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Dx Hypertension Treatment:

High Blood Pressure

The Merck Manual Home Edition
"High blood pressure (hypertension) is abnormally high pressure in the arteries.
*Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying disorder of the kidneys or a hormonal disorder.
*Obesity, a sedentary lifestyle, stress, smoking, and excessive amounts of alcohol or salt in the diet all can play a role in the development of high blood pressure in people who have an inherited tendency to develop it.
*In most people, high blood pressure causes no symptoms.
*Doctors make the diagnosis after measuring blood pressure on two or more occasions.
*People are advised to lose weight, stop smoking, and decrease the amounts of salt and fats in their diets.
*Antihypertensive drugs are given.

To many people, the word hypertension suggests excessive tension, nervousness, or stress. In medical terms, hypertension refers to high blood pressure, regardless of the cause. Because it usually does not cause symptoms for many years—until a vital organ is damaged—it has been called "the silent killer." Uncontrolled high blood pressure increases the risk of problems such as stroke, aneurysm, heart failure, heart attack, and kidney damage.

About 72 million Americans are estimated to have high blood pressure. High blood pressure occurs more often in blacks—in 41% of black adults compared with 28% of whites and 28% of Mexican Americans. It also occurs with high frequency in people whose ancestors are from China, Japan, and other East Asian or Pacific areas (such as Koreans,Thais, Polynesians, Micronesians, Filipinos, and Maori). The consequences of high blood pressure are worse for blacks. High blood pressure occurs more often in older people—in about two thirds of people aged 65 or older, compared with only about one fourth of people aged 20 to 74. People who have normal blood pressure at age 55 have a 90% risk of developing high blood pressure at some point in their life. High blood pressure is twice as common among people who are obese as among those who are not.

In the United States, only an estimated 81% of people with high blood pressure have been diagnosed. Of people with a diagnosis of high blood pressure, about 73% receive treatment, and of the people receiving treatment, about 51% have adequately controlled blood pressure.

Spotlight on Aging
Changes due to aging may contribute to primary hypertension. As people age, large arteries gradually stiffen and small arteries may become partially blocked. Some experts think that this stiffening combined with the narrowing of small arteries may partly explain why blood pressure increases as people age.

When blood pressure is checked, two values are recorded. The higher value reflects the highest pressure in the arteries, which is reached when the heart contracts (during systole). The lower value reflects the lowest pressure in the arteries, which is reached just before the heart begins to contract again (during diastole). Blood pressure is written as systolic pressure/diastolic pressure—for example, 120/80 mm Hg (millimeters of mercury). This reading is referred to as "120 over 80."

High blood pressure is defined as a systolic pressure at rest that averages 140 mm Hg or more, a diastolic pressure at rest that averages 90 mm Hg or more, or both. However, the higher the blood pressure, the greater the risk of complications—even within the normal blood pressure range—so these limits are somewhat arbitrary. In most young people with high blood pressure, both systolic and diastolic pressures are high. In contrast, many older people with high blood pressure have high systolic pressure (140 mm Hg or more) with normal or low diastolic pressure (less than 90 mm Hg). This disorder is called isolated systolic hypertension.

A hypertensive urgency is blood pressure that is more than 180/120 mm Hg but has not yet caused any organ damage that is apparent to people or their doctors. A hypertensive urgency usually does not cause symptoms.

A hypertensive emergency is a particularly severe form of high blood pressure. Blood pressure is at least 180/120 mm Hg, and there is evidence of progressive damage in one or more vital organs (typically the brain, heart, and kidneys), often accompanied by a variety of symptoms. Hypertensive emergencies are uncommon, but they are several times more common among blacks than among whites, among men than among women, and among people in lower socioeconomic groups than among those in higher socioeconomic groups. If untreated, a hypertensive emergency can be fatal.

The Body's Control of Blood Pressure The body has many mechanisms to control blood pressure: The body can change the amount of blood the heart pumps, the diameter of arteries, and the volume of blood in the bloodstream. To increase blood pressure, the heart can pump more blood by pumping more forcefully or more rapidly. Small arteries (arterioles) can narrow (constrict), forcing the blood from each heartbeat through a narrower space than normal. Because the space in the arteries is narrower, the same amount of blood passing through them increases the blood pressure. Veins can constrict to reduce their capacity to hold blood, forcing more blood into the arteries. As a result, blood pressure increases. Fluid can be added to the bloodstream to increase blood volume and thus increase blood pressure. Conversely, to decrease blood pressure, the heart can pump less forcefully or rapidly, arterioles and veins can widen (dilate), and fluid can be removed from the bloodstream.

These mechanisms are controlled by the sympathetic division of the autonomic nervous system (the part of the nervous system that regulates internal body processes requiring no conscious effort) and by the kidneys. The sympathetic division uses several means to temporarily increase blood pressure during the fight-or-flight response (the body's physical reaction to a threat). The sympathetic division stimulates the adrenal glands to release the hormones epinephrine (adrenaline) and norepinephrine (noradrenaline). These hormones stimulate the heart to beat faster and more forcefully, most arterioles to constrict, and some arterioles to dilate. The arterioles that dilate are those in areas where an increased blood supply is needed (such as in skeletal muscle—the muscles controlled by conscious effort). The sympathetic division also stimulates the kidneys to decrease their excretion of salt (sodium) and water, thereby increasing blood volume. The body controls the movement of salt in and out of cells, to prevent an excess of salt inside cells. Excessive amounts of salt inside cells can cause the body to become overly sensitive to stimulation by the sympathetic division.

The kidneys also respond directly to changes in blood pressure. If blood pressure increases, the kidneys increase their excretion of salt and water, so that blood volume decreases and blood pressure returns to normal. Conversely, if blood pressure decreases, the kidneys decrease their excretion of salt and water, so that blood volume increases and blood pressure returns to normal. The kidneys can increase blood pressure by secreting the enzyme renin, which eventually results in the production of the hormone angiotensin II. Angiotensin II helps increase blood pressure by causing the arterioles to constrict, by triggering the sympathetic division of the autonomic nervous system, and by triggering the release of two other hormones, aldosterone and antidiuretic hormone (also called vasopressin), which cause the kidneys to increase the retention of salt and water. The kidneys normally produce substances that cause arterioles within the kidney to dilate. This helps balance the effects of hormones that cause constriction of arterioles.

Primary hypertension
High blood pressure with no known cause is called primary (formerly called essential) hypertension. Between 85% and 95% of people with high blood pressure have primary hypertension. Several changes in the heart and blood vessels probably combine to increase blood pressure. For instance, the amount of blood pumped per minute (cardiac output) may be increased, and the resistance to blood flow may be increased because blood vessels are constricted. Blood volume may be increased also. The reasons for such changes are not fully understood but appear to involve an inherited abnormality affecting the constriction of arterioles, which help control blood pressure. Other changes may contribute to increases in blood pressure, including accumulation of excessive amounts of salt inside cells and decreased production of substances that dilate arterioles.

Secondary hypertension:
High blood pressure with a known cause is called secondary hypertension. Between 5% and 15% of people with high blood pressure have secondary hypertension. In many of these people, high blood pressure results from a kidney disorder. Many kidney disorders can cause high blood pressure because the kidneys are important in controlling blood pressure. For example, damage to the kidneys from inflammation or other disorders may impair their ability to remove enough salt and water from the body, increasing blood volume and blood pressure. Other kidney disorders that cause high blood pressure include renal artery stenosis (narrowing of the artery supplying one of the kidneys), which may be due to atherosclerosis, injury, or other disorders.

In a few people, secondary hypertension is caused by another disorder, such as a hormonal disorder, or by the use of certain drugs, such as birth control pills (oral contraceptives). Hormonal disorders that cause high blood pressure include Cushing syndrome (a disorder characterized by high levels of cortisol), hyperthyroidism (an overactive thyroid gland), hyperaldosteronism (overproduction of aldosterone, often by a tumor in one of the adrenal glands), and, rarely, a pheochromocytoma (a tumor that is located in an adrenal gland and that produces the hormones epinephrine and norepinephrine). Severe hyperthyroidism can also cause systolic hypertension.

Arteriosclerosis interferes with the body's control of blood pressure, increasing the risk of high blood pressure. Arteriosclerosis makes arteries stiff, preventing the dilation that would otherwise return blood pressure to normal.

Aggravating factors:
Obesity, a sedentary lifestyle, stress, smoking, and excessive amounts of alcohol or salt in the diet all can play a role in the development of high blood pressure in people who have an inherited tendency to develop it. Stress tends to cause blood pressure to increase temporarily, but blood pressure usually returns to normal once the stress is over. An example is "white coat hypertension," in which the stress of visiting a doctor's office causes blood pressure to increase enough to be diagnosed as high blood pressure in someone who has normal blood pressure at other times. In susceptible people, these brief increases in blood pressure are thought to cause damage that eventually results in permanent high blood pressure, even when no stress is present. This theory has not been proved.

In most people, high blood pressure causes no symptoms, despite the coincidental occurrence of certain symptoms that are widely, but erroneously, attributed to high blood pressure: headaches, nosebleeds, dizziness, a flushed face, and fatigue. People with high blood pressure may have these symptoms, but the symptoms occur just as frequently in people with normal blood pressure.

Severe or long-standing high blood pressure that is untreated can cause symptoms because it can damage the brain, eyes, heart, and kidneys. Symptoms include headache, fatigue, nausea, vomiting, shortness of breath, and restlessness. Occasionally, severe high blood pressure causes the brain to swell, resulting in nausea, vomiting, worsening headache, drowsiness, confusion, seizures, sleepiness, and even coma. This condition is called hypertensive encephalopathy. Severe high blood pressure increases the workload of the heart and may cause chest pain and/or shortness of breath. Sometimes very high blood pressure causes the large artery that carries blood from the heart (the aorta) to tear, causing chest or abdominal pain. People who have such symptoms have hypertensive emergencies and, as such, require emergency treatment.

If high blood pressure is due to a pheochromocytoma, symptoms may include severe headache, anxiety, an awareness of a rapid or irregular heart rate (palpitations), excessive perspiration, tremor, and paleness. These symptoms result from high levels of the hormones epinephrine and norepinephrine, which are secreted by the pheochromocytoma.

*Certain symptoms, such as headaches, nosebleeds, dizziness, a flushed face, and fatigue, are commonly attributed to high blood pressure but actually occur equally often in people who do not have high blood pressure.

Long-standing high blood pressure can damage the heart and blood vessels.

When pressure in the arteries is increased above 140/90 mm Hg, the heart enlarges and the heart's walls thicken because the heart has to work harder to pump blood. The thickened walls are stiffer than normal. Consequently, the heart's chambers do not expand normally and are harder to fill with blood, further increasing the heart's workload. These changes in the heart may result in abnormal heart rhythms and heart failure. High blood pressure causes thickening of the walls of blood vessels and also makes them more likely to develop hardening of the arteries (atherosclerosis). When these things have occurred, people are at risk of stroke, heart attack, and kidney failure.

Blood pressure is measured after a person sits or lies down for 5 minutes. It should be measured again after the person stands for a few minutes, especially if the person is older or has diabetes. A reading of 140/90 mm Hg or more is considered high, but a diagnosis cannot be based on a single high reading. Sometimes, even several high readings are not enough to make the diagnosis—because, for example, the readings may vary too much. If a person has an initial high reading, blood pressure is measured again during the same visit and then measured twice on at least two other days to make sure that the high blood pressure persists.

If there is still doubt, a 24-hour blood pressure monitor may be used. It is a portable battery-operated device, worn on the hip, connected to a blood pressure cuff, worn on the arm. This monitor repeatedly records blood pressure throughout the day and night over a 24-hour or 48-hour period. The readings determine not only whether high blood pressure is present but also how severe it is. In people with very stiff arteries (most commonly, in older people), blood pressure may be measured as high when it is not. This phenomenon is called pseudohypertension. It occurs when the artery in the arm is too stiff to be compressed by the blood pressure cuff, and as a result, blood pressure cannot be measured accurately.

After high blood pressure has been diagnosed, its effects on key organs, especially the blood vessels, heart, brain, eyes, and kidneys, are usually evaluated. Doctors also look for the cause of high blood pressure. The number and type of tests that are done to look for organ damage and to determine the cause of high blood pressure vary from person to person. In general, routine evaluation for all people with high blood pressure involves a medical history, a physical examination, electrocardiography (ECG), blood tests (including the hematocrit level [the portion of total blood volume made up of red blood cells], potassium and sodium levels, and tests of kidney function), and urine tests.

The physical examination includes checking the area of the abdomen over the kidneys for tenderness and placing a stethoscope over the abdomen to listen for a bruit (the sound caused by blood rushing through a narrowed artery) in the artery supplying each kidney.

The retina in each eye is examined with an ophthalmoscope (see see What Is an Ophthalmoscope. The retina is the only place doctors can directly view the effects of high blood pressure on arterioles. The assumption is that the changes in the arterioles of the retina are similar to changes in arterioles and other blood vessels elsewhere in the body, such as in the kidneys. By determining the degree of damage to the retina (retinopathy—see see Hypertensive Retinopathy), doctors can classify the severity of high blood pressure.

A stethoscope is used to detect heart sounds. An abnormal heart sound, called the fourth heart sound, is one of the earliest changes in the heart caused by high blood pressure. This sound develops because the left atrium of the heart has to contract harder to fill the enlarged, stiff left ventricle, which pumps blood to all of the body except the lungs.

Electrocardiography is usually done to detect changes in the heart—particularly thickening (hypertrophy) of the heart muscle or heart enlargement. If enlargement is suspected, the person may undergo echocardiography.

Kidney damage can be detected by urine and blood tests. Urine tests can detect early evidence of kidney damage. The presence of blood cells and albumin (the most abundant protein in blood) in the urine may indicate such damage. Symptoms of kidney damage (such as lethargy, poor appetite, and fatigue) do not usually develop until 70 to 80% of kidney function is lost.

Diagnosis of cause:
The higher the blood pressure and the younger the person, the more extensive the search for a cause is likely to be, even though a cause is identified in less than 10% of people. A more extensive evaluation may include x-ray, ultrasonography, and radionuclide imaging of the kidneys and their blood supply as well as a chest x-ray. Blood and urine tests are done to measure the levels of certain hormones, such as epinephrine, aldosterone, and cortisol.

The cause may be suggested by abnormal results of a physical examination or by the symptoms. For example, a bruit in the artery to a kidney may suggest renal artery stenosis (narrowing of the artery supplying a kidney). Various combinations of symptoms may suggest high levels of the hormones epinephrine and norepinephrine produced by a pheochromocytoma. The presence of a pheochromocytoma is confirmed when the breakdown products of these hormones are detected in the urine. Other rare causes of high blood pressure may be detected by certain routine tests. For example, measuring the potassium level in the blood can help detect hyperaldosteronism.

Treatment of secondary hypertension:
The cause of the high blood pressure is treated if possible. Treating kidney disease can sometimes return blood pressure to normal or at least lower it, so that antihypertensive therapy is more effective. A narrowed artery to the kidney may be dilated by inserting a balloon-tipped catheter and inflating the balloon. Or the narrowed part of the artery supplying the kidney can be bypassed. Often such surgery cures high blood pressure. Tumors that cause high blood pressure, such as a pheochromocytoma, usually can be removed surgically (see see Pheochromocytoma). If people still have high blood pressure despite taking three different drugs, doctors sometime insert a catheter into the artery to each kidney. The catheter produces radio waves that destroy the sympathetic nerves along the renal arteries, which often lowers blood pressure.

Treatment of hypertensive urgencies and emergencies:
In hypertensive emergencies, blood pressure must be lowered rapidly. Hypertensive emergencies are treated in hospital intensive care units. Most drugs used to rapidly lower blood pressure, such as fenoldopam, nitroprusside, nicardipine, or labetalol, are given intravenously.

Untreated high blood pressure increases a person's risk of developing heart disease (such as heart failure, heart attack, or sudden cardiac death), kidney failure, or stroke at an early age. High blood pressure is the most important risk factor for stroke. It is also one of the three most important risk factors for heart attack that a person can modify (the other two are smoking and high cholesterol levels in the blood).

Treatment that lowers high blood pressure greatly decreases the risk of stroke and heart failure. Such treatment may also decrease the risk of a heart attack, although not as dramatically.

Old Classifying Blood Pressure
Normal less than 120 systolic less than 80 diastolic
Prehypertension 130 90
Hypertensive: more than 130 less than 90
Stage 2 hypertension more than 160 above 100

New Guideline for Treatment of High Blood Pressure in Adults
JAMA February 5, 2014

If younger than 60,TREAT Systolic greater than 140mm Hg or Diasytolic greater than 90mm Hg
If older than 60,     TREAT Systolic greater than 150mm Hg or Diastolic greater than 90
If chronic kidney disease or diabetes at any age, treat Systolic greater than 140mm Hg or Diastolic greater than 90

Medications Used in Treatment:
1. ACE Inhibitors: Zestril® Prinivil®/lisinopril, Univasc®/moexipril, Mavik®/trandolapril Vaseretic®/enalapril-hctz, Lotensin®/benazepril, Vasotec®/enalapril
2. Calcium Channel Blockers: Norvasc®/amlodipine, Tiazac®, Vaseretic®/enalapril-hctz/diltzac, Cardizem®LA/diltiazem ER, Calan®SR
3. Thiazide Diiuretics: Microzide®/hydrochlorothiazide, Diuril®/chlorothiazide,methylclothiazide
4. Beta Blockers: Lopressor® Toprol®XL/metoprolol, Tenormin®/ atenolol, Bystolic®/nebivolol,
5. ARBs: Cozaar®/losartan, Diovan®/valsartan, Avapro®/irbesartan, Benicar®/olmesartan, Micardis®/telmisartan
6. Loop Diuretics: Lasix®/furosemide, Demadex®/torsemide 7. Combinations: Zestoretic®/lisinopril-hctz, Dyazide® Maxide®/ tramterene-hctz,Hyzaar®/losartan-hctz
8. Central Alpha Agonists: Catapres®Tts/clonidine, Tenex®/guanfacine, methyldopa, methyldopa-hctz, guanabenz
9. Aldosterone Antagonists: Aldactone®/spirolactone, Inspra®/eplerenone, Aldactazide®/spirolactone-hctz
10. Alpha Blocker: Cardura®/doxazosin, Cardura®SL/doxazosin terazosin,Minipress®/prazosin, dibenzyline,
11. Thiazide-like diuretic: chlorthalidone, indapamide®, Zaroxolyn®/metolazone, Thalitone®/chlorthalidone,
11. Arteriolar Vasodilators: hydralazine, minoxidil
12. Renin Inhibitors: Tekturna®/aliskiren, Tekturna®HCT, Tekamlo®/ aliskiren-amlodipine, Valturna®/alikiren-valsartan
13. Potassium sparing diuretic: Midamor®amiloride
14. Catecholamine Depletors: reserpine

Suggested Links:
*N.H.S. Choices (with Video)

*[Editor] Twynstar (almopidine and valsartan) is better than Azor (amlopidine and olmesartan) in controlling blood pressure. It is also less than half as expenseive.

*[Editor] A large Chinese study correlated vitamin D deficiency with high blood pressure in men, but not women. Hypertension is more common in the darker races living in the non-tropics: the vitamin D deficiency is linked to lower production due to decreased sun exposure. Supplementation of vitamin D to physiologic levels (80-100ng/ml) may be a non-pharmaceutical anti-hypertensive agent.

*[Editor] The use of amiloride 5mg and spirolactone 25mg has been shown to lower systolic blood pressure by 4.6mm mm Hg and the diastolic by 2.2 mm Hg in a comprehensive study. With alternative treatments (diet, Vitamin D3 10,000IU and daily morning exercise), this may be an effective alternative initial prescription medication with less side effects.

* [Editor Obstructive sleep apnea present with snoring, and although they can present with daytime sleepiness the majority have no daytime symptoms....They are often[present with] obesity,... hypertension, depression and diabetes. Continuous positive airway pressure (CPAP) os the first-line therapy: [Editor:blood pressure may lower or return to normal].

*[Editor] While low testosterone has been linked to increased blood pressure, the use of testosterone replacement in men may lower blood pressure (although not proven) as well as lowering triglyceride levels

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