Preventive Medicine

Hypertension

Muhammad Usman Naeem
Muhammad Usman Naeem
July 30, 2024 10 Mins Read
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Hypertension

Muhammad Usman Naeem, Abdul Ghani MD

Disease insights
In 2024, the American Heart Association reported that over 122 million individuals, which is nearly half of Americans aged 20 and above, have hypertension (HTN) [1]. The definition of HTN currently specifies that systolic blood pressure (SBP) should be higher than 140 mm Hg and/or diastolic blood pressure (DBP) should exceed 90 mm Hg [2]. HTN has been extensively studied over the last few decades and is the first disease in a chain reaction that leads to Stroke (CVA), Renal failure (CKD), Coronary heart disease (CHD), Atrial fibrillation, or Hypertensive encephalopathy. HTN is often without symptoms and is typically diagnosed incidentally during blood pressure checks. However, in some instances, symptoms of end-organ damage such as chest pain, dizziness, shortness of breath (SOB), acute pulmonary edema, blurred vision, abnormal heart rhythm, and hypertensive encephalopathy may be present at the time of diagnosis. According to WHO, it is estimated that more than 1.2 billion individuals between the ages of 30 and 79 worldwide suffer from HTN [3].
HTN at a global stage
Franklin Delano Roosevelt (FDR) led the United States through the Great Depression and the Second World War. Ten years into his Presidency, FDR developed HTN around 1940 [4]. During World War II, his blood pressure (BP) began to rise with no medication available to control it. Despite Russia fighting alongside America against Japan and Germany, they sought to occupy Eastern Europe which included Poland, Hungary, and half of Germany. During the Yalta Conference between Feb 4-11, 1945, FDR addressed his nation on the radio. People could hear him wheezing and struggling to breathe. He was in heart failure (HF), with his BP reaching 250/150. While his HF was diagnosed and treated, nothing could be done to control his HTN. FDR had hoped to negotiate with Russia to secure freedom in Eastern Europe, but the fate of these countries was sealed in the next 44 years by one person’s HTN.
Common causes of HTN
1- Obesity
For over 50 years, the definition of HTN has remained unchanged: “It is high BP and, if left untreated, can lead to a stroke.” It is the number that we are interested in. It is the pressure we treat. However, HTN is a complex systematic disease. It affects the body’s smallest blood vessels, known as capillaries. Capillaries become damaged due to inflammation, which is caused by food or obesity [5]. Obesity, specifically belly fat, is the primary cause of inflammation. The fat in the belly is compressed due to the limited space in the abdominal area. Due to compression, blood flow through vessels is difficult, causing circulatory hypoxia (inadequate oxygen), signaling something is wrong. This triggers the release of many inflammatory chemicals as if the body is fighting off an intruder, but there’s no intruder – it’s just the body dealing with the inflammatory chemicals. These inflammatory chemicals not only damages capillaries but also harm the pancreas, and contribute to the formation of plaques with the help of low-density lipoprotein (LDL) [6]. Inflammation can also lead to the formation of scar tissue in the heart muscle, causing the heart to become stiff, thinned out, stretched, and eventually enlarged, leading to weakness of the heart. When heart muscles become stretched and stiff, they can damage the cardiac electrical conduction system [7]. Cardiac Conduction transmits electrical signals throughout the heart to regulate its pumping function by coordinating the contraction of the heart’s chambers. However, in stretched heart muscles, this sequence is disrupted, leading to an irregular heartbeat, which can lead to stroke.

2- Salt
Increasing salt intake has long been linked to an elevated risk of developing HTN. Salt makes the body retain water. Consuming excessive amounts of salt results in increased pressure on the blood vessel walls and elevated blood pressure also known as fluid retention [8]. Genetic predisposition to salt response, known as salt-sensitive hypertension (SS-HT), is another factor in the development of essential HTN. Approximately 50% to 60% of patients are sensitive to salt and thus are more likely to develop HTN [9]. In SS-HT, the body’s pressure-natriuresis mechanism is compromised, preventing the kidneys from excreting sufficient sodium when the consumption of salt is high. This can cause blood pressure to rise by more than 10%.

3- Alcohol
HTN due to alcohol consumption is usually found in middle-aged men. Most of these patients are diagnosed at stage 2 HTN (140/90 mm Hg) or higher and are at high risk for CV or CKD disease. Prolonged alcohol consumption leads to stenosis which makes it harder for the heart to circulate blood throughout. Furthermore, alcohol raises the body’s renin levels. Renin causes blood vessels to constrict and decrease the amount of fluid in urine [10]. Smaller blood vessels and higher fluid levels contribute to HTN.
4- Sleep Apnea
Sleep apnea especially in older patients is associated with higher occurrences of HTN [11]. Patients experience difficulty sleeping due to excess fat around the neck obstructing the airflow in the throat and sudden decreases in blood oxygen levels. This causes them to stop breathing for a few seconds and then breathe faster to compensate, leading to snoring. Sometimes, their partner may notice that they stop breathing in the middle of the night. Low oxygen and difficulty breathing signal the heart to beat faster, further raising BP [11]. A sleep study also known as polysomnography can be used to diagnose sleep apnea.

5- Cushing’s syndrome
Overactive adrenal glands producing high cortisol is another common reason for elevated BP in young female patients. Cortisol promotes the kidneys to reabsorb sodium and enhances the sensitivity of blood vessels to angiotensin II and catecholamines causing HTN. The overnight dexamethasone suppression test can be used to diagnose Cushing’s syndrome [12]. Patient should take 2 tablets of 0.5 mg dexamethasone at 11 pm, and a serum cortisol test should be performed at 8 am the next day. Taking dexamethasone should lower adrenocorticotropic hormone (ACTH) levels and result in decreased cortisol levels. Excessive production of ACTH by the pituitary will have an atypical response to the low-dose test.
Diagnosis
The diagnosis of HTN depends on factors such as age, medical history, diet, associated symptoms, and mental health of the patient. Age and medical history particularly play a vital role in selecting the appropriate diagnostic tool to determine the severity of HTN. The patient’s mental health, diet, and alcohol consumption are discussed followed by at least two office measurements on at least two separate occasions to diagnose HTN [13]. The patient should sit quietly for at least 5 minutes before checking the BP. To understand the severity of HTN following tests and imaging are performed in most cases:
  1. Blood workups including complete metabolic panel (CMP), complete blood count (CBC), lipids, and HbA1c are performed.
  2. Urine albumin to creatinine ratio (UACR).
  3. 12 lead ECG (to document cardiac rate, rhythm and left ventricular hypertrophy).
  4. Imaging including coronary angiogram, carotid Doppler ultrasound, and echocardiography if ECG is abnormal.
Preventing hypertension
Preventing HTN at an early age is very crucial. If you have a family history of CV, HTN, or CKD that is a good sign to keep track of your BP. Even if you don’t have a family history of these conditions, consuming a high-salt diet and alcohol can lead to essential HTN. Obesity and genetic factors like hypercortisolism as mentioned above also increase the chances of HTN, especially in individuals with poor diets. Hence, taking steps to prevent HTN early on is vital for reducing the risk of chronic diseases. Here are some lifestyle modifications that should help most patients prevent hypertension:
1- Case of exercise
People are sedentary and overweight. Obesity is very common and its derivatives are Diabetes mellitus (DM), CVD, and HTN. Despite these challenges, people are living longer than they did a century ago, thanks to advancements such as childhood vaccinations, antibiotics, and clean water. However, when it comes to exercise, it often seems like extra work for many busy Americans, leading them to rely on high-calorie, low-nutrition, high-salt, and high-fat fast food high-density lipoprotein (HDL), to prevent artery blockages [14]. An effective exercise routine should include 30 minutes of walking a day, 5 days a week.

2- Eat vegetables and baked fish
Baked fish contains omega-3 fatty acids, which reduce inflammation and prevent capillaries from dying [15]. Green vegetables like spinach are high in potassium, which helps lower blood pressure by relaxing the walls of blood vessels and eliminating sodium from the body [16]. A healthy diet includes 4–5 servings of vegetables and up to 6 servings of lean fish (each serving being 1 ounce).

3- Cut down on Alcohol
As mentioned earlier heavy alcohol consumption is one of the leading causes of HTN in middle- aged male patients. Regardless of the type of alcohol consumed, research shows that individuals who heavily consume wine or beer are all susceptible to HTN [17]. Cutting down alcohol can reduce systolic pressure by approximately 5.6 mm Hg and diastolic pressure by about 4 mm Hg [18].

4- Get high-quality sleep
Ensure quality sleep at night by establishing a calming environment. Take naps during the day and limit nap time to 30 minutes. Patients with sleep apnea also need to limit caffeine intake and avoid sedative medication.
Treatment
Diagnosing and treating HTN at an early stage is very crucial to reduce the risk of developing chronic illness. It’s crucial to emphasize that treatment of HTN, without incorporating proper diet and exercise, is ineffective and leads to more complications. I have seen patients on 2-3 different blood pressure medications, yet their BP remains high due to non-adherence to the treatment and poor diet.

To effectively treat HTN, it is advised to start treatment with a low dose of an ACEi or an ARB and then gradually increase the dosage before instituting a low-dose calcium blocker [19]. If a patient starts on a calcium blocker, such as amlodipine, along with a statin, it is important to give both drugs 12 hours apart. Amlodipine should be prescribed in the morning, while statin in the evening due to potential interactions between the two drugs [20]. In patients with a higher risk of CVD, a beta blocker may be introduced as a third drug. Another approach would be to start the patient on two or more medications simultaneously, such as an ACEi or an ARB along with a calcium channel blocker. Prescribe ACEi or an ARB in the morning, while calcium channel blocker in the evening.

Both approaches have been proven successful if the patient adheres to the treatment and diet. It is also crucial to follow up with patients to review for complications. Patients also need to monitor their BP at home.
Citation list
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Muhammad Usman Naeem
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Muhammad Usman Naeem

Muhammad Usman Naeem is a pre-medical student with a Bachelor’s degree in Biomedical Sciences from the University of South Florida. His primary interests are in neuro-oncology and preventive medicine. Muhammad is actively researching the role of MR1 - Major Histocompatibility Complex Class I-related gene in cancer immunotherapy. Additionally, he has experience working with elderly patients, managing a range of chronic diseases including diabetes, hypertension, and cardiovascular disease.

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