Hypertension

Hypertension is the term used to describe high blood pressure.

Blood pressure is a measurement of the force against the walls of your arteries as the heart pumps blood through the body.

Blood pressure readings are measured in millimeters of mercury (mmHg) and usually given as two numbers -- for example, 120 over 80
(written as 120/80 mmHg). One or both of these numbers can be too high.

The top number is your systolic pressure.

 It is considered high if it is over 140 most of the time.

 It is considered normal if it is below 120 most of the time.

The bottom number is your diastolic pressure.

 It is considered high if it is over 90 most of the time.

 It is considered normal if it is below 80 most of the time.

Pre-hypertension may be considered when your:

 Top number (systolic blood pressure) is between 120 and 139 most of the time, or
 Bottom number (diastolic blood pressure) is between 80 and 89 most of the time

If you have pre-hypertension, you are more likely to develop high blood pressure.

If you have heart or kidney problems, or if you had a stroke, your doctor may want your blood pressure to be even lower than that of
people who do not have these conditions.

Causes

Many factors can affect blood pressure, including:

 How much water and salt you have in your body

 The condition of your kidneys, nervous system, or blood vessels
 The levels of different body hormones

You are more likely to be told your blood pressure is too high as you get older. This is because your blood vessels become stiffer as
you age. When that happens, your blood pressure goes up. High blood pressureincreases your chance of having a stroke, heart attack,
heart failure, kidney disease, and early death.

You have a higher risk of high blood pressure if you:

 Are African American  Have a family history of high blood pressure

 Are obese  Have diabetes
 Are often stressed or anxious  Smoke
 Eat too much salt in your diet

Most of the time, no cause is identified. This is called essential hypertension.

High blood pressure that is caused by another medical condition or medication is called secondary hypertension. Secondary
hypertension may be due to:
  Alcohol abuse  Coarctation of the aorta
 Atherosclerosis  Cocaine use
 Autoimmune disorders such as periarteritis nodosa  Diabetes (if it causes kidney damage)
 Chronic kidney disease

 Endocrine disorders, such as adrenal tumors (pheochromocytoma, aldosteronism), thyroid disorders, andCushing syndrome
 Medications
o Appetite suppressants
o Birth control pills
o Certain cold medications
o Corticosteroids
o Migraine medications
 Renal artery stenosis

Symptoms

Most of the time, there are no symptoms. Symptoms that may occur include:

 Confusion  Irregular heartbeat

 Ear noise or buzzing  Nosebleed
 Fatigue  Vision changes
 Headache

If you have a severe headache or any of the symptoms above, see your doctor right away. These may be signs of a complication or
dangerously high blood pressure called malignant hypertension.

Exams and Tests

Your health care provider will perform a physical exam and check your blood pressure. If the measurement is high, your health care
provider may think you have high blood pressure. The measurements need to be repeated over time, so that the diagnosis can be
confirmed.

If you monitor your blood pressure at home, you may be asked the following questions:

 What was your most recent blood pressure reading?

 What was the previous blood pressure reading?
 What is the average systolic (top number) and diastolic (bottom number) reading?
 Has your blood pressure increased recently?

Other tests may be done to look for blood in the urine or heart failure. Your doctor will look for signs of complications in your heart,
kidneys, eyes, and other organs in your body.

These tests may include:

 Blood tests  Urinalysis

 Echocardiogram  Ultrasound of the kidneys
 Electrocardiogram

Treatment

The goal of treatment is to reduce blood pressure so that you have a lower risk of complications. You and your health care provider
should set a blood pressure goal for you.
There are many different medicines that can be used to treat high blood pressure, including:
Your health care provider may also tell you to exercise, lose weight, and follow a healthier diet. If you have pre-hypertension, your
health care provider will recommend the same lifestyle changes to bring your blood pressure down to a normal range.

Often, a single blood pressure drug may not be enough to control your blood pressure, and you may need to take two or more drugs. It
is very important that you take the medications prescribed to you. If you have side effects, your health care provider can substitute a
different medication.

In addition to taking medicine, you can do many things to help control your blood pressure, including:

 Eat a heart-healthy diet, including potassium and fiber, and drink plenty of water.
 Exercise regularly -- at least 30 minutes a day.
 If you smoke, quit -- find a program that will help you stop.
 Limit how much alcohol you drink -- 1 drink a day for women, 2 a day for men.
 Limit the amount of sodium (salt) you eat -- aim for less than 1,500 mg per day.
 Reduce stress -- try to avoid things that cause stress for you. You can also try meditation or yoga.
 Stay at a healthy body weight -- find a weight-loss program to help you, if you need it.

Your health care provider can help you find programs for losing weight, stopping smoking, and exercising. You can also get a referral
from your doctor to a dietitian, who can help you plan a diet that is healthy for you.

Your health care provider may ask you to keep track of your blood pressure at home. Make sure you get a good quality, well-fitting
home device. It will probably have a cuff with a stethoscope or a digital readout. Practice with your health care provider or nurse to
make sure you are taking your blood pressure correctly.

Outlook (Prognosis)

Most of the time, high blood pressure can be controlled with medicine and lifestyle changes.

Possible Complications

 Aortic dissection  Hypertensive heart disease

 Blood vessel damage (arteriosclerosis)  Peripheral artery disease
 Brain damage  Pregnancy complications
 Congestive heart failure  Stroke
 Chronic kidney disease  Vision loss
 Heart attack

Prevention

Adults over 18 should have their blood pressure checked routinely.

Lifestyle changes may help control your blood pressure:

 Avoid smoking. (See: Nicotine withdrawal)

 Do not consume more than 1 drink a day for women, 2 a day for men.
 Eat a diet rich in fruits, vegetables, and low-fat dairy products while reducing total and saturated fat intake (the DASH diet is
one way of achieving this kind of dietary plan). (See: Heart disease and diet)
 Exercise regularly. If possible, exercise for 30 minutes on most days.
 If you have diabetes, keep your blood sugar under control.
 Lose weight if you are overweight. Excess weight adds to strain on the heart. In some cases, weight loss may be the only
treatment needed.
  Try to manage your stress.

Hypertension (HTN) or high blood pressure is a chronic medical condition in which the systemic arterial blood pressure is elevated. It

is the opposite of hypotension. It is classified as either primary (essential) or secondary. About 90–95% of cases are termed "primary

hypertension", which refers to high blood pressure for which no medical cause can be found.[1]The remaining 5–10% of cases

(Secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart, or endocrine system.[2]

Persistent hypertension is one of the risk factors for stroke, myocardial infarction, heart failureand arterial aneurysm, and is a leading

cause of chronic kidney failure.[3] Moderate elevation of arterial blood pressure leads to shortened life expectancy. Dietary and lifestyle

changes can improve blood pressure control and decrease the risk of associated health complications, although drug treatment may

prove necessary in patients for whom lifestyle changes prove ineffective or insufficient.[

Systolic pressure Diastolic pressure

Classification

mmHg kPa mmHg kPa

Normal 90–119 12–15.9 60–79 8.0–10.5

Prehypertension 120–139 16.0–18.5 80–89 10.7–11.9

Stage 1 140–159 18.7–21.2 90–99 12.0–13.2

Stage 2 ≥160 ≥21.3 ≥100 ≥13.3

Isolated systolic
≥140 ≥18.7 <90 <12.0
hypertension

Pathophysiology

Most of the mechanisms associated with secondary hypertension are generally fully understood. However, those associated

with essential (primary) hypertension are far less understood. What is known is thatcardiac output is raised early in the disease course,

with total peripheral resistance (TPR) normal; over time cardiac output drops to normal levels but TPR is increased. Three theories

have been proposed to explain this:

 Inability of the kidneys to excrete sodium, resulting in natriuretic factors such as Atrial Natriuretic Factor being secreted to

promote salt excretion with the side effect of raising total peripheral resistance.

 An overactive Renin-angiotensin system leads to vasoconstriction and retention of sodium and water. The increase in blood

volume leads to hypertension.[37]

 An overactive sympathetic nervous system, leading to increased stress responses.[38]

It is also known that hypertension is highly heritable and polygenic (caused by more than one gene) and a few candidate genes have

been postulated in the etiology of this condition.[39]

Recently, work related to the association between essential hypertension and sustained endothelial damage has gained popularity

among hypertension scientists. It remains unclear however whether endothelial changes precede the development of hypertension or

whether such changes are mainly due to long standing elevated blood pressures.

Diagnosis
Hypertension is generally diagnosed on the basis of a persistently high blood pressure. Usually this requires three
separate sphygmomanometer (see figure) measurements at least one week apart. Often, this entails three separate visits
to the physician's office. Initial assessment of the hypertensive patient should include a complete history and physical
examination. Exceptionally, if the elevation is extreme, or if symptoms of organ damage are present then the diagnosis
may be given and treatment started immediately.

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. [31] Laboratory tests can also be performed to identify
possible causes of secondary hypertension, and determine if hypertension has caused damage to the heart, eyes,
and kidneys. Additional tests for Diabetes and high cholesterol levels are also usually performed because they are
additional risk factors for the development of heart disease require treatment.[1] Tests typically performed are classified as
follows:

System Tests

Renal Microscopic urinalysis, proteinuria, serum BUN (blood urea nitrogen) and/or creatinine

Endocrine Serum sodium, potassium, calcium, TSH (thyroid-stimulating hormone).

Metabolic Fasting blood glucose, total cholesterol, HDL and LDL cholesterol, triglycerides

Other Hematocrit, electrocardiogram, and chest radiograph

Creatinine (renal function) testing is done to determine if kidney disease is present, which can be either the cause or
result of hypertension. In addition, it provides 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. Glucosetesting is done to determine if diabetes mellitus is
present. Electrocardiogram (EKG/ECG) testing is done to check for evidence of the heart being under strain from high
blood pressure. It may also show if there is thickening of the heart muscle (left ventricular hypertrophy) or has
experienced a prior minor heart distubance such as a silent heart attack. A chest X-ray may be performed to look for signs
of heart enlargement or damage to heart tissue.

Complications
Hypertension is the most important risk factor for death in industrialized countries.[74] It increaseshardening of the
arteries[75] thus predisposes individuals to heart disease,[76] peripheral vascular disease,[77] and strokes.[78] Types of heart
disease that may occur include: myocardial infarction,[78] heart failure,[79] and left ventricular hypertrophy[80] Other
complications include:

 Hypertensive retinopathy[81]
 Hypertensive nephropathy[82]
 If blood pressure is very high hypertensive encephalopathy may result.

MEDICAL & SURGICAL MANAGEMENT

There are three clinical indications for selecting a patient with a hemodynamically significant renal artery stenosis (RAS) for treatment.
The first is hypertension that is poorly controlled on adequate (two or three drugs) medical therapy, or in a patient intolerant of
hypertensive medications. The second is renal insufficiency, and the third is a “cardiac disturbance” syndrome, such as “flash”
pulmonary edema.
The treating physician should have a high clinical suspicion that the target RAS is causally related to the clinical symptoms. The
procedural risks, potential benefits, and alternative therapies must be considered for each patient. Generally, a RAS of <50% does not
require revascularization, while a symptomatic patient with a stenosis ?70% generally merits revascularization. Absolute criteria for
determining lesion severity have not been established; however, a systolic translesional pressure gradient of ?20 mm Hg or a mean
gradient of ?10 mm Hg is generally accepted as representing significant renal artery obstruction in symptomatic patients.
Stents are superior to balloons for both procedural success and long-term patency, due to scaffolding of the arterial lumen. The single,
randomized, controlled trial comparing stents to balloons in renovascular hypertension demonstrated procedural superiority, better
patency rates, and cost-effectiveness for primary stent placement.
Despite a uniformly high (?95%) technical success rate for renal artery stent placement, very few patients will be cured of hypertension.
However, the majority of hypertensive patients will benefit by improved blood pressure control and/or the need for fewer medications.
Patients with the highest pretreatment systolic blood pressures have the greatest decrease in systolic pressure. A multivariate logistic
regression analysis demonstrated that bilateral RAS and mean arterial pressure >110 mm Hg predicted a better blood pressure
response following stent placement.
Studies comparing the results in elderly (?75 years) versus younger (<75 years) patients or in females versus males have failed to
show any difference in response to renal stent placement. The suggestion that a high level of resistance in the segmental renal arteries
(resistance index ?80), determined by noninvasive Doppler measurement, predicted a poor response to revascularization has been
challenged by more recent data that suggested that patients with increased resistance respond favorably to renal intervention.
The benefits of renal stent placement include reperfusion of the ischemic kidney(s), resulting in a reduction in the stimulus to renin
production, which decreases angiotensin and aldosterone production, thereby decreasing peripheral arterial vasoconstriction and
intravascular volume. Improving renal perfusion enhances glomerular filtration, thus natriuresis. Finally, in patients with a solitary kidney
or bilateral RAS, the administration of angiotensin antagonists is facilitated by revascularization.