HYPERTEN

SION
DR SREELAKSHMI S
• Hypertension, also known as high or raised blood pressure, is a
condition in which the blood vessels have persistently raised
pressure.

• Blood is carried from the heart to all parts of the body in the
vessels. Each time the heart beats, it pumps blood into the vessels.
Blood pressure is created by the force of blood pushing against the
walls of blood vessels (arteries) as it is pumped by the the heart.
• The higher the pressure, the heart has to pump harder.
Hypertension is a chronic condition of concern
due to its role in the causation of coronary heart
disease, stroke and other vascular
complications.

• It is the commonest cardiovascular disorder,

posing a major public health challenge to
population in socio-economic and
epidemiological transition.
• It is one of the major risk factors for
cardiovascular mortality, which accounts for
20-50 per cent of all deaths.
• Definition of hypertension is difficult and, by necessity arbitrary.

• Sir George Peckering first fomulated a concept that blood pressure

in a population is distributed continuously as a bell-shaped curve
with no real separation between normotension and hypertension .
• There is also a direct relation between cardiovascular risk and
blood pressure: the higher the blood pressure, the higher the risk
of both stroke and coronary events.
• As a consequence, the dividing line between normal and high
blood pressure can be defined only in an operational way.
• When systolic and diastolic blood pressure fall into different categories, the higher
category should be selected to classify the individual’s blood pressure.
• “Isolated systolic hypertension is defined as a systolic blood pressure of 140 mm
of Hg or more and a diastolic blood pressure of less than 90 mm of Hg.
Blood pressure measurement
• Accurate measurements are essential under standardized conditions for valid
comparison between persons or groups over time.
• Three sources of errors have been identified in the recording of blood pressure:
(a) Observer errors: e.g.. Hearing acuity, interpretation of Korotkow sounds.
(b) Instrumental errors: e.g., leaking valve, cuffs that do not encircle the arm. If
the cuff is too small and fails to encircle the arm properly then too high a reading will
be obtained; and
(c) Subject errors: e.g., the circumstances of examination. These include the
physical environment, the position of the subject, external stimuli such as fear,
anxiety and so on.
Classification of blood pressure measurement
A few salient points need be mentioned about measuring blood pressure.
• A WHO Study recommended the sitting position than the supine
position for recording blood pressure.
• In any clinic a uniform policy should be adopted, using either the right
or left arm consistently.
• The pressure at which the sounds are first heard (phase I) is taken to
indicate the systolic pressure. Near the diastolic pressure the sounds
first become muffled (phase IV) and then disappear (phase V). Most of
the studies have used phase V to measure diastolic blood pressure.
• The systolic and diastolic pressures should be measured at least three
times over a period of at least 3 minutes and the lowest reading
recorded.
Classification
Hypertension is divided into primary (essential) and secondary.
1. Essential hypertension-Hypertension is classified as “essential” when
the causes are generally unknown. It is the most prevalent form of
hypertension accounting for 90 per cent of all cases of hypertension.
2. Secondary hypertension - Hypertension is classified as “secondary”
when some other disease process or abnormality is involved in its
causation. Prominent among these are diseases of kidney (chronic
glomerulo-nephritis and chronic pyelonephritis), tumours of the adrenal
glands, congenital narrowing of the aorta and toxemias of pregnancy.
Altogether, these are estimated to account for about 10 per cent or less of
the cases of hypertension.
“Rule of halves”
Hypertension is an “iceberg” disease.
• It became evident in the early 1970s that only about half
of the hypertensive subjects in the general population of
most developed countries were aware of the condition,
only about half of those aware of the problem were being
treated, and only about half of those treated were
considered adequately treated .
• If this was the situation in countries with highly developed
medical services, in the developing countries, the
proportion treated would be far too less.
INCIDENCE: The concept of incidence has limited value in hypertension because of
the variability of consecutive readings in individuals, ambiguity of what is “normal” blood
pressure and the insidious nature of the condition .

PREVALENCE:
The global prevalence of hypertension was estimated to
be 1.13 billion in 2015. The overall prevalence of
hypertension in adults is around 30-40 per cent, with a
global age standardized prevalence of 24 and 20 per cent
in men and women respectively. This high prevalence of
hypertension across the world is irrespective of income
status i.e., in lower, middle and higher income countries.
• Hypertension becomes progressively more common with
advancing age, with a prevalence of >60 per cent in people aged
>60 years.
• As populations age, they adopt more sedentary life styles and
increase in their body weight.
• It is estimated that the number of people with hypertension will
increase by 15-20 per cent by year 2025 .
• Elevated blood pressure is a leading cause of premature death in
2015, accounting to almost 10 million deaths.
• Systolic blood pressure greater than or equal to 140 mmHg
accounts for most of the mortality and disability burden. The
largest number of systolic blood pressure related deaths per year
are due to IHD (4.9 million), haemorrhagic stroke (2 million) and
ischaemic stroke (1.5 million) .
Prevalence in India
In the year 2015-2016, National Family Health
Survey-4 measured blood pressure in women
and men aged 15-49 years.
• The criteria of high blood pressure was systolic blood pressure greater
than or equal to 140 mmHg and diastolic blood pressure greater than or
equal to 90 mmHg, or that individual is currently taking antihypertensive
medicine.
• Based on the measurement during the survey, 11 per cent of women
were having hypertension, 61 per cent of women were having blood
pressure within normal limits, almost 30 per cent were prehypertensive
and 1 percent were taking anyi hypertensives.
The prevalence of hypertension among men aged 15-49 years was
somewhat higher than among women, 15 per cent men were
hypertensive ,43 per cent men had normal blood pressure and same
percentage were prehypertensive. One per cent were on anti-
hypertensive medicines. For both men and women, the prevalence
of hypertension increased with age.
• The prevalence of hypertension is higher among Sikhs, Jains, and
Buddhist/ Neo-Buddhist, than the rest of the religion groups. There
is a consistent increase in prevalence of hypertension with
increase in body mass index, for both men and women. 29 per
cent of obese women and 38 per cent of obese men were
hypertensive.
“Tracking” of blood pressure
If blood pressure levels of individuals were
followed up over a period of years from early
childhood into adult life,then those individuals whose
pressures were initially high in the distribution, would probably continue in
the same “track” as adults.
In other words, low blood pressure levels tend to remain low, and high
levels tend to become higher as individuals grow older. This phenomenon of
persistence of rank order of blood pressure has been described as
“tracking”. This knowledge can be applied in identifying children and
adolescents at risk of developing hypertension at a future date.
Risk factors for hypertension
Hypertension is not only one of the major risk factors for
most forms of cardiovascular disease, but that it is a
condition with its own risk factors. A WHO Scientific Group
(5) has recently reviewed the risk factors for essential
hypertension. These may be classified as:
1. Non-modifiable risk factors
(a) AGE: Blood pressure rises with age in both sexes and the
rise is greater in those with higher initial blood pressure.
• Age probably represents an accumulation of
environmental influences and the effects of genetically
programmed senescence in body systems.
(b) SEX: Early in life there is little evidence of a difference in blood
pressure between the sexes. However, at adolescence, men display a
higher average level. This difference is most evident in young and
middle aged adults. Late in life the difference narrows and the
pattern may even be reversed.
Post-menopausal changes in women may be the contributory factor
for this change. Studies are in progress to evaluate whether
oestrogen supplementation protects against the late relative rise of
blood pressure in women
• (c) GENETIC FACTORS: There is considerable evidence that blood pressure
levels are determined in part by genetic factors, and that the inheritance is
polygenic.
• The evidence is based on twin and family studies. Twin studies have
confirmed the importance of genetic factors in hypertension. The blood
pressure values of monozygotic twins are usually more strongly correlated
than those of zygotic twins. In contrast, no significant correlation has been
noted between husbands and wives, and between adopted children and
their adoptive parents .
• Family studies have shown that the children of two normotensive parents
have 3 per cent possibility of developing hypertension, whereas this
possibility is 45 per cent in children of two hypertensive parents .
• Blood pressure levels among first degree adult relatives have also been
noted to be statistically significant .
(d) ETHNICITY: Population studies have consistently revealed higher
blood pressure levels in black communities than other ethnic groups.
Average difference in blood pressure between the two groups vary
from slightly less than 5 mm Hg during the second decade of life to
nearly 20 mm Hg during the sixth. Black Americans of African origin
have been demonstrated to have higher blood pressure levels than
whites.
2. Modifiable risk factors

(a) OBESITY: Epidemiological observations have identified obesity as

a risk factor for hypertension.
• The greater the weight gain, the greater the risk of high blood
pressure.
• Data also indicate that when people with high blood pressure lose
weight, their blood pressure generally decreases.
• “Central obesity indicated by an increased waist to hip ratio, has
been positively correlated with high blood pressure in several
populations.
(b) SALT INTAKE:
• There is an increasing body of evidence to the effect that a high
salt intake (i.e., 7-8 g per day) increases blood pressure
proportionately. Low sodium intake has been found to lower the
blood pressure.
• For instance, the higher incidence of hypertension is found in
Japan where sodium intake is above 400 mmol/day while primitive
societies ingesting less than 60 mmol/day have virtually no
hypertension. It has been postulated that essential hypertensives
have a genetic abnormality of the kidney which makes salt
excretion difficult except at raised levels of arterial pressure.
• Besides sodium, there are other mineral elements such as
potassium which are determinants of blood pressure.
• Potassium antagonizes the biological effects of sodium, and
thereby reduces blood pressure.
• Potassium supplements have been found to lower blood pressure
of mild to moderate hypertensives.
• Other cations such as calcium, cadmium and magnesium have also
been suggested as of importance in reducing blood pressure levels.
(c) SATURATED FAT: The evidences suggest that saturated fat raises
blood pressure as well as serum cholesterol.
(d) DIETARY FIBRE: Several studies indicate that the risk of CHD and
hypertension is inversely related to the consumption of dietary fibre.
Most fibres reduce plasma total LDL Cholesterol.

(e) ALCOHOL: High alcohol intake is associated with an increased risk

of high blood pressure. It appears that alcohol consumption raises
systolic pressure more than the diastolic But the finding that blood
pressure returns to normal with abstinence suggests that alcohol-
induced elevations may. Not be fixed, and do not necessarily lead to
sustained blood pressure elevation .
(f)HEART RATE: When groups of normotensive and untreated
hypertensive subjects, matched for age and sex, are compared, the
heart rate of the hypertensive group is invariably higher.
This may reflect a resetting of sympathetic activity at a higher level.
The role of heart variability in blood pressure needs further research
to elucidate whether the relation is casual or prognostic.

(g) PHYSICAL ACTIVITY: Physical activity by reducing reducing body

weight may have an indirect effect on blood pressure.
(h) ENVIRONMENTAL STRESS:
• The term hypertension itself implies a disorder initiated by tension or
stress. Since stress is nowhere defined, the hypothesis is untestable .
• However, it is an accepted fact that psychosocial factors operate
through mental processes, consciously or unconsciously, to produce
hypertension.
• Virtually all studies on blood pressure and catecholamine levels in
young people revealed significantly higher noradrenaline levels in
hypertensives than in normotensives. This supports the contention
that over-activity of the sympathetic nervous system has an
important part to play in the pathogenesis of hypertrnsion.
(i) SOCIO-ECONOMIC STATUS:
• In countries that are in post-transitional stage of economic and
epidemiological change, consistently higher levels of blood
pressure have been noted in lower socio-economic groups.
• This inverse relation has been noted with levels of education,
income and occupation. However, in societies that are transitional
or pre-transitional, a higher prevalence of hypertension have been
noted in upper socio-economic groups. This probably represents
the initial stage of the epidemic of CVD .
(j) OTHER FACTORS: The commonest present cause of secondary
hypertension is oral contraception, because of the oestrogen
component in combined preparations. Other factors such as noise,
vibration, temperature and humidity require further investigation .
PREVENTION OF HYPERTENSION
The low prevalence of hypertension in some communities indicates that hypertension is
potentially preventable .
The WHO has recommended the following approaches in the prevention of hypertension:
1. Primary prevention
(a) Population strategy
(b) High-risk strategy

2. Secondary prevention

1. PRIMARY PREVENTION
Although control of hypertension can be successfully achieved by medication
(secondary prevention) the ultimate goal in general is primary prevention.
Primary prevention has been defined as "all measures to reduce the incidence
of disease in a population by reducing the risk of onset“.The earlier the
prevention starts the more likely it is to be effective.
• In connection with primary prevention, terms such as “population
strategy” and “high-risk strategy have become established. The
WHO has recommended these approaches in the prevention of
hypertension. Both the approaches are complementary.
• A) Population strategy
The population approach is directed at the whole population,
irrespective of individual risk levels. The concept of population
approach is based on the fact that even a small reduction in the
average blood pressure of a population would produce a large
reduction in the incidence of cardiovascular complications such as
stroke and CHD.
• The goal of the population approach is to shift the community
distribution of blood pressure towards lower levels or “biological
normality” .
(1)NUTRITION:
Dietary changes are of paramount importance. These comprise: (i)
reduction of salt intake to an average of not more than 5 g per day
(ii) moderate fat intake (iii) the avoidance of a high alcohol intake,
and (iv) restriction of energy intake appropriate to body needs.
(2)WEIGHT REDUCTION:
The prevention and correction of over weight/obesity (Body Mass
Index greater than 25) is a prudent way of reducing the risk of
hypertension and indirectly CHD; it goes with dietary changes.
(3) EXERCISE PROMOTION:
The evidence that regular physical activity leads to a fall in body
weight, blood lipids and blood pressure goes to suggest that regular
physical activity should be encouraged as part of the strategy for risk-
factor control.
(4) BEHAVIOURAL CHANGES:
Reduction of stress and smoking, modification of personal life-style, yoga
and transcendental meditation could be profitable.
(5)HEALTH EDUCATION: The general public require preventive advice on
all risk factors and related health behaviour. The whole community must
be mobilized and made aware of the possibility of primary prevention,
and
(6) SELF-CARE: An important element in community-based health
programmes is patient participation. The patient is taught self-care. Le.. To
take his own blood pressure and keep a log-book of his readings. By doing
so, the burden on the official health services would be considerably
reduced. Log-books can also be useful for statistical purposes and for the
long-term follow-up of cases .
Lifestyle modifications to manage Hypertension
B)High risk strategy
This is also part of primary prevention.
The aim of this approach is “to prevent the attainment of levels of
blood pressure at which the institution of treatment would be
considered. This approach is appropriate if the risk factors occur with
very low prevalence in the community .
• Detection of high-risk subjects should be encouraged by the
optimum use of clinical methods. Since hypertension tends to
cluster in families, the family history of hypertension and
“tracking” of blood pressure from childhood may be used to
identify individuals at risk.
2.SECONDARY PREVENTION

The goal of secondary prevention is to detect and control high blood pressure in
affected individuals. Modern anti hypertensive drug therapy can effectively reduce
high blood pressure and consequently, the excess risk of morbidity and mortality
from coronary, cerebrovascular and kidney disease.
The control measures comprise:

(1) EARLY CASE DETECTION:

• Early detection is a major problem.
• This is because high blood pressure rarely causes symptoms until organ damage
has already occurred, and our aim should be to control it before this happens.
• The only effective method of diagnosis of hypertension is to screen the
population.
• In the developed countries, mass screening is not considered
essential for the adequate control of blood pressure in the
population.
• In Europe, the large majority of people have at least one contact in
every 2 years with the health service.
• If blood pressure is measured at each such contact, the bulk of the
problem of detecting those in need of intervention is solved.
(2) TREATMENT:
• In essential hypertension, as in diabetes, we cannot treat the
cause, because we do not know what it is. Instead, we try to scale
down the high blood pressure to acceptable levels.
• The aim of treatment should be to obtain a blood pressure below
140/90, and ideally a blood pressure of 120/80.
• Control of hypertension has been shown to reduce the incidence
of stroke and other complications. This is a major reason for
identifying and treating asymptomatic hypertension. Care of
hypertensives should also involve attention to other risk factors
such as smoking and elevated blood cholesterol lelevel.
(3)PATIENT COMPLIANCE:
• The treatment of high blood pressure must normally be life-long
and this presents problems of patient compliance, which is
defined as “the extent to which patient behaviour (in terms of
taking medicines, following diets or executing other lifestyle
changes) coincides with clinical prescription”.
• The compliance rates can be improved through education
directed to patients, families and the community.
• Intensive research carried out during the past decade. Aiming at
control of hypertension at the community level has already
provided valuable results.
• The studies have shown that control of hypertension in a
population is feasible, that it can be carried out through the
existing system of health services in different countries, and that
the control of blood pressure leads to a reduction of complications
of high blood pressure- namely stroke, heart failure and renal
failure.
• In some of the projects the incidence of myocardial infarction was
also reduced.
• As a result of these findings some countries have launched
nationwide control programmes in the field of hypertension.
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