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Hypertension

Introduction:
Hypertension, or high blood pressure, is a serious condition that affects about one in three American adults, and two-thirds of people over age 65. Blood pressure is the force of blood as it pumps through your arteries. The more blood your heart pumps and the narrower your arteries are, the higher the blood pressure. Normal blood pressure is defined as an average systolic blood pressure of 120 mm Hg and an average diastolic pressure of 80 mm Hg. Systolic pressure measures the pressure in arteries when your heart beats. Diastolic pressure measures the pressure between beats. Hypertension is defined as an average systolic blood pressure above 140 mm Hg, a diastolic blood pressure above 90 mm Hg, or both. High blood pressure increases the risk of heart disease and stroke, the leading causes of death among Americans. It is called the "silent killer" because you usually don't have any symptoms when your blood pressure is too high. Hypertension, high cholesterol, and obesity are the biggest contributors to atherosclerosis (hardening of the arteries). It is important to talk to your doctor about how to lower your high blood pressure. In some cases, making changes in diet and exercise habits can get blood pressure under control. In other cases, you may need medications.

Signs and Symptoms:


Most people who have high blood pressure do not know they have it because they have no symptoms. Occasionally, some people may have a mild headache when their blood pressure is high. Advanced cases of hypertension may produce the following symptoms:

Severe headache Confusion Nausea Visual disturbances Seizure

Causes:
There are two major types of hypertension: essential (primary) and secondary. Primary hypertension is by far the most common, making up more than 95% of all cases. Scientists don't know what causes primary hypertension, but a combination of factors may be involved, including:

Genes for high blood pressure Low levels of nitric oxide, a naturally occurring substance that makes blood vessels dilate Insulin resistance

Obesity

Secondary hypertension has an underlying cause, which may include:


Kidney disorders Endocrine disorders, such as Cushing syndrome Obstructive sleep apnea (where breathing stops momentarily while you are asleep because your airway is obstructed) Chronic heavy alcohol use Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin, Advil) and naproxen (Aleve) Certain medications, including some birth control pills, pseudoephedrine, hormone replacement therapy, and steroids Use of cocaine, nicotine, or other stimulants or the herb licorice (Glycyrrhiza glabra) can cause or worsen existing hypertension.

Risk Factors:
The following factors increase an individual's risk for high blood pressure:

Being overweight Not getting enough exercise Having a family history of hypertension Being African-American Abusing alcohol or smoking High sodium (salt) intake Stress Chronic conditions such as diabetes, kidney disease, or high cholesterol.

Diagnosis:
Each time your heart beats, or contracts, it pumps blood into your arteries. The pressure of the blood against the artery walls is called systolic blood pressure, when blood pressure is at its maximum. When your heart is at rest, between beats, the blood pressure falls, which is known as the diastolic pressure. A person with hypertension has an average systolic blood pressure above 140 mm Hg and/or a diastolic blood pressure above 90 mm Hg (usually written as 140/90). To diagnose hypertension, your doctor will measure your blood pressure using an inflatable cuff and a stethoscope. If blood pressure is high, your doctor will check your pulse rate, examine your neck for swollen veins or an enlarged thyroid gland, listen to your heart for murmurs, and examine the eyes for damaged blood vessels in the retina. If your doctor suspects hypertension, you may be asked to measure your blood pressure at home or to come back for another office appointment. Additional laboratory and blood tests can help determine if it is secondary or primary hypertension.

Preventive Care:
Studies suggest that the following actions can help prevent hypertension: Maintaining a proper weight According to several large-scale, population-based studies, being overweight is one of the strongest predictors that you will develop high blood pressure. That is true for adolescents and young adults as well as adults. Maintaining a proper weight is one of the most effective things you can do to prevent hypertension. If you are overweight, ask your doctor or nutritionist about safely losing pounds by eating a balanced diet. Reducing salt intake Although how each person responds to salt in the diet varies, cutting back on salt can help lower blood pressure for some. The current recommended amount of sodium for healthy people is no more than 2,400 mg per day, and less is better. Most Americans get much more than that from canned, processed, and restaurant foods. Increasing physical activity Several studies suggest that sedentary people may be at higher risk for developing hypertension. According to some studies, men who lead physically active lives can reduce their risk of developing hypertension by 35 - 70 %. Regular exercise also helps keep your weight in check. Aim for at least 30 minutes of moderate exercise -- such as walking -- every day. Limiting alcohol consumption Studies suggest that people who consume three or more alcoholic beverages per day increase their risk for developing hypertension. If you drink alcohol, limit your intake to one drink per day if you are a woman and two if you are a man. Eating a diet rich in fruits and vegetables Most American eat diets that are too high in saturated fat and lack the right amount of fruits and vegetables. The Dietary Approaches to Stop Hypertension (DASH) diet, which recommends fruits, vegetables, whole grains and low-fat dairy, is often suggested for those who have hypertension. It also can help people who are at risk of hypertension.

Treatment:
The goal in treating hypertension is to reduce the risk of serious complications, including heart disease and stroke, by getting blood pressure under control. Ideally that means reducing blood pressure to 120/80 mm Hg, but even a partial lowering of blood pressure

brings benefits. You may need prescription medications to treat hypertension, but lifestyle changes -- including diet, exercise, and relaxation -- are also necessary. Often, in the early stages of hypertension when blood pressure elevation is mild, your doctor may recommend lifestyle modifications alone for 6 - 12 months. After this time, if blood pressure is still high, you will probably need medication.

Medications
Medication is recommended for people with sustained systolic pressure above 160 mm Hg or diastolic pressure above 100 mm Hg. Several medications are available to treat hypertension. Ten percent of hypertension patients may need as many as three drugs to control their condition. Some of the most commonly prescribed medications include: Diuretics Diuretics help the kidneys get rid of sodium and water from the body. This decreases the volume of blood in the body and lowers blood pressure. There are three types of diuretics: thiazide, loop, and potassium-sparing.

Thiazide diuretics -- may lower potassium levels and may increase cholesterol and blood sugar. Hydrochlorothiazide is the most common of these. Loop diuretics -- also tend to lower potassium levels. Furosemide (Lasix) and bumetanide (Bumex) are loop diuretics. Potassium-sparing diuretics -- do not lower potassium. Amiloride (Midamor) and triamterene (Maxzidel) are in this class.

Other medications Other medications used to treat hypertension include:

Beta blockers -- slow down the heart rate (reducing the workload on the heart) and reduce stress hormones in the body (which allows blood vessels to relax). Beta blockers alone don't work as well in African-Americans, but are effective when combined with a thiazide diuretic. Beta blockers include: o Atenolol (Tenormin) o Bisoprolol (Zebeta) o Metoprolol (Lopressor, Toprol XL) o Nadolol (Corgard) o Timolol (Blocadren) o Nebivolol (Bystolic) Angiotensin-converting enzyme (ACE) inhibitors -- block the chemical angiotensin from forming in the body, helping prevent blood vessels from

narrowing. As blood vessels relax, blood pressure is lowered. Like beta-blockers, ACE inhibitors along don't work as well in African Americans, but are effective when combined with a thiazide diuretic. ACE inhibitors include: o Captopril (Capoten) o Benazepril (Lotensin) o Enalapril (Vasotec) o Lisinopril (Prinivil, Zestril) o Fosinopril (Monopril) o Ramipril (Altace) o Perindopril (Aceon) o Quinapril (Accupril) o Moexipril (Univasc) o Trandolapril (Mavik) Calcium-channel blockers -- relax blood vessels and lower blood pressure by blocking calcium from entering heart cells and arteries. Side effects may include constipation, nausea, and headache. Grapefruit juice interacts with some calciumchannel blockers, so avoid it if you take these drugs. Calcium-channel blockers include: o Amlodipine (Norvasc) o Bepridil (Vascor) o Diltiazem (Cardizem) o Felodipine (Plendil) o Nifedipine (Adalat, Procardia) o Nicardipine (Cardene) o Verapamil (Calan, Isoptin) Angiotensin II receptor blockers (ARBs) -- block the effects of the chemical angiotensin in the body, lowering blood pressure. ARBs are sometimes used when a person cannot take ACE inhibitors. These drugs include: o Candesartan (Atacand) o Eprosartan (Tevetan) o Irbesartan (Avapro) o Losartan (Cozaar) o Telmisartan (Mycardis) o Valsartan (Diovan)

Complementary and Alternative Therapies


Whether or not your doctor prescribes medication to lower your blood pressure, you will need to make changes in your diet and lifestyle. A comprehensive treatment plan for treating hypertension may include a range of complementary and alternative therapies. Ask your team of health care providers about the best ways to incorporate these therapies into your overall treatment plan. Do not stop taking your medication without your doctor's supervision. Abruptly stopping some types of blood pressure medications can cause blood pressure to rise to extremely high levels, possibly resulting in stroke, hart

attack, or other medical complications. Always tell your health care provider about the herbs and supplements you are using or considering using. The following lifestyle changes will help treat hypertension:

Lose weight if you need to. Losing even a few pounds can help bring down your blood pressure. Stay physically active. Get 30 minutes of exercise each day. You can break it up into 10 minute-increments throughout the day and still get the benefit. If you are just starting, begin slowly and work your way up to 30 minutes a day. Walking is an easy way to get exercise. If you have been diagnosed with high blood pressure, talk to your doctor before starting an exercise program. If you smoke, quit. Talk to your doctor if you need help quitting.

Nutrition and Dietary Supplements


Eating a healthy diet that's low in saturated fat and sodium can help lower blood pressure. Following these nutritional tips may help:

Try the DASH diet, which emphasizes eating fresh fruits and vegetables, whole grains, and low-fat dairy, and keeping sodium intake low. Try to eliminate potential food allergens, including dairy, wheat (gluten), corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities. Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes) and vegetables (such as squash and bell peppers). Eat foods high in B-vitamins and calcium, such as almonds, beans, whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables. Avoid refined foods, such as white breads, pastas, and especially sugar. Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy), or beans for protein. Use healthy oils in foods, such as olive oil or vegetable oil. Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine. Drink 6 - 8 glasses of filtered water daily.

Some vitamins and supplements may help lower blood pressure, although scientific evidence is mixed. Be sure to talk to your doctor before taking any vitamins or supplements, especially if you take medication for high blood pressure.

Omega-3 fatty acids, such as fish oil, help reduce cholesterol levels, and may help reduce blood pressure. Most studies that showed an effect on blood pressure used an extremely high dose of fish oil, and it's not clear whether lower doses would have the same effect. At high doses, fish oil can cause an increased risk of bleeding, especially if you are also taking an anticoagulant (blood-thinner) such as

warfarin or daily aspirin. Talk to your doctor about whether taking fish oil supplements is a right for you. Adding more fish to your diet is safe. The American Heart Association recommends eating fish twice a week. Cold-water fish, such as salmon or halibut, are good sources of omega-3 fatty acids. Coenzyme Q10, 100 mg per day, was shown to reduce blood pressure slightly in several studies. Magnesium citrate, 350 - 500 mg daily, may help regulate blood pressure slightly, although evidence is mixed. People who take potassium-depleting diuretics also may have lower levels of magnesium. Ask your doctor if a magnesium supplement is right for you. Calcium, 1,000 mg per day, may help lower blood pressure slightly, although evidence is mixed. More studies are needed. L-arginine, 1 -2 gm three times daily, may help blood vessels dilate, lowering blood pressure. Potassium, by prescription, may lower blood pressure slightly. Not all studies agree, and the amount of potassium used can only be obtained through your doctor. People who take potassium-sparing diuretics should not take potassium supplements. Talk to your doctor before taking any potassium supplement, even at a low dose.

Herbs
Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted. Talk to your doctor before taking any herbs to treat hypertension, especially if you already take medication to control blood pressure.

Achillea wilhelmsii, 15 - 20 drops of tincture two times per day, may help lower blood pressure, according to one double-blind study. However, more research is needed. Hibiscus (Hibiscus sabdariffa) tea, 2 tablespoonfulls of dried herb steeped in 1 cup of water, taken one time per day, helped lower blood pressure according to one study. Reishi mushroom (Ganoderma lucidum), 150 - 300 mg two to three times daily, may help lower blood pressure, although evidence is weak. You may also take a tincture of this mushroom extract, 30 - 60 drops two to three times a day. Talk to your doctor before taking reishi, as it can interact with other medications and may increase the risk of bleeding. Garlic (Allium sativum), standardized extract, 400 mg two to three times daily, may help lower blood pressure slightly.

Homeopathy
Few studies have examined the effectiveness of specific homeopathic remedies. A professional homeopath, however, may recommend one or more of the following treatments for hypertension based on their knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person' s constitutional type -- your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

Argentum nitricum -- for people whose blood pressure increases as they feel anxious or nervous. They may be warm-blooded and subject to claustrophobia and strong carvings for sweets and salty food. Aurum metallicum -- for people who are serious in demeanor and who concentrate on their career. There is a general tendency to feel worse at the end of the day. They may have a strong desire for alcohol, and feel angry or depressed when they believe they have failed. Calcarea carbonica -- for people who often feel tired and overwhelmed when sick. They may have clammy hands and feet and often feel chilly. They may crave sweets and eggs, and may be overweight. Lachesis -- for people who are often talkative and agitated, with a fear of disease. They may be suspicious and jealous, and feel tightness in the chest. They feel worse after sleeping, and may not be able to tolerate clothing around their necks. Nux vomica -- for people who are impatient, don't like to be delayed, and are ambitious and driven. They may have a strong desire for coffee and other stimulants, and may be sensitive to light.

Acupuncture
Several studies of small numbers of people with hypertension showed a reduction in blood pressure with the use of acupuncture. However, more studies are needed to see whether there is any real benefit.

Massage and Physical Therapy


Massage may help people with hypertension cope with stress. One study found that people with hypertension who receive massage showed reductions in blood pressure and steroid hormones, an indicator of stress. Although more studies are needed to evaluate the long-term safety and effectiveness of massage, people with hypertension who tend to have high levels of stress in their lives may benefit from massage therapy.

Mind-Body Medicine
Although the association between stress and hypertension is complex and somewhat controversial, many believe that relaxation techniques may be helpful in reducing stress.

The best evidence of a relaxation technique that reduces blood pressure is for transcendental meditation (TM).

Other Considerations:

Pregnancy
Your doctor will monitor your blood pressure frequently while you are pregnant, because some women develop hypertension for the first time while pregnant. If this occurs, you may need medication. A condition known as preeclampsia, which involves high blood pressure during pregnancy, can be life threatening. In preeclampsia, high blood pressure occurs along with other symptoms and signs, such as swelling of the ankles and legs, blurred vision, liver test abnormalities, and protein in the urine.

Warnings and Precautions


Avoid fish high in mercury, which may increase blood pressure. The use of cocaine, nicotine, or licorice (Glycyrrhiza glabra) can cause or worsen hypertension. Caffeine can exacerbate high blood pressure.

Prognosis and Complications


If left untreated, hypertension can cause several serious complications, including:

Stroke Coronary artery disease and heart attack Congestive heart failure Kidney disorder Disorders of the retina, which can ultimately lead to blindness Impotence in men and decreased orgasm in women Memory impairment and dementia

Fortunately, there are several treatment options for hypertension. Comprehensive treatment, including lifestyle modifications and blood pressure medications, usually controls high blood pressure and results in a generally good prognosis.

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