CASEA 47 year-old man presents to your office for a follow-up visit. He was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164/98 mm Hg . he vaguely remembered being told in the past that his blood pressure was “borderline” . he feels fine , has no complaints , and his review of systems is entirely negative. He does not smoke cigarettes, drinks “ a couple of beers on the weekends”, and does not exercise regularly. He has a sedentary job. His father died of a stroke at the age of 69 years. His mother is alive and in good health at the age of 72 years. He has two siblings and is not aware of any chronic medical issues that they have. In the office today, his blood pressure is 156/96 mmHg in his left arm and 152/98 mmHg in the right arm. He is afebrile , his pulse is 78 bpm , respiratory rate 14 breaths per minute, he is 70 in tall, and weighs 210 Ib . a general physical examination is normal.

KEYWORD

. A 47 year-old man

. Upper respiratory infection

. Blood pressure of 164/98 mm Hg

. Blood pressure was “borderline”

. does not exercise regularly

. His father died of a stroke

. 156/96 mmHg in his left arm (today)

. 152/98 mmHg in the right arm (today)

PROBLEM

Mr. A has high blood pressure

TAKING NOTE 1Surename : A

Age : 47 years

Sex : man

Occupation : Sedentary job

Present complaint : follow up visit

O/E

General condition : 70 in tall, 210 LB

ENT : NAD

RS : RR : 14 breaths/minute

CVS : P : 78 bpm blood pressure : 156/96 mmHg in his left arm

152/98 mmHg in the right arm

HS: normal

GUS : -

CNS : -

Immediate past history : he was seen 3 weeks ago for an upper respiratory infection and noted incidentally to have a blood pressure of 164 / 98 mmHg . his father died of a stroke at the age of 69 years

Diagnosis : hypertension

Management : kaptopril, tiazid, beta blocker, diuretics

Taking note 2

System Complaint No complaint OrderENT √RS √CVS √ 156/96 mmHg

(Left Arm)152/98 mmHg (Right Arm)

GIS √GUS √CNS √Psychiatric √

Conversation

D : Good Morning, My name is dr.Octopus

P : Morning dok

D : What is your name ?

P : My name is Mr.A

D : How old are you ?

P : 47 years old

D : what is your address ?

P : Jl.Pramuka Kemiling, Bandar Lampung

D : What is you occupation ?

P : i have sedentary job

D : what brought you along today ?

P : I want to follow up my body

D : what do you feel about your body ?

P : 3 weeks ago . I was seen for upper respiration and noted incidentaly to have a blood pressure of 164/98 mmHg

D : and then ?

P : i remember in the past that my blood preasurre was “border line”

D : How about habituation ? are you smoker ?

P : No, i am not

D : Do you like drink an alkohol ?

P : I drinks “a couple of beers on the weekend”

D : Do you have any exercise regularly ?

P : No, I dont

D : In your family, do they have same problem like you ? can you tell me ?

P : My Father have died because stroke at the age of 69 years . My mother and my siblings is normal

D : Oke. Thank you . Its time to fisic excamination .

P : Oke lets go dok

D :The result of your follow up is something wrong with your blood presurre its higher than normal blood pressure.

HYPERTENSION

DEFINITION

Blood pressure is the force of blood pushing up against the blood vessel walls. The higher the pressure the harder the heart has to pump.

The normal level for blood pressure is below 120/80, where 120 represents the systolic measurement (peak pressure in the arteries) and 80 represents the diastolic measurement (minimum pressure in the arteries). Blood pressure between 120/80 and 139/89 is called prehypertension (to denote increased risk of hypertension), and a blood pressure of 140/90 or above is considered hypertension.

Hypertension, also referred to as high blood pressure, is a condition in which the arteries have persistently elevated blood pressure. Every time the human heart beats, it pumps blood to the whole body through the arteries.

EPIDEMIOLOGY

Some 70 million adults in the United States are affected by hypertension. The condition also affects about two million teens and children. According to a report issued by the Centers for Disease Control and Prevention (CDC) in September 2012, over half all Americans with hypertension do not have their high blood pressure under control.

CAUSES

Though the exact causes of hypertension are usually unknown, there are several factors that have been highly associated with the condition. These include:

Smoking Obesity or being overweight

Being obese/overweight as a child - a research team at the Indiana University School of Medicine found that obese/overweight children are much more likely to suffer from hypertension during adulthood.

Diabetes

Sedentary lifestyle

Lack of physical activity

High levels of salt intake (sodium sensitivity). According to the American Heart Association (AHA), sodium consumption should be limited to 1,500 milligrams per day, and that includes everybody, even healthy people without high blood pressure, diabetes or cardiovascular diseases. AHA's chief executive officer, Nancy Brown said "Our recommendation is simple in the sense that it applies to the entire U.S

population, not just at-risk groups. Americans of all ages, regardless of individual risk Though the exact causes of hypertension are usually unknown, there are several factors that have been highly associated with the condition factors, can improve the heart health and reduce their risk of cardiovascular disease by restricting their daily consumption of sodium to less that 1,500 milligrams." The recommendation was published in the journal Circulation (November 5th, 2012 issue)

Insufficient calcium, potassium, and magnesium consumption

Vitamin D deficiency

High levels of alcohol consumption

Stress

Aging

Medicines such as birth control pills

Genetics and a family history of hypertension - In May 2011, scientists from the University of Leicester, England, reported in the journal Hypertension that some genes in the kidneys may contribute to hypertension.

Chronic kidney disease

Adrenal and thyroid problems or tumors

RISK FACTOR

High blood pressure is more common in older people. At age 45, more men have hypertension than women. By age 65, this is reversed and more women are affected. People with diabetes have a greater risk of hypertension than those without diabetes, and having a close family member with high blood pressure also increases your risk of developing it. About 60% of all people with diabetes also have hypertension.

Hypertension and Race

African-Americans are at greater risk of developing hypertension than people of other races. Some studies suggest that African-Americans may be more sensitive to salt than other races. For those who are genetically prone to salt sensitivity, a small amount like a half-teaspoon of salt can raise blood pressure by 5 mm Hg. Dietary factors and being overweight can also raise blood pressure.

Hypertension and Sodium

Sodium, a chemical found in salt, raises blood pressure by promoting the retention of fluid by the body. This increases the workload on the heart. The American Heart Association recommends an upper daily limit for sodium consumption of 1,500 mg. Checking food labels and menus can help you calculate how much sodium you are consuming. Processed foods are particularly high in sodium and make up about 75% of our sodium intake. Among these, lunch meats and canned soups have some of the highest levels of dietary sodium.

Hypertension and Stress

Stress leads to temporary elevations of blood pressure, but there is no proof that stress causes ongoing high blood pressure. Stress may have an indirect effect on blood pressure since it can influence other risk factors for heart disease. People who are under stress tend to engage more in unhealthy habits like poor nutrition, alcohol use, and smoking, all of which can play a role in the development of high blood pressure and heart disease.

Hypertension and Weight

Being overweight increases the risk of getting hypertension and increases the workload required of your heart. Diets designed to control blood pressure are often designed to reduce calories as well. Most of these diets require decreasing consumption of fatty food and sugars while increasing your intake of lean protein, fiber, fruits, and vegetables. A weight loss of just 10 pounds can make a difference in your blood pressure.

Hypertension and Alcohol

Drinking too much alcohol is a risk factor for high blood pressure. The American Heart Association guidelines recommend the consumption of no more than two alcoholic drinks per day for men and no more than one drink a day for women. One drink is defined as one 12-ounce beer, 4 ounces of wine, 1.5 ounces of 80-proof spirits, or 1 ounce of 100-proof spirits.

Hypertension and Caffeine

Caffeine can bring on the jitters, but there is no evidence that it can cause long-term hypertension. However, especially for those not accustomed to caffeine, a caffeinated beverage might bring on a temporary rise in blood pressure.

Hypertension and Pregnancy

Gestational hypertension is high blood pressure that develops in pregnancy. If not properly managed, it may develop into preeclampsia. Preeclampsia is elevated blood pressure and the leakage of protein into the urine by the kidneys. Preeclampsia can be dangerous to both mother and baby. After the baby is born, high blood pressure of pregnancy usually returns to normal levels.

Hypertension and Medicine

Certain medications contain ingredients that can elevate blood pressure. Cold and flu medications that contain decongestants are one example of drugs that raise blood pressure. Other kinds of medicines that can raise blood pressure are steroids, diet pills, birth control pills, NSAID pain relief medications, and some antidepressants. Talk to your doctor about the medications or supplements you may be taking that might affect your blood pressure.

'White Coat' Hypertension

Sometimes people have a higher blood pressure reading when they are in the doctor’s office. This may be due to anxiety or nervousness. For the most accurate readings, take your blood pressure at home at different times and share these measurements with your doctor. To determine if your readings are accurate, bring your home blood pressure monitor to the doctor’s office so that the device and your technique can be evaluated.

Hypertension and Children

Although it's most common in older adults, hypertension can also affect children. The normal blood pressure for a child is dependent upon the child’s age, gender, and height. Your doctor can tell if your child’s blood pressure is abnormal. Children are at higher risk for hypertension if they are overweight, are African-American, or if they have a family history of the condition.

CLASSIFICATION

Hypertension may be classified as essential or secondary. Essential hypertension is the term for high blood pressure with unknown cause. It accounts for about 95% of cases. Secondary hypertension is the term for high blood pressure with a known direct cause, such as kidney disease, tumors, or birth control pills.

SYMPTOMS

There is no guarantee that a person with hypertension will present any symptoms of the condition. About 33% of people actually do not know that they have high blood pressure, and this ignorance can last for years. For this reason, it is advisable to undergo periodic blood pressure screenings even when no symptoms are present.

Extremely high blood pressure may lead to some symptoms, however, and these include: Severe headaches Fatigue or confusion

Dizziness

Nausea

Problems with vision

Chest pains

Breathing problems

Irregular heartbeat

Blood in the urine

DIAGNOSED

Hypertension may be diagnosed by a health professional who measures blood pressure with a device called a sphygmomanometer - the device with the arm cuff, dial, pump, and valve. The systolic and diastolic numbers will be recorded and compared to a chart of values. If the pressure is greater than 140/90, you will be considered to have hypertension.

A high blood pressure measurement, however, may be spurious or the result of stress at the time of the exam. In order to perform a more thorough diagnosis, physicians usually conduct a physical exam and ask for the medical history of you and your family. Doctors will need to know if you have any of the risk factors for hypertension, such as smoking, high cholesterol, or diabetes.

If hypertension seems reasonable, tests such as electrocardiograms (EKG) and echocardiograms will be used in order to measure electrical activity of the heart and to assess the physical structure of the heart. Additional blood tests will also be required to identify possible causes of secondary hypertension and to measure renal function, electrolyte levels, sugar levels, and cholesterol levels.

THREATMENT

The main goal of treatment for hypertension is to lower blood pressure to less than 140/90 - or even lower in some groups such as people with diabetes, and people with chronic kidney diseases. Treating hypertension is important for reducing the risk of stroke, heart attack, and heart failure.

High blood pressure may be treated medically, by changing lifestyle factors, or a combination of the two. Important lifestyle changes include losing weight, quitting smoking, eating a healthful diet, reducing sodium intake, exercising regularly, and limiting alcohol consumption.

Medical options to treat hypertension include several classes of drugs. ACE inhibitors, ARB drugs, beta-blockers, diuretics, *calcium channel blockers, alpha-blockers, and peripheral vasodilators are the primary drugs used in treatment. These medications may be used alone or in combination, and some are only used in combination. In addition, some of these drugs are preferred to others depending on the characteristics of the patient (diabetic, pregnant, etc.).

*Calcium-channel blockers and cancer risk - postmenopausal females who took calcium-

channel blockers for 10 years were found to be 2.5 times more likely to develop breast cancer compared to women who never took them or those on other hypertension medications.

If blood pressure is successfully lowered, it is wise to have frequent checkups and to take preventive measures to avoid a relapse of hypertension.

Treatment: The DASH Diet

Dietary changes can help control blood pressure. One diet designed to promote lower blood pressure is known as the DASH diet. This stands for Dietary Approaches to Stop Hypertension. The DASH diet recommends eating more vegetables, fruits, whole grains, low-fat dairy products, poultry, nuts, and fish. Red meat, saturated fats, and sweets should be avoided. It can also help to reduce your intake of sodium.

Treatment: Exercise

Exercise is another lifestyle factor that can lower blood pressure. It’s recommended that adults get about 150 minutes per week of moderate exercise. This can include activities like walking, bicycling, gardening, or other aerobic exercise. Muscle-strengthening activities are recommended at least twice a week.

Treatment: Diuretics

If diet and exercise are not sufficient to lower blood pressure, the first medications recommended are often diuretics or so-called "water pills." These reduce sodium and fluid levels in the body to lower blood pressure. Taking diuretics means you will urinate more frequently. Sometimes, diuretics deplete potassium levels as well, which can lead to muscle weakness, leg cramps, and tiredness. Other side effects of diuretics can include elevated blood sugars in people with diabetes. Less commonly, erectile dysfunction can occur.

Treatment: Beta-blockers

Beta-blockers are another drug used to treat hypertension. They work by slowing the heart rate and thereby decreasing the workload of the heart. They can be used to treat other conditions as well, including abnormal heart rate (arrhythmia). Side effects of beta-blockers can include dizziness, insomnia, fatigue, cold feet and hands, and erectile dysfunction.

Treatment: ACE Inhibitors

ACE (angiotensin converting enzyme) inhibitors are another class of antihypertensive drugs. They reduce the body’s levels of angiotensin II, a substance that narrows blood vessels. This means that arteries are more open (dilated) and the blood pressure is lower. Side effects of ACE inhibitors can include skin rash, dry cough, dizziness, and elevated potassium levels. Women taking ACE inhibitors should not become pregnant.

Treatment: ARBs

Instead of lowering angiotensin II levels, a related class of drugs called ARBs or angiotensin receptor blockers prevents the actions of angiotensin II on the arteries. This means the arteries stay more open and blood pressure is lowered. ARBs can take a few weeks to work. Side effects can include dizziness, muscle cramps, insomnia, and elevated potassium levels. As with ACE inhibitors, women taking ARBs should not become pregnant.

Treatment: Calcium Channel Blockers

Calcium channel blockers are drugs that reduce the movement of calcium into cells of the heart and vessels. This reduces the strength of heart contractions and relaxes the arteries, allowing them to remain more open, lowering blood pressure. Side effects of calcium channel blockers can include heart palpitations, dizziness, swollen ankles, and constipation. They should be taken with food or milk. Because of potential interactions, those taking calcium channel blockers should avoid alcohol and grapefruit juice.

Treatment: Other Medications

There are even more medication types that can lower blood pressure. Some of these are alpha blockers, vasodilators, and central alpha agonists. Your doctor may prescribe these medications if other medications have been ineffective or if you have another condition along with hypertension. Side effects can include fast pulse, palpitations, diarrhea, or headaches.

Treatment: Complementary Therapies

It has been shown that meditation and other relaxation techniques can help lower blood pressure. Yoga, tai chi, and breathing exercises can also help reduce blood pressure. It’s best when these are combined with changes in diet and exercise. Tell your doctor if you are taking any herbal remedies, since some of these preparations can actually raise blood pressure or interact with your blood pressure medications.

How can hypertension be prevented?

Hypertension can best be prevented by adjusting your lifestyle so that proper diet and exercise are key components. It is important to maintain a healthy weight, reduce salt intake, reduce alcohol intake, and reduce stress.

In order to prevent damage to critical organs and conditions such as stroke, heart attack, and kidney failure that may be caused by high blood pressure, it is important to screen, diagnose, treat, and control hyper tension in its earliest stages. This can also be accomplished by increasing public awareness and increasing the frequency of screenings for the condition.

CONCLUSION

Hypertension, also referred to as high blood pressure. Blood pressure between 120/80 and 139/89 is called prehypertension (to denote increased risk of hypertension), and a blood pressure of 140/90 or above is considered hypertension. High blood pressure is more common in older people. At age 45, more men have hypertension than women.Though the exact causes of hypertension are usually unknown, there are several factors that have been highly associated with the condition

Hypertension may be classified as essential or secondary . There is no guarantee that a person with hypertension will present any symptoms of the condition. About 33% of people actually do not know that they have high blood pressure, and this ignorance can last for years.

High blood pressure may be treated medically, by changing lifestyle factors

Hypertension can best be prevented by adjusting your lifestyle so that proper diet and exercise are key components. It is important to maintain a healthy weight, reduce salt intake, reduce alcohol intake, and reduce

REFERENCE

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