American Society Of Hypertension: Normal
Individuals with optimal levels of BP and no identifiable early markers of CVD are considered by the American Society of Hypertension as normal. Resting average BP levels are usually < 120/80mmHg, but occasional elevated BPs may occur in these individuals. Some individuals designated as having prehypertension by JNC 7 will be classified as normal in the ASH paradigm. Accurate diagnosis in some individuals may be assisted by home BP determinations or 24hour ambulatory BP recordings .
Pertinent Studies And Ongoing Trials
The SYST-EUR trial, HYVET and SHEP studies were amongst the large RCTs that formed the basis for recommendations from the 8th report of JNC.
The SPRINT trial, HOPE-3 trial, Gubbio population study, Framingham heart study along with other RCTs, formed the basis for recommendations from ACC and ESC/ESH guidelines.
Ash Stage 1 Hypertension: Characterized By Early Cvd Markers
ASH stage 1 hypertension is the earliest identifiable stage of hypertensive disease and generally arises from circulatory, vascular, or renal adaptations to environmental or genetic stimuli. This stage is often characterized by early signs of functional or structural changes in the heart or small arteries. BP levels are above 115/75mmHg and may be elevated, particularly with environmental stress. Patients frequently have more than 1 CV risk factor . This category is applied only to those individuals with early disease markers , who do not show any evidence of target organ damage .
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Facts About Hypertension In The United States
In 2017, the American College of Cardiology and the American Heart Association published new guidelines for hypertension management and defined high hypertension as a blood pressure at or above 130/80 mmHg. Stage 2 hypertension is defined as a blood pressure at or above 140/90 mmHg. 1
- Having hypertension puts you at risk for heart disease and stroke, which are leading causes of death in the United States.2
- In 2020, more than 670,000 deaths in the United States had hypertension as a primary or contributing cause.2
- Nearly half of adults in the United States have hypertension, defined as a systolic blood pressure greater than 130 mmHg or a diastolic blood pressure greater than 80 mmHg or are taking medication for hypertension.3
- Only about 1 in 4 adults with hypertension have their condition under control.3
- About half of adults with uncontrolled hypertension have a blood pressure of 140/90 mmHg or higher. This includes 37 million U.S. adults. 3
- About 34 million adults who are recommended to take medication may need it to be prescribed and to start taking it. Almost two out of three of this group have a blood pressure of 140/90 mmHg or higher.3
- High blood pressure costs the United States about $131 billion each year, averaged over 12 years from 2003 to 2014.4
Toxicity And Side Effect Management
Side effects are generally mild and resolve promptly upon decreasing the dosage or discontinuing the drug for short intervals.
Patients should be frequently monitored for side effects, more so in the early initiation phase of therapy when they are much frequent. Side effects are usually self-limited and include hypotension and ACEi/ ARBs), electrolyte imbalances, pedal edema and renal dysfunction. Renal dysfunction and electrolyte imbalance especially hyponatremia and hyperkalemia are frequent with ACEi and ARBs and need to be monitored periodically until the achievement of static levels of Cr, K, and Na.
For patients with severe side effects like symptomatic hyperkalemia or hyponatremia, syncope and acute kidney injury , treatment needs to be discontinued, and in-patient management is advised. Nephrologist and cardiologist opinions also need to be sought in such cases. Once the issues settle, treatment needs to be re-instituted gradually and cautiously with careful monitoring and frequent follow-ups.
Angioedema has been a potentially life-threatening side effect of ACEi and ARBs in susceptible individuals and warrants prompt discontinuation and is also a lifelong contra-indication for ACEi/ ARB usage.
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What Diet Helps Control High Blood Pressure
- Eat foods that are lower in fat, salt and calories, such as skim or 1% milk, fresh vegetables and fruits, and whole-grain rice and pasta.
- Use flavorings, spices and herbs to make foods tasty without using salt. The optimal recommendation for salt in your diet is to have less than 1,500 milligrams of sodium a day. Don’t forget that most restaurant foods and many processed and frozen foods contain high levels of salt. Use herbs and spices that do not contain salt in recipes to flavor your food. Dont add salt at the table.
- Avoid or cut down on foods high in fat or salt, such as butter and margarine, regular salad dressings, fatty meats, whole milk dairy products, fried foods, processed foods or fast foods and salted snacks.
- Ask your provider if you should increase potassium in your diet. Discuss the Dietary Approaches to Stop Hypertension diet with your provider. The DASH diet emphasizes adding fruits, vegetables and whole grains to your diet while reducing the amount of sodium. Since its rich in fruits and vegetables, which are naturally lower in sodium than many other foods, the DASH diet makes it easier to eat less salt and sodium.
Does One Size Fit All In The Definition Of Hypertension
The AHA/ACC guidelines committee review considered the fact that the SPRINT did not include people with diabetes or stroke in consideration of defining hypertension and recommendations for intervention. The guidelines now define stage 1 hypertension as systolic BP 130 mm Hg or diastolic BP 80 mm Hg and stage 2 hypertension as systolic BP 140 mm Hg or diastolic BP 90 mm Hg. In addition, the guidelines provide a thoughtful approach to defining hypertension on the basis of several clinical conditions. Thus, they determined and promulgated thresholds for and goals of pharmacologic therapy in patients with hypertension according to comorbidities. This recommendation indicates that one size does not fit all patients who are hypertensive. Moreover, there are unanswered questions about many of these specific comorbidities. For example, as noted above among those in the ACCORD Trial randomized to aggressive systolic BP lowering, the incidence of stroke was significantly lower compared with among those with less aggressive lowering. The key message is that clinical decision making for treatment of hypertension and target BP should be a shared experience that includes the provider, the patient, and in some cases, family members among others.
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Blood Pressure Targets In Specific Subgroups Of Hypertensive Patients
Treatment thresholds for office BP are defined as 140/90 mmHg and are the same in hypertensive patients who also have diabetes, CAD, CKD, stroke or TIA however, in very high-risk patients with CAD, previous stroke or TIA, treatment may already be considered in highnormal SBP of 130< 140 mmHg. In patients older than 80 years, a threshold of 160/90 mmHg is advised for all groups, including those with diabetes, CAD, CKD or stroke .
For patients with diabetes, the same treatment targets are recommended for an office SBP target of 130 mmHg or lower . SBP should not be lowered to < 120 mmHg. The DBP target should be < 80 mmHg. In older patients the SBP target range is 130140 mmHg if tolerated. A variable visit-to-visit BP should be noted due to associated increased cardiovascular and renal risk. Caution is emphasised in autonomic polyneuropathy concerning postural or orthostatic hypotension. Nocturnal BP should be assessed by 24-hr ABPM in order to detect hypertension in apparently normotensive diabetic patients.
In CAD, diastolic BP should not be lowered to < 70 mmHg as myocardial perfusion may be impaired in lower values . In CAD, treatment is already recommended at the threshold of highnormal BP of 130139/8589 mmHg, as these patients are considered to be at very high risk.
Chronic kidney disease
Bp As A Biomarker For Hypertension
BP serves as a biomarker for the disease hypertension. However, individuals with the same levels of BP might have different stages of hypertension . Furthermore, some individuals may exhibit elevated BP in the absence of hypertension. For purposes of calculating total CV risk, BP should be evaluated in the context of other CV risk factors and disease markers.
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The Evolving Definition Of Systemic Hypertension
- Texas Blood Pressure Institute, Dallas Nephrology Associates, Dallas, TexasUniversity of Texas Southwestern Medical Center, Dallas, Texas.
Arch Intern Med.
- Wright Jr, J.T.
- Roccella E.J.
|Descriptive category||Normal BP or rare BP elevations and no identifiable cardiovascular disease||Occasional or intermittent BP elevations or risk factors or markers suggesting early cardiovascular disease||Sustained BP elevations or evidence of progressive cardiovascular disease|
|Cardiovascular risk factors|
|2 present plus cardiovascular disease|
|Target-organ disease||Overtly present with or without cardiovascular disease events|
J Clin Hypertens.
- Bonneux L.
- de Laet C.
- Collins R.
J Clin Hypertens.
J Clin Hypertens.
- Croft J.B.
- Mensah G.A.
Arch Intern Med.
Am J Hypertens.
J Clin Hypertens.
Hypertension And Total Cardiovascular Risk Assessment
The latest ESC/ESH Guidelines further highlight the importance of the systematic estimation of total cardiovascular risk in individual hypertensive patients, endorsing the paradigm shift from the view of cardiovascular risk factors as separate silos to a more comprehensive assessment of individual total cardiovascular risk profile. Every doctor should systematically estimate individual cardiovascular risk in each hypertensive patient at the time of initial diagnosis or whether any changes occur. In Europe, the Systemic COronary Risk Evaluation system is the most frequently adopted tool for this purpose, and it is now recommended also for individuals aged > 65 years.
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Enhancing Healthcare Team Outcomes
Often hypertension is picked up by nurses charting the patients in ERs and out-patient setting, where prompt recognition and referral to a physician is essential as most of these hypertensive patients might be unaware of their disease, hence the name “silent killer.”
Inter-professional communication is of prime importance especially in picking up cases of resistant or difficult to treat hypertension where referral and inter-specialty approach will benefit a patient the most. Effective communication in an interprofessional team approach including nursing staff and nurse practitioner, primary referring physician, cardiologist, nephrologist and pharmacist is essential for ensuring blood pressure control. This team can also monitor for adequate patient compliance as well as potential toxicities and adverse effects, all of which will result in minimizing future complications and reducing health care costs as well as improving patient outcomes.
Can High Blood Pressure Affect Pregnancy
High blood pressure complicates about 10% of all pregnancies. There are several different types of high blood pressure during pregnancy and they range from mild to serious. The forms of high blood pressure during pregnancy include:
Chronic hypertension: High blood pressure which is present before pregnancy.
Gestational hypertension: High blood pressure in the latter part of pregnancy.
Preeclampsia: This is a dangerous condition that typically develops in the latter half of pregnancy and results in hypertension, protein in the urine and generalized swelling in the pregnant person. It can affect other organs in the body and cause seizures .
Chronic hypertension with superimposed preeclampsia: Pregnant people who have chronic hypertension are at increased risk for developing preeclampsia.
Your provider will check your blood pressure regularly during prenatal appointments, but if you have concerns about your blood pressure, be sure to talk with your provider.
How Do I Know If I Have High Blood Pressure
Theres only one way to know if you have high blood pressure: Have a doctor or other health professional measure it. Measuring your blood pressure is quick and painless.
Talk with your health care team about regularly measuring your blood pressure at home, also called self-measured blood pressure monitoring.
High blood pressure is called the silent killer because it usually has no warning signs or symptoms, and many people do not know they have it.
Ash Stage 3 Hypertension: Overt Cvd
Untreated individuals with ASH stage 3 hypertension usually have sustained resting BP levels 140/90mmHg, and marked elevations to levels > 160/100mmHg are common. All individuals with clinical evidence of overt target organ damage or CVD are included in this category, as well as those who have already sustained CV events, regardless of BP levels.
ASH stage 3 hypertension is an advanced stage of the hypertensive continuum in which overt target organ damage is demonstrable and CV events may have already occurred or are imminent. Aging and the persistence of other identifiable risk factors together with a BP elevation, if present, exacerbate and accelerate the risk of morbidity and mortality. Management strategies for this phase of hypertension are well described.6 Reaching this stage of hypertension means that damage to target organs as well as overt vascular, cardiac, and renal disease have already occurred or are imminent. Vigorous attempts at BP lowering as well as aggressive management of other CVD risk factors must be started promptly and sustained in these individuals to prevent or delay further progression.
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What Do Blood Pressure Numbers Mean
Blood pressure is measured using two numbers:
The first number, called systolic blood pressure, measures the pressure in your arteries when your heart beats.
The second number, called diastolic blood pressure, measures the pressure in your arteries when your heart rests between beats.
If the measurement reads 120 systolic and 80 diastolic, you would say, 120 over 80, or write, 120/80 mmHg.
How Can You Reduce Your Risk Of High Blood Pressure
Fortunately, there are certain things you can do to help reduce your risk of developing high blood pressure. These include the following:
- Eat right: A healthy diet is an important step in keeping your blood pressure normal. The DASH diet emphasizes adding fruits, vegetables and whole grains to your diet while reducing the amount of sodium. Since its rich in fruits and vegetables, which are naturally lower in sodium than many other foods, the DASH diet makes it easier to eat less salt and sodium.
- Keep a healthy weight: Going hand-in-hand with a proper diet is keeping a healthy weight. Since being overweight increases your blood pressure, losing excess weight with diet and exercise will help lower your blood pressure to healthier levels.
- Cut down on salt: The recommendation for salt in your diet is to have less than 1,500 milligrams of sodium a day . To prevent hypertension, you should keep your salt intake below this level. Don’t forget that most restaurant foods and many processed and frozen foods contain high levels of salt. Use herbs and spices that do not contain salt in recipes to flavor your food do not add salt at the table.
- Keep active: Even simple physical activities, such as walking, can lower your blood pressure .
- Drinkalcoholin moderation: Having more than one drink a day and two drinks a day can raise blood pressure.
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Evidence Linking Osa To Htn
Animal models of OSA have provided strong evidence for a causal relationship of OSA in the development of HTN. Studies in humans have demonstrated that patients with OSA have an increased BP and a higher incidence of HTN. This relationship appears to be the strongest in patients who report excessive daytime somnolence which may underscore the significance of sleep architecture disruption in abnormal BP control. Conversely, patients with essential HTN are more likely to suffer from sleep-disordered breathing, and this association is particularly evident in hypertensive patients who are resistant to conventional BP-lowering pharmacotherapy. Up to 84% of subjects with refractory HTN may have previously undiagnosed OSA.
Figure 2. Odds ratios for hypertension after four years observation according to API. Odds adjusted for baseline hypertension status, non-modifiable risk factors, habitus, and weekly alcohol and cigarette use. Peppard PE et al. The New England Journal of Medicine.
Figure 3. Mean ambulatory BP profile before and after treatment. Bars are SEs for every 30-min. period, synchronized to wake and sleep times. Pepperell JCT et al. Lancet 2002 with permission.
Rates Of High Blood Pressure Control Vary By Sex And Race
Uncontrolled high blood pressure is common however, certain groups of people are more likely to have control over their high blood pressure than others.
- A greater percentage of men have high blood pressure than women .3
- High blood pressure is more common in non-Hispanic black adults than in non-Hispanic white adults , non-Hispanic Asian adults , or Hispanic adults .3
- Among those recommended to take blood pressure medication, blood pressure control is higher among non-Hispanic white adults than in non-Hispanic black adults , non-Hispanic Asian adults , or Hispanic adults .3
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New Acc/aha High Blood Pressure Guidelines Lower Definition Of Hypertension
High blood pressure should be treated earlier with lifestyle changes and in some patients with medication at 130/80 mm Hg rather than 140/90 based on new ACC and American Heart Association guidelines for the detection, prevention, management and treatment of high blood pressure.
The new guidelines the first comprehensive set since 2003 lower the definition of high blood pressure to account for complications that can occur at lower numbers and to allow for earlier intervention. The new definition will result in nearly half of the U.S. adult population having high blood pressure, with the greatest impact expected among younger people. Additionally, the prevalence of high blood pressure is expected to triple among men under age 45, and double among women under 45, the guideline authors note. However, only a small increase is expected in the number of adults requiring antihypertensive medication.
“You’ve already doubled your risk of cardiovascular complications compared to those with a normal level of blood pressure,” said Paul K. Whelton, MB, MD, MSc, FACC, lead author of the guidelines. “We want to be straight with people if you already have a doubling of risk, you need to know about it. It doesn’t mean you need medication, but it’s a yellow light that you need to be lowering your blood pressure, mainly with non-drug approaches.”
Blood pressure categories in the new guideline are: