| High blood pressure or hypertension occurs when smaller blood vessels (arterioles) become narrowed, forcing blood to exert excessive pressure against the blood vessel walls and making the heart work harder. Although blood pressure usually varies during the day and often increases as a normal response to stress and physical activity, an individual with hypertension has high blood pressure even at rest. This type of primary or essential high blood pressure does not have a direct cause although it can be influenced by both heredity and certain triggers or risk factors such as obesity, high dietary salt (sodium) intake, tobacco use, high-fat diet, excessive use of alcohol, stressful lifestyle, and lack of exercise. It represents the largest percentage (90%) of hypertension in middle-aged and older individuals. Up to 50% of adults over age 50 may have primary or essential hypertension. Secondary hypertension is the result of another (primary) disorder such as kidney disease or arteriosclerosis, accounting for only 10% of cases. Secondary high blood pressure may be classified as acute if associated with acute renal failure.
Blood pressure is recorded as two numbers. The top number (systolic pressure) represents pressure in the arteries when the heart muscle contracts to pump blood. The bottom number (diastolic pressure) represents pressure in the arteries between heartbeats when the heart is at rest. Hypertension is usually defined as a resting systolic pressure greater than or equal to 140 mm Hg (millimeters of mercury) or resting diastolic pressure greater than or equal to 90 mm Hg. Normal blood pressure is considered below 130/85. Mild hypertension ranges from 140-159/90-99, moderate from 160-179/100-109, and severe from 180-209/110-119. Very severe hypertension is over 210/120. According to current World Health Organization (WHO) guidelines, individuals with kidney disease are considered to have high blood pressure if systolic blood pressure is greater than 125 mm Hg or diastolic blood pressure is greater than 75 mm Hg. In diabetes, diastolic blood pressure over 80 is considered elevated.Risk: Several genetic and environmental or lifestyle factors increase the risk of essential high blood pressure, including obesity, high dietary salt (sodium) intake, tobacco use, high-fat diet, excessive use of alcohol, stressful lifestyle, lack of exercise, anxiety or depression, and living in the southeast region of the US. Essential hypertension may be inherited; specific genetic risk factors include abnormalities in angiotensin-renin genes and inherited abnormalities of the sympathetic nervous system controlling heart rate, blood pressure, and blood vessel diameter. Men and postmenopausal women have a higher risk of developing hypertension. Diabetes also increases the risk of hypertension. Incidence and Prevalence: Hypertension is an extremely common disorder affecting approximately 29% of the US population; 58 million adults have been diagnosed and are taking antihypertensive medication (Schwartz). 90% of all cases of hypertension (essential, primary, or benign) have no obvious cause. Secondary hypertension, a result of another (primary) disorder such as kidney disease or arteriosclerosis, accounts for the remaining 10% of cases. Hypertension occurs 4 times more frequently among blacks than whites at all ages (Schwartz). Blood pressure is known to increase with increasing age; up to 50% of the population over age 50 suffer from primary or essential hypertension. |
Source: Medical Disability Advisor
| History: For most individuals, primary hypertension causes no symptoms for years. Symptoms of severe hypertension or its complications may include headache, dizziness, racing or irregular heartbeat, tiring easily, sexual dysfunction, nosebleeds, chest pain, or shortness of breath. As the disease progresses, damage to the brain, eyes, heart, and kidneys may occur. Family history may reveal high blood pressure, stroke, heart problems, kidney disease, or diabetes. Individuals may present with risk factors for high blood pressure such as tobacco use, salt intake, obesity, sedentary lifestyle, and elevated cholesterol. Medication history may reveal use of medications that elevate blood pressure. Social history may suggest emotional or environmental factors that could affect blood pressure. Physical exam: Because early hypertension does not cause notable symptoms, it is usually detected during a routine physical examination. Once hypertension is suspected, evaluation may include blood pressure readings recorded in both arms, repeated after the individual sits or lies down for five minutes (and at least 30 minutes after smoking or coffee ingestion). If a person has a high reading, blood pressure is immediately measured again, and then twice on at least two other days to make sure the high blood pressure reading is consistent. Readings may need to be repeated at home; some individuals will have elevated blood pressure in the doctor's office because of anxiety (white-coat syndrome). If blood pressure is elevated, the neck veins may be swollen (distended), the thyroid or heart may be enlarged, and heart murmurs may be noted. If characteristic changes in the eyes are evident, the eyes may be further evaluated with an ophthalmoscope. Tests: Laboratory tests are seldom used to diagnose primary hypertension. After hypertension is diagnosed, however, diagnostic testing such as routine blood and urine tests are usually performed to identify or rule out causes of secondary hypertension (diabetes, kidney disease, arteriosclerosis). A chest x-ray and an electrocardiogram may be performed to evaluate heart size and function. A blood test for renin may identify increased production of angiotensin, a chemical that narrows blood vessels. High renin levels may predict heart attacks in white males with high blood pressure. An exercise stress test performed on individuals with borderline elevated pressure may predict risk of enlargement of the left side of the heart (left ventricular hypertrophy). |
Source: Medical Disability Advisor
| Primary hypertension cannot be cured but can be treated to manage the condition and prevent complications. Treatment of hypertension usually follows a progressive (stepped-care) approach; each step being slightly more aggressive than the previous one until blood pressure is controlled.
The first step includes lifestyle modifications such as losing weight (especially in the abdominal area), increasing exercise, moderating alcohol and caffeine intake, stopping smoking, and making dietary changes that include a reduction in salt intake, saturated fat, and cholesterol while increasing consumption of fruits, vegetables, and whole grains. The DASH (Dietary Approaches to Stop Hypertension) diet is low in saturated fat, rich in whole grains, fruits and vegetables, and contains modest amounts of protein, preferably from fish, poultry, low-fat dairy, or soy products. This diet contains more than twice the amounts of potassium, calcium, and magnesium than the average American diet. If blood pressure is not controlled with lifestyle modifications, the individual will proceed to drug therapy in step 2. The individual will be advised to continue lifestyle modifications throughout all steps of therapy. Drug therapy at step 2 usually begins with a thiazide diuretic to remove excess fluid or a beta-blocker (alpha blockers are not considered appropriate initial therapy because of the increased risk for heart failure). Beta-blockers reduce blood pressure by blocking beta-adrenergic substances such as adrenaline, thereby blocking the action of the involuntary nervous system on the heart. The desired result is to slow the heartbeat, reduce the strength of heart muscle contractions, and reduce blood vessel contractions throughout the body. In studies, however, diuresis has proven to have better results as initial therapy than alpha-blockers, ACE inhibitors, or calcium antagonists. If blood pressure is still not adequately controlled at step 2, the individual proceeds to the third step.
In the third step, treatment will involve increasing the drug dosage, substituting a drug in the same class, or switching to a drug in a different class. If blood pressure is still not controlled, the individual proceeds to step 4.
The fourth step involves combination drug therapy, adding a second or third agent to the drug regimen. A diuretic will likely be included, if not already used, or drugs such as vasodilators, alpha-1 antagonists, peripherally acting adrenergic neuron antagonists, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists (ARBs), or calcium channel blockers. |
Source: Medical Disability Advisor
| With appropriate lifestyle changes and the wide variety of drug therapy available, most individuals with high blood pressure can control the condition. However, because hypertension rarely has symptoms and individuals do not feel sick, they may not feel compelled to make lifestyle changes or follow medication regimens (noncompliance). This may lead to further complications from hypertension. The mortality rate from high blood pressure rose 6.8% over the previous 10 years and the actual number of deaths increased by one-third. Among blacks, death occurs in 30% of men and 20% of hypertensive women. |
Source: Medical Disability Advisor
| Although benign high blood pressure may appear to have no cause, elevated blood pressure is always considered a risk for related cardiovascular disease. The principles of aerobic conditioning in physical therapy were used to develop a program for high blood pressure, benign or malignant. Such a rehabilitation program occurs in several phases and follows a progression similar to that of other cardiac diseases.
At the initial rehabilitation stage individuals may be monitored for heart rate and rhythm and blood pressure while performing low-demand aerobic activities that use large muscle groups such as the lower extremities. Initial exercises will include calisthenics of varying intensity like marching in place or raising both arms overhead.
Rehabilitation professionals experienced in cardiac rehabilitation often keep a daily log of the individual's blood pressure, heart rate, and cardiac rhythm. Individuals with significantly high blood pressure are typically tested using electrocardiography (ECG) to record the continuous electrical activity of the heart muscle. Higher levels of exercises are given in addition to recreational activities such as swimming and hiking. Light jogging and cycling are appropriate as long as the individual tolerates the rehabilitation program well.
The later part of the program for benign high blood pressure involves aerobic exercises to increase cardiovascular fitness. These exercises include walking briskly, running, jogging, swimming, climbing stairs, or bicycling. According to the American Heart Association, this type of aerobic activity will help keep high blood pressure under control. Throughout all stages of the rehabilitation program for high blood pressure, the healthcare team monitors the individual closely to assure that the heart rate slowly returns to normal after exercises. |
Source: Medical Disability Advisor
| Obesity significantly increases the risk of hypertension and the rate of its progression and smoking tobacco appears to intensify its effects. Increased blood pressure can damage the inner linings of the arteries leading to atherosclerosis or thickening of the walls of the arteries. This in turn leads to increased hypertension and heart disease as the heart becomes enlarged (hypertrophy).
Complications of untreated hypertension also include injury to vessels in the kidneys, brain, heart, and eyes that may cause kidney failure, stroke, heart failure, and retinopathy (impaired vision due to retinal damage at the back of the eye). High blood pressure indirectly increases the excretion of calcium in the urine that may lead to loss of bone mineral density, osteoporosis, and fractures, especially in elderly women. Sexual dysfunction occurs in 17% of hypertensive men. Long-term (chronic) high blood pressure may lead to decreased memory and mental function in the elderly. Women of childbearing age who have high blood pressure before they become pregnant are at greater risk for pre-eclampsia, a severe and sudden increase in blood pressure during pregnancy that can be very serious for both mother and child. If primary hypertension is untreated, it can lead to malignant hypertension with severe blood pressure elevations that can be life-threatening. |
Source: Medical Disability Advisor
| Work restrictions or special accommodations are not usually required for mild cases of benign primary hypertension. Some individuals, however, may need a less stressful environment. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Does the individual have a family history of hypertension?
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Does the individual smoke, use salt, or have a sedentary lifestyle?
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Is the individual overweight?
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Is the individual's cholesterol elevated?
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Does the individual complain of headache, dizziness, irregular heartbeat, tiring easily, sexual dysfunction, nosebleeds, chest pain, or shortness of breath?
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Are medications or emotional or environmental factors contributing to hypertension?
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Are blood pressure readings elevated consistently?
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Does the individual have distension of neck veins, enlarged thyroid, heart murmur(s), or changes in the eyes?
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Has a urine analysis been done?
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Have blood tests, including a test for renin, which often identifies an increase in the chemical that narrows blood vessels (angiotensin) been done?
Regarding treatment:
- Has the individual attempted to make lifestyle changes?
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Does the individual require assistance such as a weight loss program, counseling with a dietitian, an exercise regimen designed for the individual, or a cease smoking program?
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What drug has the individual taken? Has the dosage been increased?
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Is another drug of the same class required?
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Is a drug in a different class required?
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Is noncompliance with the treatment regimen an issue?
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What second or third drug has been added to the individual's drug regimen?
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Is noncompliance with the treatment regimen an issue?
Regarding prognosis:
- Is the individual adhering to recommended lifestyle changes and to the prescribed drug regimen?
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Does the individual understand the potential risks of untreated hypertension, including heart disease, stroke, kidney disease, and diabetes? If not, would education encourage compliance with recommended treatment?
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Source: Medical Disability Advisor
| Schwartz, Gary L., and Sheldon G. Sheps. "Hypertension." Medscape. 16 Dec. 2004. WebMD Inc. 16 Dec. 2004 <http://www.medscape.com/viewarticle/474790>. |
Source: Medical Disability Advisor
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