Hypertension is a chronic medical
condition in which the blood pressure is elevated. It is also referred
to as high blood pressure. The word "hypertension", by
itself, normally refers to systemic, arterial hypertension.
can be classified as either essential (primary) or secondary. Essential
or primary hypertension means that no medical cause can be found
to explain the raised blood pressure. It is common. About 90-95%
of hypertension is essential hypertension. Secondary hypertension
indicates that the high blood pressure is a result of another condition,
such as kidney disease or tumors.
Essential hypertension is the form of hypertension that by definition
has no identifiable cause.
It is the more common type and affects 90-95% of hypertensive
patients and even though there are no direct causes, there are
many risk factors such as sedentary lifestyle, obesity etc.
Salt sensitivity, alcohol intake and vitamin D deficiency.
It is also related to aging and to some inherited genetic mutations.
Family history increases the risk of developing hypertension.
Renin elevation is another risk factor.
Insulin resistance which is a component of syndrome X, or the
metabolic syndrome is also thought to cause hypertension.
low birth weight has been questioned as a risk factor for adult
Secondary hypertension by definition results from an identifiable
cause. This type is important to recognize since it's treated
differently than essential type by treating the underlying cause.
Many secondary causes can cause hypertension; some are common
and well recognized secondary causes such as Cushing's syndrome,
which is a condition where both adrenal glands can overproduce
More than 80% of patients with Cushing's syndrome have hypertension.
Another important cause is the congenital abnormality coarctation
of the aorta. The symptoms are obesity, sweating and anxiety.
Hypertension results from the interplay of several pathophysiological
mechanisms regulating plasma volume, peripheral vascular resistance
and cardiac output, all of which may be increased.
A variety of adrenal cortical abnormalities can cause hypertension,
in primary aldosteronism there is a clear relationship between
the aldosterone-induced sodium retention and the hypertension.
Other well known causes include diseases of the kidney. This
includes diseases such as polycystic kidney disease which is
a cystic genetic disorder of the kidneys
Neuroendocrine tumors are also a well known cause of secondary
medications, especially NSAIDs (Motrin/Ibuprofen) and steroids
can cause hypertension. High blood pressure that is associated
with the sudden withdrawal of various antihypertensive medications
is called rebound hypertension.
Few women of childbearing age have high blood pressure; up to
11% develop hypertension of pregnancy.
common and under-recognized sign of hypertension is sleep apnea,
Because of the presence of arsenic in ground water supplies
and its effect on cardiovascular health, low dose arsenic poisoning
should be considered as a part of the pathogenesis of idiopathic
Arsenic exposure has also many of the same signs of primary
hypertension such as headache, confusion, proteinuria, visual
disturbances, nausea and vomiting.
Due to the role of intracellular potassium in regulation of
cellular pressures related to sodium, establishing potassium
balance has been shown to reverse hypertension.
Signs and symptoms
to moderate essential hypertension is usually asymptomatic.
Accelerated hypertension is associated with headache, somnolence,
confusion, visual disturbances and nausea and vomiting.
Retina is affected with narrowing of arterial diameter to less
than 50% of venous diameter,
Some signs and symptoms are especially important in infants
and neonates such as failure to thrive, seizure, irritability
or lethargy and respiratory distress.
In children hypertension may cause headache, fatigue, blurred
vision, epistaxis and bell palsy.
Some signs and symptoms are especially important in suggesting
a secondary medical cause of chronic hypertension, such as centripetal
In hyperthyroidism there may be weight loss, tremor, tachycardia
, palmer erythema and sweating.
Signs and symptoms associated with growth hormone excess such
as coarsening of facial features, prognathism, macroglossia,
hypertrichosis, hyperpigmentation and hyperhidrosis may occur
in these patients.
The typical attack lasts from minutes to hours and is associated
with headache, anxiety, palpitation, profuse perspiration, pallor,
tremor and nausea and vomiting. Blood pressure is markedly elevated.
Signs and symptoms associated with pre-eclampsia and eclampsia,
can be proteinuria, edema and hallmark of eclampsia which is
convulsions, Other cerebral signs may precede the convulsion
such as nausea, vomiting, headaches and blindness.
High blood pressure that is associated with the sudden withdrawal
of various antihypertensive medications is called rebound hypertension.
Initial assessment of the hypertensive patient should include
a complete history and physical examination to confirm a diagnosis
of hypertension. Most patients with hypertension have no specific
symptoms referable to their blood pressure elevation. Although
popularly considered a symptom of elevated arterial pressure,
headache generally occurs only in patients with severe hypertension.
Characteristically, a "hypertensive headache" occurs
in the morning and is localized to the occipital region. Other
non specific symptoms that may be related to elevated blood
pressure include dizziness, palpitations, easy fatigability
of hypertension is generally on the basis of a persistently
high blood pressure. Usually this requires three separate measurements
at least one week apart. Exceptionally, if the elevation is
extreme, or end-organ damage is present then the diagnosis may
be applied and treatment commenced immediately.
When taking manual measurements, the person taking the measurement
should be careful to inflate the cuff suitably above anticipated
Tests are undertaken to identify possible causes of secondary
hypertension and seek evidence for end-organ damage to the
heart itself or the eyes (retina) and kidneys. Diabetes and
raised cholesterol levels being additional risk factors for
the development of cardiovascular disease are also tested for
as they will also require management. Tests are performed e.g.
urinalysis, Creatitine, electrolytes, TSH, Lipid Profile etc.
changes such as the DASH (Dietary Approaches to Stop Hypertension)
diet, physical exercise and weight loss have been shown to significantly
reduced blood pressure in people with high blood pressure. If
hypertension is high enough to justify immediate use of medications,
lifestyle changes are initiated concomitantly.
A series of UK guidelines advocate treatment initiation thresholds
and desirable targets to be reached. Of particular note is that
for patients with blood pressures between 140-159/80-99 and
without additional factors, that only lifestyle action and regular
blood pressure and risk-factor review is proposed.
There are many classes of medications for treating hypertension,
together called antihypertensive, which act by lowering blood
pressure. Evidence suggests that reduction of the blood pressure
by 5–6 mmHg can decrease the risk of stroke by 40%, of
coronary heart disease by 15–20% and reduces the likelihood
of dementia, heart failure and mortality from vascular disease.
The aim of treatment should be blood pressure control to <140/90
mmHg for most patients and lower in certain contexts such as
diabetes or kidney disease (some medical professionals recommend
keeping levels below 120/80 mmHg). Each added drug may reduce
the systolic blood pressure by 5–10 mmHg, so often multiple
drugs are often necessary to achieve blood pressure control.
mild blood pressure elevation, consensus guidelines call for
medically-supervised lifestyle changes and observation before
recommending initiation of drug therapy. However, according
to the American Hypertension Association, evidence of sustained
damage to the body may be present even prior to observed elevation
of blood pressure. Therefore the use of hypertensive medications
may be started in individuals with apparent normal blood pressures
but who show evidence of hypertension related nephropathy, proteinuria,
atherosclerotic vascular disease, as well as other evidence
of hypertension related organ damage.
If lifestyle changes are ineffective, then drug therapy is initiated,
often requiring more than one agent to effectively lower hypertension.
Which type of many medications should be used initially for
hypertension has been the subject of several large studies and
various national guidelines.