Hypertension Disease

BASICS

DESCRIPTION

Hypertension is defined as a sustained elevated blood pressure (systolic blood pressure of 140 mm Hg or greater and/or diastolic blood pressure of 90 mm Hg or greater). Also conceptually includes the blood pressure level at which the benefits of action exceed those of inaction. Hypertension is a strong risk factor for cardiovascular disease.

System(s) affected: Cardiovascular
Genetics: Blood pressure levels are strongly familial but no clear genetic pattern has been discerned. The strong familial risk for cardiovascular diseases should be concomitantly considered.
Incidence/Prevalence in USA: 50 million (1988-1991 NHANES III); 20% of the U.S. population
Predominant age: Essential (primary, benign, idiopathic) hypertension usually has its onset in the 20's to 30's
Predominant sex: Males > Females (males tend to run higher pressures than females but more importantly have a significantly higher risk of cardiovascular disease at any given blood pressure)

SIGNS AND SYMPTOMS

Hypertension should be considered asymptomatic except in extremes or after related cardiovascular complications develop
Headache can be seen especially with higher blood pressures. This is often present on awakening and occipital in nature.
Retinopathy - narrowed arteries, AV nicking, copper or silver wiring of retinal arterioles
Increased A2 heart sound

CAUSES

Over 90% of hypertension has no identified cause. These can be labeled essential or primary hypertension.
Secondary causes of hypertension include four areas:
Renal parenchymal
- Glomerulonephritis
- Pyelonephritis
- Polycystic kidneys
Endocrine
- Primary hyperaldosteronism
- Pheochromocytoma
- Hyperthyroidism
- Cushing's syndrome
Vascular
- Coarctation
- Renal artery stenosis
Chemical
- Oral contraceptives
- NSAIDs
- Decongestants
- Antidepressants
- Sympathomimetics
- Many industrial chemicals
- Corticosteroids
- Ergotamine alkaloids
- Lithium
- Cyclosporine

RISK FACTORS

Family history
Obesity
Alcohol
Excess dietary sodium
Stress
Physical inactivity

DIAGNOSIS

LABORATORY

Hemoglobin and hematocrit or CBC
Complete urinalysis (sometimes reveals proteinuria)
Potassium, calcium and creatinine
Cholesterol (total and HDL)
Fasting blood glucose
Uric acid

Drugs that may alter lab results: Numerous drugs and foods interfere with catecholamine measurements in considering pheochromocytoma
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Late complications include
- Stroke
- Retinal vascular narrowing, hemorrhages, exudates, papilledema
- Left ventricular hypertrophy
- Congestive heart failure
- Ischemic heart disease
- Proteinuria and nephrosclerosis

SPECIAL TESTS

Only if history, physical or lab indicates
- IVP and renal arteriogram
- Plasma catecholamines, urinary metanephrines/vanillylmandelic acid
- Plasma renin
- Aortogram
- ECG

IMAGING

If history or physical indicate
- Chest x-ray
- Ultrasonography
- IVP
- Provocative renal nuclear scans (e.g., captopril renogram)
- Digital subtraction arteriography
- Angiogram

DIAGNOSTIC PROCEDURES

Renal biopsy if renal parenchymal disease is suspected
A presumptive diagnosis of hypertension can be made if the average of at least three blood pressure measurements exceeds either 90 mm Hg diastolic or 160 mm Hg systolic, assuming proper resting conditions, cuff size and application are maintained
The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC) recommends a good history and physical exam with emphasis on:
- Family history of hypertension and cardiovascular disease
- Personal past history of cardiovascular, cerebrovascular and renal disease as well as diabetes
- Previous elevated blood pressures
- Previous treatments
- History of weight gain, exercise activities, sodium intake, fat intake and alcohol use
- Symptoms suggesting secondary hypertension
- Psychosocial and environmental factors affecting blood pressure
- Other cardiovascular risk factors such as obesity, smoking, hyperlipidemia, and diabetes
- Funduscopic exam for arteriolar narrowing, arteriovenous compression, hemorrhages, exudates, and papilledema
- Complete cardiac and peripheral pulse exam. Compare radial and femoral pulse for differences in volume and timing.
- Abdominal exam for masses and bruits. Listen high in the flanks over the kidneys.

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient

GENERAL MEASURES

Individualize goal blood pressures based on risk factors but generally treat to diastolic < 90 mm Hg (< 12 kPa) and systolic < 160 mm Hg (< 21.3 kPa)
Weight reduction for obese patients may lower blood pressures
Smoking cessation is an important part of a cardiovascular risk reduction program
Biofeedback and relaxation exercises reduce blood pressure
Risk stratification affects treatment:
- High normal (130-139/85-89) - drug therapy only for diabetics, existing cardiovascular disease, or target organ disease
- Stage 1 (140-159/90-99) - drug therapy after 6 months with one other cardiovascular risk factor
- Stage 2 and 3 (≥160/≥100) - drug therapy

SURGICAL MEASURES

N/A

ACTIVITY

Normal activity with an appropriate aerobic fitness program

DIET

Some patients will respond to a reduced salt diet
Reduce alcohol consumption to < 1 oz/day
Decrease saturated fats and increase monounsaturated fats
Consider potassium and calcium, although absolute effect uncertain

PATIENT EDUCATION

Emphasize asymptomatic nature of hypertension and importance of lifetime treatment
Review risk factors for cardiovascular disease with emphasis on comprehensive preventive program
Printed Aids for High Blood Pressure Education, NIH Publication No. 301-251-1222

FOLLOW UP

PREVENTION/AVOIDANCE

Diet, exercise, reduce stress, stop smoking, little or no alcohol, compliance in taking medications

POSSIBLE COMPLICATIONS

Congestive heart failure
Renal failure
Myocardial infarction
Stroke
Hypertensive heart disease

EXPECTED COURSE AND PROGNOSIS

Good with adequate control

MISCELLANEOUS

ASSOCIATED CONDITIONS

See list in Causes

AGE-RELATED FACTORS

Pediatric:

Blood pressure should be measured during routine examinations
Hypertension can accompany a wide variety of acute and chronic illnesses in this age group

Geriatric: Isolated systolic hypertension more common in this group. Therapy has been shown to be effective although adverse reactions to medications are more frequent.
Others: N/A

PREGNANCY

Elevated blood pressures during pregnancy may be either chronic hypertension or pregnancy induced preeclampsia. Maternal and fetal mortality benefit from treatment. See topic on preeclampsia. Some medications may adversely affect the fetus.

OTHER NOTES

N/A

ABBREVIATIONS

SR = sustained release

Clinical Investigations

ROLE OF HOMOEOPATHY

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