The Pressure When the Heart Beats

With every beat of the heart, blood is pumped to the organs and tissues of your body. As the blood moves around the body, it puts pressure on the walls of the arteries. When the pressure becomes uncontrolled, it can lead to high blood pressure.

Hypertension (high blood pressure) is a detrimental, wide-spread disease affecting the lives of many patients worldwide. The oracle ranks this disease in a high-impact category for patients of African ancestry. It is essential to consider the harmful effects of uncontrolled hypertension and the consequences leading to poor quality of life and a decline in longevity.

Etiology:

Hypertension (HTN) is a multifactorial disease involving biological, environmental, and genetic factors. Also, pre-existing comorbidities significantly contribute to high blood pressure. Hypertension is defined via a binary classification:

I. Essential, primary hypertension is high blood pressure in which there is no apparent etiology. Primary hypertension accounts for the majority of all hypertensive cases. It has been proposed that primary hypertension is polygenic, and many genetic factors may contribute to its pathophysiology; however, more research is undergoing to elucidate the actual genes that control the hallmarks of essential hypertension.1

II. Secondary hypertension is caused by an underlying condition such as kidney disease, obstructive sleep apnea, excess production of aldosterone (a steroid hormone that regulates salt and water in the body), and medications.1 It accounts for only 10% of hypertensive cases.2 This form of hypertension is usually reversible and requires the management of the pre-existing condition.

Common Risk Factors1:

• Aging

• Obesity

• Race

• Family History

• High dietary salt intake

• Low potassium, magnesium, and calcium intake

• Psychosocial Stress3

• Diabetes

• High alcohol consumption

• History of cigarette smoking and second-hand smoke

Diagnosis:

• Aneroid manometer

• Electronic home blood pressure monitor attached to an arm cuff

Table 1: Diagnostic measurement of BP in Adults2

Blood pressure reading appears in two numbers: SBP (when the heart beats) is the upper value, and DBP (when the heart relaxes between beats) is the lower value. DBP: diastolic blood pressure, SBP: systolic blood pressure, mmHg: millimeters of mercury

Treatment:

First-line treatment can be used as monotherapy or in combination1:

• Thiazide-type diuretics

• Angiotensin-converting enzyme inhibitors (ACEIs)

• Angiotensin receptor blockers (ARBs)

• Calcium channel blockers (CCBs)

ACEIs and ARBs should not be combined in the same patient. It is strongly advised in black patients to initiate a thiazide-type diuretic or a CCB, alone or in combination. The ALLHAT study outcomes showed a decrease in the efficacy of ACEIs and ARBs among African Americans.4 The 2017 ACC/AHA HTN guideline recommends ACEIs or ARBs as monotherapy in this population if there is a compelling indication for chronic kidney disease.1

Table 2: Indications for Specific Drug Classes5

CVD: cardiovascular disease

Some alternative drug classes are β-blockers and aldosterone antagonists. These agents are typically prescribed as second-line therapy; however, they can be recommended initially because of pre-existing comorbidities. Patients with hypertensive crisis are administered intravenous antihypertensive drugs in the ICU.

Standard BP Goal in Adults1: <130/80

Table 3: BP Goals in Special Population1

*The elderly patient does not have Chronic Kidney Disease (CKD) or diabetes.

Management:

To control high blood pressure, it is essential to remain compliant and adhere to a medication regimen. Patients can also implement these lifestyle modifications:

• Maintain a healthy weight: the ultimate goal is to achieve ideal body weight; however, aim for at least a 1 kg reduction for overweight adults7

• Incorporate a healthy diet plan: the DASH dietary pattern consists of a diet rich in fruits, vegetables, low-fat dairy products, and whole grains (rice, pasta, and bread). Enhance dietary potassium and magnesium intake by eating broccoli, carrots, and sweet potatoes

• Reduce intake of dietary sodium: the optimal goal is to consume <1500 mg/day

• Combine the DASH regimen with regular aerobic physical activity: brisk walking for at least 30 minutes each day

• Moderate alcohol intake:

Men: <2 drinks/day

Women:<1 drink/day

1 drink = 1/2 oz or 15 mL ethanol (e.g., 12 oz beer, 5 oz wine)

• Smoking cessation

The NIH promoted the DASH dietary regimen, and it is defined as Dietary Approaches to Stop Hypertension.8

Complications9 :

• Heart attack

• Kidney damage

• Heart failure

• Stroke

These conditions usually arise when high blood pressure remains uncontrolled.

References:

1. Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Himmerlfarb CD, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018; 71(19): e127-e248.

2. Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension. 2008; 51: 1403-19.

3. Spruill TM. Chronic Psychosocial Stress and Hypertension. Curr Hypertension Rep. 2010; 12: 10-16

4. Wright JT Jr, Harris-Haywood S, Pressel S, et al. Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2008; 168: 207-17.

5. National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; 2003.

6. Qaseem Am Wilt TJ, Rich R, Humphrey LL, Frost J and Forciea MA. Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets. A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2017; 166(6): 430-437.

7. Neter JE, Stam BE, Kok FJ, et al. Influence of weight reduction on blood pressure: a meta-analysis of randomized controlled trials. Hypertension. 2003; 42: 878-84.

8. National Heart, Lung, and Blood Institute. Your Guide to Lowering Your Blood Pressure With DASH- How Do I Make the DASH? National Heart, Lung, and Blood Institute; 2006.

9. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report from the Panel Members Appointed to the Eighth Joint National Committee (JNC8). JAMA. 2014; 311(5): 507-520.

Cover Image created by Jessica Lewis