eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Hypertension
Edwin Rodriguez-Cruz, MD, Assistant Professor, Department of Pediatrics, San Juan Bautista Medical School and Medical Center; Consulting Interventional/Clinical Pediatric Cardiologist, Department of Pediatrics, ospital !l Maestro and San Juan Bautista Medical Center; Consulting Interventional/Clinical Pediatric Cardiologist, Department of Cardiolog", Cardiovascular Center of Puerto #ico and the Cari$$ean and %eterans Affairs ospital and Medical Center of Puerto #ico Leig M Ettinger, MD, MS, Clinical Assistant Professor, Division of Pediatric &ephrolog", 'he Joseph M San(ari Children)s ospital, ac*ensac* +niversit" Medical Center; !drian Spitzer, MD, Professor, Department of Pediatrics, Al$ert !instein College of Medicine; Director of &I 'raining Program, Children)s ospital at Montefiore Medical Center +pdated, &ov -, .//0

"ntroduction
#ac$ground
"pertension is a ma1or cause of mor$idit" and mortalit" in the +nited States and in man" other countries2 'he prevalence of h"pertension in the +nited States for people aged 3/435 "ears is more than 6/72 'his prevalence increases to appro8imatel" -67 among those aged -6 "ears2 "pertension is no9 commonl" discovered in children2 'he long4term health ris*s to these children 9ith h"pertension ma" $e su$stantial2 :or children in the +nited States, e8tensive normative data for $lood pressure ;BP< are availa$le2 'he 'as* :orce on Blood Pressure Control in Children commissioned $" the &ational eart, =ung, and Blood Institute ;& =BI< of the &ational Institutes of ealth developed standards for BP $" using the results of >> surve"s of more than 0?,/// person visits of infants and children2 Appro8imatel" e@ual num$ers of $o"s and girls 9ere surve"ed2 'he percentile curves 9ere first pu$lished in >50- and descri$e age4specific distri$utions of s"stolic and diastolic BPs in infants and children 9ith corrections for height and 9eight2> 'he 'hird #eport of the 'as* :orce, pu$lished in >553, provides further details regarding the diagnosis and treatment of h"pertension in infants and children2. In .//A, the :ourth #eport added normative data and adapted the data to gro9th charts from the Centers for Disease Control and Prevention ;CDC< for .///2? See ./// CDC Bro9th Charts, +nited States2 In accordance 9ith the recommendations of the 'as* :orce, BP is considered normal 9hen the s"stolic and diastolic values are less than the 5/th percentile for the child)s age, se8, and height2

'he :ourth #eport introduced a ne9 categor" called preh"pertension2 'he condition is diagnosed 9hen a child)s average BP e8ceeds the 5/th percentile $ut is less than the 56th percentile2 An" adolescent 9hose BP is greater than >.//0/ mm g is also given this diagnosis, even if their reading is less than the 5/th percentile2 'his classification 9as created to align the categories for children 9ith the categories for adults from the .//? recommendations of the Seventh #eport of the Joint &ational Committee on Prevention, Detection, !valuation, and 'reatment of igh Blood Pressure2 Stage I h"pertension is diagnosed if a child)s BP is greater than the 56th percentile $ut less than or e@ual to the 55th percentile plus 6 mm g2 A child is classified as having stage II h"pertension if their BP is greater than the 55th percentile plus 6 mm g2 If the s"stolic and diastolic classifications cause a discrepanc", the child)s condition should $e categori(ed $" using the higher value2 'a$le > serves as a guide to the practicing ph"sician2 :ull ta$les from the & =BI ma" $e found at Blood Pressure 'a$les for Children and Adolescents2 'a$le >2 'he 56th Percentiles of Blood Pressure in Children and Adolescents? #P %or &irls 'y Percentile %or Heig t, (( Hg !ge, y )*t +)t > >/A/60 >/6/65 3 >>>/-A >>?/-A >. >.?/0/ >.A/0> >>.5/0A >?//06 #P %or #oys 'y Percentile %or Heig t, (( Hg )*t +)t >/?/63 >/A/60 >>A/-A >>6/-6 >.?/0> >.6/0. >?3/0>?0/0-

Pat op ysiology
BP is determined $" the $alance $et9een cardiac output and vascular resistance2 A rise in either of these varia$les, in the a$sence of a compensator" decrease in the other, increases mean BP, 9hich is the driving pressure2 Several factors regulate cardiac output and vascular resistance2 :actors that affect BP include the follo9ing,A

Cardiac output o Baroreceptors o !8tracellular volume o !ffective circulating volume Atrial natriuretic hormones Mineral corticoids Angiotensin o S"mpathetic nervous s"ndrome %ascular resistance

Pressors Angiotensin II Calcium ;intracellular< Catecholamines S"mpathetic nervous s"stem %asopressin Depressors Atrial natriuretic hormones !ndothelial rela8ing factors Cinins Prostaglandin ! . Prostaglandin I .

Changes in electrol"te homeostasis, particularl" changes in sodium, calcium, and potassium concentrations, affect some of the factors sho9n a$ove2 +nder normal conditions, the amount of sodium e8creted in the urine matches the amount ingested, resulting in near constanc" of e8tracellular volume2 #etention of sodium results in increased e8tracellular volume, 9hich is associated 9ith an elevation of BP2 B" means of various ph"sical and hormonal mechanisms, this elevation triggers changes in $oth the glomerular filtration rate and the tu$ular rea$sorption of sodium, resulting in e8cretion of e8cess sodium and restoration of sodium $alance2 A rise in the intracellular calcium concentration, due to changes in plasma calcium concentration, increases vascular contractilit"2 In addition, calcium stimulates the release of renin, s"nthesis of epinephrine, and activit" of the s"mpathetic nervous s"stem2 Increased potassium inta*e suppresses production and release of renin and induces natriuresis, decreasing BP2 'he comple8it" of the s"stem e8plains the difficulties often encountered in identif"ing the mechanism that accounts for h"pertension in a particular patient2 'his difficult" e8plains 9h" treatment is often designed to affect regulator" factors rather than the cause of the disease2 In a child 9ho is o$ese, h"perinsulinemia ma" elevate BP $" increasing sodium rea$sorption and s"mpathetic tone2

,re-uency
.nited States 'he true incidence of h"pertension in the pediatric population is not *no9n2 'his vagueness partl" stems from the some9hat ar$itrar" definition of h"pertension2 In adults, h"pertension is defined on the $asis of data from e8tensive studies that allo9ed for correlation of BP 9ith adverse events, such as heart failure or stro*e2 Similar studies have not $een performed in children, although reports from small populations of children provided compelling evidence of a relationship $et9een h"pertension and $oth ventricular h"pertroph" and atherosclerosis2 In children, the definition of h"pertension is $ased e8clusivel" on fre@uenc"4distri$ution curves for BP2 As a conse@uence, estimations of the prevalence of pediatric h"pertension lac* a scientific $asis2 'he num$er of children 9ho might $e defined as having h"pertension and the fre@uenc" 9ith 9hich the" develop complications during adulthood remains un*no9n2

"nternational Because of differences in genetic and environmental factors, incidences var" from countr" to countr" and even from region to region in the same countr"2

Mortality/Mor'idity
igh $lood pressure is a precursor of heart attac*s and stro*es; 9ell esta$lished in the adult literature2 Children 9ho are o$ese have appro8imatel" a ?4fold higher ris* for h"pertension than children 9ho are not o$ese2 In studies, as man" as A>7 of children 9ith high BP have left ventricular h"pertroph"2 6 Almost 3/7 of children 9ith persistent elevated BP had relative 9eights greater than >./7 of the median for their se8, height, and age2

Race
'he 'as* :orce on Blood Pressure Control in Children noted no differences in BP $et9een African American and Caucasian children2 o9ever, peripheral vascular resistance and sensitivit" of BP to salt inta*e appear greater in African American children than in Caucasian children, at an" age2

Se0
&o significant differences are o$served in BP $et9een girls and $o"s "ounger than 3 "ears2 :rom that age until pu$ert", BP is slightl" higher in girls than in $o"s2 At pu$ert" and $e"ond, BP is slightl" higher in male adolescents and men than in compara$l" aged female adolescents and 9omen2

!ge
eight and 9eight affect BP2 o9ever, these relationships do not $ecome evident until children are school aged2 'he 'as* :orce on Blood Pressure Control in Children considered these factors 9hen the" pu$lished their normative data in >50-2> &umerous investigators have noted a correlation $et9een the BP of parents and that of their offspring2 :amilial aggregation of BP is detecta$le earl" in life2 Some data relate this association to concomitant o$esit" in $oth parent and child2

Clinical
History
A 9ell4ta*en histor" provides clues a$out the cause of h"pertension and guides the nature and se@uence of ensuing investigations2

#elevant information includes the follo9ing, o Prematurit" o Bronchopulmonar" d"splasia o istor" of um$ilical arter" catheteri(ation o :ailure to thrive

istor" of head or a$dominal trauma :amil" histor" of herita$le diseases ;eg, neurofi$romatosis, h"pertension< Medications ;eg, pressor su$stances, steroids, tric"clic antidepressants, cold remedies, medications for attention deficit h"peractivit" disorder DAD DE< o !pisodes of p"elonephritis ;perhaps suggested $" une8plained fevers< that ma" result in renal scarring o Dietar" histor", including caffeine, licorice, and salt consumption o Sleep histor", especiall" snoring histor" o a$its, such as smo*ing, drin*ing alcohol, and ingesting illicit su$stances Presenting s"mptoms and signs are not specific in neonates and a$sent in most older children unless their h"pertension is severe2 Signs and s"mptoms that should alert the ph"sician to the possi$ilit" of h"pertension include the follo9ing, o &eonates :ailure to thrive Sei(ure Irrita$ilit" or letharg" #espirator" distress Congestive heart failure o Children ;:indings in addition to those o$served in neonates< eadache :atigue Blurred vision !pista8is Bell pals"
o o o

P ysical

Measurement and recording of $lood pressure ;BP< o Best medical care includes "earl" measurement of BP in ever" child older than ? "ears, prefera$l" $" means of auscultation 9ith a mercur" gravit" manometer2 Doppler and oscillometric techni@ues can $e used in children in 9hom auscultator" BP measurements are difficult to o$tain2 Measurements o$tained $" using oscillometric devices that e8ceed the 5/th percentile should $e repeated 9ith auscultation2 o Measurements repeated over time are re@uired to o$tain meaningful information2 o Proper cuff si(e is essential for accurate measurement of BP2 'he 9idth of the ru$$er $ladder inside the cloth cover should cover at least A/7 of the patient)s arm circumference at a point mid9a" $et9een the olecranon and the acromion2 'he length of the $ladder in the cuff should cover 0/4>//7 of the circumference of the arm2 If a cuff is too small, the ne8t larger cuff si(e should $e used, even if it appears too large2 o 'he child should $e rela8ed and in a comforta$le, prefera$l" sitting, position 9ith the child)s feet on the floor and the $ac* supported2 'he patient)s right arm should $e resting on a supportive surface at the level of the heart2 Infants can $e e8amined 9hile supine2 o 'he cuff should $e inflated at a pressure appro8imatel" ./ mm greater than that at 9hich the radial pulse disappears and then allo9ed to deflate at a rate of .4? mm g/s2

'he first Corot*off sound ;ie, appearance of a clear tapping sound< defines the s"stolic pressure, 9hereas the fifth Corot*off sound ;ie, disappearance of all sounds< defines the diastolic pressure2 'he fourth ;lo94pitched, muffled< sound and the fifth sound fre@uentl" occur simultaneousl", or the fifth sound ma" not occur at all2 Diastolic BP must $e recorded2 Fhen Corot*off sounds can $e heard do9n to / mm g, the BP measurement should $e repeated 9ith less pressure applied to the head of the stethoscope than 9as applied $efore2 o S"stolic BP in the lo9er e8tremities must $e measured 9hen elevated s"stolic BP in the upper e8tremities is first noted regardless of 9hether amplitude of the arterial pulse seems lo9er in the legs to $e lo9er than that in the arms2 Increased s"stolic pressure in the arm suggests coarctation of the aorta2 If found, s"stolic pressure must also $e measured in the left arm and leg2 Fith the patient in the supine position, place a cuff on the calf2 'he cuff should $e 9ide enough to cover at least t9o thirds of the distance from *nee to an*le2 Doppler sonograph" can $e used to detect onset of $lood flo9, 9hich reflects s"stolic BP, in the posterior ti$ial or dorsalis pedis arter"2 'he value should $e compared 9ith a similarl" o$tained Doppler s"stolic BP in the arm, again 9ith the patient supine2 o #emem$er that the artifact of distal pulse amplification causes the measured s"stolic BP at the $rachial arter" to $e less than that at the posterior ti$ial or dorsalis pedis arter"2 'his difference ma" $e onl" a fe9 millimeters in the infant $ut can rise to >/4./ mm g in the older child or adult2 Magnitude of this artifact is directl" proportional to the pulse pressure2 In a patient 9ith chronic aortic regurgitation, for e8ample, the difference in measured s"stolic pressure ma" e8ceed A/ mm g2 At no time should the s"stolic pressure in the arm e8ceed that in the foot2 If it does, pressures in $oth arms and legs should $e measured2 Consistent recording of high arm s"stolic pressure indicates aortic coarctation2 igh pressure in onl" the right arm suggests that an o$struction is present pro8imal to origin of the left su$clavian arter"2 Interpretation of BPs o "pertension is defined as average s"stolic or diastolic BPs greater than those at the 56th percentile ;see 'a$le ><2 An" child 9ith a BP e8ceeding the 5/th percentile re@uires scrutin"2 o Patients 9ith severe h"pertension and target4organ damage re@uire immediate attention2 :or other patients, several measurements of BP should $e made at 9ee*l" intervals to determine if the elevation is sustained2 o 'he average of multiple measurements should $e plotted on an appropriate percentile chart2 If the average measurement is $et9een the 5/th and 56th percentiles ;ie, preh"pertensive< the child)s BP should $e monitored at 34month intervals2 If the average BP is greater than the 56th percentile, the child should $e evaluated further and therap" considered2 o Patients 9ith stage I h"pertension should $e seen again in >4. 9ee*s2 'hose 9ith stage II h"pertension should $e reevaluated in > 9ee* or sooner if the patient is s"mptomatic2 o Fhite4coat h"pertension is diagnosed in a patient 9ho has a BP a$ove the 56th percentile 9hen measured in the ph"sician)s office $ut 9ho is normotensive outside the clinical setting2 Am$ulator" monitoring of BP usuall" is re@uired to diagnose 9hite4coat h"pertension2 G$1ective of ph"sical e8amination, A primar" o$1ective of the ph"sical e8amination is to identif" signs of secondar" h"pertension, including the follo9ing,
o

o o o o o o o o o o o

Bod" mass inde8 to assess for meta$olic s"ndrome 'ach"cardia to assess for h"perth"roidism, pheochromoc"toma, and neuro$lastoma Bro9th retardation to assess for chronic renal failure CafH au lait spots to assess for neurofi$romatosis A$dominal mass to assess for Films tumor and pol"c"stic *idne" disease !pigastric and/or a$dominal $ruit to assess for coarctation of the a$dominal aorta or renal arter" stenosis BP difference $et9een upper and lo9er e8tremities to assess for coarctation of the thoracic aorta 'h"romegal" to assess for h"perth"roidism %irili(ation or am$iguit" to assess for adrenal h"perplasia Stigmata of Bardet4Biedl, von ippel4=andau, Filliams, or 'urner s"ndromes Acanthosis nigricans to assess for meta$olic s"ndrome

Causes
"pertension can $e primar" ;ie, essential< or secondar"2

In general, the "ounger the child and the higher the BP, the greater the li*elihood that h"pertension is secondar" to an identifia$le cause2 A secondar" cause of h"pertension is most li*el" to found $efore pu$ert"2 After pu$ert", h"pertension is li*el" to $e essential2 A revie9 of literature revealed that -07 of 63? "oung patients 9ith secondar" h"pertension had a renal parench"mal a$normalit"2 In the remaining ..7, the cause of h"pertension, in order of fre@uenc", 9as renal arter" stenosis, coarctation of the aorta, pheochromoc"toma, and a variet" of other conditions2 'a$le .2 Common Causes of "pertension $" Age C ildren "n%ants 1-2 y +-13 y !dolescents o 'hrom$o o #enal o #enal o !ss sis of renal arter" arter" stenosis parench"mal ential or vein o #enal disease h"pertensi o Congenit o #eno on parench"mal o #e al renal disease vascular anomalies o Films a$normalitie nal o Coarctati s parench"m tumor o !ndo al disease on of the aorta o &euro o Bronchop crine causes $lastoma o !n o !ssen ulmonar" o Coarct docrine d"splasia tial ation of the causes h"pertension aorta

Di%%erential Diagnoses
4t er Pro'le(s to #e Considered
Pheochromoc"toma

5or$up
La'oratory Studies

In patients 9ith h"pertension, proceed from simple tests that can $e performed in an am$ulator" setting to comple8 noninvasive tests and finall" to invasive tests2 :indings from the patient)s histor" and ph"sical e8amination dictate the appropriate order of tests2 o Gn urine dipstic* testing, a positive result for $lood and/or protein indicates renal disease2 o +rine cultures are used to evaluate the patient for chronic p"elonephritis2 o 'he CBC count ma" indicate anemia due to chronic renal disease2 o Blood chemistr" ma" $e helpful2 An increased serum creatinine concentration indicates renal disease2 "po*alemia suggests h"peraldosteronism2 o Blood hormone levels ma" $e measured2 igh plasma renin activit" indicates renal vascular h"pertension, including coarctation of the aorta, 9hereas lo9 activit" indicates glucocorticoid remedia$le aldosteronism, =iddle s"ndrome, or apparent mineralocorticoid e8cess2 A high plasma aldosterone concentration is diagnostic of h"peraldosteronism2 igh values of catecholamine ;epinephrine, norepinephrine, dopamine< are diagnostic of pheochromoc"toma or neuro$lastoma2 o igh urinar" e8cretion of catecholamines and catecholamine meta$olites ;metanephrine< indicates pheochromoc"toma or neuro$lastoma2 o :asting lipid panels and oral ;PG< glucose4tolerance tests are performed to evaluate meta$olic s"ndrome in o$ese children2 o Drug screening is performed to identif" su$stances that might cause h"pertension2 o +rine sodium levels reflect dietar" sodium inta*e and ma" $e used as a mar*er to follo9 up a patient after dietar" changes are attempted2

"(aging Studies

!chocardiograph" o =eft ventricular h"pertroph" results from chronic h"pertension2 'his finding confirms the chronicit" of the h"pertension and is an a$solute indication for starting or intensif"ing treatment2 o =eft ventricular h"pertroph" is s"mmetric, consisting of e@uivalent increases in thic*ness of $oth the left ventricular portion of the ventricular septum and the left ventricular posterior 9all2 o Also assess left ventricular function2 o !chocardiograph" is essential in the evaluation of suspected aortic coarctation2 Precise anatomic detail of the aortic arch and its $ranches must $e o$tained2 A$dominal ultrasonograph" o 'his test ma" reveal tumors or structural anomalies of the *idne"s or renal vasculature2 o #enal scarring suggests e8cessive renin release2 o As"mmetr" in renal si(e suggests renal d"splasia or renal arter" stenosis2 o #enal or e8trarenal masses suggest a Films tumor or neuro$lastoma, respectivel"2

#adionuclide imaging ;9ithout or 9ith captopril<, As"mmetr" suggests renal arter" stenosis2 Doppler studies, As"mmetr" in renal arter" $lood flo9 suggests renal arter" stenosis2 Digital su$traction arteriograph", As"mmetr" $et9een the . renal arteries indicates renal arter" stenosis2 Angiograph" o 'his test ma" reveal differences in the structure ;diameter< of the renal vessels2 o Sampling of $lood from renal arteries, renal veins, and aorta ma" reveal differences in renin secretion $et9een the *idne"s2 o A renin activit" ratio of ?,> $et9een the *idne"s is considered diagnostic of renal vascular h"pertension2 Gther tests o Cardiac catheteri(ation is not necessar" in the evaluation of aortic coarctation2 o C' and M#I 9ith angiograph" can provide further anatomic definition of an aortic coarctation, $ut neither stud" is necessar" for diagnosis2

4t er 6ests

Monitoring of $lood pressure ;BP< on a .A4hour $asis ma" help in diagnosing 9hite4 coat h"pertension and provides information a$out the ris* of target end4organ damage2 o Fhite4coat h"pertension is common $ecause most children are uncomforta$le at the ph"sicians) office $ecause of invasive e8aminations, vaccinations, $lood dra9s, and other factors2 o +se of the .A4hour monitor should $e considered first in most uncomplicated cases of pediatric stage I h"pertension2 Pol"somnograph" helps in identif"ing sleep disorders associated 9ith h"pertension2 'his test should $e considered in o$ese children 9ith a histor" of snoring, da"time sleepiness, or an" sleep difficulties2 #etinal e8amination ma" reveal retinal vascular changes2

6reat(ent
Medical Care
'o the e8tent possi$le, treatment of h"pertension should address the cause and correct it2 #eserve the therapeutic modalities descri$ed $elo9 for those children 9ho have irremedia$le causes of h"pertension or essential h"pertension2

&onpharmacologic measures o &onpharmacologic measures are important in the treatment of all patients 9ith h"pertension, regardless of its etiolog" or severit"2 In children 9ith mild or moderate h"pertension, this approach ma" suffice to lo9er $lood pressure ;BP< to 9ithin normal limits2 A nonpharmacologic approach avoids the need for drugs that have adverse effects and that re@uire a degree of compliance difficult to achieve in children2 o Feight reduction should $e a goal in over9eight children 9ith h"pertension regardless of its etiolog"2 G$esit" and h"pertension are closel" correlated, particularl" in adolescents2

Aero$ic and isotonic e8ercises have a direct $eneficial effect on BP2 'he" help in reducing e8cess 9eight or maintaining appropriate $od" 9eight2 !ncourage participation in sports2 Gnl" patients 9ith severe uncontrolled h"pertension or cardiac a$normalities that re@uire e8ercise restriction are e8empt from aero$ic and isotonic e8ercises2 o Salt restriction pro$a$l" $enefits onl" a su$group of patients 9ith h"pertension, particularl" African American patients, 9ho ma" have a defect in the cellular handling of sodium2 o9ever, given the e8cessive amount of salt in the t"pical American diet, reduced salt inta*e should $e recommended to all patients 9ith h"pertension2 o 'he 'as* :orce recommends the Dietar" Approaches to Stop "pertension ;DAS < eating plan ;see Iour Buide 'o =o9ering Iour Blood Pressure Fith DAS from the & =BI<2 o Potassium supplementation can decrease BP and reduce ventricular h"pertroph" in adults2 o9 potassium supplementation affects children 9ith h"pertension remains to $e tested2 o9ever, avoiding potassium depletion ;eg, from diuretic therap"< and prescri$ing a potassium4rich diet in patients 9ithout renal insufficienc" appear reasona$le2 o Stress4reducing activities ;eg, meditation, "oga, $iofeed$ac*< can reduce BP 9hen performed on a regular $asis2 o9ever, this effect is lost 9hen the activit" is discontinued2 o Fhen sleep4disordered $reathing is discovered, 9eight loss, tonsillectom" and adenoidectom", and/or use of continuous positive air9a" pressure ma" improve the patient)s sleep and secondaril" improve BP2 Pharmacologic measures o Some drugs currentl" used to treat h"pertension in adults have $een formall" tested in children2 Indications for pharmacologic treatment include s"mptomatic h"pertension, secondar" h"pertension, h"pertensive target4organ damage, dia$etes, and h"pertension that persists despite nonpharmacologic measures2 o 'he :ourth #eport recommends starting 9ith a class of antih"pertensive medication appropriate for each specific patient2 Pediatric clinical trials have focused on the a$ilit" of each drug to lo9er BP, $ut the effects of these drugs on clinical endpoints have not $een compared2 'herefore, the choice of drug is the clinician)s2 o 'he 'as* :orce recommends the use of AC! inhi$itors or angiotensin II receptor $loc*ers ;A#Bs< onl" for children 9ith dia$etes and microal$uminuria or proteinuric renal disease and recommends $eta4$loc*ers or calcium4channel $loc*ers for children 9ith h"pertension and migraine headaches2 A lo9 dose of one drug should $e started first2 If unsuccessful, the dose should $e uptitrated2 BP is considered controlled 9hen it is less than the 56th percentile in children 9ith uncomplicated primar" h"pertension2 Fhen patients have chronic renal disease, dia$etes, or h"pertensive target4organ damage, the goal should $e less than the 5/th percentile2 If BP is not controlled, a drug from another class should $e added2 If control is not achieved 9ith . drugs, reconsider the possi$ilit" of secondar" h"pertension $efore adding a third drug2 o In general, the treatment of chronic h"pertension re@uires e8pertise that is seldom availa$le in the general pediatrician2 'herefore, referring patients to ph"sicians 9ho speciali(e in treatment of children 9ith high BP is advisa$le2
o

'he American Societ" of "pertension, Inc2 ;AS < identifies ph"sicians 9ith e8pert s*ills and *no9ledge in the management of clinical h"pertension and related disorders2 It also grants such ph"sicians the title Specialist in Clinical "pertension2 AS provides a list of availa$le specialists $" cit", state, and countr" ;see the AS Specialist Director"<2 o After BP is sta$ili(ed, the patient can return to the general pediatrician for follo94up care2 'he pediatrician should 9or* in close colla$oration 9ith the specialist2 Management of h"pertensive crisis o "pertensive crises occur as a result of an acute illness, such as postinfectious glomerulonephritis or acute renal failure, the e8cessive ingestion of drugs or ps"chogenic su$stances, or e8acer$ated moderate h"pertension2 o 'he clinical manifestations ma" $e those of cere$ral edema, sei(ures, heart failure, pulmonar" edema, or renal failure2 #emem$er that accuratel" assessing BP in ever" patient presenting 9ith a sei(ure is essential, particularl" 9hen no sei(ure disorder has $een esta$lished in that patient2 o Anticonvulsant drugs are usuall" ineffective in treatment of a sei(ure due to a h"pertensive crisis2 o9ever, sei(ures due to severe h"pertension must $e treated 9ith a fast4acting antih"pertensive drug2 o Drugs currentl" used to treat h"pertensive emergencies include nicardipine, la$etalol, and sodium nitroprusside2 o 'he goal of therap" is to decrease BP to normal2 Clinicians should $e familiar 9ith the effect and adverse effects of these drugs2 Patients must $e supervised closel" to avoid an e8cessivel" rapid decrease in BP, 9hich ma" result in underperfusion of vital organs2 'ranscatheter therap" o Interventional cardiac catheteri(ation procedures can $e used to treat coarctation of the aorta2 Balloon dilation of a previousl" untreated coarctation remains controversial2 Some pediatric cardiologists recommend this approach and ma" also place a stent at the coarctation site2 'he appropriateness of this approach remains to $e determined in studies of long4term outcome2 o Balloon dilation, 9ith or 9ithout stent placement, has gained 9idening acceptance for treatment of recurrent coarctation2 #ecurrence is most li*el" to arise 9hen "oung infants must undergo surgical repair $ecause of the severit" of the lesion2 o Interventional catheteri(ation 9ith $alloon dilation can also successfull" relieve man" instances of discrete renal arter" stenosis2

Surgical Care
Surger" ma" $e re@uired for children 9ith severe renal vascular h"pertension, renal segmental h"poplasia, coarctation of the aorta, Films tumor, or pheochromoc"toma2

Consultations
A pediatric endocrinologist should $e consulted 9hen pheochromoc"toma is suspected2 If the diagnosis is confirmed, a @ualified surgeon must remove the tumor2 A pediatric endocrinologist should also $e consulted 9hen meta$olic s"ndrome is diagnosed2 A nutritionist can revie9 the DAS eating plan 9ith the patient)s famil" and ma*e further suggestions for 9eight loss and sodium reduction2

'he :ourth #eport provides a management algorithm ;see Media file ><2

Medication
'he follo9ing drugs currentl" are used in the treatment of h"pertensive emergencies, la$etalol /2.4> mg/*g/dose up to A/ mg/dose as an intravenous ;I%< $olus or /2.64? mg/*g/h I% infusion, nicardipine >4? mcg/*g/min I% infusion, and sodium nitroprusside /26?4>/ mcg/*g/min I% infusion to start2 Su$lingual nifedipine is no longer recommended for the treatment of acute h"pertension $ecause of reports of death from h"potension in the adult population2 Additional drug recommendations for patients aged >4>- "ears ma" $e found in 'he :ourth #eport on the Diagnosis, !valuation, and 'reatment of igh Blood Pressure in Children and Adolescents2? :or neonatal doses, see the eMedicine article &eonatal "pertension2 Man" antih"pertensive drugs are availa$le for the treatment of chronic h"pertension2 'he choice of drug is usuall" $ased on the mode of action and the potential for adverse effects2 :rom a pharmacologic point of vie9, antih"pertensive drugs are classified in the follo9ing categories, diuretics, 9hich $loc* sodium rea$sorption at various levels of the renal tu$ules; adrenergic $loc*ers, 9hich act $" competitivel" inhi$iting the catecholamines; direct vasodilators, 9hich act $" means of a variet" of mechanisms; AC! inhi$itors, 9hich $loc* the conversion of angiotensin I to angiotensin II; angiotensin II receptor $loc*ers ;A#Bs<, 9hich interfere 9ith the $inding of angiotensin II to angiotensin I receptors; and calcium4 channel $loc*ers, 9hich $loc* the entr" of calcium into the cells, producing vasodilation2 Drug Category: ACE inhibitors J4 'hese drugs prevent conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, and lo9er aldosterone secretion2 AC! inhi$itors are effective and 9ell4tolerated drugs 9ith no adverse effects on plasma lipid levels or glucose tolerance2 'he" prevent the progression of dia$etic nephropath" and other forms of glomerulopathies $ut appear to $e less effective in African American patients than in Caucasian patients2 Patients 9ith high plasma renin activit" ma" have an e8cessive h"potensive response to AC! inhi$itors2 Patients 9ith $ilateral renal vascular disease or 9ith single *idne"s, 9hose renal perfusion is maintained $" high levels of angiotensin II, ma" develop irreversi$le acute renal failure 9hen treated 9ith AC! inhi$itors2 AC! inhi$itors ma" cause h"per*alemia; therefore, monitor serum potassium levels2 AC! inhi$itors are contraindicated in pregnanc"2 Cough and angioedema are less common 9ith ne9er mem$ers of this class than 9ith captopril2 Serum potassium and serum creatinine concentrations should $e monitored for the development of h"per*alemia and a(otemia2 !8amples of agents from this class include captopril, lisinopril, and enalapril2 !CE "n i'itors Captopril ;Capoten< Enalapril ;%asotec< Pediatric Dose 71-1+ y8 /2?4/26 mg/*g/dose PG tid; ma" graduall" increase to 3 mg/*g/d !dult Dose 32.64.6 mg PG $id/tid initiall"; ma" uptitrate; not to e8ceed A6/ mg/d divided $id/tid /2/0 mg/*g/d PG @d or divided .2646 mg PG @d or divided $id $id; not to e8ceed 6 mg/d initiall"; initiall"; ma" uptitrate $" .2646 ma" graduall" increase to /23 mg/d @>4.9*; dosage range >/4A/ mg/*g/d; not to e8ceed A/ mg/d mg/d

Lisinopril ;Prinivil, Kestril<

/2/- mg/*g/d PG @d; not to e8ceed >/ mg PG @d; ma" graduall" 6 mg/d initiall"; ma" graduall" uptitrate $" 64>/ mg/d @>4. 9*; increase to /23 mg/*g/d; not to not to e8ceed A/ mg/d e8ceed A/ mg/d

Drug Category: Beta-blockers 44 Beta4$loc*ers are especiall" useful in the concurrent treatment of h"pertension and migraine disorder2 Dosing is limited $" the $rad"cardia adverse effect2 Drugs of this class should not $e prescri$ed to athletes $ecause their athletic performance ma" $e compromised2 'his class should not $e used in patients 9ith insulin4 dependent dia$etes $ecause these drugs $lunt the normal 9arning s"mptoms of h"pogl"cemia2 &oncardioselective agents ;ie, agents that elicit $eta> and $eta. $loc*ade, eg, propranolol< are contraindicated in asthma and heart failure, due to their a$ilit" to cause $rad"cardia and $ronchospastic actions2 Selective $eta>4adrenergic $loc*ers include atenolol and metoprolol2 =a$etalol elicits a mi8ed alpha and $eta $loc*ade2 Another agent from this class is propranolol2 #eta-#loc$ers !tenolol ;'enormin< Pediatric Dose 71-1+ y8 !dult Dose /264> mg/*g/d PG @d or divided 6/ mg PG @d; ma" increase to >// $id initiall"; ma" graduall" mg/d increase to . mg/*g/d; not to e8ceed >// mg/d >4? mg/*g/d PG divided $id >// mg/d PG $id; ma" increase initiall"; ma" graduall" increase to @.4?d $" >// mg until ade@uate La'etalol >/4>. mg/*g/d; not to e8ceed >.// response; not to e8ceed .2A g/d ;&ormod"ne, mg/d 'randate< Metoprolol >4. mg/*g/d PG divided $id >// mg/d PG @d or divided $id/tid ;=opressor, 'oprol L=< initiall"; ma" graduall" increase to initiall"; ma" increase @>9*; not to 3 mg/*g/d; not to e8ceed .// mg/d e8ceed A6/ mg/d Propranolol >4. mg/*g/d PG divided $id/tid >/ mg PG $id/tid ;prompt release< ;Inderal, Betachron !4 initiall"; ma" graduall" increase to or ?/4A/ mg @d ;sustained4release #< J nonselective $eta4 A mg/*g/d; not to e8ceed 3A/ mg/d cap<; increase dose @?46d; not to $loc*er e8ceed 3A/ mg/d Drug Category: Thiazide diuretics 44 'hese drugs inhi$it the rea$sorption of sodium in the distal tu$ules, increasing the e8cretion of sodium, 9ater, and potassium and h"drogen ions2 'hia(ide diuretics have $een effective in treating h"pertension of various etiologies2 'heir primar" effect is to diminish sodium rea$sorption2 'he" also appear to diminish the sensitivit" of $lood vessels to circulating vasopressor su$stances2 In all patients treated 9ith diuretics, electrol"te levels should $e monitored2 !8amples from this class include h"drochlorothia(ide and chlorthalidone2 6 iazide Diuretics Pediatric Dose 71-1+ y8 Hydroc lorot iazide > mg/*g PG @d initiall"; ma" ;!sidri8< graduall" increase to ? mg/*g/d; not to e8ceed 6/ mg/d C lort alidone /2? mg/*g PG @d initiall"; ma" ; "groton< graduall" increase to . mg/*g/d; not to e8ceed 6/ mg/d !dult Dose .64>// mg/d PG divided @d/$id, ma" increase graduall"; not to e8ceed .// mg/d .6 mg PG @d initiall"; ma" graduall" increase to >// mg/d

Drug Category: Loop diuretics 44 'hese agents inhi$it the rea$sorption of sodium chloride in

the thic* ascending lim$ of the loop of enle2 =oop diuretics can $e used to treat h"pertension in patients 9ith renal insufficienc"2 'he" are less effective than thia(ide diuretics in patients 9ho are h"pertensive 9ith normal renal function2 !8amples from this class include furosemide and $umetanide2 Loop Diuretics ,urose(ide ;=asi8< #u(etanide ;Bume8< Pediatric Dose 71-1+ y8 /264. mg/*g PG @d/$id initiall"; ma" graduall" increase to 3 mg/*g/d /2/>64/2> mg/*g/dose PG @34.Ah; not to e8ceed >/ mg/d !dult Dose ./40/ mg/d PG @d or in divided doses; ma" uptitrate to 3// mg/d for severe edematous conditions /264. mg PG @d/$id; ma" graduall" increase; not to e8ceed >/ mg/d

Drug Category: Potassiu(-sparing diuretics 44 Potassium4sparing diuretics are used alone or in com$ination 9ith other diuretics to prevent or correct h"po*alemia2 o9ever, these drugs can cause h"per*alemia, particularl" in patients 9ith renal insufficienc" or 9hen the" are administered in com$ination 9ith AC! inhi$itors and A#Bs2 !8amples from this class include spironolactone and amiloride2 Potassiu(-Sparing Pediatric Dose 71-1+ y8 !dult Dose Diuretics Spironolactone > mg/*g/d PG @d or divided $id .64.// mg/d PG @d or divided $id ;Aldactone< initiall"; ma" graduall" increase to ?2? mg/*g/d; not to e8ceed >// mg/d !(iloride /2A4/23.6 mg/*g PG @d initiall"; 6 mg PG @d initiall"; ma" ;Midamor< ma" graduall" increase to ./ mg/d graduall" increase to ./ mg/d Drug Category: Calciu(-c annel 'loc$ers 44 'hese drugs affect BP $" decreasing vascular peripheral resistance2 Fith short4acting calcium4channel $loc*ers the cardiac response to this action is varia$le, resulting in tach"cardia2 =ong4acting preparations ma" cause decrease in heart rate2 Calcium4channel $loc*ers are classified $" their structure, and the" have different degrees of selectivit" in their effects on vascular smooth muscle2 'he dih"drop"ridines do not e8ert electroph"siologic effects and are commonl" used to manage h"pertension2 :acial flushing ma" occur2 !8amples from this class include amlodipine and isradipine2 Calciu(-C annel #loc$ers !(lodipine ;&orvasc< "sradipine ;D"naCirc< Pediatric Dose 71-1+ y8 M3 "ears, &ot esta$lished 34>- "ears, .2646 mg PG @d /2>64/2. mg/*g/d PG divided tid/@id initiall"; ma" graduall" increase to /20 mg/*g/d; not to e8ceed ./ mg/d !dult Dose 6 mg PG @d; ma" increase to >/ mg/d .26 mg PG $id ;prompt release< or 6 mg PG @d ;sustained release<; ma" graduall" increase to ./ mg/d

Drug Category: !R#s 44 'hese drugs lo9er BP $" $loc*ing the final receptor ;ie, angiotensin II< in the renin4angiotensin a8is2 =i*e the AC! inhi$itors, this class is contraindicated in pregnanc"2 Serum electrol"te and creatinine levels should $e monitored2 !8amples from this class include ir$esartan and losartan2

!R#s "r'esartan ;Avapro< Losartan ;Co(aar< 9alsartan ;Diovan<

Pediatric Dose 71-1+ y8 M3 "ears, &ot esta$lished 34>. "ears, -64>6/ mg PG @d N>? "ears, Administer as in adults /2- mg/*g/d PG @d; not to e8ceed 6/ mg/d initiall"; ma" graduall" increase to >2A mg/*g/d; not to e8ceed >// mg/d M3 "ears, &ot esta$lished N3 "ears, >2? mg/*g PG @d initiall", not to e8ceed A/ mg/d; ma" ad1ust dose according to $lood pressure response up to .2mg/*g/d ;not to e8ceed >3/ mg/d<

!dult Dose >6/ mg PG @d; ma" graduall" increase, not to e8ceed ?// mg/d .6 mg PG @d or divided $id initiall"; ma" graduall" increase, not to e8ceed >// mg/d 0/4>3/ mg PG @d; ma" graduall" increase, not to e8ceed ?./ mg/d

Drug Category: Central alpha-agonists -- 'his class of drug lo9ers BP $" stimulating alpha.4adrenergic receptors in the $rainstem and activates an inhi$itor" neuron resulting in decreased vasomotor tone and heart rate2 'his class of drugs ma" cause dr" mouth and/or sedation2 Caution is 9arranted in patients 9ith cere$rovascular disease, coronar" insufficienc", sinus4node d"sfunction, or renal impairment2 A transdermal patch is availa$le2 'he sudden discontinuation of this drug ma" lead to severe re$ound h"pertension2 'his drug has $een used in the past for the treatment of children 9ith AD D, and it still ma" $e used successfull" in patients 9ith AD D 9ho also have h"pertension2 An e8ample from this class is clonidine2 Central !lp a!gonists Clonidine ;Catapres< Pediatric Dose 71-1+ y8 !dult Dose

>4>> "ears, &ot esta$lished /2> mg PG $id initiall"; ma" N>. "ears, Administer as in adults increase to /2.4>2. mg/d divided $id/@id; not to e8ceed .2A mg/d

Drug Category: Direct Vasodilator -- 'his class of drug directl" vasodilates the smooth muscle in the peripheral vasculature, causing vasodilation2 'ach"cardia and fluid retention are common side effects2 Prolonged use of mino8idil can cause h"pertrichosis2 "drala(ine can cause a lupus4li*e s"ndrome in certain populations of slo9 acet"lators2 !8amples from this class include mino8idil and h"drala(ine2 Direct 9asodilators Pediatric Dose 71-1+ y8 Mino0idil ;=oniten< >4>> "ears, /2. mg/*g/d PG @d or divided tid; not to e8ceed 6/ mg/d >.4>- "ears, Administer as in adults Hydralazine /2-6 mg/*g/d PG divided @id ;Apresoline< initiall"; ma" graduall" increase to -26 mg/d; not to e8ceed .// mg/d !dult dose 6 mg PG @d initiall"; ma" graduall" increase @?d to >/4A/ mg/d @d or divided $id; not to e8ceed >// mg/d >/ mg PG @id initiall" for .4A da"s; ma" graduall" increase to .6 mg PG @id for rest of first 9*; increase to 6/ mg @id second 9*; not to e8ceed ?// mg/d

Drug Category: Perip eral alp a-antagonists 44 'hese agents inhi$it posts"naptic alpha4 adrenergic receptors, resulting in vasodilation of veins and arterioles and decreasing total

peripheral resistance and BP2 'hese drugs often cause mar*ed h"potension after the first dose2 igh doses are li*el" to cause postural h"potension2 Drugs of this class that are selective for alpha>4receptors include do8a(osin and tera(osin2 Pra(osin is nonselective and inhi$its $oth alpha>4 and alpha.4receptors2 Perip eral !lp aPediatric Dose 71-1+ y8 !ntagonists Do0azosin > mg PG @d initiall"; ma" ;Cardura< graduall" increase to A mg/d Prazosin ;Minipress< 6erazosin ; "trin< !dult Dose

> mg PG @d; ma" graduall" increase to .4A mg/d; further increases ma" $e needed, not to e8ceed >3 mg/d /2/64/2> mg/*g/d PG divided tid > mg PG $id/tid initiall"; ma" initiall"; ma" graduall" increase to graduall" increase to 34>6 mg/d; /26 mg/*g/d further increases ma" $e needed, not to e8ceed ./ mg/d > mg/d PG @d; ma" graduall" > mg PG hs initiall"; ma" increase to ./ mg/d graduall" increase to .46 mg/d; further increases ma" $e needed, not to e8ceed ./ mg/d

,ollow-up
,urt er 4utpatient Care

Closel" monitor patients 9ith h"pertension, particularl" during the initial phase of therap"2 A chemistr" panel should $e chec*ed after therap" 9ith an AC! inhi$itor or an angiotensin II receptor $loc*ers ;A#Bs< is started or increased2 'he fre@uenc" of visits is dictated $" various factors, including the follo9ing, o Degree of control o !8tent of understanding of the disease and its treatment $" $oth the parents and/or caregivers and the patient o Adherence to nonpharmacologic and pharmacologic treatments o A$ilit" to properl" monitor $lood pressure ;BP< at home o =i*elihood of drug adverse effects o &eed to monitor for complications of h"pertension o &eed to monitor for 9eight loss After surgical or catheter treatment of coarctation of the aorta, patients must $e monitored "earl" 9ith accurate measurement of s"stolic and diastolic pressures in the right arm2 :or these measurements, the patient should $e properl" positioned2 S"stolic pressures in $oth the right arm and leg should $e o$tained 9ith the patient supine2 #emem$er that s"stolic pressure in the lo9er leg should e8ceed that in the arm2

Patient Education

:or e8cellent patient education resources, see eMedicine)s Dia$etes Center2 Also, visit eMedicine)s patient education article, igh Blood Pressure2

Miscellaneous

Medicolegal Pit%alls

:ailure to recogni(e remedia$le causes of h"pertension, especiall" coarctation of the aorta in a s"mptomatic infant :ailure to properl" advise the parents and/or caregivers and child a$out restriction of e8ercise, 9hen appropriate :ailure to inform parents and/or caregivers and child a$out the potential adverse effects of medication :ailure to inform parents and/or caregivers and child a$out the potential complications of persistent h"pertension

Multi(edia

Media %ile 1: Manage(ent algorit (: !MC ; !pparent (ineralocorticoid e0cess< &R! ; &lucocorticoid re(edial aldosteronis(< 9M! ; 9anillyl(andelic acid:

eMedicine Specialties > =ep rology > Hypertension and t e >idney

Hypertension
Sat S ar(a, MD, ,RCPC, Professor and ead, Division of Pulmonar" Medicine, Department of Internal Medicine, +niversit" of Manito$a; Site Director, #espirator" Medicine, St2 Boniface Beneral ospital Claude >ortas, MD, Program Director, Associate Professor, Department of Medicine, +niversit" of Festern Gntario, Canada +pdated, Aug 3, .//0

"ntroduction
#ac$ground
"pertension is one of the most common 9orld9ide diseases afflicting humans2 Because of the associated mor$idit" and mortalit" and the cost to societ", h"pertension is an important pu$lic health challenge2 Gver the past several decades, e8tensive research, 9idespread patient education, and a concerted effort on the part of health care professionals have led to decreased mortalit" and mor$idit" rates from the multiple organ damage arising from "ears of untreated h"pertension2 "pertension is the most important modifia$le ris* factor for coronar" heart disease ;the leading cause of death in &orth America<, stro*e ;the third leading cause<, congestive heart failure, end4stage renal disease, and peripheral vascular disease2 'herefore, health care professionals must not onl" identif" and treat patients 9ith h"pertension $ut also promote a health" lifest"le and preventive strategies to decrease the prevalence of h"pertension in the general population2 Historical perspecti?es Blood pressure 9as measured for the first time $" Stephen ales in >--?2 ales also descri$ed the importance of $lood volume in $lood pressure regulation2 'he contri$ution of peripheral arterioles in maintaining $lood pressure, descri$ed as Otone,O 9as first descri$ed $" =o9er in >335 and su$se@uentl" $" SHnac in >-0?2 'he role of vasomotor nerves in the regulation of $lood pressure 9as o$served $" such eminent investigators as Claude Bernard, Charles !2 !douard, Charles Bro9n4SH@uard, and Augustus Faller2 Filliam Da"liss advanced this concept in a monograph pu$lished in >5.?2 Cannon and #osen$lueth developed the concept of humoral control of $lood pressure and investigated pharmacologic effects of epinephrine2 'hree contri$utors 9ho advanced the *no9ledge of humoral mechanisms of $lood pressure control are '2#2 !lliott, Sir enr" Dale, and Gtto =oe92 #ichard Bright, a ph"sician 9ho practiced in the first half of the >5th centur", o$served the changes of h"pertension on the cardiovascular s"stem in patients 9ith chronic renal disease2

Beorge Johnson in >030 postulated that the cause of left ventricular h"pertroph" ;=% < in Bright disease 9as the presence of muscular h"pertroph" in the smaller arteries throughout the $od"2 :urther clinical pathologic studies $" Sir Filliam Bull and 2B2 Sutton ;>0-.< led to further description of the cardiovascular changes of h"pertension2 :rederic* Mahomed 9as one of the first ph"sicians to s"stematicall" incorporate $lood pressure measurement as a part of a clinical evaluation2 'he recognition of primar", or essential, h"pertension is credited to the 9or* of uchard, %on$asch, and Al$utt2 G$servations of Jane9a" and Falhard led to the recognition of target organ damage, 9hich $randed h"pertension as the Osilent *iller2O 'he concepts of renin, angiotensin, and aldosterone 9ere advanced $" several investigators in the late >5th and earl" ./th centuries2 'he names of Ir9ine, Page, van Sl"*e, Bold$latt, =aragh, and 'uttle prominentl" appear throughout the h"pertension literature, and their 9or* enhances our understanding of the $iochemical $asis of essential h"pertension2 Cushman and Gndetti developed an orall" acting converting en("me inhi$itor from sna*e venom peptides and are credited 9ith the successful s"nthesis of the modern antih"pertensive captopril2 De%inition Defining a$normall" high $lood pressure is e8tremel" difficult and ar$itrar"2 :urthermore, the relationship $et9een s"stemic arterial pressure and mor$idit" appears to $e @uantitative rather than @ualitative2 A level for high $lood pressure must $e agreed upon in clinical practice for screening patients 9ith h"pertension and for instituting diagnostic evaluation and initiating therap"2 Because the ris* to an individual patient ma" correlate 9ith the severit" of h"pertension, a classification s"stem is essential for ma*ing decisions a$out aggressiveness of treatment or therapeutic interventions2 Based on recommendations of the Seventh #eport of the Joint &ational Committee of Prevention, Detection, !valuation, and 'reatment of igh Blood Pressure ;J&C %II<, the classification of $lood pressure ;e8pressed in mm g< for adults aged >0 "ears or older is as follo9sP,

&ormalQ 4 S"stolic lo9er than >./, diastolic lo9er than 0/ Preh"pertension 4 S"stolic >./4>?5, diastolic 0/455 Stage > 4 S"stolic >A/4>65, diastolic 5/455 Stage . 4 S"stolic e@ual to or more than >3/, diastolic e@ual to or more than >//

PBased on the average of . or more readings ta*en at each of . or more visits after initial screening Q&ormal $lood pressure 9ith respect to cardiovascular ris* is less than >.//0/ mm g2 o9ever, unusuall" lo9 readings should $e evaluated for clinical significance2 Preh"pertension, a ne9 categor" designated in the J&C %II report, emphasi(es that patients 9ith preh"pertension are at ris* for progression to h"pertension and that lifest"le modifications are important preventive strategies2 "pertension ma" $e either essential or secondar"2 !ssential h"pertension is diagnosed in the a$sence of an identifia$le secondar" cause2 Appro8imatel" 567 of American adults have essential h"pertension, 9hile secondar" h"pertension accounts for fe9er than 67 of the cases2

Pat op ysiology
Arterial $lood pressure is a product of cardiac output and s"stemic vascular resistance2 'herefore, determinants of $lood pressure include factors that affect $oth cardiac output and arteriolar vascular ph"siolog"2 'here is potential relevance of $lood viscosit", vascular 9all sheer conditions ;rate and stress<, and $lood flo9 velocit" ;mean and pulsatile components< on vascular and endothelial function regulating $lood pressure in humans2 :urthermore, changes in vascular 9all thic*ness affect the amplification of peripheral vascular resistance in h"pertensive patients and result in reflection of 9aves $ac* to the aorta, increasing s"stolic $lood pressure2

Regulation o% 'lood pressure

#egulation of normal $lood pressure is a comple8 process2 Although a function of cardiac output and peripheral vascular resistance, $oth of these varia$les are influenced $" multiple factors2 'he factors affecting cardiac output include sodium inta*e, renal function, and mineralocorticoids; the inotropic effects occur via e8tracellular fluid volume augmentation and an increase in heart rate and contractilit"2 Peripheral vascular resistance is dependent upon the s"mpathetic nervous s"stem, humoral factors, and local autoregulation2 'he s"mpathetic nervous s"stem produces its effects via the vasoconstrictor alpha effect or the vasodilator $eta effect2 'he humoral actions on peripheral resistance are also mediated $" other mediators such as vasoconstrictors ;angiotensin and catecholamines< or vasodilators ;prostaglandins and *inins<2 :or additional resource, please visit Angiotensin II #eceptor Bloc*ade2 Autoregulation of $lood pressure occurs $" 9a" of intravascular volume contraction and e8pansion, as 9ell as $" transfer of transcapillar" fluid2 Interactions $et9een cardiac output and peripheral resistance are autoregulated to maintain a set $lood pressure in an individual2 :or e8ample, constriction of the arterioles elevates arterial pressure $" increasing total peripheral resistance, 9hereas venular constriction leads to redistri$ution of the peripheral intravascular volume to the central circulation, there$" increasing preload and cardiac output2

Pat ogenesis o% ypertension

'he pathogenesis of essential h"pertension is multifactorial and highl" comple82 Multiple factors modulate the $lood pressure for ade@uate tissue perfusion and include humoral mediators, vascular reactivit", circulating $lood volume, vascular cali$er, $lood viscosit", cardiac output, $lood vessel elasticit", and neural stimulation2 A possi$le pathogenesis of essential h"pertension has $een proposed in 9hich multiple factors, including genetic predisposition, e8cess dietar" salt inta*e, and adrenergic tone, ma" interact to produce h"pertension2 Although genetics appears to contri$ute to essential h"pertension, the e8act mechanism has not $een esta$lished2 'he natural histor" of essential h"pertension evolves from occasional to esta$lished h"potension2 After a long invaria$le as"mptomatic period, persistent h"pertension develops into complicated h"pertension, in 9hich target organ damage to the aorta and small arteries, heart, *idne"s, retina, and central nervous s"stem is evident2 'he progression $egins 9ith preh"pertension in persons aged >/4?/ "ears ;$" increased cardiac output< to earl"

h"pertension in persons aged ./4A/ "ears ;in 9hich increased peripheral resistance is prominent< to esta$lished h"pertension in persons aged ?/46/ "ears, and, finall", to complicated h"pertension in persons aged A/43/ "ears2 'he earl" stage of h"pertension has $een descri$ed as high4output h"pertension2 igh4output h"pertension results from decreased peripheral vascular resistance and concomitant cardiac stimulation $" adrenergic h"peractivit" and altered calcium homeostasis2 In contrast, the chronic phase of essential h"pertension characteristicall" has normal or reduced cardiac output and elevated s"stemic vascular resistance2 'he vasoreactivit" of the vascular $ed, an important phenomenon mediating changes of h"pertension, is influenced $" the activit" of vasoactive factors, reactivit" of the smooth muscle cells, and structural changes in the vessel 9all and vessel cali$er, e8pressed $" a lumen4to49all ratio2 Patients 9ho develop h"pertension are *no9n to develop a s"stemic h"pertensive response secondar" to vasoconstrictive stimuli2 Alterations in structural and ph"sical properties of resistance arteries, as 9ell as changes in endothelial function, are pro$a$l" responsi$le for this a$normal $ehavior of vasculature2 :urthermore, vascular remodeling occurs over the "ears as h"pertension evolves, there$" maintaining increased vascular resistance irrespective of the initial hemod"namic pattern2 &enetic %actors "pertension is li*el" to $e related to multiple genes2 "pertension develops secondar" to multiple environmental factors, as 9ell as to several genes, 9hose inheritance appears to $e comple82 %er" rare secondar" causes are related to single genes2 Role o% t e ?ascular endot eliu( 'he vascular endothelium is presentl" considered a vital organ, 9here s"nthesis of various vasodilating and constricting mediators occurs2 'he interaction of autocrine and paracrine factors ta*es place in the vascular endothelium, leading to gro9th and remodeling of the vessel 9all and to the hemod"namic regulation of $lood pressure2 &umerous hormonal, humeral vasoactive, and gro9th and regulating peptides are produced in the vascular endothelium2 'hese mediators include angiotensin II, $rad"*inin, endothelin, nitric o8ide, and several other gro9th factors2 !ndothelin is a potent vasoconstrictor and gro9th factor that li*el" pla"s a ma1or role in the pathogenesis of h"pertension2 Angiotensin II is a potent vasoconstrictor s"nthesi(ed from angiotensin I 9ith the help of an angiotensin4 converting en("me ;AC!<2 Another vasoactive su$stance manufactured in the endothelium is nitric o8ide2 &itric o8ide is an e8tremel" potent vasodilator that influences local autoregulation and other vital organ functions2 Additionall", several gro9th factors are manufactured in the vascular endothelium; each of these pla"s an important role in atherogenesis and target organ damage2 'hese factors include platelet4derived gro9th factor, fi$ro$last gro9th factor, insulin gro9th factor, and man" others2

Pat op ysiology o% target organ da(age

Hypertension and t e cardio?ascular syste(

Cardiac involvement in h"pertension manifests as =% , left atrial enlargement, aortic root dilatation, atrial and ventricular arrh"thmias, s"stolic and diastolic heart failure, and ischemic heart disease2 =% is associated 9ith an increased ris* of premature death and mor$idit"2 A higher fre@uenc" of cardiac atrial and ventricular d"srh"thmias and sudden cardiac death ma" e8ist2 Possi$l", increased coronar" arteriolar resistance leads to reduced $lood flo9 to the h"pertrophied m"ocardium, resulting in angina despite clean coronar" arteries2 "pertension, along 9ith reduced o8"gen suppl" and other ris* factors, accelerates the process of atherogenesis, there$" further reducing o8"gen deliver" to the m"ocardium2 "pertension remains the most common cause of congestive heart failure2 Antih"pertensive therap" has $een demonstrated to significantl" reduce the ris* of death from stro*e and coronar" heart disease2 '9o pu$lished meta4anal"ses have sho9n >A7 and .37 reductions in cardiovascular mortalit" rates2 Le%t ?entricular ypertrop y 'he m"ocardium undergoes structural changes in response to increased afterload2 Cardiac m"oc"tes respond $" h"pertroph", allo9ing the heart to pump more strongl" against the elevated pressure2 o9ever, the contractile function of the left ventricle remains normal until later stages2 !ventuall", =% lessens the cham$er lumen, limiting diastolic filling and stro*e volume2 'he left ventricular diastolic function is mar*edl" compromised in long4standing h"pertension2 'he mechanisms of diastolic d"sfunction have $een elucidated onl" recentl"2 An a$erration in the passive rela8ation of the left ventricle during diastole appears to e8ist2 Gver time, fi$rosis ma" occur, further contri$uting to the poor compliance of the ventricle2 As the left ventricle does not rela8 during earl" diastole, left ventricular end4diastolic pressure increases, further increasing left atrial pressure in late diastole2 'he e8act determinants of left ventricular diastolic d"sfunction have not $een 9ell studied; possi$l", the a$normalit" is governed $" a$normal calcium *inetics2 6 e central ner?ous syste( =ong4standing h"pertension ma" manifest as hemorrhagic and atheroem$olic stro*e or encephalopath"2 Both the high s"stolic and diastolic pressures are harmful; a diastolic pressure of more than >// mm g and a s"stolic pressure of more than >3/ mm g have led to a significant incidence of stro*es2 Gther cere$rovascular manifestations of complicated h"pertension include h"pertensive hemorrhage, h"pertensive encephalopath", lacunar4t"pe infarctions, and dementia2 Renal disease Despite 9idespread treatment of h"pertension in the +nited States, the incidence of end4stage renal disease continues to rise2 'he e8planation for this rise ma" $e concomitant dia$etes mellitus, the progressive nature of h"pertensive renal disease despite therap", or a failure to reduce $lood pressure to a protective level2 A reduction in renal $lood flo9 in con1unction 9ith elevated afferent glomerular arteriolar resistance increases glomerular h"drostatic pressure secondar" to efferent glomerular arteriolar constriction2 'he result is glomerular h"perfiltration, follo9ed $" development of glomerulosclerosis and further impairment of renal function2

'9o studies have demonstrated that a reduction in $lood pressure ma" result in improved renal function2 'herefore, earlier detection of h"pertensive nephrosclerosis using means to detect microal$uminuria and aggressive therapeutic interventions, particularl" 9ith AC! inhi$itor drugs, ma" prevent progression to end4stage renal disease2 &ephrosclerosis is one of the possi$le complications of long4standing h"pertension2 'he ris* of h"pertension4induced end4stage renal disease is higher in $lac* patients, even 9hen the $lood pressure is under good control2 :urthermore, patients 9ith dia$etic nephropath" 9ho are h"pertensive are also at high ris* for developing end4stage renal disease2 'he renin4 angiotensin s"stem activit" influences the progression of renal disease2 Angiotensin II acts at $oth the afferent and the efferent arterioles, $ut more so on the efferent arteriole, 9hich leads to an increase of the intraglomerular pressure2 'he e8cess glomerular pressure leads to microal$uminuria2 #educing intraglomerular pressure using an AC! inhi$itor has $een sho9n to $e $eneficial in patients 9ith dia$etic nephropath", even in those 9ho are not h"pertensive2 'he $eneficial effect of AC! inhi$itors on the progression of renal insufficienc" in patients 9ho are nondia$etic is less clear2 Hypertension in renal disease "pertension is commonl" o$served in patients 9ith *idne" disease2 %olume e8pansion is the main cause of h"pertension in patients 9ith glomerular disease ;nephrotic and nephritic s"ndrome<2 "pertension in patients 9ith vascular disease is the result of the activation of the renin4angiotensin s"stem, 9hich is often secondar" to ischemia2 Most patients 9ith chronic renal failure are h"pertensive ;0/45/7<2 'he com$ination of volume e8pansion and the activation of the renin4angiotensin s"stem is $elieved to $e the main factor $ehind h"pertension in patients 9ith chronic renal failure2 Meta'olic syndro(e 'he meta$olic s"ndrome is an assem$lage of meta$olic ris* factors that directl" promote the development of atherosclerotic cardiovascular disease2 D"slipidemia, h"pertension, and h"pergl"cemia are the most 9idel" recogni(ed meta$olic ris* factors2 'he com$ination of these ris* factors leads to a prothrom$otic, proinflammator" state in humans and identifies individuals 9ho are at elevated ris* for atherosclerotic cardiovascular disease2 'he predominant underl"ing ris* factors for the meta$olic s"ndrome appear to $e a$dominal o$esit" and insulin resistance2 Gther associated conditions are ph"sical inactivit", aging, hormonal im$alance, and atherogenic diet2 Insulin resistance, an essential cause of the meta$olic s"ndrome, predisposes to h"pergl"cemia and t"pe . dia$etes mellitus2 Individuals 9ho insulin resistant ma" not $e clinicall" o$ese, $ut the" commonl" have an a$normal fat distri$ution that is characteri(ed $" predominant upper $od" fat2 +pper $od" o$esit" can occur either intraperitoneall" ;visceral fat< or su$cutaneousl", $oth of 9hich correlate strongl" 9ith insulin resistance and the meta$olic s"ndrome2 'he rising prevalence of the meta$olic s"ndrome is secondar" to the increasing $urden of o$esit" in our societ"2 'he adipose tissue in people 9ho are o$ese is insulin resistant, raises nonesterified fatt" acid levels, alters hepatic meta$olism, and produces several adipo*ines2 'hese include increased production of inflammator" c"to*ines, plasminogen activator inhi$itor4>, and other $ioactive products, 9hile the s"nthesis of potentiall" protective adipo*ine, adiponectin, is reduced2 #ecentl", this s"ndrome has $een noted to $e associated

9ith a state of chronic, lo94grade inflammation2 Although the meta$olic s"ndrome une@uivocall" predisposes to t"pe . dia$etes mellitus, this s"ndrome is multidimensional ris* factor for atherosclerotic cardiovascular disease2

,re-uency
.nited States :ort"4three million people are estimated to have h"pertension, defined $" a s"stolic $lood pressure of >A/ mm g or greater and/or diastolic $lood pressure of 5/ mm g or greater or defined as those ta*ing antih"pertensive medications2 'he age4ad1usted prevalence of h"pertension varies from >04?.7, according to data from the &ational ealth !8amination Surve"s2 According to the &ational Center for ealth Statistic Surve"s, the a9areness for h"pertension increased from 6?7 in >53/4>53. to 057 in >5004>55>2 'he percentage of patients engaged in h"pertension treatment increased from ?67 to -57 during this period2

'he &ational igh Blood Pressure !ducation Program ;& BP!P< has reported estimates of h"pertension prevalence in +nited States2 'he h"pertension surve" 9as conducted from >5054>55A, and actual $lood pressure and self4reported information 9as used2 "pertension 9as defined as s"stolic $lood pressure e@ual to or more than >A/ mm g, diastolic $lood pressure e@ual or more than 5/ mm g, or ta*ing medication for h"pertension2 'he data estimated A?2? million adults 9ith h"pertension in &ovem$er >55>2 'he prevalence according to age group, se8, and race is sho9n in 'a$le >2

'a$le >2 Prevalence ;7< of "pertension in the +nited States, >5054>55AP !ge &roups >04.A .64?A ?64AA A646A 6643A 364-A -6R 'otal !ll Races Fomen ;7< A23 02A >32/ ?/2/ AA2. 6620 3/26 .?26 5 ite Fomen ;7< A23 02> >A2? .52> A?2/ 6A25 652/ .?2A #lac$ Fomen ;7< A2> >/23 .526 AA2? 602/ 362. ->2? .-25

Men ;7< .23 62A >?2/ .-23 A?26523 -/2? .?2A

'otal ;7< /2.2A >/2. .62. A?2. 3.2-32. .?2?

Men ;7< .26 A25 >>2? .620 A.2> 6023 352.?2.

'otal ;7< /26 >23 026 ..23 A>2A 3>2-32> .?2>

Men ;7< .23 02. .625 A325 3/2/ ->2/ -626 .02>

'otal ;7< >2A 32. ..25 A020 3?2/ -623 --25 .02.

PIncludes racial/ethnic groups not sho9n separatel" $ecause of small sample si(es

A .//6 surve" in the +nited States found that in the population aged ./ "ears or older, an estimated A>25 million men and .-20 million 9omen have preh"pertension, >.20 million men and >.2. million 9omen have stage > h"pertension, and A2> million men and 325 million 9omen have stage . h"pertension2 Age4 and se84ad1usted rates of preh"pertension and stage I h"pertension increased among non4 ispanic 9hite, African American, and ispanic persons $et9een >5004>55. and >5554.///2 Age4 and se84ad1usted rates of stage . h"pertension decreased among non4 ispanic 9hites

$et9een >5004>55. and >5554.///, $ut the" 9ere unchanged for African American and ispanic persons2 "nternational &ational health surve"s in various countries have sho9n a high prevalence of poor control of h"pertension2 'hese studies have reported that prevalence of h"pertension is ..7 in Canada, of 9hich >37 is controlled; .32?7 in !g"pt, of 9hich 07 is controlled; and >?237 in China, of 9hich ?7 is controlled2 "pertension is a 9orld9ide epidemic; in man" countries, 6/7 of the population older than 3/ "ears has h"pertension2 Gverall, appro8imatel" ./7 of the 9orld)s adults are estimated to have h"pertension2 'he ./7 prevalence is for h"pertension defined as $lood pressure in e8cess of >A//5/ mm g2 'he prevalence dramaticall" increases in patients older than 3/ "ears2

Mortality/Mor'idity

In the :ramingham eart Stud", the age4ad1usted ris* of congestive heart failure 9as .2? times higher in men and ? times higher in 9omen 9hen highest $lood pressure 9as compared to the lo9est2 Multiple #is* :actor Intervention 'rial ;M#:I'< data sho9ed that the relative ris* for coronar" heart disease mortalit" varied from .2?4325 times higher for persons 9ith mild4to4severe h"pertension compared to persons 9ith normal $lood pressure2 'he relative ris* for stro*e ranged from ?234>52.2 'he population4attri$uta$le ris* percentage for coronar" arter" disease varied from .2?4.6237, 9hereas the population4 attri$uta$le ris* for stro*e ranged from 3204A/72

Race
Blac*s have a higher prevalence and incidence of h"pertension than 9hites2 'he prevalence of h"pertension 9as increased $" 6/7 in African Americans2 In Me8ican Americans, the prevalence and incidence of h"pertension is similar to or lo9er than in 9hites2 'he &ational ealth and &utrition !8amination Surve" ;& A&!S< III reported an age4ad1usted prevalence of h"pertension at ./237 in Me8ican Americans and .?2?7 in non4 ispanic 9hites2

Are there ethnic differences in the pathogenesis of h"pertension, and do these differences influence the choice of treatmentS 'o understand ethnic influence, an understanding of the renin angiotensin s"stem is essential2 #enin secretion is suppressed 9hen the *idne" detects that the amount of sodium e8cretion is increased; thus, a clue to the e8cess sodium in the circulation2 Blac* people tend to develop h"pertension at an earlier age and have lo9er rennin activit"; target organ damage also differs in $lac* people from that in 9hite people2 Most studies in the +nited Cingdom and the +nited States report a higher prevalence and lo9er a9areness of h"pertension in $lac* people than in 9hite people2 Mortalit" from h"pertension in African4Cari$$eanJ$orn people is ?26 times the national rate; similar data have $een pu$lished for African American citi(ens2 Stro*es are more common in $lac* people, $ut coronar" heart disease is more common in Asians2 Both groups have a higher incidence of chronic renal failure than 9hite people, $ut this is more due to h"pertension in $lac* people and dia$etes in Asians2

Blac* people have a poorer response to treatment 9ith AC! inhi$itors compared to 9hite people; the evidence for $eta4$loc*ers $eing less effective in $lac* people is also clear2 o9ever, diuretics are more effective at a "oung age in $lac* people2

Se0
'he age4ad1usted prevalence of h"pertension 9as ?A7, .62A7, and .?2.7 for men and ?>7, .>7, and .>237 for 9omen among African Americans, 9hites, and Me8ican Americans, respectivel"2 In the & A&!S III stud", the prevalence of h"pertension 9as >.7 for 9hite men and 67 for 9hite 9omen aged >04A5 "ears2 o9ever, the age4related $lood pressure rise for 9omen e8ceeds that of men2 'he prevalence of h"pertension 9as reported at 6/7 for 9hite men and 667 for 9hite 9omen aged -/ "ears or older2

!ge
A progressive rise in $lood pressure 9ith increasing age is o$served2 'he third & A&!S surve" reported that the prevalence of h"pertension gro9s significantl" 9ith increasing age in all se8 and race groups2 'he age4specific prevalence 9as ?2?7 in 9hite men ;aged >04.5 "<; this increased to >?2.7 in the group aged ?/4?5 "ears2 'he prevalence further increased to ..7 in the group aged A/4A5 "ears, to ?-267 in the group aged 6/465 "ears, and to 6>7 in the group aged 3/4-A "ears2 In another stud", the incidence of h"pertension appeared to increase appro8imatel" 67 for each >/4"ear interval of age2 Age4related h"pertension appears to $e predominantl" s"stolic rather than diastolic2 'he s"stolic $lood pressure rises into the eighth or ninth decade, 9hile the diastolic $lood pressure remains constant or declines after age A/ "ears2>

Clinical
History

:ollo9ing the documentation of h"pertension, 9hich is confirmed after an elevated $lood pressure, properl" measured, has $een documented on at least ? separate occasions ;$ased on the average of . or more readings ta*en at each of . or more visits after initial screening<, a detailed histor" should e8tract the follo9ing information, o !8tent of target organ damage o Assessment of patients) cardiovascular ris* status o !8clusion of secondar" causes of h"pertension Patients ma" have undiagnosed h"pertension for "ears 9ithout having had their $lood pressure chec*ed2 'herefore, a careful histor" of end organ damage should $e o$tained2 A histor" of cardiovascular ris* factors includes h"percholesterolemia, dia$etes mellitus, and to$acco use ;including che9ing to$acco<2 G$tain a histor" of over4the4counter medication use, current and previous unsuccessful antih"pertensive medication trials, and ethanol inta*e2 'he historical and ph"sical findings that suggest the possi$ilit" of secondar" h"pertension are a histor" of *no9n renal disease, a$dominal masses, anemia, and urochrome pigmentation2 A histor" of s9eating, la$ile h"pertension, and palpitations suggests the diagnosis of pheochromoc"toma2

A histor" of cold or heat tolerance, s9eating, lac* of energ", and $rad"cardia or tach"cardia ma" indicate h"poth"roidism or h"perth"roidism2 A histor" of 9ea*ness suggests h"peraldosteronism2 A$dominal $ruit suggests the possi$ilit" of renal arter" stenosis2 A$sence of femoral pulses suggests coarctation of aorta2 Cidne" stones raise the possi$ilit" of h"perparath"roidism2 'he presence of papilledema and other neurologic signs raises the possi$ilit" of increased intracranial pressure2 A histor" of drug ingestion, including oral contraceptives, licorice, and s"mpathomimetics, should $e o$tained2

P ysical
An accurate measurement of $lood pressure is the *e" to diagnosis2 Several determinations should $e made over a period of several 9ee*s2 At an" given visit, an average of ? $lood pressure readings ta*en . minutes apart using a mercur" manometer is prefera$le2 Blood pressure should $e measured in $oth the supine and sitting positions, auscultating 9ith the $ell of the stethoscope2 Gn the first visit, $lood pressure should $e chec*ed in $oth arms and in one leg to avoid missing the diagnosis of coarctation of aorta or su$clavian arter" stenosis2 As the improper cuff si(e ma" influence $lood pressure measurement, a 9ider cuff is prefera$le, particularl" if the patient)s arm circumference e8ceeds ?/ cm2 'he patient should rest @uietl" for at least 6 minutes $efore the measurement2 Although some9hat controversial, the common practice is to document phase % ;a disappearance of all sounds< of Corot*off sounds as the diastolic pressure2

A funduscopic evaluation of the e"es should $e performed to detect an" evidence of h"pertensive retinopath"2 'hese are flame4shaped hemorrhages and cotton 9ool e8udates2 Palpation of all peripheral pulses should $e performed2 =oo* for renal arter" $ruit over the upper a$domen; the presence of a unilateral $ruit 9ith $oth a s"stolic and diastolic component suggests renal arter" stenosis2 A careful cardiac e8amination is performed to evaluate signs of =% 2 'hese include displacement of ape8, a sustained and enlarged apical impulse, and the presence of an SA2 Gccasionall", a tam$our S. is heard 9ith aortic root dilatation2

Causes

Primar" or essential h"pertension ;5/4567< Secondar" h"pertension, A small percentage of patients ;.4>/7< have a secondar" cause2 'he follo9ing is a list of secondar" causes of h"pertension, o #enal ;.26437< #enal parench"mal disease Pol"c"stic *idne" disease +rinar" tract o$struction #enin4producing tumor =iddle s"ndrome

o o

o o

o o o o o

o o

#enovascular h"pertension ;/2.4A7< %ascular Coarctation of aorta %asculitis Collagen vascular disease !ndocrine ;>4.7< 4 Gral contraceptives Adrenal Primar" aldosteronism Cushing s"ndrome Pheochromoc"toma Congenital adrenal h"perplasia "perth"roidism and h"poth"roidism "percalcemia "perparath"roidism Acromegal" &eurogenic Brain tumor Bul$ar poliom"elitis Intracranial h"pertension Pregnanc"4induced h"pertension Drugs and to8ins Alcohol Cocaine C"closporin !r"thropoietin Adrenergic medications

Di%%erential Diagnoses
Adrenal Adenoma "peraldosteronism, Primar" Aortic Coarctation "pertension and Pregnanc" Aortic Dissection "pertension, Malignant Apnea, Sleep "pertensive eart Disease Atherosclerosis "perth"roidism Atherosclerotic Disease of the Carotid Arter" G$structive Sleep Apnea4 "popnea S"ndrome Cardiom"opath", Cocaine Pheochromoc"toma Cardiom"opath", "pertrophic #enal Arter" Stenosis

5or$up
La'oratory Studies

+nless a secondar" cause for h"pertension is suspected, onl" the follo9ing routine la$orator" studies should $e performed, o CBC count, serum electrol"tes, serum creatinine, serum glucose, uric acid, and urinal"sis o =ipid profile ;total cholesterol, lo94densit" lipoprotein D=D=E and high4densit" lipoprotein D D=E, and trigl"cerides<

Additional tests descri$ed $elo9 are indicated 9hen specific clinical situations 9arrant further investigation2 o Microal$uminuria is an earl" indication of h"pertensive nephrosclerosis and is also a mar*er for a higher ris* of cardiovascular mor$idit" and mortalit"2 Present recommendations suggest that individuals 9ith t"pe I dia$etes should $e screened for microal$uminuria2 +sefulness of this screening in h"pertensive patients 9ithout dia$etes has not $een esta$lished2 o Plasma renin activit" ;P#A< is performed to detect evidence of primar" h"peraldosteronism2 =o9 renin values confirm the diagnosis of primar" h"peraldosteronism; ho9ever, h"po*alemia ma" $e associated 9ith a form of h"pertension, $ut it is not often present2 o Determination of sensitive th"roid4stimulating hormone ;'S < level e8cludes h"poth"roidism or h"perth"roidism as a cause of h"pertension2

"(aging Studies

!chocardiograph", 'he limited echocardiograph" stud", rather than the complete e8amination, ma" detect =% more fre@uentl" than electrocardiograph"2 'he main indication for limited echocardiograph" is evaluation for end organ damage in a patient 9ith $orderline high $lood pressure2 'herefore, the presence of =% despite normal or $orderline high $lood pressure measurements re@uires antih"pertensive therap"2 Imaging studies for renovascular stenosis, If the histor" suggests renal arter" stenosis and if a corrective procedure is considered, further radiologic investigations are performed2

4t er 6ests

#outine testing includes electrocardiograms2 Am$ulator" $lood pressure monitoring, Indications for am$ulator" $lood pressure monitoring include la$ile $lood pressure, a discrepanc" $et9een $lood pressure measurement inside and outside the ph"sician)s office, and poor $lood pressure control2 Am$ulator" monitoring also identifies patients 9ho have the distinct s"ndrome called 9hite coat h"pertension2

6reat(ent
Medical Care
Consider lifest"le modifications2 As the cardiovascular disease ris* factors are assessed in individuals 9ith h"pertension, pa" attention to the lifest"les that favora$l" affect $lood pressure level and reduce overall cardiovascular disease ris*2 A relativel" small reduction in $lood pressure ma" affect the incidence of cardiovascular disease on a population $asis2 A decrease in $lood pressure of . mm g reduces the ris* of stro*e $" >67 and the ris* of coronar" arter" disease $" 37 in a given population2 J&C %II recommendations to lo9er $lood pressure and decrease cardiovascular disease ris* include the follo9ing,

=ose 9eight if over9eight2 =imit alcohol inta*e to no more than > o( ;?/ m=< of ethanol ;ie, .A o( D-./ m=E of $eer, >/ o( D?// m=E of 9ine, . o( D3/ m=E of >//4proof 9his*e"< per da" or /26 ;>6 m=< ethanol per da" for 9omen and people of lighter 9eight2 Increase aero$ic activit" ;?/4A6 min most da"s of the 9ee*<2 #educe sodium inta*e to no more than >// mmol/d ;.2A g sodium or 3 g sodium chloride<2 Maintain ade@uate inta*e of dietar" potassium ;appro8imatel" 5/ mmol/d<2 Maintain ade@uate inta*e of dietar" calcium and magnesium for general health2 Stop smo*ing and reduce inta*e of dietar" saturated fat and cholesterol for overall cardiovascular health2

Clinical trials Multiple clinical trials suggest that most antih"pertensive drugs provide the same degree of cardiovascular protection for the same level of $lood pressure control2 Fell4designed prospective randomi(ed trials, such as the S9edish 'rial in Gld Patients 9ith "pertension ;S'GP4.<, the &ordic Diltia(em ;&G#DI=< trial, and the Intervention as a Boal in "pertension 'reatment ;I&SIB '< trial, have sho9n a similar outcome 9ith older drugs ;eg, diuretics, $eta4$loc*ers< compared to the ne9er antih"pertensive agents ;eg, AC! inhi$itors, calcium channel $loc*ers<2 &o consensus e8ists regarding optimal drug therap" for treatment of h"pertension; most clinicians recommend initiating therap" 9ith a single agent and advancing to the lo94dose com$ination therap"2 An" of the first4line medications decrease $lood pressure in A/43/7 of patients 9ith mild4to4moderate h"pertension2 In unresponsive patients, s9itching to a second drug ;rather than com$ining it 9ith the first drug< or s9itching to a third drug if the second drug is not effective ma" allo9 a -/40/7 response rate to monotherap"2 'herefore, attempt to identif" a particular class of drug to 9hich the patient responds rather than adding multiple drugs ;as in com$ination therap"<2 'he J&C %II report recommends either a thia(ide diuretic or a $eta4$loc*er as the initial therap" of uncomplicated h"pertension2 A lo9 dose of thia(ide diuretic ;>.264.6 mg h"drochlorothia(ide< is a lo94cost therap" 9ith fe9er complications, and it provides e@uivalent cardiovascular protection2 Patients unresponsive to lo94dose thia(ide therap" should tr" an AC! inhi$itor, $eta4$loc*er, or calcium channel $loc*er, se@uentiall"2 Patients unresponsive to a diuretic ma" not respond to a calcium channel $loc*er, and an AC! inhi$itor or a $eta4$loc*er should $e tried as a second4line agent in these patients2 Calcium channel $loc*ing agents and diuretics ma" $e more effective in h"pertensive $lac* patients2 Initial therap" $ased on the J&C %II report recommendations is as follo9s,

Preh"pertension ;s"stolic >./4>?5, diastolic 0/405<, &o antih"pertensive drug is indicated2 Stage > h"pertension ;s"stolic >A/4>65, diastolic 5/455<, 'hia(ide4t"pe diuretics are recommended for most2 AC! inhi$itor, angiotensin II receptor $loc*er ;A#B<, $eta4 $loc*er, calcium channel $loc*er, or com$ination ma" $e considered2 Stage . h"pertension ;s"stolic more than >3/, diastolic more than >//<, '9o4drug com$ination ;usuall" thia(ide4t"pe diuretic and AC! inhi$itor or A#B or $eta4$loc*er or calcium channel $loc*er< is recommended for most2

:or the compelling indications, other antih"pertensive drugs ;eg, diuretics, AC! inhi$itor, A#B, $eta4$loc*er, calcium channel $loc*er< ma" $e considered as needed2

Rando(ized trials '9o randomi(ed controlled trials, the "pertension Detection and :ollo94up Program ; D:P< and the Medical #esearch Council ;M#C< trials, randomi(ed patients 9ith elevated levels of diastolic $lood pressure to either diuretic4$ased stepped4care treatment or usual care2 'he usual care group received some form of therap" from their o9n ph"sicians, 9hereas the stepped4care group received s"stematic care2 In $oth studies, stepped4care treatment reduced diastolic $lood pressure $" 6 mm more than that reduced in the control group2 Both trials sho9ed a $enefit from stepped4care therap" compared to the control group2 In the D:P trial, stepped4care led to relative ris* reduction of >-7 for total mortalit"; -3 h"pertensive patients needed to $e treated 9ith stepped4care therap" for 6 "ears to prevent one death2 A meta4anal"sis pu$lished in the Journal of the American Medical Association ;JAMA< in >55- included several randomi(ed controlled clinical trials2 'he total num$er of participants randomi(ed to active therap" 9as .A,.5A, and the num$er for the control therap" 9as .?,5.32 Active treatment reduced diastolic $lood pressure $" at least 6 mm g2 'he meta4anal"sis sho9ed a ris* reduction of coronar" heart disease of 04>A7 and the reduction in stro*e incidence of ?64A/72 Su$se@uent meta4anal"sis reported that $enefits of active treatment are similar in men and 9omen2 Reco((endations %or (anage(ent o% ypertension 'he J&C recommends certain situations for 9hich a specific class of drug ma" $e administered2 An AC! inhi$itor should $e the initial treatment in situations in 9hich h"pertension is associated 9ith congestive heart failure, dia$etes mellitus 9ith proteinuria, and postm"ocardial infarction 9ith s"stolic left ventricular d"sfunction2 In patients 9ho develop persistent cough 9hile on AC! inhi$itor therap", an angiotensin II receptor antagonist ma" $e su$stituted, $ut these agents) efficac" in lo9ering cardiovascular mortalit" rates has not "et $een proven2 A $eta4$loc*er should $e prescri$ed follo9ing an acute m"ocardial infarction2 A diuretic or a long4acting calcium channel $loc*er ma" $e more effective in elderl" patients 9ith isolated s"stolic h"pertension2 'he .//A Canadian "pertension Societ" recommendations ;similar to J&C %II guidelines< for the management of h"pertension in specific patient groups are listed in 'a$le . and 'a$le ?, as follo9s, 'a$le .2 S"nopsis of Considerations in the +se of Antih"pertensive Drug ClassesP Class o% Medication =oop diuretics Potassium4sparing Diuretics 'hia(ides 5 en to .se #enal insufficienc" ;additional therap"< Primar" h"peraldosteronism ;additional therap" in com$ination 9ith thia(ide diuretics< +ncomplicated h"pertension ;preferred therap"<, s"stolic h"pertension in elderl" people ;preferred therap"<, for older dia$etic patients 9ithout nephropath" 5 en =ot to .se Bout #enal insufficienc" Bout, d"slipidemia ;high4dose<

Asthma, PostJm"ocardial infarction, peripheral Beta4adrenergic antagonists uncomplicated h"pertension ;preferred vascular disease therap"<, dia$etes ;9ithout nephropath"< ;severe< Dia$etes, postJm"ocardial infarction, Bilateral heart failure, renal disease, renovascular AC! inhi$itors uncomplicated h"pertension ;preferred disease, therap"< pregnanc" Dia$etes ;alternative therap"<, heart Bilateral failure ;alternative therap"<, renovascular Angiotensin II antagonists uncomplicated h"pertension ;preferred disease, therap"< pregnanc" +ncomplicated h"pertension ;alternative eart $loc*, heart &ondih"drop"ridines therap"< failure Calcium channel S"stolic h"pertension ;preferred eart $loc*, heart $loc*ers Dih"drop"ridines therap"<, uncomplicated therap" failure ;alternative therap"< Alpha4adrenergic +ncomplicated h"pertension ;alternative Autonomic antagonists/central acting agents therap"< d"sfunction PCMAJ >555, >3>,S>4S.. 'a$le ?2 Considerations in the Individuali(ation of Antih"pertensive 'herap"P Ris$ ,actor/Disease Pre%erred 6 erapy !lternati?e 6 erapy !?oid 6 erapy

=o94dose thia(ideli*e diuretics, $eta4 +ncomplicated $loc*ers, AC! h"pertension ;M3/ inhi$itors, or long4 "< acting dih"drop"ridine calcium channel $loc*ers =o94dose thia(ideli*e diuretics, AC! +ncomplicated inhi$itors, or long4 h"pertension ;U 3/ acting dih"drop"ridine "< calcium channel $loc*ers As for uncomplicated D"slipidemia h"pertension Dia$etes mellitus AC! inhi$itors 9ith nephropath" Dia$etes mellitus AC! inhi$itors or $eta4 9ithout $loc*ers nephropath" Dia$etes mellitus =o94dose thia(ideli*e

Com$inations of first4line drugs

Com$inations of first4line drugs

T Angiotensin II receptor $loc*ers T T

T igh4dose diuretics and centrall" acting agents ;in the setting of autonomic neuropath"< T T

9ithout nephropath", 9ith s"stolic h"pertension

diuretics or long4acting dih"drop"ridine calcium channel $loc*ers Beta4$loc*ers ;AC! Angina inhi$itors as add4on therap"< Prior m"ocardial Beta4$loc*ers, AC! infarction inhi$itors AC! inhi$itors ;thia(ide or loop S"stolic diuretics, $eta4 d"sfunction $loc*ers, spironolactone is additive therap"< =eft ventricular Most antih"pertensives h"pertroph" reduce =% Peripheral arterial As for uncomplicated disease h"pertension AC! inhi$itors #enal disease ;diuretics as additive therap"<

=ong4acting calcium channel $loc*ers T Angiotensin II receptor $loc*ers, h"drala(ine/isosor$ide dinitrate, amlodipine T As for uncomplicated h"pertension

T T &ondih"drop"ridine calcium channel $loc*ers ;diltia(em, verapamil< "drala(ine, mino8idil

Beta4$loc*ers ;9ith severe disease< AC! inhi$itors in cases Dih"drop"ridine calcium of $ilateral renal arter" channel $loc*ers stenosis

PShort4acting calcium channel $loc*ers are not recommended in the treatment of h"pertension Several situations demand the addition of a second drug $ecause . drugs ma" $e used at lo9er doses to avoid adverse effects, 9hich ma" occur 9ith higher doses of an individual agent2 Diuretics generall" potentiate the effects of other antih"pertensive drugs $" minimi(ing volume e8pansion2 Specificall", the use of the diuretic thia(ide in con1unction 9ith a $eta4 $loc*er or an AC! inhi$itor has an additive effect, controlling $lood pressure in up to 067 of patients2 Most drug com$inations using agents that act $" different mechanisms have an additive effect2 'he com$ination of a calcium channel $loc*er 9ith either an AC! inhi$itor or a dih"drop"ridine calcium channel $loc*er and a $eta4$loc*er has additive effects2 An AC! inhi$itor ma" $e com$ined 9ith an angiotensin II receptor antagonist $ecause the $loc*ing of angiotensin I receptors ma" lead to increased plasma angiotensin II concentration, 9hich ma" compete 9ith a drug for the receptor2 Some com$inations ma" not $e additive, including a $eta4$loc*er and AC! inhi$itor, a $eta4$loc*er and an alpha>4$loc*er and an alpha. stimulant, and, more controversiall", a diuretic and a calcium channel $loc*er2 Some com$inations ma" have additive adverse effects; these include a $eta4$loc*er com$ined 9ith verapamil or diltia(em, 9hich leads to cardiac depression, $rad"cardia, or heart $loc*2 Clinical trials have sho9n that the effective control of $lood pressure reduces the ris* of cardiovascular events in high4ris* patients2 In the patients 9ho achieved optimal $lood pressure control compared 9ith those 9ith uncontrolled h"pertension, significant reductions in the incidence of cardiac events, stro*e, and all4cause mortalit" occurred ;according to the %alsartan Antih"pertensive =ong4term +se !valuation D%A=+!E 'rial<2 'he lac* of significant difference in cardiovascular mortalit" and mor$idit" among patients receiving

diuretics, calcium channel $loc*ers, or AC! inhi$itors in the Antih"pertensive and =ipid4 =o9ering 'reatment to Prevent eart Attac* 'rial ;A== A'< possi$l" occurred due to confounding $ecause of differences in the $lood pressure reductions achieved 9ith the ? treatments2 #ecent studies have consistentl" sho9n that ne9er antih"pertensive agents, such as AC! inhi$itors and calcium channel $loc*ers, reduce cardiovascular events to a similar, or possi$l" greater, e8tent as older therapies, such as diuretics and $eta4$loc*ers2 AC! inhi$itors specificall" offer additional $enefits $e"ond $lood pressure reduction, 9hich include reduction of cardiovascular events and renal protection2 Similarl", A#Bs have demonstrated $eneficial effects in heart failure, stro*e, and renal protection2

Ce" messages of the Seventh #eport of the Joint &ational Committee on Prevention, Detection, !valuation, and 'reatment of igh Blood Pressure ;J&C %II< are as follo9s, o In those older than 6/ "ears, s"stolic $lood pressure ;BP< of greater than >A/ mm g is a more important cardiovascular disease ris* factor than diastolic BP2 o Beginning at >>6/-6 mm g, the cardiovascular disease ris* dou$les for each increment of .//>/ mm g2 o Individuals 9ho are normotensive at 66 "ears 9ill have a 5/7 lifetime ris* of developing h"pertension2 o Preh"pertension ;s"stolic >./4>?5, diastolic 0/405< re@uires health4promoting lifest"le modifications to prevent the progressive rise in $lood pressure and cardiovascular disease2 o In uncomplicated h"pertension, a thia(ide diuretic, either alone or com$ined 9ith drugs from other classes, should $e used for the drug treatment of most2 o In specific high4ris* conditions, there are compelling indications for the use of other antih"pertensive drug classes ;eg, AC! inhi$itors, angiotensin4receptor $loc*ers, $eta4$loc*ers, calcium channel $loc*ers<2 o '9o or more antih"pertensive medications 9ill $e re@uired to achieve goal BP ;M>A//5/ mm g or M>?//0/ mm g< for patients 9ith dia$etes and chronic *idne" disease2 o :or patients 9hose BP is more than ./ mm g a$ove the s"stolic BP goal or more than >/ mm g a$ove the diastolic BP goal, initiation of therap" using . agents, one of 9hich usuall" 9ill $e a thia(ide diuretic, should $e considered2 o #egardless of therap" or care, h"pertension 9ill $e controlled onl" if patients are motivated to sta" on their treatment plan2 #esistant h"pertension, Some patients ma" have persistent diastolic $lood pressures a$ove >// mm g despite the use of ? or more antih"pertensive medications2 'hese patients ma" $e e8periencing of the follo9ing factors as the cause of resistant h"pertension, o Inade@uate treatment 9as descri$ed as the most common cause of resistant h"pertension in several pu$lished series2 Patients ma" not $e on an effective drug, or concomitant volume e8pansion ma" occur as a side effect of the drug2 o !8tracellular volume e8pansion, %olume e8pansion ma" contri$ute to the ina$ilit" to lo9er s"stemic $lood pressure2 'he volume e8pansion ma" occur $ecause of renal insufficienc", sodium retention due to treatment 9ith vasodilators, high4salt diet, or insufficient dosing of diuretic2 'his situation can

$e treated 9ith more aggressive diuretic therap" until clinical signs of e8tracellular volume depletion ;eg, orthostatic h"potension< develop2 o Poor compliance, &oncompliance 9ith medical therap" or dietar" modifications ;eg, salt restriction< ma" pla" a role in causing resistant h"pertension2 Address noncompliance 9ith e8tensive patient education, simplification of the drug regimen, and use of drugs 9ith the fe9est adverse effects2 o Secondar" h"pertension, Fhenever confronted 9ith resistant h"pertension, tr" to e8clude an" secondar" causes of h"pertension2 A reevaluation of the patient)s histor", ph"sical e8amination, and la$orator" results ma" provide clues to secondar" h"pertension ;eg, renal arter" stenosis, primar" h"peraldosteronism<2 o Fhite coat h"pertension, Blood pressure rise secondar" to an8iet" ma" $e o$served in ./4?/7 of patients2 'his ma" $e avoided $" having patients rest prior to measurement, having a nurse chec* the $lood pressure, or arranging to have the $lood pressure monitored at home2 Development of h"potensive s"mptoms on medications is an indication of 9hite coat h"pertension2 Fhite coat h"pertension can also $e evaluated $" the use of a .A4hour am$ulator" monitor2 Pseudoh"pertension ma" $e o$served in elderl" individuals 9ho have thic*ened, calcified arteries2 Much higher cuff pressure ma" $e re@uired to occlude a thic*ened $rachial arter", and diastolic pressure ma" also $e overestimated2 Consider pseudoh"pertension in situations in 9hich no organ damage occurs despite mar*ed h"pertension, 9hen patients develop h"potensive s"stems on medications, and 9hen calcification of the $rachial arter" is o$served on radiologic e8amination2 Direct measurement of intra4arterial pressure ma" $e re@uired in this setting2 %asoactive su$stances, #esistant h"pertension ma" $e encountered in patients 9ho are ingesting vasoactive su$stances despite ta*ing antih"pertensive drugs regularl"2 +se of salt and alcohol are the common e8amples; others include use of cocaine, amphetamines, ana$olic steroids, oral contraceptives, c"closporine, antidepressants, and nonsteroidal anti4inflammator" drugs2 "pertension in special populations o Age 'he s"stolic pressure continues to progressivel" rise throughout life, reaching the highest levels in later stages of life2 Isolated s"stolic h"pertension ma" $e present in >/7 of the population aged -/ "ears and in .A7 of those aged 0/ "ears2 :urthermore, severe arteriosclerosis ma" lead to pseudoh"pertension2 Isolated h"pertension results in lo9 cardiac output $ecause of the decreased stro*e volume and high peripheral resistance2 'his ma" reduce glomerular filtration further, 9hich is 9h" lo9 activit" of renal angiotensin aldosterone cascade is encountered in elderl" individuals 9ho are h"pertensive2 Despite lo9 P#A, $lood pressure responds 9ell to AC! inhi$itor and angiotensin receptor inhi$itor therap"2 =o9 doses of diuretics ma" also $e effective2 Calcium antagonists are @uite useful $ecause of their strong antih"pertensive effects2 Gften, com$ining . drugs at a lo9er dose ma" $e prefera$le to using a single drug at a high dose that has the potential for adverse effects2 o Se8, 'he prevalence of h"pertension is similar $et9een men and 9omen, $ut 9omen are protected from coronar" heart disease prior to menopause2

Premenopausal 9omen have a higher resting heart rate, a higher cardiac inde8, and a lo9er peripheral resistance than men2 'hese changes are not encountered in postmenopausal females2 'herefore, in premenopausal situations, a medication such as $eta4$loc*er ma" $e effective2 o9ever, postmenopausal h"pertension is treated similarl" to that in men2 o #ace Blac*s have a higher prevalence of h"pertension and a much higher fre@uenc" of end organ damage, such as occurs in end4stage renal disease, stro*es, and heart failure2 Blac* patients also develop more severe =% than 9hite patients2 #enal function in h"pertensive $lac* patients continues to deteriorate over time despite aggressive management of the $lood pressures2 Blac* patients respond less 9ell to $eta4$loc*ers, AC! inhi$itors, and angiotensin receptor $loc*ers than 9hite patients2 At times, this relative lac* of efficac" ma" $e overcome $" increasing the dosage of the medications2 Blac*s ma" respond 9ell to treatment 9ith calcium antagonists, diuretics, and posts"naptic alpha4$loc*ers2 o G$esit" "pertensive patients 9ho are o$ese have a higher cardiac output and a lo9er peripheral vascular resistance than h"pertensive patients 9ho are not o$ese2 'he increase in cardiac output manifests secondar" to increased preload2 'he end4diastolic volume and pressure are elevated, leading to left ventricular dilatation2 =eft ventricular 9all thic*ening also occurs secondar" to increased afterload, 9hich increases the ris* of congestive heart failure2 'he concomitant dia$etes often present in patients 9ho are o$ese produces a devastating effect on *idne"s and leads to a much higher incidence of renal failure2 &o class of drugs seems to $e of particular advantage in h"pertensive patients 9ho are o$ese, $ut thia(ide diuretics ma" $e helpful, unless the patient also has coe8isting dia$etes2 In patients 9ho are dia$etic and 9ho ma" have microal$uminuria, AC! inhi$itors or calcium antagonists are recommended $ecause the" ma" slo9 declining renal function2 Because of the high preload and afterload, drugs that have negative inotropic effects, such as $eta4$loc*ers, should $e avoided2 'he management of secondar" h"pertension ma" result in cure $" the surgical correction of the underl"ing pro$lem, such as removal of a pheochromoc"toma2 Surger" ma" not $e feasi$le in a su$stantial num$er of patients for 9hom medical therap" is instituted to control h"pertension2 o #enovascular h"pertension 'he goals of therap" are maintenance of normal $lood pressure and prevention of end4stage renal disease2 'he therapeutic options include medical therap", percutaneous transluminal renal angioplast", and surgical revasculari(ation2 'hese options must $e individuali(ed $ecause no randomi(ed studies document the superiorit" of one option over the other2 'he indications for surger" or angioplast" include an ina$ilit" to control $lood pressure 9hile on a medical regimen, the need to preserve renal function, and intolera$le effects of medical therap"2 Aortal renal $"pass using saphenus vein or h"pogastric arter" is a common revasculari(ation techni@ue2 A s"nthetic graft has also $een used2 Percutaneous transluminal renal angioplast" ;P'#A< can $e

effective treatment for $oth h"pertension and preservation of renal function2 P'#A ma" $e the initial choice in "ounger patients 9ith fi$romuscular lesions amena$le to $alloon angioplast"2 #enal arter" stenting of osteal lesions has $een associated 9ith improved long4term patenc"2 P'#A ma" also $e used for arthrosclerotic renal arter" stenosis; the outcome ma" $e compara$le to surgical revasculari(ation2 Medical therap" is re@uired in the preoperative phase of interventional therap"2 Medical therap" is also indicated for high4ris* individuals and for older patients 9ho have easil" controlled h"pertension2 AC! inhi$itors are @uite effective in patients 9ith unilateral renal arter" stenosis; ho9ever, avoid AC! inhi$itors in patients 9ith $ilateral renal arter" stenosis or stenosis of a solitar" *idne"2 A diuretic can $e com$ined 9ith an AC! inhi$itor2 Because of their glomerular vasodilator" effect, calcium antagonists are effective in renal arter" stenosis and do not compromise renal function2 Pheochromoc"toma :ollo9ing suspicion of pheochromoc"toma, the presence of a tumor should $e confirmed $iochemicall" $" measuring urine and plasma concentrations of catecholamine or their meta$olites2 In most situations, a C' scan or an M#I ma" $e used to locali(e the tumor in the a$domen2 In the a$sence of a$dominal imaging, nuclear scan 9ith metaiodo$en("lguanidine ;MIBB< ma" further help 9ith the locali(ation2 Surgical resection is the treatment of choice $ecause h"pertension is cured $" tumor resection2 In the preoperative phase, com$ined alpha4 and $eta4adrenergic $loc*ade is recommended for h"pertension control2 Alpha4adrenergic $loc*ade is initiated 9ith pheno8"$en(amine or pra(osin, and, follo9ing ade@uate alpha4adrenergic $loc*ade, $eta4 adrenergic $loc*ade is initiated2 'hese patients are often volume contracted and re@uire saline or sodium ta$lets2 Catecholamines can $e reduced further $" met"rosine2 :or adrenal pheochromoc"toma, laparoscopic adrenalectom" is $ecoming the procedure of choice in suita$le patients2 :ollo94up .A4hour urinar" e8cretion studies of catecholamines should $e performed . 9ee*s follo9ing surger" ;and periodicall" thereafter< to detect recurrence, metastases, or development of second primar" lesion2 Primar" h"peraldosteronism "per*alemia is an important clue to the presence of primar" aldosteronism2 o9ever, in a su$set of patients, the serum potassium concentration ma" $e 9ithin the reference range2 Measurement of P#A has $een used as a screening test2 A suppressed P#A value that fails to rise a$ove . mg/m=/h after salt and 9ater depletion is considered a positive test result2 'he $est initial test is the determination of the aldosterone e8cretion rate during prolonged salt loading2 'he appropriate therap" depends on the cause of e8cessive aldosterone production2 A C' scan ma" help locali(e an adrenal mass, indicating adrenal adenoma2 If the results of the C' scan are inconclusive, adrenal venous sampling for aldosterone and cortisol levels should $e performed2 Medical therap" is indicated in patients 9ith adrenal h"perplasia, patients 9ith adenoma 9ho are poor surgical ris*s, and

patients 9ith $ilateral adenomas2 'hese patients are $est treated 9ith sustained salt and 9ater depletion2 "drochlorothia(ide or furosemide in com$ination 9ith either spironolactone or amiloride corrects h"po*alemia and normali(es the $lood pressure2 Some patients ma" re@uire the addition of a vasodilator or a $eta4$loc*er for $etter control of h"pertension2 Adrenal adenomas ma" $e resected via a laparoscopic procedure2 Surgical resection often leads to the control of $lood pressure and the reversal of $iochemical a$normalities2 'hese patients ma" develop h"poaldosteronism during the postoperative follo94up period and re@uire supplementation 9ith fludrocortisone2

Surgical Care
Aortorenal $"pass using saphenus vein graft or h"pogastric arter" is a common revasculari(ation techni@ue for renovascular h"pertension2 Surgical resection is the treatment of choice for pheochromoc"toma $ecause h"pertension is cured $" tumor resection2 In patients 9ith fi$romuscular renal disease, angioplast" has a 3/40/7 success rate for cure or improvement of h"pertension2 Surgical correction of renal arter" stenosis has resulted in cure of h"pertension in appro8imatel" 3>7 of patients and amelioration in .-7 of patients 9ith fi$romuscular lesions2 Fith respect to renal arter" stenosis secondar" to atherosclerotic lesions, surgical correction has resulted in cure of h"pertension in ?07 of patients and amelioration in a$out A>7 of patients2 See Medical Care for more details2

Consultations
Consultations 9ith a nutritionist and e8ercise specialist are often helpful in changing lifest"le and initiating 9eight loss2 Consultations 9ith an appropriate consultant are indicated for management of secondar" h"pertension attri$uta$le to a specific cause2

Diet
A num$er of studies have documented an association $et9een sodium chloride inta*e and $lood pressure2 'he effect of sodium chloride is particularl" important in individuals 9ho are middle4aged to elderl" 9ith a famil" histor" of h"pertension2 A moderate reduction in sodium chloride inta*e can lead to a small reduction in $lood pressure2 'he American eart Association recommends that the average dail" consumption of sodium chloride not e8ceed 3 g, this ma" lo9er $lood pressure $" .40 mm g2

'he Dietar" Approaches to Stop "pertension ;DAS < eating plan encompasses a diet rich in fruits, vegeta$les, and lo94fat dair" products and ma" lo9er $lood pressure $" 04>A mm g2. Dietar" potassium, calcium, and magnesium consumption have an inverse association 9ith $lood pressures2 =o9er inta*e of these elements potentiates the affect of sodium on $lood pressure2 Gral potassium supplementation ma" lo9er $oth s"stolic and diastolic pressure2 Calcium and magnesium supplementation have elicited small reductions in $lood pressures2 In population studies, lo9 levels of alcohol consumption have sho9n a favora$le effect on $lood pressure, 9ith reductions of .4A mm g2 o9ever, the consumption of

? or more drin*s per da" is associated 9ith elevation of $lood pressure2 Alcohol inta*e should $e restricted to less than > o( of ethanol in men and /26 o( in 9omen2 Feight reduction ma" lo9er $lood pressure $" 64./ mm g per >/ *g of 9eight loss in a patient 9ho 9eighs more than >/7 of ideal $od" 9eight2

!cti?ity
+p to 3/7 of all individuals 9ith h"pertension are more than ./7 over9eight2 'he centripetal fat distri$ution is associated 9ith insulin resistance and h"pertension2 !ven modest 9eight loss ;67< can lead to reduction in $lood pressure and improved insulin sensitivit"2 #egular aero$ic ph"sical activit" can facilitate 9eight loss, decrease $lood pressure, and reduce the overall ris* of cardiovascular disease2 Blood pressure ma" $e lo9ered $" A45 mm g 9ith moderatel" intense ph"sical activit"2 'hese activities include $ris* 9al*ing for ?/ minutes a da", 6 da"s per 9ee*2 More intense 9or*outs for ./4?/ minutes, ?4A times a 9ee* ma" also lo9er $lood pressure and have additional health $enefits2

Medication
'he goals of pharmacotherap" are to reduce mor$idit" and to prevent complications2

Diuretics
Cause diuresis, 9hich decreases plasma volume and edema, there$" decreasing cardiac output and $lood pressure2

Hydroc lorot iazide 7Esidri0, HydroD".R"L, Microzide8 Inhi$its rea$sorption of sodium in distal tu$ules, causing increased e8cretion of sodium, 9ater, potassium, and h"drogen ions2 Dosing

Adult
.64>// mg PG @d; not to e8ceed .// mg/*g/d

Pediatric
M3 months, .4? mg/*g/d PG divided $id N3 months, . mg/*g/d PG divided $id "nteractions Ma" decrease effects of anticoagulants, antigout agents, and sulfon"lureas; ma" increase to8icit" of allopurinol, anesthetics, antineoplastics, calcium salts, loop diuretics, lithium, dia(o8ide, digitalis, amphotericin B, and nondepolari(ing muscle rela8ants

Contraindications Documented h"persensitivit"; anuria; renal decompensation Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions
Caution in renal and hepatic disease, gout, dia$etes mellitus, and lupus er"thematosus

Spironolactone 7!ldactone8 +sed for management of h"pertension2 Ma" $loc* effects of aldosterone on arteriolar smooth muscles2 Dosing

Adult
.64.// mg/d PG @d or divided $id

Pediatric
>264?26 mg/*g/d PG in divided doses @34.Ah "nteractions Ma" decrease effect of anticoagulants; potassium and potassium4sparing diuretics ma" increase to8icit" of spironolactone Contraindications Documented h"persensitivit"; anuria; renal failure; h"per*alemia Precautions

Pregnancy
D 4 :etal ris* sho9n in humans; use onl" if $enefits out9eigh ris* to fetus

Precautions

Caution in renal and hepatic impairment

!(iloride 7Mida(or8 l4car$on"l4guanidine unrelated chemicall" to other *no9n anti*aliuretic or diuretic agents2 Potassium4conserving ;anti*aliuretic< drug that, compared 9ith thia(ide diuretics, possesses 9ea* natriuretic, diuretic, and antih"pertensive activit"2 Dosing

Adult
64./ mg PG @d

Pediatric
&ot esta$lished "nteractions Concomitant therap" 9ith potassium supplementation ma" increase serum potassium levels ;if concomitant use indicated $ecause of demonstrated h"po*alemia, use caution and monitor serum potassium fre@uentl"<; lithium generall" should not $e administered 9ith diuretics $ecause ma" reduce renal clearance and increase ris* of lithium to8icit"; administration of nonsteroidal anti4inflammator" agents can reduce diuretic, natriuretic, and antih"pertensive effects of loop, potassium4sparing, and thia(ide diuretics ;9hen used concomitantl", o$serve patient closel" to determine if desired effect of diuretic achieved<; indomethacin and potassium4sparing diuretics, including amiloride, ma" $e associated 9ith increased serum potassium levels, so consider potential effects on potassium *inetics and renal function Contraindications Documented h"persensitivit"; elevated serum potassium levels N626 m!@/=; impaired renal function, acute or chronic renal insufficienc", and evidence of dia$etic nephropath" Precautions

Pregnancy
B 4 :etal ris* not confirmed in studies in humans $ut has $een sho9n in some studies in animals

Precautions
Potassium retention associated 9ith use of an anti*aliuretic agent accentuated in presence of renal impairment and ma" result in rapid development of h"per*alemia; monitor serum potassium level; mild h"per*alemia usuall" not associated 9ith a$normal !CB findings;

monitor electrol"tes closel" if evidence of renal functional impairment present, B+& N?/ mg/>// m=, or serum creatinine levels N>26 mg/>// m=

,urose(ide 7Lasi08 Increases e8cretion of 9ater $" interfering 9ith chloride4$inding cotransport s"stem, 9hich, in turn, inhi$its sodium and chloride rea$sorption in ascending loop of enle and distal renal tu$ule2 Dose must $e individuali(ed to patient2 Depending on response, administer at increments of ./4A/ mg no sooner than 340 h after previous dose until desired diuresis occurs2 Fhen treating infants, titrate 9ith >4mg/*g per dose increments until satisfactor" effect achieved2 Dosing

Adult
./40/ mg/d PG/I%/IM; titrate up to 3// mg/d for severe edematous states

Pediatric
>4. mg/*g/dose PG; not to e8ceed 3 mg/*g/dose; not to administer more often than @3h Alternativel", > mg/*g I%/IM slo9l" under close supervision; not to e8ceed 3 mg/*g "nteractions Metformin decreases furosemide concentrations; furosemide interferes 9ith h"pogl"cemic effect of antidia$etic agents and antagoni(es muscle4rela8ing effect of tu$ocurarine; auditor" to8icit" appears to $e increased 9ith coadministration of aminogl"cosides and furosemide; hearing loss of var"ing degrees ma" occur; anticoagulant activit" of 9arfarin ma" $e enhanced 9hen ta*en concurrentl" 9ith this medication; increased plasma lithium levels and to8icit" possi$le 9hen ta*en concurrentl" Contraindications Documented h"persensitivit"; hepatic coma; anuria; state of severe electrol"te depletion Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions
Perform fre@uent serum electrol"te, CG., glucose, creatinine, uric acid, calcium, and B+& determinations during first fe9 mo of therap" and periodicall" thereafter

!lp a1-adrenergic 'loc$ers

Selectivel" $loc* posts"naptic alpha>4adrenergic receptors2 Dilate arterioles and veins, thus lo9ering $lood pressure2

Prazosin 7Minipress8, 6erazosin 7Hytrin8 Pra(osin treats prostatic h"pertroph"2 Improves urine flo9 rates $" rela8ing smooth muscle, 9hich is caused $" $loc*ing alpha>4adrenoceptors in $ladder nec* and prostate2 Fhen increasing dose, administer first dose of each increment at $edtime to reduce s"ncopal episodes2 Although doses N./ mg/d usuall" do not increase efficac", some patients ma" $enefit from as much as A/ mg/d2 'era(osin decreases arterial tone $" allo9ing peripheral posts"naptic $loc*ade2 as minimal alpha. effect2 Dosing

Adult
Pra(osin, > mg PG $id/tid initial; 34>6 mg/d PG $id/tid maintenance 'era(osin, > mg PG hs; increase slo9l" to effect; not to e8ceed ./ mg/d

Pediatric
Pra(osin, &ot esta$lished; suggested dose is /264- mg PG tid 'era(osin, &ot esta$lished "nteractions Acute postural h"potensive reaction from $eta4$loc*ers ma" 9orsen; indomethacin ma" decrease antih"pertensive activit"; verapamil ma" increase serum levels and ma" increase patient)s sensitivit" to drug4induced postural h"potension; ma" decrease antih"pertensive effects of clonidine Contraindications Documented h"persensitivit" Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions

Caution in renal impairment; ma" cause mar*ed h"potension follo9ing first dose and coadministration 9ith $eta4$loc*ers

#eta-adrenergic 'loc$ing agents

+sed to treat h"pertension as initial agents or in com$ination 9ith other drugs ;eg, thia(ides<2

!tenolol 76enor(in8, Metoprolol 7Lopressor, 6oprol @L8, Propranolol 7"nderal8, =e'i?olol 7#ystolic8 Atenolol and metoprolol selectivel" $loc* $eta>4receptors 9ith little or no effect on $eta. t"pes2 Propranolol is a class II antiarrh"thmic, nonselective, $eta4adrenergic receptor $loc*er 9ith mem$rane4sta$ili(ing activit" that decreases automaticit" of contractions2 &e$ivolol actions depend on meta$olic factors and dose2 In e8tensive meta$oli(ers ;ma1orit" of the population< and doses M>/ mg, preferentiall" elicits $eta> selective inhi$ition, 9hereas in poor meta$oli(ers and at higher doses, inhi$its $oth $eta>4 and $eta.4receptors2 Dosing

Adult
Atenolol, 6/ mg PG @d; increase to >// mg/d, if necessar" Metoprolol, >// mg/d PG @d or divided $id/tid initial; increase at >49* intervals prn to a total of A6/ mg/d if necessar" Propranolol, A/40/ mg PG $id initial; increase to >3/4?./ mg/d ;ma" re@uire up to 3A/ mg/d< &e$ivolol, 6 PG @d initiall"; if further $lood pressure reduction re@uired after . 9*, ma" increase dose at . 9* intervals, not to e8ceed A/ mg/d; decrease initial dose to .26 mg/d for CrCl M?/ m=/min and moderate hepatic impairment

Pediatric
Atenolol, >4. mg/*g/dose PG @d Metoprolol, >46 mg/*g/d PG divided $id Propranolol, /26 mg/*g/d PG divided $id/@id; increase graduall" @?4-d; range is .4A mg/*g/d divided $id; not to e8ceed . mg/*g/d &e$ivolol, &ot esta$lished "nteractions Coadministration 9ith aluminum salts, $ar$iturates, calcium salts, cholest"ramine, &SAIDs, penicillins, and rifampin ma" decrease effects; haloperidol, h"drala(ine, loop diuretics, and MAGIs ma" increase to8icit"; coadministration 9ith m"ocardial depressants, A% conduction inhi$itors ;eg, verapamil, diltia(em<, or antiarrh"thmic agents ;eg, disop"ramide< ma" increase ris* for $rad"cardia; if coadministered 9ith clonidine, discontinue ne$ivolol several da"s $efore graduall" tapering clonidine

Contraindications Documented h"persensitivit"; congestive heart failure; pulmonar" edema; cardiogenic shoc*; A% conduction a$normalities; heart $loc* ;9ithout a pacema*er< Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions
Beta4adrenergic $loc*ade ma" reduce signs and s"mptoms of acute h"pogl"cemia and ma" decrease clinical signs of h"perth"roidism; a$rupt 9ithdra9al ma" e8acer$ate s"mptoms of h"perth"roidism, including th"roid storm; monitor patient closel" and 9ithdra9 drug slo9l"; during I% administration, carefull" monitor $lood pressure, heart rate, and !CB

!lp a/'eta-adrenergic 'loc$ing agents

Bloc* alpha4, $eta>4, and $eta.4adrenergic receptor sites, thus decreasing $lood pressure2

La'etalol 7=or(odyne, 6randate8, Car?edilol 7Coreg8 &onselective $eta4 and alpha4adrenergic $loc*ers2 Do not appear to have intrinsic s"mpathomimetic activit"2 Ma" reduce cardiac output and decrease peripheral vascular resistance2 +se in aortic dissection not advisa$le 9hen titrata$le drugs, such as esmolol and nitroprusside, availa$le2 Dosing

Adult
=a$etalol, ./4?/ mg I% over . min follo9ed $" A/40/ mg at >/4min intervals; not to e8ceed ?// mg/dose Carvedilol, 32.6 mg PG $id; maintain for >4. 9* if tolerated and increase to >.26 mg $id to ma8imum .6 mg $id

Pediatric
=a$etalol, &ot esta$lished; suggested dose is /2A4> mg/*g/h; not to e8ceed ? mg/*g/h Carvedilol, &ot esta$lished "nteractions

=a$etalol decreases effect of diuretics and increases to8icit" of methotre8ate, lithium, and salic"lates; ma" diminish refle8 tach"cardia resulting from nitrogl"cerin use 9ithout interfering 9ith h"potensive effects; cimetidine ma" increase la$etalol and carvedilol $lood levels; glutethimide ma" decrease la$etalol effects $" inducing microsomal en("mes; rifampin, $ar$iturates, cholest"ramine, colestipol, &SAIDs, salic"lates, and penicillins ma" decrease carvedilol effects; carvedilol ma" increase effects of antidia$etic agents, digo8in, and calcium channel $loc*ers; concurrent administration 9ith clonidine ma" increase $lood pressure and decrease heart rate; carvedilol ma" decrease effect of sulfon"lureas; fluo8etine, paro8etine, and propafenone ma" increase carvedilol levels Contraindications Documented h"persensitivit"; cardiogenic shoc*; pulmonar" edema; $rad"cardia; A% $loc*; uncompensated congestive heart failure; reactive air9a" disease; severe $rad"cardia Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions
Caution in impaired hepatic function; discontinue therap" if signs of liver d"sfunction present; in elderl" patients, a lo9er response rate and higher incidence of to8icit" ma" $e o$served; caution in congestive heart failure $eing treated 9ith digitalis, diuretics, or AC! inhi$itors ;A% conduction ma" $e slo9ed<; caution in peripheral vascular disease, h"perth"roidism, and dia$etes mellitus

Perip eral ?asodilators

#ela8 $lood vessels to improve $lood flo9, thus decreasing $lood pressure2

Hydralazine 7!presoline8, Mino0idil 7Rogaine Loniten8 "drala(ine decreases s"stemic resistance through direct vasodilation of arterioles2 Mino8idil rela8es arteriolar smooth muscle, causing vasodilation, 9hich, in turn, ma" reduce $lood pressure2 Dosing

Adult
"drala(ine, >/4./ mg/dose I%/IM @A43h prn initial; increase to A/ mg/dose if necessar"; change to PG as soon as possi$le

Mino8idil, 6 mg PG @d; increase graduall" @?d; >/4A/ mg/d PG @d or divided $id maintenance; not to e8ceed >// mg/d

Pediatric
&ot esta$lished "nteractions MAGIs and $eta4$loc*ers ma" increase h"drala(ine to8icit"; pharmacologic effects of h"drala(ine ma" $e decreased $" indomethacin; concurrent use of mino8idil 9ith guanethidine, diuretics, or h"potensive agents ma" result in additive h"potension Contraindications Documented h"persensitivit"; mitral valve, rheumatic heart disease ;h"drala(ine<; pheochromoc"toma ;mino8idil< Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions
"drala(ine has $een implicated in MI; mino8idil ma" e8acer$ate angina pectoris; caution in pulmonar" h"pertension, congestive heart failure, coronar" arter" disease, and significant renal failure

Calciu( c annel 'loc$ers

Ma" $e a more effective class of medication for $lac* patients2

Diltiaze( 7Cardize(, Dilacor8, 9erapa(il 7Calan, Co?era-HS8, =i%edipine 7!dalat8 During depolari(ation, inhi$its calcium ion from entering slo9 channels or voltage4sensitive areas of vascular smooth muscle and m"ocardium2 Dosing

Adult
Diltia(em, Cardi(em S#, 3/4>./ mg PG $id Cardi(em CD, >0/4.A/ mg PG @d

Dilacor, "pertension, >0/4.A/ mg PG @d Angina, >./ mg/d PG; titrate slo9l" over -4>A d up to A0/ mg/d prn; not to e8ceed 6A/ mg/d %erapamil, .A/4A0/ mg/d PG divided tid/@id &ifedipine, >/4?/ mg I# cap PG tid; not to e8ceed >./4>0/ mg/d ?/43/ mg S# ta$ PG @d; not to e8ceed 5/4>./ mg/d

Pediatric
Diltia(em, &ot esta$lished %erapamil, &ot esta$lished &ifedipine, /2.64/26 mg/*g/dose PG tid/@id prn "nteractions Ma" increase car$ama(epine, digo8in, c"closporine, and theoph"lline levels; 9hen administered 9ith amiodarone, ma" cause $rad"cardia and a decrease in cardiac output; 9hen administered 9ith $eta4$loc*ers, ma" increase cardiac depression; cimetidine ma" increase levels Contraindications Documented h"persensitivit"; severe C :; sic* sinus s"ndrome; second4 or third4degree A% $loc*; h"potension ;M5/ mm g s"stolic< Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions
Caution in impaired renal or hepatic function; ma" increase =:'s, and hepatic in1ur" ma" occur; nifedipine ma" cause lo9er e8tremit" edema

!ngiotensin-con?erting enzy(e 7!CE8 in i'itors

Competitive inhi$itors of AC!2 #educes angiotensin II levels, thus decreasing aldosterone secretion2

Captopril 7Capoten8, Enalapril 79asotec8, Lisinopril 7Aestril8, Ra(ipril 7!ltace8 Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lo9er aldosterone secretion2

Dosing

Adult
Captopril, >.264.6 mg PG $id/tid; ma" increase $" >.264.6 mg/dose at >4 to .49* intervals up to 6/ mg tid !nalapril, .2646 mg/d PG ;increase as necessar"<; range is >/4A/ mg/d PG in >4. divided doses >2.6 mg/dose I% over 6 min @3h =isinopril, >/ mg/d PG; increase 64>/ mg/d at >4 to .49* intervals; not to e8ceed A/ mg #amipril, .2646 mg PG @d; not to e8ceed ./ mg/d

Pediatric
Captopril, 32.64>.26 mg/dose PG @>.4.Ah; not to e8ceed 3 mg/*g/d !nalapril, &ot esta$lished =isinopril, &ot esta$lished #amipril, &ot esta$lished "nteractions &SAIDs ma" reduce h"potensive effects; AC! inhi$itors ma" increase digo8in, lithium, and allopurinol levels; rifampin decreases levels; pro$enecid ma" increase levels; h"potensive effects of AC! inhi$itors ma" $e enhanced 9hen administered concurrentl" 9ith diuretics Contraindications Documented h"persensitivit"; histor" of angioedema Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions
Categor" D in second and third trimester of pregnanc"; caution in renal impairment, valvular stenosis, or severe congestive heart failure

!ngiotensin "" receptor antagonists

:or patients una$le to tolerate AC! inhi$itors2

Losartan 7Cozaar8, 9alsartan 7Dio?an8

&onpeptide angiotensin II receptor antagonists that $loc* vasoconstrictor and aldosterone4 secreting effects of angiotensin II2 Ma" induce more complete inhi$ition of renin4angiotensin s"stem than AC! inhi$itors, do not affect response to $rad"*inin, and are less li*el" to $e associated 9ith cough and angioedema2 Dosing

Adult
=osartan, .64>// mg PG @d/$id %alsartan, 0/ mg/d PG; ma" increase to >3/ mg/d if needed

Pediatric
&ot esta$lished "nteractions Cetocona(ole, troleandom"cin, sulfaphena(ole, and pheno$ar$ital ma" decrease effects; cimetidine ma" increase effects Contraindications Documented h"persensitivit" Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions
Categor" D in second and third trimester of pregnanc"; caution in unilateral or $ilateral renal arter" stenosis, severe hepatic insufficienc", $iliar" cirrhosis or o$struction, primar" h"peraldosteronism, and h"per*alemia

Eprosartan 76e?eten8, 4l(esartan 7#enicar8 Angiotensin receptor antagonist that $inds to A'> angiotensin II receptor, $loc*ing vasoconstrictor and aldosterone4secreting effects of angiotensin II2 Ma" induce a more complete inhi$ition of renin4angiotensin s"stem than AC! inhi$itors and do not affect response to $rad"*inin and, thus, is less li*el" to $e associated 9ith cough and angioedema2 :or patients una$le to tolerate AC! inhi$itors2 Dosing

Adult
!prosartan ;'eveten<, A//40// mg PG @d or divided $id Glmesartan ;Benicar<, ./ mg PG @d initiall"; ma" increase to A/ mg/d after . 9* if further BP reduction re@uired &ote, =o9er dose in volume4 or salt4depleted patients

Pediatric
&ot esta$lished "nteractions Ma" increase to8icit" of lithium; ma" decrease angiotensin II antagonist efficac"; ma" increase ris* of h"per*alemia if ta*en concurrentl" 9ith potassium supplements Contraindications Documented h"persensitivit"; $ilateral renal arter" stenosis and pree8isting renal insufficienc"; significant aortic/mitral stenosis Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions
Pregnanc" categor" D in second and third trimester of pregnanc"; avoid use or use lo9er dose in patients 9ho are volume depleted ;correct volume depletion first<; renal deterioration can occur 9ith initiation of therap"; caution in unilateral renal arter" stenosis and pree8isting renal insufficienc"; caution in aortic/mitral stenosis

!ldosterone antagonists
Compete 9ith aldosterone receptor sites, reducing $lood pressure and sodium rea$sorption2

Eplerenone 7"=SPR!8 Selectivel" $loc*s aldosterone at the mineralocorticoid receptors in epithelial ;eg, *idne"< and nonepithelial ;eg, heart, $lood vessels, $rain< tissues, thus decreasing $lood pressure and sodium rea$sorption2 Dosing

Adult
6/ mg PG @d; ma" increase dose after A 9*, not to e8ceed >// mg/d

Pediatric
&ot esta$lished "nteractions CIPA6/ ?AA su$strate; potent CIP?AA inhi$itors ;eg, *etocona(ole< increase serum levels a$out 64fold, less potent CIP?AA inhi$itors ;eg, er"throm"cin, sa@uinavir, verapamil, flucona(ole< increase serum levels a$out .4fold; grapefruit 1uice increases serum levels a$out .67; coadministration 9ith potassium supplements, salt su$stitutes, or drugs *no9n to increase serum potassium ;eg, amiloride, spironolactone, triamterene, AC! inhi$itors, angiotensin II inhi$itors< increases ris* of h"per*alemia Contraindications Documented h"persensitivit"; h"per*alemia or coadministration 9ith drugs causing increased potassium; t"pe . dia$etes 9ith microal$uminuria; moderate4to4severe renal insufficienc" ;ie, CrCl M6/ m=/min or serum creatinine N. mg/d= DmalesE or N>20 mg/d= DfemalesE< Precautions

Pregnancy
B 4 :etal ris* not confirmed in studies in humans $ut has $een sho9n in some studies in animals

Precautions
Ma" cause h"per*alemia, headache, or di((iness; caution 9ith hepatic insufficienc"

!lp a-adrenergic agonists

Stimulate pres"naptic alpha.4adrenergic receptors in the $rain stem, 9hich reduces s"mpathetic nervous activit"2

Met yldopa 7!ldo(et8 Stimulates central alpha4adrenergic receptors $" a false transmitter, resulting in decreased s"mpathetic outflo92 'his results in inhi$ition of vasoconstriction2 Dosing

Adult
.6/ mg PG $id/tid; increase @.d prn; not to e8ceed ? g/d

Pediatric
>/ mg/*g/d PG divided $id/@id; increase @.d prn to ma8imum 36 mg/*g/d; not to e8ceed ? g/d "nteractions !ffects ma" decrease 9ith concurrent administration of $ar$iturates and tric"clic antidepressants; increase in $lood pressure ma" occur 9ith coadministration of iron supplements, MAGIs, s"mpathomimetics, phenothia(ines, and $eta4$loc*ers Contraindications Documented h"persensitivit"; acute liver disease Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions
Caution in previous histor" of liver disease; hemol"tic anemia and liver disease ma" occur; reduce dose in renal disease

Clonidine 7Catapres8 Stimulates alpha.4adrenoreceptors in $rain stem, activating an inhi$itor" neuron, 9hich, in turn, results in reduced s"mpathetic outflo92 'hese effects result in a decrease in vasomotor tone and heart rate2 Dosing

Adult
/2> mg PG $id initial; /2.4>2. mg/d divided $id/@id maintenance; not to e8ceed >2. mg/d

Pediatric
&ot esta$lished

"nteractions 'ric"clic antidepressants inhi$it h"potensive effects of clonidine; coadministration of clonidine 9ith $eta4$loc*ers ma" potentiate $rad"cardia; tric"clic antidepressants ma" enhance h"pertensive response associated 9ith a$rupt clonidine 9ithdra9al; h"potensive effects of clonidine are enhanced $" narcotic analgesics Contraindications Documented h"persensitivit" Precautions

Pregnancy
C 4 :etal ris* revealed in studies in animals $ut not esta$lished or not studied in humans; ma" use if $enefits out9eigh ris* to fetus

Precautions
Caution in cere$rovascular disease, coronar" insufficienc", sinus node d"sfunction, and renal impairment

Renin in i'itor
&e9est class of antih"pertensive drugs2 Acts $" disrupting the renin4angiotensin4aldosterone s"stem feed$ac* loop2

!lis$iren 76e$turna8 Direct renin inhi$itor2 Decreases plasma renin activit" and inhi$its conversion of angiotensinogen to angiotensin I ;as a result, also decreasing angiotensin II< and, there$", disrupts the renin4angiotensin4aldosterone s"stem ;#AAS< feed$ac* loop2 Indicated for h"pertension as monotherap" or in com$ination 9ith other antih"pertensive drugs2 Dosing

Adult
>6/ mg PG @d initiall"; if needed, ma" increase to ?// mg/d

Pediatric
M>0 "ears, &ot esta$lished "nteractions

Coadministration 9ith ir$esartan decreases Cma8 $" 6/7; coadministration 9ith atorvastatin increases Cma8 and A+C $" 6/7; *etocona(ole increases plasma levels $" a$out 0/7; does not inhi$it CIPA6/ isoen("mes or induce CIP?AA; coadministration 9ith furosemide decreases furosemide Cma8 and A+C $" ?/7 and 6/7, respectivel"; high4fat meals su$stantiall" decrease a$sorption; use 9ith ma8imal dose of AC! inhi$itors has not $een studied Contraindications Documented h"persensitivit" Precautions

Pregnancy
D 4 :etal ris* sho9n in humans; use onl" if $enefits out9eigh ris* to fetus

Precautions
Discontinue use in pregnanc" as soon as possi$le $ecause use of drugs affecting the renin4 angiotensin s"stem during second and third trimesters has $een associated 9ith fetal and neonatal in1ur", including h"potension, neonatal s*ull h"poplasia, anuria, renal failure, and fetal death; ma" cause angioedema; dose4related BI adverse effects ma" occur

,ollow-up
,urt er "npatient Care

"pertensive crisis, "pertensive crisis rarel" occurs and is characteri(ed $" e8tremel" high $lood pressure, diastolic pressure usuall" e8ceeding >?/ mm g, and evidence of potentiall" life4threatening end organ d"sfunction2 'he clinical conditions associated 9ith h"pertensive crisis include h"pertensive encephalopath", e8treme h"pertension 9ith acute pulmonar" edema, e8treme h"pertension 9ith acute aortic dissection, e8treme h"pertension 9ith intracere$ellar hemorrhage, e8treme h"pertension 9ith an acute m"ocardial infarction, and malignant h"pertension2 "pertensive crisis should $e differentiated from ver" high $lood pressure 9ithout evidence of acute, severe end organ d"sfunction2 Malignant h"pertension, Malignant h"pertension ma" or ma" not $e associated 9ith clinical conditions present in h"pertensive crisis2 A patient 9ith malignant h"pertension al9a"s has retinal papilledema and flame4shaped hemorrhages and e8udates2 Gther clinical features of malignant h"pertension ma" include encephalopath", confusion, left ventricular failure, intravascular coagulation, and impaired renal function, 9ith hematuria and 9eight loss2 'he pathological hallmar* of malignant h"pertension is fi$rinoid necrosis of the arterioles, 9hich occurs s"stemicall", $ut specificall" in the *idne"s2 'hese patients develop fatal complications if untreated, and more than 5/7 9ill not survive $e"ond >4. "ears2 'reatment of h"pertensive crisis consists of the acute reduction of $lood pressure using aggressive pharmacological therap", follo9ed $" maintenance therap" 9ith oral medications2

Sodium nitroprusside is a commonl" used medication2 It is a short4acting agent, and the $lood pressure response can $e titrated from minute to minute2 o9ever, patients must have constant monitoring in an intensive care unit2 'he potential e8ists for thioc"anate and c"anide to8icit" 9ith prolonged use or if the patient has renal or hepatic failure2 Dia(o8ide ma" also $e used in h"pertensive crisis2 Small $oluses of >// mg are administered ever" 6 minutes, as indicated2 Dia(o8ide is not preferred 9ith concomitant congestive heart failure or lo9 cardiac output2 =a$etalol, an alpha4 and $eta4$loc*ing agent, has proven to $e @uite $eneficial in the treatment of patients 9ith h"pertensive emergencies2 =a$etalol is particularl" preferred in patients 9ith acute dissection2 Boluses of >/4./ mg ma" $e administered, or the drug ma" $e infused at > mg/min until the desired $lood pressure is o$tained2 Gnce an ade@uate $lood pressure level is o$tained, oral h"pertensive therap" should $e initiated, and patients are graduall" 9eaned from parenteral agents2 Clevidipine, a dih"drop"ridine calcium channel $loc*er, is administered intravenousl" for rapid and precise $lood pressure reduction2 Clevidipine is rapidl" meta$oli(ed in the $lood and tissues and does not accumulate in the $od"2 Initiate I% infusion at >4. mg/h; titrate the dose at short intervals ;ie, 5/ seconds< initiall" $" dou$ling the dose2 As $lood pressure approaches its goal, increase the dose $" less than dou$le and lengthen the time $et9een dose ad1ustments to ever" 64>/ minutes2 An appro8imatel" >4 to .4mg/h increase produces an additional .4 to A4mm g decrease in s"stolic pressure2 '"picall", the therapeutic response is achieved 9ith A43 mg/h, although severe h"pertension ma" re@uire higher doses2 Most patients have received ma8imum doses of >3 mg/h or less; e8perience is limited 9ith short4term dosing as high as ?. mg/h2 Because of lipid load restrictions, do not e8ceed >/// m= or an average of .> mg/h 9ithin a .A4hour period; e8perience is limited 9ith use $e"ond -. hours2

,urt er 4utpatient Care

Interventions can $e used to improve the control of $lood pressure in patients 9ith h"pertension2 o %arious interventions can $e implemented to treat uncontrolled h"pertension2 'hese interventions include the follo9ing, ;>< self4monitoring, ;.< educational interventions directed to the patient, ;?< educational interventions directed to the health professional, ;A< health professional ;nurse or pharmacist<Jled care, ;6< organi(ational interventions that aim to improve the deliver" of care, and ;3< appointment reminder s"stems2 o 'he Cochrane Colla$oration has sho9n that these interventions are associated 9ith large net reductions in $lood pressure and that health professional ;nurse or pharmacist<Jled care ma" $e a promising 9a" of delivering care2 'heir recommendations include that famil" practices and communit"4$ased clinics should have an organi(ed s"stem of regular follo94up and revie9 of their patients 9ith h"pertension2 Antih"pertensive drug therap" should $e implemented $" means of a vigorous stepped care approach 9hen patients do not reach target $lood pressure levels2

Deterrence/Pre?ention

A comprehensive strateg" for reduction in mortalit" and mor$idit" from h"pertension must include prevention strategies, earlier detection, and ade@uate treatment2 Ideall", a population strateg" should $e used in order to lo9er $lood pressure in the communit"2 More intensive efforts are re@uired to lo9er $lood pressure in high4ris* population groups, 9hich include individuals 9ith a famil" histor" of h"pertension, $lac* ancestr", o$esit", e8cessive sodium consumption, ph"sical inactivit", and/or alcohol consumption2 !ven a small reduction in $lood pressure confers significant health $enefits2 A .4mm g reduction in diastolic pressure is estimated to decrease the ris* of stro*e $" >67 and the ris* of coronar" heart disease $" 372 Prevention of h"pertension ma" $e achieved $" the follo9ing interventions, o Feight control o Increased ph"sical activit" o Moderated sodium and alcohol inta*e o Increased potassium inta*e o A dietar" pattern rich in fruits and vegeta$les and lo94fat meat, fish, and dair" products

Co(plications

Central nervous s"stem 4 Intracere$ral hemorrhage, lacunar infarcts, encephalopath", throm$otic stro*e, transient ischemic attac* Gphthalmologic 4 :undal hemorrhages, e8udates, papilledema Cardiac 4 =% , congestive heart failure, angina pectoris, m"ocardial infarction %ascular 4 Aortic dissection, diffuse arthrosclerosis #enal 4 &ephrosclerosis, renal arter" stenosis

Prognosis

Most individuals diagnosed 9ith h"pertension 9ill have increasing $lood pressure as the" age2 +ntreated h"pertension is notorious for increasing the ris* of mortalit" and is often descri$ed as a silent *iller2 Mild4to4moderate h"pertension, if left untreated, is associated 9ith a ris* of atherosclerotic disease in ?/7 of people and organ damage in 6/7 of people after onl" 04>/ "ears of onset2

Patient Education

"pertension is a lifelong disorder2 :or optimal control, a long4term commitment to lifest"le modifications and pharmacological therap" is re@uired2 'herefore, repeated in4depth patient education and counseling not onl" improve compliance 9ith medical therap" $ut also reduce cardiovascular ris* factors2 %arious strategies to decrease cardiovascular disease ris* include the follo9ing, o Prevention and treatment of o$esit" o Appropriate amounts of aero$ic ph"sical activit" o Diets lo9 in salt, total fat, and cholesterol o Ade@uate dietar" inta*es of potassium, calcium, and magnesium o =imited alcohol consumption o Avoidance of cigarette smo*ing

:or e8cellent patient education resources, visit eMedicine)s Dia$etes Center and Cholesterol Center2 Also, see eMedicine)s patient education articles igh Blood Pressure, igh Cholesterol, Chest Pain, Coronar" eart Disease, and eart Attac*2

Miscellaneous
Medicolegal Pit%alls

"pertension is one of the most common modifia$le ris* factors for atherosclerotic disease2 According to the J&C %I enrollment report, onl" 6?7 of patients 9ith h"pertension are $eing treated in the +nited States2 Gf these, onl" .-7 have ade@uatel" controlled $lood pressure, and onl" A67 of treated patients have a $lood pressure less than >A//5/ mm g2 Despite an arra" of pharmaceutical agents to treat h"pertension, J&C %I recommends diuretics and $eta4$loc*ers as the preferred initial agents $ecause of proven efficac" and lo9er cost2 Patients 9ith h"pertension should $e identified and staged $ased on $lood pressure determinations and cardiovascular ris* and the presence or a$sence of target organ damage2 J&C %I recommends lo9er target $lood pressure goals in . select populations, ;>< patients 9ith dia$etes mellitus ;$lood pressure M>?//06 mm g< and ;.< patients 9ith renal disease ;$lood pressure M>?//06 mm g; if urinar" protein is N> g/d, a $lood pressure M>.6/-6 mm g<2 Malignant h"pertension is a medical emergenc" and re@uires hospitali(ation and urgent therap"2 'he $lood pressure should $e reduced rapidl", $ut diastolic $lood pressure should $e maintained at appro8imatel" 56 mm g2

Special Concerns

#enovascular h"pertension is li*el" the cura$le form of secondar" h"pertension2 'he causes of renovascular h"pertension include atherosclerosis, fi$romuscular d"splasia, coarctation of the aorta, em$olic renal arter" occlusion, aneur"sm of the renal arter", and diffuse arteritis2 Additionall", causes of diffuse $ilateral renal ischemia, such as accelerated h"pertension, vasculitis, hepatitis B, and intravenous drug a$use, ma" also lead to h"pertension2 Although the true incidence of renovascular h"pertension is not *no9n, an incidence of >7 is estimated in patients 9ith h"pertension2? In h"pertensive individuals 9ho had one or more clinical features *no9n to $e associated 9ith renovascular h"pertension, .A7 had renal arter" stenosis and >A7 had renovascular h"pertension2A 'his stud" also demonstrated that renovascular h"pertension is more common in the 9hite population ;>07< than in the $lac* population ;57<2 o A 9or*up for renovascular h"pertension should $e recommended for patients 9ho meet the follo9ing criteria, #ecent onset of moderate4to4severe h"pertension Sudden une8plained e8acer$ation of pree8isting h"pertension "pertension associated 9ith an a$dominal $ruit Gnset of h"pertension in a "oung patient ;M?/ "< Severe h"pertension resistant to pharmacologic management Deterioration of renal function follo9ing treatment for h"pertension

'he 9or*up for renovascular h"pertension is recommended onl" in patients in 9hom further interventional therap", such as angioplast" or surger", is feasi$le and 9ill $e pursued2 o Digital su$traction angiograph" ;DSA< is performed follo9ing intravenous contrast in1ection to detect the a$dominal aorta and its $ranches2 'he radioisotope renogram ma" $e performed as a screening test, $ut renal arteriograph" is re@uired for definitive diagnosis2 Duple8 ultrasonograph" of the renal arteries has a sensitivit" of greater than 5/7 for $oth the presence and degree of renal disease26 #enograph" using iodohippurate sodium I >?> or technetium 'C 55m dieth"lenetriamine pentaacetic acid after administration of the oral AC! inhi$itor captopril can identif" right ventricular h"pertroph" 9ith a$out 0/7 sensitivit" and specificit"2 o Appropriate management of patients 9ith $ilateral or unilateral renal arter" stenosis and significant renal d"sfunction is controversial2 Correction of stenosis ma" not result in improvement of renal function or reduction in $lood pressure $ecause renal d"sfunction and h"pertension ma" $e caused $" renal parench"mal disease2 #ecent studies have sho9n onl" a modest improvement in $lood pressure control in medication reduction and in significant improvement in renal function follo9ing percutaneous transluminal renal angioplast"2 Pheochromoc"toma is an infre@uent cause of h"pertension, $ut cure often is possi$le 9ith surgical therap"2 'he incidence is not *no9n, $ut up to /2>7 of individuals 9ith h"pertension ma" have these lesions2 Pheochromoc"tomas are chromaffin cell tumors, 9hich arise mainl" in the adrenal medulla, s"mptomatic ganglia, and paraganglia along the s"mptomatic chain2 +p to 0/45/7 of pheochromoc"tomas are found in one or $oth adrenal glands2 Most patients 9ith pheochromoc"toma have headache, s9eating, or palpitations2 "pertension ma" $e sustained or paro8"smal2 Patients ma" manifest nervousness, nausea, vomiting, 9eight loss, and funduscopic changes of h"pertension2 eadaches are paro8"smal, thro$$ing, and $ilateral2 S9eating is @uite profuse and generali(ed2 Palpitations are due to the concomitant tach"cardia2 o 'he 9or*up of pheochromoc"toma includes measurement of urinar" catecholamines and their meta$olites2 +rinar" e8cretion of metanephrine, normetanephrine, free catecholamines, and vanill"lmandelic acid can $e performed2 Measurement of catecholamines increases the sensitivit" from -/4 5/7, compared to measuring metanephrine alone2 Fhen an a$normal value is detected $" metanephrine or vanill"lmandelic acid assa", measurement of free catecholamines should $e performed to confirm the diagnosis2 o Gnce the diagnosis of pheochromoc"toma is confirmed $" chemical anal"sis, the precise location and e8tent of the tumor is assessed 9ith an imaging stud"2 An a$dominal C' scan often allo9s locali(ation of the tumor, $ut the a$sence of a lesion on C' scan re@uires adrenal venous sampling or e8plorator" laparotom"2 Initial sta$ili(ation is 9ith medical therap"2 Surgical resection is re@uired $ecause up to >/7 of tumors ma" $e malignant2 In difficult cases, plasma, catecholamine assa"s, and a clonidine suppression test ma" $e used2 In normal and essential h"pertension, clonidine suppresses plasma norepinephrine levels2 An ina$ilit" to suppress catecholamines ma" indicate pheochromoc"toma; ho9ever, the sensitivit" and specificit" of this test is not *no9n2 Mineralocorticoid4induced h"pertension, Mineralocorticoid e8cess secondar" to primar" aldosteronism is infre@uentl" o$served and is characteri(ed $" e8cessive
o

production of aldosterone2 #enal sodium retention, *aliuresis, h"po*alemia, and h"pochloremic meta$olic al*alosis are the common manifestations2 'hese patients develop increased intravascular volume, resulting in h"pertension2 'he $lood pressure increase ma" var" from mild h"pertension to mar*ed elevation in primar" aldosteronism2 Patients ma" have underl"ing adenoma or h"perplasia of the adrenal gland and rarel" have an e8tra4adrenal source for aldosterone2 Gral contraceptiveJassociated h"pertension, 'he most common form of secondar" h"pertension is an endocrine cause, oral contraceptive use2 Activation of the renin4 angiotensin4aldosterone s"stem is the li*el" mechanism $ecause hepatic s"nthesis of angiotensinogen is induced $" the estrogen component of oral contraceptives2 Appro8imatel" 67 of 9omen prescri$ed oral contraceptives ma" develop h"pertension, 9hich a$ates 9ithin 3 months of discontinuation2 'he ris* factors for oral contraceptiveJassociated h"pertension include mild renal disease, familial histor" of essential h"pertension, age greater than ?6 "ears, and o$esit"2 :or the patient 9ho has h"pertension and is h"po*alemic, a .A4hour urine specimen should $e collected for sodium and potassium measurement2 If the urine sodium level is more than >// mmol/= and urine potassium is less than ?/ mmol/=, aldosteronism is unli*el"2 If urinar" potassium e8ceeds ?/ mmol/=, the patient should have P#A measured2 If the P#A is high, the li*el" causes are estrogen therap", renovascular h"pertension, malignant h"pertension, or salt49asting renal disease2 In the presence of lo9 P#A, the serum aldosterone level can $e measured2 A lo9 aldosterone level indicates licorice ingestion or other mineralocorticoid ingestions2 A high aldosterone level indicates primar" aldosteronism2 A C' scan ma" identif" the presence of an adenoma2 In the a$sence of C' scan findings, differentiating h"perplastic aldosteronism from adenoma is often difficult2 #ecent advances in understanding of the regulation of $lood pressure and pathoph"siologic events that result in h"pertension have led to the development of ne9 classes of drugs2 'hese agents are in various stages of development and include the follo9ing, o %asopressin antagonists o Compounds to enhance the effects of endogenous vasodilators ;eg, natriuretic peptides< o !ndothelin antagonists o #enin inhi$itors o Antagonists of the angiotensin receptors, Several of these have alread" $een mar*eted2 o '4calcium ion channelJselective antagonists

Hig #lood Pressure

igh Blood Pressure Gvervie9 igh Blood Pressure Causes igh Blood Pressure S"mptoms Fhen to See* Medical Care !8ams and 'ests igh Blood Pressure 'reatment Self4Care at ome Medical 'reatment Medications

Surger" Gther 'herap" &e8t Steps :ollo94up Prevention Gutloo* :or More Information Fe$ =in*s Multimedia S"non"ms and Ce"9ords Authors and !ditors #elated high $lood pressure articles, igh $lood pressure 4 on Fe$MD igh $lood pressure 4 on Medicine&et

Hig #lood Pressure 4?er?iew

Fhen the heart pumps $lood into the arteries, the $lood flo9s 9ith a force pushing against the 9alls of the arteries2 Blood pressure is the product of the flo9 of $lood times the resistance in the $lood vessels2 igh $lood pressure is also called h"pertension2 Fhat ma*es high $lood pressure important is that initiall" it ma" cause no s"mptoms $ut can still cause serious long4term complications2

Man" people have high $lood pressure and don)t even *no9 it2 'he *e" complications of high $lood pressure include heart disease, heart attac*, congestive heart failure, stro*e, *idne" failure, peripheral arter" disease, and aortic aneur"sms ;outpouchings of the aorta<2 Pu$lic a9areness of these dangers has increased2 igh $lood pressure has $ecome the second most common reason for medical office visits in the +nited States2

Blood pressure is measured 9ith a $lood pressure cuff and recorded as t9o num$ers, such as >.//0/ mm g ;millimeters of mercur"<2

'he top, larger num$er is called the s"stolic pressure2 'his is the pressure generated 9hen the heart contracts ;pumps<2 It reflects the pressure of the $lood against arterial 9alls2 'he $ottom, smaller num$er is called the diastolic pressure2 'his reflects the pressure in the arteries 9hile the heart is filling and resting $et9een heart$eats2

Scientists have determined a normal range for $oth s"stolic and diastolic $lood pressure after e8amining the $lood pressure of man" people2

'hose 9hose $lood pressure is consistentl" higher than this norm are said to have high $lood pressure or h"pertension2 igh $lood pressure in adults is defined as a consistentl" elevated $lood pressure of >A/ mm g s"stolic and 5/ mm g diastolic or higher2

As man" as 3/ million Americans have high $lood pressure2

'hat)s a$out one in four adults aged >0 "ears and older2 +ncontrolled high $lood pressure is indirectl" responsi$le for man" deaths and disa$ilit" resulting from heart attac*, stro*e, and *idne" failure2 According to research studies, the ris* of d"ing of a heart attac* is directl" lin*ed to $lood pressure, especiall" s"stolic h"pertension2 'he higher "our $lood pressure, the higher "our ris*, even 9ith $lood pressure in the normal range2 o9ever, the progress of heart disease caused $" high $lood pressure can $e slo9ed do9n2

Hig #lood Pressure Causes

In a$out >/7 of people, high $lood pressure is caused $" another disease ;this is called secondar" h"pertension<2 In such cases, 9hen the root cause is treated, $lood pressure usuall" returns to normal2 'hese causes of secondar" h"pertension include the follo9ing conditions,

Chronic *idne" disease 'umors or other diseases of the adrenal gland Coarctation of the aorta 4 A narro9ing of the aorta that "ou are $orn 9ith that can cause high $lood pressure in "our arms Pregnanc" +se of $irth control pills Alcohol addiction 'h"roid d"sfunction

In the other 5/7 of cases, the cause of high $lood pressure is not *no9n ;referred to as primar" h"pertension<2 Although the specific cause is un*no9n, certain factors are recogni(ed as contri$uting to high $lood pressure2 ,actors t at canBt 'e c anged

!ge: 'he older "ou get, the greater the li*elihood that "ou 9ill develop high $lood pressure, especiall" s"stolic, as "our arteries get stiffer2 'his is largel" due to arteriosclerosis, or Ohardening of the arteries2O Race: African Americans have high $lood pressure more often than 9hites2 'he" develop high $lood pressure at a "ounger age and develop more severe complications sooner2 Socioecono(ic status: igh $lood pressure is also more common among the less educated and lo9er socioeconomic groups2 #esidents of the southeastern +nited States, $oth 9hites and $lac*s, are more li*el" to have high $lood pressure than Americans from other regions2 ,a(ily istory 7 eredity8: 'he tendenc" to have high $lood pressure appears to run in families2 &ender: Benerall" men have a greater li*elihood of developing high $lood pressure than 9omen2 'his li*elihood varies according to age and among various ethnic groups2

,actors t at can 'e c anged

4?erweig t 7o'esity8: G$esit" is defined as having a $od" mass inde8 ;BMI< greater than ?/ *g/m.2 It is ver" closel" related to high $lood pressure2 Medical professionals strongl" recommend that all o$ese people 9ith high $lood pressure lose 9eight until the" are 9ithin >67 of their health" $od" 9eight2 Iour health care provider can help "ou calculate "our BMI and health" range of $od" 9eight2 Sodiu( 7salt8 sensiti?ity: Some people have high sensitivit" to sodium ;salt<, and their $lood pressure goes up if the" use salt2 #educing sodium inta*e tends to lo9er their $lood pressure2 Americans consume >/4>6 times more sodium than the" need2 :ast foods and processed foods contain particularl" high amounts of sodium2 Man" over4the4counter medicines, such as pain*illers, also contain large amounts of sodium2 #ead la$els to find out ho9 much sodium is contained in food items2 Avoid those 9ith high sodium levels2 !lco ol use: Drin*ing more than one to t9o drin*s of alcohol per da" tends to raise $lood pressure in those 9ho are sensitive to alcohol2 #irt control pills 7oral contracepti?e use8: Some 9omen 9ho ta*e $irth control pills develop high $lood pressure2 Lac$ o% e0ercise 7p ysical inacti?ity8: A sedentar" lifest"le contri$utes to the development of o$esit" and high $lood pressure2 Drugs: Certain drugs, such as amphetamines ;stimulants<, diet pills, and some pills used for cold and allerg" s"mptoms, tend to raise $lood pressure2

As $od" 9eight increases, the $lood pressure rises2

G$ese people are t9o to si8 times more li*el" to develop high $lood pressure than people 9hose 9eight is 9ithin a health" range2 &ot onl" the degree of o$esit" is important, $ut also the manner in 9hich the $od" accumulates e8tra fat2 Some people gain 9eight around their $ell" ;central o$esit" or Oapple4shapedO people<, 9hile others store fat around their hips and thighs ;Opear4 shapedO people<2 OApple4shapedO people tend to have greater health ris*s than Opear4 shapedO people2

Hig #lood Pressure Sy(pto(s

igh $lood pressure usuall" causes no s"mptoms2

!ven if high $lood pressure does cause s"mptoms, the s"mptoms are usuall" mild and nonspecific ;vague, or suggesting man" different disorders<2 'hus, high $lood pressure often is la$eled Othe silent *iller2O People 9ho have high $lood pressure t"picall" don)t *no9 it until their $lood pressure is measured2

Sometimes people 9ith high $lood pressure have the follo9ing s"mptoms,

eadache

Di((iness Blurred vision &ausea

People often do not see* medical care until the" have s"mptoms arising from the organ damage caused $" chronic ;ongoing, long4term< high $lood pressure2 'he follo9ing t"pes of organ damage are commonl" seen in chronic high $lood pressure,

eart attac* eart failure Stro*e or Omini stro*eO ;transient ischemic attac*, 'IA< Cidne" failure !"e damage 9ith loss of vision Peripheral arterial disease Gutpouchings of the aorta, called aneur"sms

A$out >7 of people 9ith high $lood pressure do not see* medical care until the high $lood pressure is ver" severe, a condition *no9n as malignant h"pertension2

In malignant h"pertension, the diastolic $lood pressure ;the lo9er num$er< often e8ceeds >A/ mm g2 Malignant h"pertension ma" $e associated 9ith headache, light4headedness, or nausea2 'his degree of high $lood pressure re@uires emergenc" hospitali(ation and lo9ering of $lood pressure to prevent $rain hemorrhage or stro*e2

It is of utmost importance to reali(e that high $lood pressure can $e unrecogni(ed for "ears, causing no s"mptoms $ut causing progressive damage to the heart, other organs, and $lood vessels2

5 en to See$ Medical Care

Call "our health care provider if a routine $lood pressure measurement ;during health screening< reveals s"stolic $lood pressure higher than >A/ mm g, diastolic $lood pressure higher than 5/ mm g, or $oth2 Call "our health care provider if "ou have an" of the follo9ing s"mptoms,

+ne8plained severe headache Sudden or gradual changes in vision =ight4headedness or di((iness &ausea associated 9ith severe headache Chest pain or shortness of $reath upon e8ertion

'ell "our health care provider if an" famil" mem$er has or has had high $lood pressure, heart attac*, stro*e, or *idne" failure2

Bo to a hospital emergenc" department if "our $lood pressure is high 9hen measured ;for e8ample, if "our diastolic pressure is greater than >// mm g<2 Bo to a hospital emergenc" department if "ou have an" of the follo9ing s"mptoms,

Severe headache +ne8plained di((iness of faintness +ne8plained $lurred vision or loss of vision ;partial or complete< Chest pain or $reathlessness that is severe or occurs at rest +ne8plained sudden 9ea*ness or other s"mptoms of stro*e

E0a(s and 6ests

'he onl" 9a" to tell 9hether "ou have high $lood pressure is to have it measured 9ith a $lood pressure cuff ;sph"gmomanometer<2

'his device consists of a gauge and a ru$$er cuff that is placed around "our arm and inflated2 aving "our $lood pressure measured is painless and ta*es 1ust a fe9 minutes2

Blood pressure ;BP< is classified as follo9s,

&ormal BP 4 S"stolic less than >./ mm g; diastolic less than 0/ mm g Preh"pertension 4 S"stolic >./4>?5 or diastolic 0/405 mm g igh BP o Stage > 4 S"stolic >A/4>65; diastolic 5/455 mm g o Stage . 4 S"stolic more than >3/; diastolic more than >// mm g

'ests 9ill $e ordered to chec* for causes of high $lood pressure and to assess an" organ damage from high $lood pressure or its treatment2 'hese tests ma" include the follo9ing,

Blood tests including measurement of electrol"tes, $lood urea, and creatinine levels ;to assess potential *idne" damage< =ipid profile for levels of various *inds of cholesterol Special tests for hormones of the adrenal gland or th"roid gland +rine tests for electrol"tes and hormones

A noninvasive, painless e"e e8amination 9ith an ophthalmoscope 9ill loo* for ocular damage2 +ltrasound of the *idne"s, C' scan of the a$domen, or $oth ma" $e done to assess damage or enlargement of the *idne"s and adrenal glands2 An" of the follo9ing ma" $e performed to detect damage to the heart or $lood vessels,

!lectrocardiogram;!CB< is a noninvasive test that detects the electrical activit" of the heart and records it on paper2 !CB is helpful for @uantitating an" damage of the heart muscle, such as heart attac*, and/or thic*ening/h"pertroph" of the heart 9all/muscle, common complications of high $lood pressure2 !chocardiogram is an ultrasound e8amination of the heart ta*en through the chest2 Sound 9aves ta*e a picture of the heart as it $eats and rela8es and then transmits these images to a video monitor2 'he echo can detect pro$lems 9ith the heart such as enlargement, a$normalities in motion of the heart 9all, $lood clots, and heart valve a$normalities2 It also gives a good measurement of the strength of the heart muscle ;e1ection fraction<2 'he echocardiogram is more accurate than an !CB, $ut also more e8pensive2 A plain chest 84ra" primaril" provides an estimate of the si(e of the heart, $ut it is much less specific than echocardiograph", 9hich loo*s inside the heart2 Doppler ultrasound is used to chec* $lood flo9 through arteries at pulse points in "our arms, legs, hands, and feet2 'his is an accurate 9a" to detect peripheral vascular disease, 9hich can $e associated 9ith high $lood pressure2 It also can depict the arteries to $oth *idne"s and sometimes depicts narro9ings that can lead to high BP in a minorit" of patients2

Hig #lood Pressure 6reat(ent

Iou and "our health care provider have options for treating "our high $lood pressure2

Man" people can lo9er their $lood pressure significantl" 9ith lifest"le changes, such as 9eight loss and e8ercise, $ut most still need medication to *eep their $lood pressure in the health" range2 Fhichever therap" "ou choose, it is important to have "our $lood pressure chec*ed regularl" to ma*e sure that "our treatment is 9or*ing2 +ncontrolled high $lood pressure is a leading cause of heart disease, heart attac*s, heart failure, *idne" failure, vision pro$lems, and stro*e2

Iou ma" have 9ondered 9hether the $lood pressure machines at the pharmac" or supermar*et are accurate2

A recent stud" sho9ed that the" can $e accurate, $ut sometimes are not2 It usuall" is not possi$le to tell 9hether a particular machine is 9or*ing properl"2 'he cuff should inflate and fit snugl" around "our arm2 +se the machine as directed2 Measure "our $lood pressure three times, t9o minutes apart2 'he third measurement is usuall" the most accurate2 If "our $lood pressure is high on the third reading, even $orderline, have it chec*ed $" another machine that "ou *no9 is accurate ;for e8ample, at the office of "our health care provider<2 Do not rel" on the machines in stores alone to chec* "our $lood pressure2 ave it chec*ed regularl" $" a trained medical professional 9ith a machine that is *no9n to $e accurate2

Sel%-Care at Ho(e
'he management and control of high $lood pressure involves t9o ma1or options, lifest"le modification ;detailed here< and medications ;detailed in 'reatment<2

=ifest"le options include changing 9hat "ou eat and "our activit" level2 Vuitting smo*ing and moderating alcohol consumption 9ill also help *eep "our $lood pressure in the health" range2

Maintain a health" 9eight2

If "ou are over9eight or o$ese, lose 9eight2 Aim for a health" 9eight range for "our height and $od" t"pe2 Iour health care provider can help "ou calculate a target 9eight2 !ven a small amount of 9eight loss can ma*e a ma1or difference in lo9ering or preventing high $lood pressure2 'o lose 9eight, "ou must $urn more calories than "ou ta*e in2 Crash or fad diets are not helpful and ma" $e dangerous2 Some 9eight loss medications also carr" ma1or ris*s and ma" even elevate $lood pressure, and great caution is advised in using these drugs2 'he healthiest and longest4lasting 9eight loss re@uires slo9 loss, such as losing one4 half to one pound each 9ee*2 !ating 6// calories less than "ou $urn ever" da" ma" help achieve this goal2 In a 9ee*, "ou 9ill eat ?6// calories less than "ou $urn, 9hich is enough to lose one pound2 Increasing "our ph"sical activit" 9ill help "ou $urn more calories2

=ose 9eight and *eep it off2

Choose foods lo9 in calories and fat2 :at is a concentrated source of calories2 Iou should cut do9n on $utter, margarine, regular salad dressing, fatt" or red meats, the s*in of poultr", 9hole mil*, cheese, fried foods, ice cream, man" coo*ies, ca*es, pastries, and snac*s2 Instead, choose $a*ed, $roiled, or poached chic*en and tur*e" ;9ithout s*in<, fish, lean cuts of meat ;such as round or sirloin<; s*im, >7, or evaporated mil*; lo9er fat, lo94sodium cheeses; fresh, fro(en, or canned fruit or vegeta$les ;9ithout $utter, cream, or cheese sauces<; plain 9hole 9heat rice and pasta; 9hole 9heat !nglish muffins; 9hole 9heat $agels; 9hole 9heat sand9ich $read and rolls; soft tortillas; cold ;read"4to4eat< and hot 9hole4grain cereals ;avoid OinstantO t"pes, 9hich are high in sodium<2 Choose foods high in starch and fi$er, 'hese foods are lo9 in fat and also good sources of vitamins and minerals2 'r" fruits, vegeta$les, 9hole4grain cereals, 9hole 9heat pasta, rice, and dr" peas and $eans2 =imit serving si(es, Iou should especiall" tr" to ta*e smaller helpings of high4calorie foods such as meats and cheeses2 'r" to avoid the temptation of going $ac* for seconds2 Frite do9n 9hat "ou eat and 9hen, It ma" $e helpful to trac* "our ha$its2 Iou should note 9here "ou are and 9hat "ou are doing 9hen "ou snac* on high4calorie foods2 :or

instance, man" people snac* 9hile 9atching television2 Gr do "ou s*ip $rea*fast and then eat a large lunchS Identif"ing "our eating patterns can help "ou overcome the situations in 9hich "ou overeat2 #eplace high4calorie, high4fat snac*s 9ith fresh fruits, air4popped popcorn ;9ithout salt or $utter<, or unsalted pret(els2 If there is no time for $rea*fast, ta*e a lo94fat muffin, a $agel ;9ithout cream cheese<, or 9hole4grain cereal along to eat at 9or*2 'his 9ill reduce the craving for a large lunch2

E0ercise or increase p ysical acti?ity2

Ph"sical activit" $urns calories, helps "ou lose 9eight, and reduces stress2 Ph"sical activit" reduces total cholesterol and $ad cholesterol ;=D=< and raises the good cholesterol ; D=<2 'he American eart Association ;A A< recommends at least ?/ minutes of e8ercise ever" other da" for cardiovascular fitness2 'he Surgeon Beneral recommends ?/ minutes of ph"sical activit" on most da"s of the 9ee*2 Ph"sical activit" doesn)t have to mean running a marathon2 ouse cleaning or pla"ing golf or $ase$all can $urn as man" as ?// calories per hour; $ris* 9al*ing ;at ?26 mph<, c"cling ;at 626 mph<, gardening, dancing, or pla"ing $as*et$all $urns as man" as A6/ calories per hour; 1ogging ;5 min/mile<, pla"ing foot$all, or s9imming can $urn as man" as -?/ calories per hour; and running ;- min/mile<, rac@uet$all, or s*iing can $urn as man" as 5./ calories per hour2 Iou can fit ph"sical e8ercise into "our dail" routine2 o +se the stairs instead of the elevator2 o Bet off the $us one or t9o stops earl" and 9al* the rest of the 9a"2 o Par* farther a9a" from the store or office2 o #ide a $i*e2 o For* in the "ard or garden2 o Clean house2 o Fash the car the old4fashioned 9a"2 o Bo dancing2

Beneral tips for controlling $lood pressure include the follo9ing,

#educe sodium ;salt< inta*e2 =imit alcohol to no more than t9o drin*s a da"2 Vuit smo*ing2 'a*e medicines as directed2

Medication is an important part of $lood pressure control for almost ever"$od" 9ith high $lood pressure2 Man" people cannot *eep their $lood pressure in the health" range $" lifest"le changes alone2

Gnl" .>7 of people 9ith high $lood pressure are on $lood pressure medicines and have their pressure ade@uatel" controlled2 At least >37 of people 9ith high $lood pressure are not on an" medication2

Appro8imatel" .07 are ta*ing medicines incorrectl", and their $lood pressure is uncontrolled2 'herefore, the $iggest challenge in the treatment of high $lood pressure is ta*ing the medication correctl"2

Medical 6reat(ent
In a$out half of people 9ith high $lood pressure, limiting sodium inta*e $" eliminating ta$le salt, coo*ing salt, and salt" and processed foods can reduce $lood pressure $" 6 mm g2 =osing 9eight and doing regular ph"sical activit" can reduce the $lood pressure further2 If these lifest"le changes and choices don)t 9or*, medications should $e added2 'he medications have $een proven to reduce the ris* of stro*e, heart disease, and *idne" pro$lems2 Do not stop ta*ing "our medications 9ithout tal*ing to "our health care provider2

Medications
Medications most often prescri$ed for high $lood pressure include the follo9ing, 5ater pills 7diuretics8

Diuretics are used ver" 9idel" to control mildl" high $lood pressure, and are often used in com$ination 9ith other medications2 'he" increase sodium e8cretion and urine output and decrease $lood volume2 'he sensitivit" to the effect of other hormones in "our $od" is decreased2 !8ample 4 "drochlorothia(ide ; "droDI+#I=<

#eta-'loc$ers

Beta4$loc*ers reduce heart rate and decrease the force of heart contraction, there$" reducing the pressure generated $" the heart2 'he" are preferred for people 9ho have associated coronar" heart disease, angina, or histor" of a heart attac*, since the" also prevent recurrent heart attac*s and sudden death2 !8amples 4 Carvedilol ;Coreg<, metoprolol ;=opressor<, atenolol ;'enormin< Side effects 4 :atigue, depression, impotence, nightmares

Calciu( c annel 'loc$ers

Calcium channel $loc*ing agents 9or* $" rela8ing the muscle in the 9alls of the arteries2 'he" also reduce the force of contraction of the heart2 !8amples 4 &ifedipine ;Procardia<, diltia(em ;Cardi(em<, verapamil ;Isoptin, Calan<, nicardipine ;Cardene<, amlodipine ;&orvasc<, felodipine ;Plendil< Side effects 4 An*le s9elling, fatigue, headache, constipation, flushing

!ngiotensin-con?erting enzy(e 7!CE8 in i'itors

AC! inhi$itors stop the production of a chemical called angiotensin II, a ver" potent chemical that causes $lood vessels to contract, a cause of high $lood pressure2 Bloc*age of this chemical causes the $lood vessels to rela82 !8amples 4 Captopril ;Capoten<, enalapril ;%asotec<, lisinopril ;Kestril, Prinivil<, @uinapril ;Accupril<, fosinopril ;Monopril< Side effects are infre@uent $ut sometimes the" can 9orsen *idne" function and raise $lood potassium levels, especiall" in patients 9ith damaged *idne"s2 AC! inhi$itors sometimes cause dr" cough and rarel" angioedema ;severe s9elling around the trachea/9indpipe<2

!ngiotensin receptor 'loc$ers or !R#s

A#Bs 9or* on receptors in tissues all over the $od" to prevent upta*e of angiotensin II, and therefore inhi$it the vasoconstrictor effect of angiotensin II2 !8amples 4 =osartan ;Co(aar<, valsartan ;Diovan<, candesartan ;Atacand<, and ir$esartan ;Avapro< Side effects tend to $e less 9ith A#Bs than AC!Is 9ith much less cough2

!lp a-'loc$ers

Alpha4$loc*ers rela8 $lood vessels $" $loc*ing messages from the nervous s"stem that cause muscular contraction2 !8amples 4 'era(osin ; "trin<, do8a(osin ;Cardura< Since pu$lication of a stud" *no9n as the A== A' ;Antih"pertensive and =ipid4 =o9ering 'reatment to Prevent eart Attac* 'rial< in A.,/// patients, and premature termination of the alpha4$loc*er arm ;discontinuation of treatment in the group receiving alpha4$loc*ers< $ecause of e8cessive incidence of congestive heart failure, alpha4$loc*ers are no longer fre@uentl" prescri$ed and are primaril" used in men 9ith associated prostatism ;$enign prostatic h"perplasia, or enlargement of the prostate< s"mptoms2

#loc$ers o% central sy(pat etic 7autono(ic ner?ous8 syste(

'hese agents $loc* messages out of the $rain from the autonomic nervous s"stem that contract $lood vessels2 'he autonomic nervous s"stem is the part of the nervous s"stem that is automatic and controls heart rate, $reathing rate, and other $asic functions2 'he effect of these drugs is to rela8 $lood vessels, thus lo9ering $lood pressure2 'hese agents are not as popular $ecause of e8cessive side effects, and no randomi(ed trials demonstrate their effectiveness in lo9ering heart attac*s, stro*es, etc2 !8ample 4 Clonidine ;Catapres<

Direct ?asodilators

Direct vasodilators rela8 ;dilate< the $lood vessels to allo9 $lood to flo9 under lo9er pressure2

'hese medications are often given through an I% line in an emergenc" ;that is, in malignant h"pertension<2 !8amples 4 &itroprusside ;&itropress<, dia(o8ide ; "perstat<2 Gral medications are h"drala(ine and mino8idil2

Surgery
#arel", surger" is needed to remove $enign, hormone4producing tumors of the adrenal gland2 If a narro9ing of a renal arter" is discovered, sometimes a $alloon dilatation, follo9ed $" placement of a metal stent, is done in the invasive vascular la$orator"2

4t er 6 erapy
Alternative therapies ma" $e helpful to people tr"ing to control their $lood pressure2

Acupuncture and $iofeed$ac* are 9ell4accepted alternative techni@ues that ma" help some people 9ith high $lood pressure2 'echni@ues that induce rela8ation and reduce stress are recommended2 'hese include meditation, "oga, and rela8ation training2 'hese techni@ues alone 9ill not *eep the $lood pressure in the health" range for man" people2 Do not use these as a su$stitute for medical therap" 9ithout first tal*ing this over 9ith "our health care provider2

Dietar" supplements and alternative medications and therapies are sometimes recommended for high $lood pressure2

!8amples are vitamins, garlic, fish oil, =4arginine, so", coen("me V>/, her$s, ph"tosterols, and chelation therap"2 Fhile these su$stances ma" $e $eneficial, the e8act nature of their $enefits is not *no9n2 Scientific studies have produced no evidence that these therapies lo9er $lood pressure or prevent the complications of high $lood pressure2 Most of these su$stances are harmless if ta*en in moderate doses2 Most people can ta*e them 9ithout pro$lems2 'al* to "our health care provider if "ou are considering an" of these treatments2 Su$stituting these therapies for medical therapies that have $een sho9n to lo9er $lood pressure and the ris* of complications ma" have a harmful effect on "our health2

=e0t Steps ,ollow-up

'he most important element in the management of high $lood pressure is follo94up care2

Chec* 9ith "our health care provider periodicall" to ma*e sure that "our $lood pressure is in the recommended range2 If it is not, "our treatment should $e ad1usted2

If "ou are dia$etic or have had a prior heart attac* or stro*e, "our doctor ma" 9ant "our $lood pressure lo9ered to >.64>?/ mm B to prevent recurrent events2 Fith aging and progression of the process of hardening of the arteries, "our s"stolic $lood pressure ma" creep up 9ith time2 A treatment that once 9or*ed 9ell ma" no longer 9or* as 9ell2 Iour drug dosage ma" need to $e changed or "ou ma" $e prescri$ed a ne9 medication2 At "our follo94up visits, "ou should $e screened for damage to the heart, e"es, $rain, *idne", and peripheral arteries that ma" $e related to high $lood pressure2 :ollo94up visits are a good time to let "our health care provider *no9 a$out an" side effects "ou are having from "our medication2 e or she 9ill have suggestions for coping 9ith side effects or ma" change "our treatment2 :ollo94up visits are a great opportunit" for monitoring for other associated ris* factors, such as high cholesterol and o$esit"2

Pre?ention
'he follo9ing strategies ma" help to prevent high $lood pressure and organ damage it ma" cause2 :or more details on ho9 "ou can achieve these goals, see Self4Care at ome2

!at a nutritious, lo94fat diet2 !8ercise regularl"2 Decrease salt ;sodium< inta*e, #ead food la$els so "ou *no9 the salt content $efore "ou $u" a product in the grocer" store2 Maintain a health" 9eight, If "ou are over9eight or o$ese, tr" to lose 9eight2 +se alcohol in moderation, if at all2 Stop smo*ing2 Bet "our $lood pressure chec*ed periodicall"2 Consider getting an accurate and eas"4 to4use home monitor2 'a*e "our $lood pressure medications as directed, even if "ou)re feeling fine2 #educe stress and practice rela8ation, Ph"sical activit" 9ill help 9ith this2