HEALTH CHALLENGE: HYPERTENSION
1.0 INTRODUCTION
Healthy living is one of man’s most treasured need, and there are many
ailments that have continued to contribute to man’s unhealthy living and health
challenges, one of such ailment is Hypertension. Hypertension is a major health
problem throughout the world because of its high prevalence and its association
with increased risk of cardiovascular disease. Advances in the diagnosis and
treatment of hypertension have played a major role in recent dramatic declines in
heart disease and stroke mortality in some countries. However, in many of these
countries, the control rates for high blood pressure have actually slowed in the last
few years. It is estimated that by 2025, 2 billion people will be suffering
hypertension worldwide
In the Eastern Mediterranean Region, the prevalence of hypertension
averages 26% and it affects approximately 125 million individuals [2]. Of greater
concern is that cardiovascular complications of high blood pressure are on the
increase, including the incidence of stroke, end-stage renal disease and heart
failure. Recent data suggest that individuals who are normotensive at age 55 years
have a 90% lifetime risk for developing hypertension.
According to the World Health Organization (2011) hypertension is also
known as high or raised blood pressure. It is a condition in which the blood vessels
have persistently raised pressure. Blood is carried from the heart to all parts of the
body in the vessels. Each time the heart beats, it pumps blood into the vessels.
Blood pressure is created by the force of blood pushing against the walls of blood
vessels (arteries) as it is pumped by the heart. The higher the pressure, the harder
the heart has to pump. High blood pressure (BP) or hypertension is the most
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common non-communicable disease and a significant risk factor for renal disease
and cardiovascular diseases such as heart attacks, stroke, and left ventricular
hypertrophy globally (Lim et al., 2012). Sufferers of hypertension are usually
unaware that they have the condition, thus many present with the complications or
sudden death, and is therefore referred to as a ’silent killer’ (Ekore et al., 2009;
Ataklte et al., 2015; Adeloye et al., 2015). According to the World Health
Organization (WHO), the prevalence of hypertension is highest in the African
Region at 46% of adults aged 25 years and above while the lowest was found in
the American region (WHO, 2011). The incidence of hypertension and
cardiovascular mortality has been increasing in sub-Saharan Africa over the past
few decades (Ataklte et al., 2015) and is expected to nearly double by the year
2030 (Damasceno et al., 2009). In a systematic review of articles published on
hypertension between 2000 and 2013 in sub-Saharan Africa, Ataklte et al. reported
a pooled hypertension prevalence of 30% in adults and a range from 14.7 to 69.9%
depending on the site and age.
In Nigeria, the prevalence of hypertension has been on the increase affecting
a significant number of highly productive populations. A review of prevalence
among adults from 1990 to 2009 showed combined prevalence of 22% and range
from a minimum of 12.4% to a maximum of 34.8% (Ekwunife and Aguwa, 2011).
It was estimated that there were about 20.8 million cases of hypertension in
Nigeria among people aged at least 20 years, with a prevalence of 28.0% and
projected increase to 39.1 million cases with a prevalence of 30.8% by 2030
(Adeloye et al., 2015). A review with wider coverage (1968 -2015) found overall
crude prevalence of hypertension to range from 2.1 to 47.2% in adults and from 0.1
to 17.5% in children depending on the study site, target population, type of
measurement and cut-off value used for defining hypertension (Akinlua, 2015).
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Hypertension and its complications constitute approximately 25% of emergency
medical admissions in urban hospitals in Nigeria (Ekere et al., 2005).
2.0 REVIEW OF RELATED LITERATURE
The following related literature will be reviewed in this study:
1. Aging and Hypertension
2. Diagnosis of Hypertension
3. Causes of Hypertension
4. Complications of Hypertension
5. Prevention of Hypertension
6. Management and Treatment of Hypertension
2.1 AGING AND HYPERTENSION
Among the potential targets for improving health among older adults,
hypertension represents one of the most prevalent. Hypertension causes over 7
million premature deaths per year and contributes to 4.5% of the total disease
burden worldwide (Bramlage and Hasford, 2009). Notably, older adults account
for the bulk of hypertension-related morbidity and mortality – due largely to
dramatically greater prevalence among the elderly (Mozaffarian et al., 2015). In
fact, recent data from the National Health and Nutrition Examination Survey
indicate that 70% of older adults have hypertension, compared to only 32% for
adults aged 40-59 years (Mozaffarian et al., 2015). Despite the well-documented
pervasiveness of late-life hypertension among older adults, many challenges
remain. A 2010 report from the Institute of Medicine (IOM) called hypertension a
neglected disease that is often ignored by the general public and underappreciated
by the medical community (Institute of Medicine, 2010). “Although hypertension
is relatively easy to prevent, simple to diagnose, and relatively inexpensive to treat,
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it remains the second leading cause of death among Americans, and as such should
rightly be called a neglected disease”, said David W. Fleming, MD, chair of the
committee that prepared the report (Mitka, 2010). Proper screening and adherence
to treatment guidelines was particularly emphasized for elderly patients.
Hypertension stands out as the major risk factor for cardiovascular morbidity
and mortality in the elderly population (Forette, Henry and Hervy, 2018). The risk
from hypertension has been demonstrated for stroke, left ventricular hypertrophy,
congestive heart failure, coronary and peripheral artery diseases, vision
impairment, end-stage renal disease, cognitive impairment, and dementia. Both
systolic blood pressure (SBP) and diastolic blood pressure (DBP) are established
risk factors, but, with advancing age, SBP becomes a better predictor than DBP in
men and women (Vokonas et al, 2008). Although rise in blood pressure (BP) is not
a normal part of aging, the incidence of hypertension in the elderly population is
high. After the age of 69, the prevalence of hypertension rises to 50% (Burt,
Whelton and Roccella, 2015).
2.2 Diagnosis of Hypertension
According to Whelton, Carey and Aronow (2017), the diagnosis of
hypertension requires measurement of BP in the proper environment under
optimum conditions. It requires that the patient be relaxed in a chair for at least 5
minutes with the arm resting. In order to establish diagnosis, ≥2 readings of
elevated BP on ≥2 occasions are needed. (Whelton et al, 2017). White coat
hypertension is more common among elderly patients possibly related to
increasing arterial stiffness, thus, ambulatory or out-of-office blood pressure
readings is important in the subgroup of patients with mildly elevated in-office BP
readings (Williams, Mancia and Spiering, 2018). The 2017 ACC has set a blood
pressure reading above ≥130/80 mmhg to be considered hypertensive while the
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European Society of Hypertension guidelines have maintained a blood pressure
reading of ≥140/90 mmhg to be considered to be hypertensive (Cobos et al., 2015)
Since high BP is primarily asymptomatic, structured community programs play an
important role in the diagnosis and have proven effective in diagnosis patients
unaware they have hypertension (Chow, Teo, Rangarajan, 2013; Irazola, Gutierrez,
Bloomfield, 2016)
3.0 CAUSES OF HYPERTENSION
Research has indicated that blood vessels naturally ‘harden’ with age, losing
their elasticity. This may be one explanation for why older people are more at risk
of developing high blood pressure. (Forette, Henry and Hervy, 2018). Some of the
causes of hypertension are:
3.1 Obesity
Studies show that the increase in body mass index as well as the increase in age are
linked to rising blood pressure and can lead to hypertension. Statistics from the
Journal of American Medicine show that, in 2017, 37% of Americans over 60
years old are classified as obese (Kabakov, Norymberg, Osher, Koffler and
Tordjman, 2006). Aside from high blood pressure, obesity is linked to many other
health issues such as high cholesterol, heart disease and stroke, all of which have
links to high blood pressure.
3.2 Diabetes
Diabetes is often linked to obesity and is also a contributor to the development of
high blood pressure in elderly people (CDC, 2015). Poor diet and high sugar intake
can aid the development of diabetes and the incidence of the disease increases with
age among American older adults according to statistics. This can lead to further
issues. Such as heart disease. A 2007 review in the Postgraduate Medical Journal
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shows that older individuals with systolic hypertension are at greater risk of
mortality due to heart disease (Care, 2012).
3.3 Kidney disease
Statistics from the National Kidney Foundation show that kidney disease is the
leading cause of high blood pressure, just behind diabetes. There is some
speculation on whether high blood pressure causes kidney disease or the other way
around. High blood pressure leads to narrowed, weakened and hardened arteries
which cannot deliver blood efficiently to the kidneys (Pinto, 2007; Factsheet,
2017). Alternatively, kidney disease can damage the blood vessels of the kidneys
which cannot then remove waste appropriately. This can lead to pressure on the
arteries leading to hypertension. Development of these conditions can cause blood
pressure to rise, but this can also exacerbate existing conditions. Maintaining a
healthy diet and lifestyle lowers the risk of developing hypertension in elderly
people.
Other causes includes aging, excess alcohol, high fat diet, genetics, mental
stress, poor eating habit, smoking, and physical inactivity.
4.0 COMPLICATIONS OF HYPERTENSION
High blood pressure, also known as hypertension, is unlike low blood
pressure in that it rarely has any noticeable symptoms. However, it often causes
long-term health problems if undetected. Many health conditions are associated
with high blood pressure, including heart disease and stroke [CDC, 2015].
1. Heart Attack
When your blood moves through your body with too much force, it can
create small tears in the blood vessels that form scar tissue, which can catch debris
like fat and cholesterol. Those trapped particles form clusters called “plaques” that
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hinder the easy flow of blood. A heart attack is the result of a blocked blood supply
to the heart muscle tissue, and is often caused by high blood pressure.
2. Stroke
High blood pressure is a major risk factor for stroke, because it can cause
blockages in blood vessels that lead to the brain and in the brain itself. If a clot
blocks a blood vessel, or if one bursts, that is a stroke. Strokes can be devastating
because brain tissue no longer receives vital nutrients and oxygen to the affected
area, which begins to die.
3. Aneurysm
When high blood pressure creates weak spots in arteries, the areas may fill
up with blood and balloon out from the artery wall, which is called an aneurysm.
Aneurysms tend to enlarge slowly and become weaker as they grow. If
undiagnosed or untreated, they can cause a serious form of stroke called a
hemorrhagic stroke, which bleeds into the brain and can be life-threatening.
4. Heart Failure
Heart failure does not mean that your heart stops working, but rather that
your heart is not supplying sufficient blood flow to the rest of the body. Heart
muscle may thicken as a result of high blood pressure, and your heart can become
enlarged, so that it has to work harder to pump blood—that’s heart failure. Proper
treatment may help make your heart grow stronger and improve pumping
efficiency.
5. Kidney Damage
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High blood pressure is the second leading cause of kidney failure in the United
States, after diabetes. When blood vessels in the kidneys become weakened and
narrow because of damage from high blood pressure, it’s harder for the kidneys to
do their job. They may be unable to remove waste and fluid from the body
efficiently or at all. The extra fluid may then raise blood pressure even more,
creating a dangerous cycle.
6. Vision Loss
High blood pressure can damage the delicate blood vessels in your eyes,
reducing blood flow through them and even leading to ruptures. This is called
hypertensive retinopathy, which can cause bleeding in the eye, blurred vision or
blindness. High blood pressure can also cause fluid to build up within your retina
that can distort or impair your vision or damage the optic nerve, which can also
cause vision loss.
7. Peripheral Artery Disease
The plaque that builds up from high blood pressure can reduce the blood
flow to the arteries in your legs, which can cause pain, cramping, numbness, or
heaviness in the legs, feet, and buttocks after mild activity. Peripheral artery
disease tends to go undiagnosed because people think it is a normal sign of aging,
but it puts you at a higher risk of stroke or heart attack and can also lead
to gangrene and amputation. Treatment includes lifestyle changes, medicine and
sometimes surgery.
8. Metabolic Syndrome
High blood pressure is one of the traits that can lead to a diagnosis of
metabolic syndrome, a group of factors that indicate you are more likely to develop
diabetes or have a heart disease or stroke. About one in three adults in the U.S.
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has metabolic syndrome, which can be addressed by lifestyle changes and
medication.
9. Trouble Thinking or Remembering
People who have high blood pressure are more likely to have cognitive
impairment, which means their ability think, learn and recall things is reduced.
Some studies show that people who have high blood pressure when they are
middle-aged have a higher risk of developing dementia as they grow older. There
is evidence that the younger you are when you get your blood pressure under
control, the more you reduce your chance of having cognitive impairment later in
life.
10. Erectile Dysfunction
Anything that disrupts blood flow can cause erectile dysfunction, and that
includes high blood pressure. Without adequate blood flow, it is difficult to
achieve and maintain an erection. High blood pressure can also interfere with
ejaculation and reduce sexual desire.
PREVENTION OF HYPERTENSION
Reducing hypertension prevents heart attack, stroke and kidney damage, as well as
other health problems. Some of the ways of preventing hypertension according to
the world health organization WHO (2021) are:
1. Reducing salt intake (to less than 5g daily)
2. Eating more fruit and vegetables
3. Being physically active on a regular basis
4. Avoiding the use of tobacco
5. Reducing Alcohol consumption
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6. Limiting the intake of foods high in saturated fats
7. Eliminating/ reducing trans fats in diet
6.0 MANAGEMENT AND TREATMENT OF HYPERTENSION
6.1 NON-PHARMACOLOGIC INTERVENSIONS
Non-pharmacologic lifestyle interventions should be encouraged as
preventive care for the development of HTN and as adjunctive therapy for
established HTN. Current recommendations advocate for regular physical activity,
weight control, smoking cessation, stress reduction, and avoidance of excessive
alcohol intake (Whelton, Carey and Aronow, 2017). A heart healthy diet, such as
the Dietary Approaches to Stop Hypertension (DASH) diet, low carbohydrate,
vegetarian, plant-based and Mediterranean diet. As well as low sodium intake,
potassium supplementation (1500 to >3000 mg), calcium or magnesium
supplements, consumption of probiotics, fiber, flaxseed, increased protein intake,
consumption of garlic, dark chocolate, tea, coffee, and fish oil (Whelton, Carey and
Aronow, 2017) Behavioral therapies including transcendental meditation, yoga,
Taiichi and biofeedback have known effect in decreasing BP. Contributing co-
morbidities such as sleep apnea, renal artery stenosis, prostatism, primary
aldosteronism should also be addressed. Review the patients’ medications to
ensure they are not on any medications such as nonsteroidal anti-inflammatory
drugs, steroids, angiogenesis inhibitors, tyrosine kinase inhibitors, atypical
antipsychotics, antidepressants, amphetamines, hormone replacement therapy,
immunosuppressant, and decongestants which can cause HTN (Grossman,
Messerli and Grossman, 2015).
Use of recreational drugs, caffeine, tea and herbal supplements should also
be inquired. Reduction is sodium intake (approximately 1000 mg per day) and
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weight loss constitute effective and safe ways to improve BP, as seen in the Trial
of Non-pharmacologic Interventions in the Elderly (TONE) (Shea, Nicklas and
Houston, 2011). Some observational studies have argued that low salt intake
maybe associated with activation of renin-angiotensin aldosterone system with
increased sympathetic system activity leads to adverse cardiovascular effects
(Alderman, 2010; Batuman, 2013). This was however refuted by a meta-analysis
by Aburto et al, which showed that lowering salt intake to less than 1200 mg per
day was safe and beneficial (Aburto et al, 2013) It has also been described that
intentional weight loss is associated with increased mortality, but in a post hoc
analysis of the TONE data, there was no association with an increase in all-cause
mortality in elderly patients that had weight loss and improvement of BP (Shea et
al, 2011) The DASH eating plan is the best diet with most data supporting
lowering BP (Whealton et al, 2017)
The recommended physical activity recommended are aerobic exercise (90-
150 minutes per week with achievement of 65% to 75% of heart rate reserve),
dynamic resistance (90-150 minutes per week), or isometric resistance (3 sessions
per week for 8 to 10 weeks of 4 × 2 minutes of hand grip, 1-minute rest, 30% to
40% of maximum voluntary contraction) (Whealton et al, 2017). Older adults at
any submaximal exercise load will exert at a higher maximal capacity and effort
than younger individuals, (Lee, Jackson and Richardson, 2017) they may benefit of
experienced fitness trainers to define optimal frequency, intensity, and duration of
each type of exercise. Aging causes decline in muscle strength and power,
(Costello, Kafchinski, Vrazel and Sullivan, 2011) so there are specific goals from
the American College of Sports Medicine which recommend in older adults a
minimum of 150 minutes of moderate intensity aerobic activity or 75 minutes of
vigorous intensity aerobic activity, and two or more non-consecutive days of
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moderate-intensity strengthening activities, with 8 to 10 exercises involving the
major group muscles and 8 to 12 repetitions of each exercise.(Lee et al., 2017)
Dolan et al, highlighted the importance of home ambulatory BP monitoring over
clinic BP measurement to predict mortality. In clinical practice home ambulatory
monitoring it is a better tool diagnosis and for titration of medications (Dolan,
Stanton and Thijs, 2005) The use of telemedicine to manage our patients is a
modern tool that will improve our management in older persons that require slow
and careful adjustments in their medication, without asking them to overcome the
hurdles of transportation, walking and time of having a clinic visit (Czaja, Lee,
Arana, Nair, Sharit, 2014).
6.2 PHARMACOLOGIC INTERVENTIONS
When medications are needed to manage older adults with uncontrolled
HTN, factors to consider prior to selecting a medication include comorbidities,
frailty of the patient, ability to follow instructions, complexity of the current
regimen, supporting care (ie, spouses and family) and lastly electrolytes and renal
function (Whelton et al, 2015) Thiazide diuretics, angiotensin-converting-enzyme
inhibitor (ACEI), angiotensin II receptor blockers (ARB), and calcium channel
blocker (CCB), have all shown benefit on CVD outcomes in older age patients.
Unless clinically indicated by comorbidities, beta blockers should not be used as
first line medications because they may worsen CVD outcomes in those over 60
years of age. Loop diuretics and alpha-blockers should also be avoided given their
association with falls (Costello et al, 2011)
Commonly, BP remains uncontrolled on monotherapy and a combination of
different agents is needed to achieve adequate BP control. Any of the four first line
BP medications can be combined, however based on multiple RCTs RAAS
blockers and CCB/thiazide is the preferred combination (Jamerson, Weber, Bakris,
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2008). Single pill combination can be utilized with the added benefit of improving
medication compliance (Zanchetti, Dominiczak and Coca, 2018). The medications
should then be up titrated, with additional medications added as needed to achieve
BP targets. Initiation of any medication should be done with assessment of
orthostatic hypotension and gradual titration according to tolerance. Renal function
should be assessed to detect possible increases in serum creatinine and reductions
in GFR as a result of BP-related reductions in renal perfusion. Hypokalemia is also
an important side effects of diuretics which needs to be monitored. The medical
team needs to be cognizant of treatment related side effects which may occur more
frequently than reported in clinical trials.
SUMMARY AND CONCLUSION
High blood pressure (hypertension) is a common condition in which the
long-term force of the blood against your artery walls is high enough that it may
eventually cause health problems, such as heart disease.
Blood pressure is determined both by the amount of blood your heart pumps
and the amount of resistance to blood flow in your arteries. The more blood your
heart pumps and the narrower your arteries, the higher your blood pressure. A
blood pressure reading is given in millimeters of mercury (mm Hg). It has two
numbers.
Top number (systolic pressure). The first, or upper, number measures the
pressure in your arteries when your heart beats.
Bottom number (diastolic pressure). The second, or lower, number measures
the pressure in your arteries between beats.
You can have high blood pressure for years without any symptoms.
Uncontrolled high blood pressure increases your risk of serious health problems,
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including heart attack and stroke. Fortunately, high blood pressure can be easily
detected. And once you know you have high blood pressure, you can work with
your doctor to control it.
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