Hypertension is an average or sustained systolic blood pressure over 140 mm
Hg and/or a diastolic blood pressure over 90 mm Hg. Hypertension has an overall
incidence of 20%, with onset usually occurring after age 20. The prevalence
rises with age to over 50% over age 65. Ninety-five to 99% of hypertensive
individuals have essential hypertension. Persons with hypertension are three to
four times more likely to experience a major cardiovascular event (e.g.,
myocardial infarction, cerebrovascular accident, congestive heart failure).
Categories of hypertension (measured in mm Hg):
Stage 1 (mild)Systolic BP 140 to 159Diastolic BP 90 to 99
Stage 2 (moderate)Systolic BP 160 to 179 Diastolic BP 100 to 109
Stage 3 (severe)Systolic BP 180 to 209 Diastolic BP 110 to 119
Stage 4 (very severe)Systolic BP >210Diastolic BP
- Essential, or primary, hypertension has no identifiable
- Secondary hypertension may be caused by renal, endocrine, and
vascular conditions; coarctation of the aorta, certain neurological conditions,
acute stress, and chronic heavy alcohol use. Use of oral contraceptives,
decongestants, and antidepressants may also cause secondary
Hypertension is more common in African-Americans at all ages and in persons
from lower socioeconomic groups. Individual risk factors include the
- Family history
- Alcohol use
- High sodium intake
- Sedentary lifestyle
- High sugar intake
|Signs and Symptoms|
Essential hypertension has no symptoms except in extreme cases or after
cardiovascular complications result. Extremely high blood pressures may cause
Severe hypertension or hypertensive crisis (usually secondary hypertension)
with end-organ damage may produce headache, nausea and vomiting, seizure,
retinopathy, and other symptoms.
Tests to determine possible causes are performed only if a secondary cause is
Hypertension is diagnosed through blood pressure measurements. Guidelines
include controlling the patient's posture when taking the blood pressure;
restricting the use of caffeine, nicotine, and other stimulants before taking
the blood pressure; using the appropriate size cuff; and taking at least three
readings at least one week apart.
Diagnostic procedures focus on screening for causes and risk factors,
assessing potential end-organ damage from sustained hypertension.
The history should include past blood pressure levels, family history, past
conditions, diet (especially salt and cholesterol intake), exercise, current
medications, alcohol and tobacco use, and stressors.
Physical examination should include the following.
- Blood pressure taken on right and left arms, both sitting and
- Heart rate and rhythm
- Peripheral and femoral pulses
- Complete family and patient
- Complete blood count
- Calcium level
- Creatinine level
- Potassium level
- Sodium level
- Fasting glucose and insulin levels
- Cholesterol levels
- Uric acid level
There are pathological findings only if organ damage has begun to occur from
sustained hypertension; see "Complications."
Only required for differential diagnosis or if end-organ damage is
- Chest X ray
- IVP and renal arteriogram
- Provocative renal nuclear scan
- Digital subtraction arteriography
Only required for differential diagnosis or if end-organ damage is
- Plasma catecholamines
- Urinary metanephrines
- Plasma renin
The goal of treatment is to lower the risk of future cardiovascular damage by
lowering the blood pressure to below 140 mm Hg (systolic) and 90 mm Hg
(diastolic). In stage 3 or 4 hypertension, significant partial reduction is
Nonpharmacological therapies may be used with or without drug therapy.
Nondrug therapies are generally used with stage 1 hypertension and should be
evaluated over the course of 6 to 12 months. Drug treatment is usually required
for more severe hypertension and usually provides control within one to three
Lifestyle modifications that lower blood pressure include the
- Weight reduction
- Sodium restriction
- Discontinuation or restriction of alcohol
- Discontinuation of caffeine
- Patient education about the importance of lowering blood
- Biofeedback and relaxation
Each case should be considered individually, yet drug therapy is recommended
for patients with sustained systolic pressure over 160 mm Hg or diastolic
pressure over 100 mm Hg. Traditionally, therapy with a diuretic or beta-blocker
is tried first. The dosage may be modified or an additional drug from another
class may be added. Ten percent of patients may require three
- Diuretics—e.g., hydrochlorothiazide
(Hydrodiuril; 12.5 to 50 mg/day); side effects include decreased level of
potassium and increased cholesterol and glucose levels; contraindicated in
patients with gout and diabetes
- Potassium-sparing agents—spironolactone
(Aldactazide; 25 to 100 mg/day); side effects include hyperkalemia and
Adrenergic inhibitors include the following.
- Alpha-blockers—doxazosin (Cardura; 1 to 20
mg/day); side effects include postural hypotension and lassitude
- Beta-blockers—acebutolol (Sectral; 200 to
800 mg/day); side effects include congestive heart failure, bronchospasm,
masking of hypoglycemia induced by insulin, depression, insomnia, fatigue;
contraindicated relatively in heart failure, airway disease, heart block,
diabetes, and peripheral vascular disease
- Alpha/beta blockers—labetalol (Normodyne;
200 to 1,200 mg/day in two doses); side effects include postural hypotension and
beta-blocker side effects
- Centrally acting sympatholytics—methyldopa
(Aldomet; 500 to 3,000 mg/day in two doses); side effects include hepatic
disorders, sedation, dry mouth
- Peripherally acting sympatholytics—reserpine
(Serpasil; 0.05 to 0.25 mg/day); side effects include sedation and
- Calcium-channel blockers—verapamil (Isoptin;
90 to 480 mg/day); side effects include constipation, nausea, headache,
conduction defects; use with caution in heart failure or block
- Dihydropyridines—amlodipine (Norvase; 2.5 to
10 mg/day); side effects include flushing, headache, ankle edema
- Direct vasodilators—hydralazine (Apresoline;
50 to 400 mg/day in two doses); side effects include headache, tachycardia,
- Angiotensin-converting enzyme (ACE)
inhibitors—benazepril (Lotensin; 5 to 40 mg/day); side
effects include cough, rash, loss of taste; use with caution in renovascular
|Complementary and Alternative
Mind-body techniques (such as biofeedback, yoga, meditation, and stress
management), nutritional and herbal support may be effective in improving
hypertension and concurrent pathologies.
- Avoid caffeine and decrease intake of refined foods, sugar, and
saturated fats (meats and dairy products). Some kinds of hypertension respond to
a reduction of salt intake.
- Eliminate food allergens as these may exacerbate hypertension.
Increase dietary fiber, vegetables and vegetable proteins, and essential fatty
acids (cold-water fish, nuts, and seeds).
- EPA, flaxseed oil, or evening primrose oil (1,000 to 1,500 mg one to
two times/day) lowers cholesterol and mildly reduces hypertension.
- Magnesium (200 mg bid to tid) induces mild vasodilation to decrease
- Zinc (30 mg/day) may help reduce blood pressure that is associated
with high levels of cadmium (usually secondary to cigarette smoking).
- Coenzyme Q10 (50 to 100 mg one to two times/day) is protective to the
- B complex (50 to 100 mg/day) with additional folic acid (800
mcg/day), B12 (1,200 mcg/day), and betaine (1,000 mg/day) may increase
resistance of stress and lower blood pressure that is secondary to
- Vitamin E (400 IU/day) reduces platelet aggregation.
- Some patients are sensitive to grains. A trial of limiting
grain-based foods in the diet should be implemented to assess the effect on
Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink two to four cups/day. Tinctures may be used singly or in
combination as noted.
Hawthorn (Crataegus monogyna), linden flowers (Tilia cordata),
passionflower (Passiflora incarnata), valerian (Valeriana
officinalis), and cramp bark (Viburnum opulus) may be safely used
long-term. These herbs relax and strengthen the cardiovascular system while
moderately reducing blood pressure. Combine equal parts in a tincture, 20 to 30
drops tid or qid. Hawthorn may be taken as a dried extract, 250 mg tid.
Dandelion leaf (Taraxacum officinale) has a diuretic effect and spares
potassium. Drink three to four cups/day.
The following herbs have a stronger hypotensive effect and may have toxic
side effects. These herbs must be used under the supervision of a qualified
practitioner. Lily of the valley (Convallaria majalis), night-blooming
cereus (Selenicereus grandiflorus), mistletoe (Viscum album),
motherwort (Leonurus cardiaca), and Indian tobacco (Lobelia inflata).
Combine 3 to 4 of these herbs with equal parts of cramp bark and valerian
and take 30 to 60 drops tid.
An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and
Acupuncture may be helpful in reducing blood pressure, alleviating stress,
and addressing concurrent pathologies.
Therapeutic massage may be effective in reducing the effects of stress and
inducing relaxation and lowered blood pressure.
Since patient compliance is poor with antihypertensive medications, with up
to 20% of patients discontinuing the drug, patient education and follow-up are
critical. Even after blood pressure is stabilized, changes in the medical
regimen will be required for some patients for months and years. Schedule
follow-up visits every three to six months.
Individuals with high normal or stage 1 hypertension may be able to prevent
hypertension with a low-sodium diet, exercise, relaxation techniques, weight
reduction, alcohol avoidance, and smoking cessation.
The complications of untreated hypertension include the
- Aortic aneurysm
- Myocardial infarction
- Congestive heart failure
- Cardiac enlargement
- Left ventricular hypertrophy
- Renal insufficiency
- Cerebral thrombosis or
Controlled hypertension results in greatly diminished risks of complications
and a generally good prognosis.
Mild elevation of blood pressure can be normal in pregnancy, however,
pregnancy-induced hypertension can progress rapidly to life-threatening
sequelae. Blood pressure should be monitored frequently during pregnancy.
Hawthorn, linden flowers, passionflower, valerian, and cramp bark may be used
safely in pregnancy after the first trimester. Further intervention must be
under the supervision of a physician.
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Golik A, Zaidenstein R, Dishi V, et al. Effects of captopril and enalapril on
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Copyright © 2007 Drugs Area
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information relating to general principles
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instructions for individual patients. The publisher does not accept any
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