Question

hypertension

Answer 1

Hypertension (high blood pressure) is defined as having a blood pressure reading of more than 140/90 mmHg. High blood pressure is a common condition in which the long-term force of the blood against your artery walls is high enough that it may eventually cause health problems, such as heart disease.

Blood pressure is determined both by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. The more blood your heart pumps and the narrower your arteries, the higher your blood pressure.

Symptoms

Most people with high blood pressure have no signs or symptoms, even if blood pressure readings reach dangerously high levels.

A few people with high blood pressure may have headaches, shortness of breath or nosebleeds, but these signs and symptoms aren't specific and usually don't occur until high blood pressure has reached a severe or life-threatening stage.

Primary (Essential)—94%

Secondary—6%

Renal (4%)

Vascular Renal artery stenosis

Parenchymal Glomerulonephritis (acute/chronic)

Chronic pyelonephritis

Polycystic kidneys

Amyloidosis

Diabetes.

Endocrine (1%)

Acromegaly

Hyperthyroidism

Hypothyroidism

Hyperparathyroidism

Cushing’s syndrome

Conn’s syndrome

Pheochromocytoma.

Miscellaneous (1%)

Drugs

1. Steroids

Anabolic steroids

Corticosteroids

Oral contraceptive pills

2. Cyclosporine

3. Beta receptor agonists

4. Sympathomimetics (Cold remedies/Nasal drops)

5. NSAIDs.

Coarctation of aorta

Causes of Isolated Systolic Hypertension

1. Atherosclerosis (old age)

2. Coarctation of aorta

3. Severe AR

4. Thyrotoxicosis.

Factors Influencing Prognosis

I. Used for Risk Stratification

a. Levels of systolic and diastolic BP (grade I-III)

b. Men > 55 years

c. Women > 65 years

d. Smoking

e. Total cholesterol 250 mg%

f. Diabetes mellitus

g. Family history of pre-mature CVD

II. Other Factors Adversely Influencing

Prognosis

a. Reduced HDL cholesterol

b. Raised LDL cholesterol

c. Micro-albuminuria in diabetes/HT

d. Impaired glucose tolerance

e. Obesity

f. Sedentary lifestyle

g. Raised fibrinogen

h. High-risk socio-economic group

i. High risk ethnic group

j. High risk geographic region

III. Target Organ Damage (TOD)

a. LVH

b. Proteinuria or slight elevation of plasma creatinine

(1.2-2 mg%)

c. Radiological evidence of atherosclerotic plaque

(carotid, femoral, iliac, aorta)

d. Generalised or focal narrowing of retinal arteriole

IV. Associated Clinical Conditions (ACC)

a. Cerebrovascular disease (infarcts, haemorrhages,

TIA)

b. Heart disease (MI, angina, CCF, coronary revascularisation)

c. Renal disease (nephropathy, renal failure—P.

creatinine > 2 mg%)

d. Vascular disease (dissecting aneurysm, symptomatic

arterial disease)

e. Advanced hypertensive retinopathy (grade III and

IV)

Category Systolic pressure Diastolic pressure

(mm Hg) . (mm Hg)

Normal . < 120 . < 80

Pre-hypertension 120-139 80-89

Hypertension

Stage 1. 140-159 90-99

Stage 2 > 160 > 100

Isolated systolic

Hypertension. > 140 < 90

Non-Drug Therapy

1. Diet

• Weight reduction in obese and overweight patients (Aim: BMI < 25 kg/m2)

• Avoid excess salt consumption (advised to restrict salt intake to 3 to 4 gm/day; normal daily salt consumption is about 10 gm/day)

• Avoid alcohol

• Fat restriction (saturated, mono and polyunsaturated fatty acids each 10%, cholesterol less than 300 mg/day)

• Calcium, magnesium and potassium supplementation

• Fresh food preferred to processed food (as processed food has increased salt content and decreased potassium content.

2. Exercise and Relaxation

• Regular exercise programme (isotonic exercise)

• Avoid isometric exercise

• Meditation.

3. Smoking

• Smoking should be stopped as it constitutes the single most important and effective risk reduction.

Drug Therapy :

Strategy for drug therapy in hypertension

• Step-wise approach is no longer advocated

• Confirm that hypertension is present on repeated measurements

• Determine whether drug therapy is required

• Thiazide diuretic may be initiated as first line treatment, especially in the elderly (especially in those with isolated systolic hypertension)

• β-adrenoceptor antagonists can be used in combination with a thiazide especially relevant in presence of angina

• Calcium antagonists and α-blockers may be used when β-adrenoceptor antagonists are contraindicated or not tolerated

• Young hypertensive – (Renin ↑) Use beta-blockers and ACE inhibitors

• Elderly hypertensive – (Renin ↓) Use diuretics and calcium channel blockers

• Angiotensin converting enzyme inhibitors may be used where first line treatment fails, or may be used as an alternative to β-adrenoceptor antagonist or calcium antagonist

• β-blockers, calcium channel blockers and ACE inhibitors can be used individually as first line drugs

• There is an individualised approach to drug therapy

• Always select a single appropriate drug

• Start with minimal dose of drug and then titrate to achieve optimal dose

• If the drug in optimal dose does not give the desired result, in order to avoid adverse effect of that drug as a result of increasing its dose, another appropriate drug can be added to achieve the desired effect

• Treatment is life long

• In the course of treatment, 25% of mild hypertensives can become normotensives for a duration of one year or so without drugs. The patient requires frequent monitoring at this stage as the BP may rise at a later date and patient will require re-introduction of the antihypertensive drugs