Hypertension a serious health threat

Dr Sashi Acharya




Hypertension is a major health issue as well as one of the prominent health challenges all through the world. U.S. alone has as many as 60 million people (above the age18 and older) suffering from high blood pressure. Both developed and developing countries are equally pressing needs for providing awareness as well as medical advice making both the young and aged conscious of the so-called silent killer disease the hypertension. Distant foresightedness assures us the firm belief that in near future by the year 2025 almost three quarters of the world's population mainly of the developing countries may be victimized to hypertension. Most of the people with high blood pressure are unaware that they have high blood pressure just because hypertension usually is symptom free disease and hence not seeking medical advice in time. It is therefore called a silent killer. Longstanding, uncontrolled and left untreated hypertension resulting to heart attacks, stroke, kidney disease, and blindness is responsible for many deaths and disability every year.

Above 40% to 50% of patients with coronary heart disease has shown high blood pressure. It has recently been started to realize with new finding that high normal blood pressure (systolic pressure of 130 to 139 mm Hg, diastolic pressure of 85 to 89) is associated with an increase in the risk for cardiovascular diseases.


Types of Hypertension: There are basically two kinds of hypertension: 1) Essential hypertension when the underlying cause is unknown.2) Secondary hypertension when there is specific root cause for hypertension. In 95% of cases the cause of hypertension remains undetermined. Only in about 5% of such cases causes are identified by some underlying diseases like chronic kidney disease, tumors or other diseases of the adrenal gland, coarctation of the aorta, pregnancy, use of birth control pills, alcohol addiction, thyroid dysfunction. In secondary hypertension once the underlying cause is treated, blood pressure usually returns to normal.


Hypertension in special social groups: Hypertension embraces everybody irrespective of age, sex and of any circumstances. Below are explained about (1) Hypertension in racial and ethnic groups, (2) Hypertension in children and adolescents, (3) adult and (4) women.

 Hypertension in racial and ethnic groups: Study of hypertension in racial and ethnic group has remarkably revealed one very interesting concept. High blood pressure was more common among the African Americans in the United States affecting about 40% of the black people (see fig I), just suggesting the impact of environmental and socioeconomic factors among them Despite the treatment the target organ damage like left ventricular hypertrophy, congestive heart failure, end stage renal disease due to hypertension are more common in this race even at lower levels of blood pressure.  On the other hand the prevalence of hypertension amongst the Asian Indians in Europe or USA is the same as the white people there i.e. less than 20%. It drives us to think about the possibility of specific mode of life style including poor socioeconomic condition, poor dietary habits among the African Americans living in the States which leads to being the hypertension more common among them. Genetic factors also may play a significant role in the epidemiology, detection and management of the hypertensive African American patient.





Figure 1The prevalence of hypertension among the African Americans and white Americans.

Hypertension in children and adolescence: Hypertension traced among the children is mostly the secondary hypertension. There is no difference in blood pressure between black and white children and between male and female sex among the children younger than six years. At puberty and beyond males have a slightly higher blood pressure than females. Primary hypertension is more common among adolescents than secondary hypertension. Hypertension increase steadly with age.See fig 2 below.



Hypertension in Adults: 90%of the adults have essential hypertension. About two-thirds of people over age 65 have high blood pressure.  Isolated systolic hypertension (when systolic blood pressure is >140mm Hg and diastolic blood pressure <90 mm Hg) accounts for 65% among the adults. For most Americans, systolic blood pressure increases with age, while diastolic increases until about age 55 and then declines (see fig 2 below)


Figure 2. The prevalence of systolic hypertension rises steadily with age and declines with aging

 Hypertension in women: The prevalence of hypertension is higher in men till the age of 55 years. In women after menopause generally after 55 years there is comparatively greater chance for hypertension. Women are more prone to develop hypertension during pregnancy leading to a fatal complication like eclampsia. Besides, women taking contraceptive pills, hormone replacement therapy is more likely to develop hypertension.


The predisposing factors of Hypertension are:


        Heredity: Heredity seems to play role in the genesis of Hypertension. People with hypertensive parents are more susceptible to hypertension.

        Race: Hypertension is more common among the African Americans. They develop high blood pressure at younger age and develop early more severe hypertension related complications.

        Pregnancy: Pregnant women and women taking birth-control pills are prone to develop high blood pressure.

        Old age: With age the prevalence of hypertension increases.

         Overweight. Obese people are 2-6 times more likely to develop high blood          pressure.

        Sedentary life: It is another predisposing factor for hypertension.

        Alcohol consumption: There is evidence that those who consume more than two drinks per day are more susceptible to have hypertension the risk factor for coronary heart disease. The heavier drinkers are at higher risk for CHD

        Smoking: Nicotine the chemical in smoke stimulates adrenal glands in our body secreting a hormone adrenaline thereby constricting blood vessels and raising blood pressure.

        Oral contraceptives: Some women who take oral contraceptives fall an easy prey to high blood pressure.

        Diet:  People who take foods high in cholesterol or sodium low in potassium are more likely to be attacked by hypertension.

        Some drugs: Drugs as steroids, nonsteroids (NSAIDs), some nasal decongestants , cyclosporine, erythropoietin, tricyclic antidepressants, and monoamine oxidase inhibitors are often associated with hypertension

Complications of Hypertension: The potential complications of the inadequate treatment of hypertension are: Stroke, MI, angina, CHF, LVF, LVH, renal disease, aortic aneurism, retinopathy and accelerated malignant hypertension. LVH should be treated aggressively as the patients with LVH are at the highest risk for cardiovascular events and death.

Hypertension, its Classification and importance: The WHO/ISH defines hypertension as a systolic blood pressure ≥140 mm Hg and or a diastolic ≥90 mm Hg. Isolated systolic hypertension (ISH) is considered when systolic BP is > 140 mm Hg with a diastolic BP < 90 mm Hg. Increase in both systolic and diastolic BP may be detrimental to health making greater risk for heart attacks, strokes and kidney failure.

 Researchers came forward with many classifications with the appropriate guidelines for the treatment and understanding the problem of hypertension. Updated classifications of hypertension are given below in tables 1&2. The primary goal of treatment is to achieve the maximum reduction in the long-term total risk of cardiovascular morbidity and mortality. From the guidelines which are given in the tables below doctors attending the patients have to be cautious while deciding about the mode of treatment to the patients with hypertension and the right time to begin drug treatment to achieve the target blood pressure level below 140/90 mm Hg in an uncomplicated hypertension and <130/80 mm Hg in case of diabetic patients and patients with renal diseases. WHO/ISH blood pressure classification includes 3 grades of hypertension (Table 1).

Table 1. WHO/ISH Classification of Hypertension

Blood pressure


Grade 2

Grade 3

SBP (mm Hg)    



≥ 180

DBP (mm Hg) 





DBP, diastolic blood pressure; SBP, systolic blood pressure 


Table 2 Blood JNC VI BP classification






< 120

< 80




High normal



Stage 1



Stage 2



Stage 3

≥ 180

≥ 110





Values are for patients not taking antihypertensive drugs. ISH=Isolated systolic hypertension

Table3. WHO/ISH Stratification of Risk to Quantify Prognosis



Other Risk Factors and Disease History

Blood Pressure (mm Hg)

Grade 1
SBP 140-159
DBP 90-99

Grade 2
SBP 160-179
DBP 100-109

Grade 3
SBP >/= 180
DBP >/= 110

I No other risk factors




II 1-2 risk factors





Risk category refers to the risk of a cardiovascular event within 10 years: Low risk <15%, medium15-20%, high 20-30%

The modifiable and nonmodifiable risk factors for cardiovascular events: These are smoking, hypertension, overweight and high blood cholesterol, age (Men younger than 55 years; women 55 years or older), gender, family history of heart disease and diabetes mellitus (See fig 3) Associated clinical conditions (see table 4) include diabetes mellitus, cerebrovascular disease, heart disease, renal disease, peripheral vascular disease, and advanced retinopathy.

Figure 3 several risk factors that compound global cardiovascular risk

Prevention of Hypertension: To prevent hypertension is not an easy job. However, it is one the most modifiable cardiovascular risk factor. Life style changes can play an important role in the primary prevention of hypertension. From the table 4 we can say that life style changes are recommended to all the patients with hypertension not depending upon their stages and whether they are on antihypertensive drugs or not.

The life style changes include: 



Table 4 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. Journal of Hypertension. 2003;1:1024


Other Risk Factors and Disease History	Normal BP

Normal BP
SBP 120-129 or DBP 80-84

High Normal BP
SBP 130-139 or DBP 85-89

Mild Hypertension SBP 140-159 or DBP 90-99

Moderate Hypertension SBP 160-179 or DBP 100-109

Severe Hypertension SBP > 180 or DBP > 110

No other risk factors

No BP intervention

No BP intervention

Initiate lifestyle changes; consider drug treatment if BP is not controlled

Initiate lifestyle changes; begin drug treatment if BP is not controlled in 3 months

Begin drug treatment immediately; add lifestyle changes

1 to 2 risk factors

Initiate lifestyle changes

Initiate lifestyle changes

Initiate lifestyle changes; begin drug treatment if BP is not controlled in 3 months

Initiate lifestyle changes; begin drug treatment if BP is not controlled in 3 months

Begin drug treatment immediately; add lifestyle changes

3 or more risk factors or target-organ damage or diabetes

Initiate lifestyle changes; monitor BP frequently

Begin drug treatment; initiate lifestyle changes

Begin drug treatment promptly; initiate lifestyle changes

Begin drug treatment promptly; initiate lifestyle changes

Begin drug treatment immediately; add lifestyle changes









Associated clinical conditions

Begin drug treatment; initiate lifestyle changes

Begin drug treatment; initiate lifestyle changes

Begin drug treatment promptly; initiate lifestyle changes

Begin drug treatment promptly; initiate lifestyle changes

Begin drug treatment immediately; add lifestyle changes


Mild, moderate and severe hypertension in this table is equivalent to grade1, grade2 and grade3 hypertension of WHO/ISH classification.

Goal of medical professionals: The goal of treatment is to achieve the maximum reduction in the long-term total risk of cardiovascular morbidity and mortality and to achieve the target blood pressure level <140/90 mm Hg with uncomplicated hypertension and even lower 130/85 mm Hg for diabetic patients and 125/75 mm Hg for patients with renal insufficiency.

Conclusion: Hypertension is really a big threat to our health that may lead to heart attacks and strokes making many people die and disabled every year. My clinical practice reveals that many patients even educated people do not prefer to take medicine to control their high blood pressure with the assumption that once they start to take medicine they have to continue it lifelong. Most of them discontinue medicine against medical advice most probably due to poverty, ignorance and negligence. My experience dictates me that there is tendency of rising blood pressure level in some hypertensive patients especially in winter season. Sedentary life in winter season may lead to higher level of blood pressure. The researchers believe that almost three quarters of the world's hypertensive population will be in the developing countries by the year 2025 as cited above. The poor socio-economic condition, poor dietary habits, stress and strain are likely to be the key factors for developing hypertension in those countries. Early diagnosis, prevention and timely management of hypertension can definitely help in preventing its fatal complications and disastrous consequences. Patientís education about the hypertension truth is very important weapon to strive against hypertension.


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