systemic hypertension

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Unveiling the Silent Threat: Systemic Hypertension

Unveiling the Silent Threat: Systemic Hypertension

Systemic hypertension is characterized by a persistent elevation of systolic blood pressure above 140 mmHg and/or diastolic blood pressure above 90 mmHg in a setting of mental and physical rest. It's a condition of considerable importance, given its high prevalence and potential for serious health consequences.

How Common is This Pressure? Epidemiology

Hypertension is a widespread issue. In Egypt, the estimated prevalence stands at 26.3%. Notably, this prevalence increases significantly with age, reaching up to 50% in individuals above 75 years old. This underscores the growing importance of understanding and managing hypertension in an aging population.

The Roots of High Pressure: Etiology

Hypertension isn't always straightforward in its origin. We broadly categorize it into two main types:

Primary Hypertension (Essential Hypertension)

This accounts for the vast majority, around 95% of cases. Despite being termed 'idiopathic' (meaning without a clear single cause), several risk factors are strongly associated with its development:

  • Family history of hypertension or heart diseases
  • Being of Black/African descent
  • Advanced age
  • High sodium intake
  • Smoking
  • Obesity
  • Sedentary lifestyle
  • Alcohol intake
  • Emotional stress

Secondary Hypertension

This accounts for a smaller proportion, about 5% of cases. It arises due to an identifiable underlying medical condition. Several clues can suggest secondary hypertension:

  • Severe or resistant hypertension (poor response to multiple medications)
  • Sudden onset of hypertension
  • Onset at an unusual age (before puberty or after age 50 without a strong family history)
  • Absence of a family history of hypertension
  • Clinical or laboratory findings suggesting an underlying cause, such as:
    • Upper limb hypertension with normal leg blood pressure, potentially indicating coarctation of the aorta
    • Abdominal bruit suggesting renal artery stenosis
    • Features of Cushing syndrome
    • Symptoms of pheochromocytoma (episodic headaches, sweating, tachycardia)
    • Signs or symptoms suggestive of sleep apnea
    • Cold intolerance, heat intolerance, or weight changes indicating thyroid disorders
    • Hypertension developing during pregnancy (pre-eclampsia)
    • History of relevant drug intake (e.g., steroids, NSAIDs, oral contraceptives)
    • Severe morning headaches with vomiting and blurred vision, possibly indicating central causes of increased intracranial tension

Detecting the Elevated Pressure: Diagnosis

Diagnosing hypertension involves more than a single high reading. It requires repeated measurements to confirm a persistent elevation, unless the initial reading is very high (grade 3) or associated with significant target organ damage. To get a more complete picture, doctors may recommend:

  • Home-based blood pressure measurement: This uses an automatic, calibrated device and is helpful for educated patients.
  • Ambulatory blood pressure monitoring (ABPM): This measures blood pressure throughout the day and night, providing averages for daytime, nighttime, and overall blood pressure.

Out-of-Office Measurements

These out-of-office measurements are crucial for identifying specific patterns:

  • White coat hypertension: Elevated blood pressure readings in the clinic but normal readings at home.
  • Masked hypertension: Normal blood pressure readings in the clinic but elevated readings at home.

Understanding the Levels: Grading of Hypertension

The sources mention the concept of grading hypertension, implying different categories based on the severity of blood pressure elevation. While the specific grades aren't detailed, this highlights that hypertension exists on a spectrum.

How High Pressure Shows Itself: Presentations

Chronic hypertension is often a silent condition, with most individuals being asymptomatic. However, some may experience mild headaches, fatigue, or a lack of concentration. Sometimes, it's discovered incidentally during routine check-ups.

When blood pressure reaches very high levels, it can lead to more serious situations:

  • Hypertensive Urgency: This involves grade 3 hypertension without severe symptoms.
  • Hypertensive Emergency: This is grade 3 hypertension accompanied by severe symptoms, indicating acute target organ damage. These symptoms can include:
    • Severe dyspnea (difficulty breathing)
    • Severe chest pain
    • Severe headache
    • Disturbed conscious level

Specific Hypertensive Emergencies

  • Hypertensive Encephalopathy: Characterized by very high BP with neurological abnormalities like severe headache, loss of consciousness, convulsions, sensory disturbances, speech or vision problems, and retinopathy.
  • Malignant Hypertension: Defined by severe hypertension with a diastolic BP >130 mmHg, along with grade III or IV retinopathy (retinal hemorrhages or exudates and papilledema) and potential kidney failure or encephalopathy. Without treatment, malignant hypertension can be fatal within months.

Charting the Course of Action: Management

  • Confirmation: As mentioned earlier, persistent elevation needs to be confirmed.
  • Ruling out Secondary Causes: This involves a thorough:
    • History: Looking for clues suggesting underlying conditions.
    • Examination: Including specific checks like upper and lower limb blood pressure comparison, fundus examination, thyroid examination, and back auscultation for renal artery stenosis.
    • Investigations: Routine tests include ECG, chest X-ray, kidney function tests, thyroid profile, and serum potassium levels. Further investigations like renal artery Doppler, echocardiography, sleep study, and hormone tests are done based on clinical suspicion.
  • Assessment of Risk Factors: Identifying and addressing modifiable risk factors like smoking, obesity, and high sodium intake.
  • Assessment of Target Organ Damage: Checking for any damage to organs like the heart (left ventricular hypertrophy), brain (cognitive impairment, retinopathy, stroke), kidneys (nephropathy), and blood vessels (atherosclerosis).
  • (Mentioned for reading but not detailed) Risk Stratification: This helps in tailoring the treatment approach.
  • Treatment Decision: Based on risk stratification and the presence of target organ damage.

  • Lifestyle Advice

    • Weight reduction
    • Adopting the DASH (Dietary Approaches to Stop Hypertension) diet (composition not detailed)
    • Reducing salt intake (to less than 5g daily)
    • Regular aerobic exercise (30 minutes/day for 5-7 days/week)
    • Smoking cessation
    • Moderation of alcohol consumption
    • Eating more fruits and vegetables
    • Avoiding foods high in saturated and trans fats
    • Moderation of coffee and tea consumption
    • Control of stress

  • Medication Strategy

    Antihypertensive medications are often necessary to achieve target blood pressure. The choice of medication may be influenced by co-existing conditions:

    • Peripheral Vascular Diseases (PVD): Calcium channel blockers, alpha-blockers, and ACE inhibitors (unless renal artery stenosis is present) may be used. Beta-blockers are generally avoided.
    • Diabetes Mellitus (DM): ACE inhibitors, ARBs, and calcium channel blockers are preferred. Thiazides and beta-blocker combinations that can worsen hyperglycemia or mask hypoglycemic symptoms should be avoided. SGLT2

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