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Resource Description: 
Get comprehensive information about hypertension from the American Society of Hypertension.
Learn all about heart health through the American Heart Association.
Get comprehensive information on how to manage hypertension in the PDF version of Your Guide to Lowering Blood Pressure from the National Heart, Lung, and Blood Institute.
Learn about a clinically proven dietary approach for significantly reducing blood pressure in the PDF version of Facts About the DASH Eating Plan.
Use an interactive online tutorial from MedlinePlus to increase your understanding of hypertension.
Get the facts about ALLHAT, a major clinical study of antihypertensive medications completed in 2002.
Andrew Liebman, of the PBS series, Frontline, produced a documentary entitled, "Dangerous Prescription," which explores issues surrounding the safety of drugs, including antihypertensives. The complete documentary, along with sidebars and follow-ups, are on the PBS.org.
Episode number: 
105

Some call it hypertension. Others know it as high blood pressure. Whichever term you use, it is the same serious health problem - one that increases your risk for heart disease and stroke (the first and third leading causes of death among Americans) and can also contribute to heart failure , kidney disease, vision problems, and other conditions. In this episode of Second Opinion, you will learn all about hypertension, its symptoms and consequences, how to avoid it and, if you have it, what you need to do to keep it under control. 

Hypertension, the medical term for abnormally high blood pressure, is one disease that has no trouble living up to its nickname: the silent killer. Unlike some medical conditions, hypertension does not give you any warning signs. You can have it, feel perfectly healthy, and may never even know that something is wrong until serious, sometimes life-threatening, damage has already been done to critical organs in your body.

The statistics surrounding hypertension in the United States are alarming:

  • Hypertension is the number one world wide epidemic, but treatable, medical condition.
  • An estimated 50 million Americans have hypertension, including one in three adults, and over 60% of all senior citizens.
  • About two million people are diagnosed with hypertension annually.
  • Hypertension contributes to about 700,000 deaths a year from stroke, and heart and kidney disease.
  • A third of those who have this disease do not know they have it.
  • The illnesses brought on by uncontrolled high blood pressure cost Americans billions of dollars each year.

The good news is that hypertension is easily detectable and usually can be treated with a high degree of success. The bad news is that when it goes undetected, as is the case with millions of Americans who have hypertension but do not know it, the "silent killer" can cause:

  • The heart enlarges and leads to heart failure
  • Aneurysms (like small blisters) to form in the brain's blood vessels, which may burst and cause a stroke
  • Blood vessels in the kidney to narrow, which may lead to kidney failure
  • Arteries throughout the body to "harden" faster, especially those in the heart, brain, kidneys, and legs. This can lead to a heart attack, stroke, kidney failure, or amputation of part of the leg
  • Blood vessels in the eyes to burst, bleed or thicken, which may cause vision changes and can result in blindness

While hypertension can strike both adults and children, those at greater risk include:

  • People over age 35
  • African Americans
  • People with a family history of high blood pressure
  • Overweight people
  • People who are not physically active
  • People who consume too much salt
  • People who drink too much alcohol
  • People who have diabetes, gout and kidney disease
  • Pregnant women
  • Women who take birth control pills, who are overweight, had high blood pressure during pregnancy, have a family history of high blood pressure, or have mild kidney disease

Because usually there are no symptoms, hypertension can only be detected by measuring blood pressure-a simple, painless test that is part of routine physical exams. It is not unusual for someone who is seeing a physician about one condition to leave the office with a major surprise: a diagnosis of hypertension.

Discovering that you have hypertension may initially seem like bad news, but having that knowledge can transform you into an informed patient and literally save your life. You can then begin working with your physician to develop a sound plan for reducing and controlling your blood pressure - therapy which may include a variety of lifestyle changes as well as treatment with one or more antihypertensive drugs.

Hypertension usually can be controlled but not cured. It is a disease that usually requires lifelong monitoring with treatment that may go on indefinitely. Once you settle into a treatment plan, which may include lifestyle changes or drug therapy or both, keeping your blood pressure lower may seem easier than you imagined. And by sticking with your treatment, you will go a long way toward reducing your risk of diseases like stroke, heart attack, heart failure and kidney disease.

 

Quick Facts

An estimated 50 million Americans have hypertension, including one in three adults, and over 60% of all senior citizens.

About two million people are diagnosed with high blood pressure every year. One third of the people who have high blood pressure don't know they have the disease.

The frequency of hypertension increases with increasing age and body weight. Half of patients suffering their first heart attack are hypertensive and two thirds of patients suffering their first stroke are significantly hypertensive.

Certain people are at greater risk of developing high blood pressure: they include the elderly, people with a family history of high blood pressure, people who are overweight, and African Americans. Hypertension is the leading cause of kidney failure among African Americans.

Medical complications that commonly result from hypertension include atherosclerosis, stroke, aneurysm, heart attack, heart failure, kidney failure , and eye damage.

Factors that can seriously aggravate hypertension and increase the risk of complications include: obesity, smoking, diabetes (types 1 and 2), kidney disease, high alcohol intake, excessive salt intake, lack of exercise, and certain medicines, such as steroids.

Ask Your Doctor

Provided by John Bisognano, M.D.
Preventative Cardiologist and Hypertension Specialist
University of Rochester Medical Center

This list of questions is a good starting point for discussion with your doctor; however, it is not a comprehensive list.

  1. What is my blood pressure today?
  2. Should I be taking my blood pressure at home?
  3. What should my blood pressure be?
  4. How much can I improve my blood pressure by losing weight, eating better, and exercising more? What about salt?
  5. What do the top and the bottom number mean, and what should mine be?
  6. If diet and exercise doesn't work, how soon can I be started on a drug?
  7. Will treating my blood pressure decrease my chance of stroke, kidney disease, and heart disease?
  8. Can you give me any help in losing weight, exercising more, and eating better?
  9. Should my relatives be checked for high blood pressure too?
  10. Should elderly people have their blood pressure treated to the same goals as younger people?

Key Point 1

Blood pressure numbers are the numbers.  You cannot fudge them, you cannot cheat. If your numbers are high, you have high blood pressure and you have to get it down.

Hypertension is abnormally high blood pressure. Any reading higher than 120/80 mmHg puts you in a hypertension risk category. 

In 90% to 95% of the cases where a specific cause is unknown, the disease is called essential or primary hypertension . When the cause stems from a known medical problem or medication, it is referred to as secondary hypertension.

To understand hypertension, it helps to know what blood pressure is and how it is measured.

  • Blood pressure is the amount of force pushing against the walls of your arteries as blood is pumped by your heart and distributed throughout your body.
  • It is measured with an instrument called a sphygmomanometer (blood pressure cuff) .
  • Blood pressure readings are expressed as two numbers measured in units of millimeters (mm) of mercury (Hg). For example: 130/78 mm Hg .
  • The top number is called systolic pressure (the maximum pressure produced in the arteries as the heart contracts) and the bottom number is the diastolic pressure  (the lowest pressure in the arteries when the heart is between contractions, and reflects the elasticity and tone of the arteries).

For more detailed information on how blood pressure works, visit The American Heart Association Website.

When you have your blood pressure tested, you may be curious about the testing method, the numbers that represent the results, and the risk classifications that correspond with the numbers. Here are a few things to consider:

  • The standard blood pressure testing method has been in use for decades. For doctors and other caregivers, administering the test is almost second nature.
  • The testing instruments which are used by medical professionals (manual and digital sphygmomanometers) are extremely precise and accurate. They are checked regularly to ensure they are functioning properly.
  • The standards for blood pressure levels and their corresponding risk classifications are based on exhaustive medical research and studies. They are established only after broad consensus among hypertension experts. These standards are updated regularly as new medical knowledge becomes available.

The bottom line?
Have your blood pressure checked regularly. It is the only way to find out if you have hypertension. And if the results indicate that your blood pressure is outside the normal range, waste no time in talking with your physician about a treatment plan.

What the numbers mean
The chart below is the latest guide for classification and management of blood pressure for adults age 18 and older. It is based on the latest clinical practice guidelines for the prevention, detection, and treatment of high blood pressure, presented in 2003 by the National Heart, Lung, and Blood Institute.  Regarded as the standard for diagnosing and treating hypertension, this is the guide that your physician uses for hypertension screening.

Diagnosing Hypertension
For adults 18 and older who:

  • Are not on high blood pressure medicine
  • Are not having a short-term serious illness
  • Do not have other conditions such as diabetes and kidney disease

 

CategorySystolic
(Top number)
 
Diastolic
(Bottom number)
Normal  Less than 120Less than 80
Prehypertension 120-13980-89
High Blood Pressure   
  Stage 1140-15990-99
  Stage 2160 or higher100 or higher

Note: When systolic and diastolic blood pressures fall into different categories, the higher category should be used to classify blood pressure level. For example, 160/80 would be stage 2 high blood pressure.  There is an exception to the above definition of high blood pressure. A blood pressure of 130/80 or higher is considered high blood pressure in persons with diabetes and chronic kidney disease.

Additional diagnostic testing
If you have been diagnosed with hypertension, your doctor will usually conduct blood and urine tests to determine whether the condition has damaged any of your body's organs. Your doctor will also test for other complications such as kidney disease, diabetes, or a hormone disorder. Sometimes an echocardiogram will be done to determine whether the high blood pressure has started to damage the heart. A chest x-ray might also be ordered to determine if any damage to the lungs has occurred. The results of these tests, together with your blood pressure reading, will guide your physician in selecting the best treatment for you.

    

Key Point 2

When it comes to blood pressure control, lifestyle changes have their limits. Once diagnosed with high blood pressure, it is critical that you meet your blood pressure goal, and in many cases, that can only be done with the addition of medication.

If you are diagnosed with hypertension, it is essential to get treatment started quickly to lower your blood pressure. While there is no complete cure for primary or essential hypertension, there is a lot that you and your doctor can do to reduce and control your blood pressure. The two primary strategies are to:

  1. Make changes in the way you live
  2. Take antihypertensive medications as prescribed by your doctor.

For most patients, it is necessary to do both.

Lifestyle changes
The things you eat, the things you do (or do not do), what is happening in your life, and many other factors can all influence your blood pressure. The American Heart Association has developed recommendations for very specific lifestyle changes that can help you lower and control your blood pressure.

These include:

  • Lose weight if you are overweight
  • Eat a healthy diet low in saturated fat, cholesterol and salt
  • Be more physically active
  • Limit alcohol to no more than one drink per day for women or two drinks a day for men
  • Take medicine the way your doctor tells you to
  • Know what your blood pressure should be and work to keep it at that level

Drug therapy
When lifestyle changes alone are not enough to help you achieve and maintain your optimum blood pressure, your doctor will probably augment your therapy by prescribing one or more medications. (Most persons with high blood pressure will eventually need two or more medications to achieve ideal control.) There are a few things to bear in mind when you begin drug therapy:

  • Everybody responds differently to medications. You may have to go through trial periods on one or more drugs before finding the right combination of medications that are right for you.
  • Results take time. It sometimes takes many weeks for some drugs to begin producing the desired effect. You need to be patient.
  • Drugs can have side effects that may make you feel worse than you did before you were diagnosed. Be sure to report all side effects to your doctor, but stay on the medication until you are told otherwise.
  • Taking pills and capsules can be an inconvenience, but it is well worth it to avoid heart attack, stroke, and other consequences of hypertension.
  • Once you begin taking blood pressure medicine, you may have to take medication for the rest of your life. However, if you successfully modify your lifestyle (by losing weight, for instance) and keep your hypertension under control for at least one year, your physician may consider stepping down your medication.


Key antihypertensive agents and how they work

Class of drug Action

  • Diuretics: Sometimes called "water pills" because they work in the kidney and flush excess water and sodium from the body.
  • Beta-blockers: Block the response of the heart and blood vessels to nerve stimuli. This makes the heart beat slower and with less force. Blood pressure falls and the heart works less hard.
  • Angiotensin: Converting enzyme (ACE) inhibitors  Prevent the formation of a hormone called angiotensin II, which normally causes blood vessels to narrow. These drugs cause blood vessels to relax and blood pressure goes down.
  • Angiotensin receptor antagonists (ARB's): Block the response of blood vessels from angiotensin II. As a result, the vessels widen and blood pressure goes down.
  • Calcium channel blockers: (CCBs)  Keep calcium from entering the muscle cells of the heart and blood vessels. This relaxes the blood vessels and pressure goes down.
  • Alpha-blockers: Block the response of blood vessels to alpha nerve stimuli, which allows blood to pass more easily, causing the blood pressure to go down.
  • Alpha-beta-blockers: Work the same way as alpha-blockers but also slow the heartbeat, as beta-blockers do. So less blood is pumped through the vessels and the blood pressure goes down.
  • Nervous system inhibitors (including centrally acting drugs): Relax blood vessels by controlling nerve impulses. This causes blood vessels to get wider so that blood pressure goes down.
  • Vasodilators: Open blood vessels directly by relaxing the muscle in the vessel walls, causing the blood pressure to go down.

Monitoring and follow-up

  • If you are diagnosed with hypertension, you will have regularly scheduled appointments with your doctor. Keep them.
  • Check your blood pressure at regular intervals - as often as your doctor recommends. A quality home monitor can be helpful as long as you use it properly.
  • Between appointments, if you have any of the symptoms listed below, or if your blood pressure remains high even with treatment, call your doctor right away.
    • Severe headache
    • Excessive fatigue
    • Confusion
    • Visual changes
    • Nausea and vomiting
    • Chest pain
    • Shortness of breath
    • Significant sweating
    

Key Point 3

There are many medication combinations that can help you get your blood pressure to your target normal. The treatments should be individualized - there is no standard formula.

Everyone responds to antihypertensive medications differently because biochemistry and other factors vary widely from person to person. So the hypertension drugs that are working so well for your best friend may not work for you. Fortunately, there are scores of antihypertensive agents available today, and your physician can explore many different options in tailoring a treatment to your individual needs.

Keep in mind that your doctor may have you try a number of different medications before finding the best regimen for you.  If a single antihypertensive drug does not reduce your blood pressure to normal levels, your doctor may increase your dosage or try a combination therapy, adding additional medications until your blood pressure is under control.

The goal of combination therapy is to use smaller amounts of one or more agents in combination to minimize side effects while maximizing the antihypertensive effect. Diuretics, for instance, are often used in low doses in combination with an antihypertensive drug from a different class. When the two are combined, the diuretic causes fewer side effects while improving the blood pressure-lowering effect of the other drug.

According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), "Most patients who are hypertensive will require two or more antihypertensive medications to achieve their blood pressure goals. Addition of a second drug from a different class should be initiated when use of a single drug in adequate doses fails to achieve the blood pressure goal."  The report, published by the National Heart, Lung, and Blood Institute (NHLBI) also notes that therapy with more than one drug may increase the likelihood of reaching blood pressure goals more quickly.  Click here to read the key-points version of the report JNC 7 Express.

Remember take as directed.
Forgetting to take your medications compromises your therapy and puts you at risk. If remembering your meds is a problem for you, check out Tips to Help You Remember to Take Your Blood Pressure Drugs from the National Heart, Lung, and Blood Institute.

Treating Hypertension with Drug Therapy

 

Classification and Management of Blood Pressure for Adults*
    Initial Drug Therapy
BP classificationSBP* (mm Hg) DBP* (mm Hg)Lifestyle modification Without compelling indicationsWith compelling indications (see table 2)
Normal < 120and < 80EncourageNo antihypertensive drug indicatedDrug(s) for compelling indications**
Pre-hypertension120-139or 80-89Yes  
Stage 1 hypertension140-159or 90-99YesThiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combinationDrug(s) for the compelling indications.** Other antihypertensive drugs diuretics (ACEI, ARB, BB, CCB), as needed
Stage 2 hypertensionGreater than or equal to 160Or greater than or equal to 100YesTwo-drug combination or most*** (usually thiazide-type diuretic and ACEI or ARB or BB or CCB)

BP, blood pressure; SBP, systolic BP; DBP, diastolic BP; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BB, b-blocker; CCB, calcium channel blocker.
* Treatment determined by highest BP category. 
** Treat patients with chronic kidney disease or diabetes to BP goal of < 130/80 mm Hg. 
*** Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
Source: JNC 7 Express.

Medline Plus

Medline Description: 

Conduct an off-site search for Hypertension information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

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