still often necessary in people for whom
lifestyle changes are not enough or not effective. The treatment of moderately high arterial blood
pressure (defined as >160/100 mmHg) with medications is associated with an improved life
expectancyThe benefits of treatment of blood pressure that is between 140/90 mmHg and
160/100 mmHg are less clear, with some reviews finding absence of a proven benefit and others
finding benefit
What causes high blood pressure?

Blood pressure is the measure of the force of blood pushing against blood vessel walls.
The heart pumps blood into the arteries (blood vessels), which carry the blood throughout
the body. High blood pressure, also called hypertension, is dangerous because it makes
the heart work harder to pump blood out to the body and contributes to hardening of the
arteries, or atherosclerosis, to stroke, kidney disease, and to the development of heart
failure.

What Is "Normal" Blood Pressure?

A blood pressure reading has a top number (systolic) and bottom number (diastolic). The ranges
are:

Normal: Less than 120 over 80 (120/80)

Prehypertension: 120-139 over 80-89
Stage 1 high blood pressure: 140-159 over 90-99
Stage 2 high blood pressure: 160 and above over 100 and above
High blood pressure in people over age 60: 150 and above over 90 and above
People whose blood pressure is above the normal range should consult their doctor about steps to
take to lower it.
What Causes High Blood Pressure?
The exact causes of high blood pressure are not known, but several factors and conditions may
play a role in its development, including:

Smoking
Being overweight or obese
Lack of physical activity
Too much salt in the diet
Too much alcohol consumption (more than 1 to 2 drinks per day)
Stress
Older age
Genetics
Family history of high blood pressure
Chronic kidney disease
Adrenal and thyroid disorders
Sleep apnea
Essential hypertension is also greatly influenced by diet and lifestyle. The link between salt and
high blood pressure is especially compelling. People living on the northern islands of Japan eat
more salt per capita than anyone else in the world and have the highest incidence of essential
hypertension. By contrast, people who add no salt to their food show virtually no traces of
essential hypertension.

The majority of all people with high blood pressure are "salt sensitive," meaning that anything
more than the minimal bodily need for salt is too much for them and increases their blood
pressure. Other factors that can raise the risk of having essential hypertension include obesity;
diabetes; stress; insufficient intake of potassium, calcium, and magnesium; lack of physical
activity; and chronic alcohol consumption.
Secondary Hypertension
When a direct cause for high blood pressure can be identified, the condition is described as
secondary hypertension. Among the known causes of secondary hypertension, kidney disease
ranks highest. Hypertension can also be triggered by tumors or other abnormalities that cause the
adrenal glands (small glands that sit atop the kidneys) to secrete excess amounts of the hormones
that elevate blood pressure. Birth control pills -- specifically those containing estrogen -- and
pregnancy can boost blood pressure, as can medications that constrict blood vessels.

Pathophysiology

Determinants of mean arterial pressure

Illustration depicting the effects of high blood pressure

In most people with established essential hypertension, increased resistance to blood flow (total
peripheral resistance) accounts for the high pressure while cardiac output remains normal 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 These individuals develop the typical features of established essential
hypertension in later life as their cardiac output falls and peripheral resistance rises with
age Whether this pattern is typical of all people who ultimately develop hypertension is
disputed The increased peripheral resistance in established hypertension is mainly attributable to
structural narrowing of small arteries and arterioles although a reduction in the number or density
of capillaries may also contribute Whether increased active arteriolarvasoconstriction plays a
role in established essential hypertension is unclear. Hypertension is also associated with
decreased peripheral venous compliance] which may increase venous return, increase
cardiac preload and, ultimately, cause diastolic dysfunction.
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.]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
Many mechanisms have been proposed to account for the rise in peripheral resistance in
hypertension. Most evidence implicates either disturbances in the kidneys' salt and water
handling (particularly abnormalities in the intrarenal renin-angiotensin system) and/or

abnormalities of the sympathetic nervous system 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 inflammationmay also contribute
to increased peripheral resistance and vascular damage in hypertension 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 astumor necrosis factor
alpha, interleukin 1, interleukin 6, and interleukin

Diagnosis
Hypertension is diagnosed on the basis of a persistently high blood pressure. Traditionally,
theNational Institute of Clinical Excellence recommends three separate sphygmomanometer
measurements at one monthly intervals The American Heart Association recommends at least
three measurements on at least two separate health care visits.] Ambulatory blood pressure
monitoring over 12 to 24 hours is the most accurate method to confirm the diagnosis
An exception to this is those with very high blood pressure readings especially when there is
poor organ function 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 The United States
Preventative Services Task Force also recommends getting measurements outside of the
healthcare environment 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 Orthostatic hypertension is when blood
pressure increases upon standing Once the diagnosis of hypertension has been made, healthcare
providers should 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 kidney disease. Primary or essential hypertension is more common in
adolescents and has multiple risk factors, including obesity and a family history of
hypertension 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 treatmentSerum 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 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 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
Prevention
Much of the disease burden of high blood pressure is experienced by people who are not labeled
as hypertensive. 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 proposed the following lifestyle changes consistent with those
outlined by the US National High BP Education Program in 2002 or the primary prevention of
hypertension:

maintain normal body weight for adults (e.g. body mass index 2025 kg/m2)

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
Management

Main article: Management of hypertension

According to one review published in 2003, 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
Target blood pressure[edit]
See also: Comparison of international blood pressure guidelines
Various expert groups have produced guidelines regarding how low the blood pressure target
should be when a person is treated for hypertension. These groups recommend a target below the
range 140-160 / 90-100 mmHg for the general population. Controversy exists regarding the
appropriate targets for certain subgroups, including the elderly, people with diabetes and people
with kidney diseaseMany expert groups recommend a slightly higher target of 150/90 mmHg for
those over 80 years of age One expert group, the JNC-8, recommends the target of 150/90
mmHg for those over 60 years of age, but some experts within this group disagree with this
recommendation Some expert groups have also recommended slightly lower targets in those with
diabetes] or chronic kidney disease with proteinuriabut others recommend the same target as for
the general population In 2015 a large trial suggests that among people over 50 with increased
heart disease risk, aiming to reduce systolic blood pressure to 120 mmHg was associated with
lower mortality but increased side effects compared to a target of 140 mmHg
Lifestyle modifications]
The first line of treatment for hypertension is lifestyle changes, including dietary
changes physical exercise, and weight loss. These have all been shown to significantly reduce
blood pressure in people with hypertension. Their potential effectiveness is similar to and at
times exceeds a single medication If hypertension is high enough to justify immediate use of
medications, lifestyle changes are still recommended in conjunction with medication.
Dietary changes shown to reduce blood pressure include diets with low sodium the DASH diet,
vegetarian dietsand high potassium diets.
Physical exercise regimens which are shown to reduce blood pressure include isometric
resistance exercise, aerobic exercise, resistance exercise, and device-guided breathing.
Stress reduction techniques such as biofeedback or transcendental meditation may be considered
as an add-on to other treatments to reduce hypertension, but do not have evidence for preventing
cardiovascular disease on their own

Medications[
Several classes of medications, collectively referred to as antihypertensive medications, are
available for treating hypertension.
First line medications for hypertension include thiazide-diuretics, calcium channel
blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blockers.[1] These
drugs may be used alone or in combination; the latter option may serve to minimize counterregulatory mechanisms that act to revert blood pressure values to pre-treatment levels.[1][91] The
majority of people require more than one medication to control their hypertension.

CHAPTER IV
CLOSING
1. Conclusion.

Epidemiologic and biological evidence suggest that CMI may be an independent risk factor for
the development of HBP. Elevated plasma levels of CRP, TNF-alpha and IL-6, within the normal
range, have been associated to HBP. There is cross-sectional evidence of an independent
association between CRP plasma levels and HBP.23 IL-6 also seems to be significantly and
independently correlated with systolic and diastolic blood pressure,32 and with IEDD.7 TNFalpha appears to be the critical cytokine in the process of endothelial stunning,37 and has been
associated to the insulin-resistant syndrome16,40 and to HBP.34,45 However, prospective cohort
studies are needed to elucidate whether cytokine elevation predicts the development or is just a
consequence of HBP. Knowledge of the contribution of CMI to HBP development could
facilitate current efforts on detection, evaluation, and treatment of hypertension.

REFERENCES
http://www.nature.com/jhh/journal/v17/n4/full/1001537a.html
https://en.wikipedia.org/wiki/Hypertension

http://emedicine.medscape.com/article/979588-overview