High blood pressure can be defined as a sustained lift of systemic arterial force per unit area more than 140/90 mmHg. In normal healthy person, arterial force per unit area is ranged around 100-140/70-90 mmHg. Hypertension is a often happening abnormalcy in worlds. It can be caused by many diseases and most normally due to increased peripheral opposition. It leads to many serious upsets and it is the major cause of premature vascular diseases.
High blood pressure can be graded as follows harmonizing to its badness. In grade 1, mild high blood pressure, blood force per unit area is around 140-159/90-99. In grade 2, moderate high blood pressure, it is about 160-179/100-109 and in grade 3 terrible high blood pressure ?180/ ?109 ( 2 ) .
High blood pressure is discussed under two major classs harmonizing to the cause, indispensable or primary and secondary high blood pressure. In bulk of instances ( 88 % ) , cause of the elevated blood force per unit area is unknown. It may be a consequence of a combination of causes. It can be treatable, but non curable. Secondary high blood pressure is caused due to an identifiable and potentially treatable.
Causes of high blood pressure
Essential high blood pressure: –
Low birth weight
Environmental factors – fleshiness, intoxicant consumption, increased Na consumption, emphasis
Secondary high blood pressure: –
80 % of instances are caused by nephritic diseases such as diabetic kidney disease, chronic glomerulonephritis, grownup polycystic disease, chronic tubulointerstitial Bright’s disease, renovascular disease, etc.
Hormone causes – Conn ‘s syndrome, adrenal hyperplasia, phaeochromocytma, Cushing ‘s syndrome, acromegalia
Congenital cardiovascular diseases – constriction of aorta
Drugs – preventive pills, steroids, sympathomimetics, antidiuretic hormone
Treatment of high blood pressure
Many sorts of interventions are used to pull off high blood pressure. The intervention should be chosen harmonizing to the cause and besides to the age, sex, cultural beginning and physiological position of the patient. Both pharmacological and non pharmacological therapies are used. Hypertensive patients excepting terrible or malignant hypertensive 1s, should be treated after a period of appraisal with repeated blood force per unit area measurings ( 2 ) . It should be combined with advice and non pharmacological therapy.
Pharmacological intervention: –
Several groups of drugs are used to this type of intervention. Those can be used as one drug therapy or as drug combinations. Using drug combinations is more effectual than the other in most of the instances. Diuretic drugs, ? Adrenergic receptor blockers, Angiotensin II receptor adversaries, Angiotensin Converting Enzyme ( ACE ) inhibitors, Renin inhibitors, Calcium channel blockers, ? Blockers, Vasodilators and centrally moving drugs are the chief categories of drugs that used to handle high blood pressure. This therapy should be based on following guidelines.
What are the phases that hypertensive therapy should be started,
Drug therapy should be initiate topics with sustained systolic blood force per unit area ? 160 or sustained diastolic blood force per unit area ? 100 mmHg.
Persons with sustained systolic blood force per unit area 140-150 or sustained diastolic blood force per unit area 90-99 mmHg who have a hazard of mark organ harm or a 10 old ages cardiovascular disease hazard & A ; gt ; 20 % .
Start therapy for topics with systolic blood force per unit area sustained ? 140 or diastolic blood force per unit area sustained ? 90 mmHg associated with diabetes mellitus.
Targets of blood force per unit area decrease,
For most patients, a mark of ?140/85 mmHg is recommended. For patients with diabetes mellitus, nephritic damage or cardiovascular disease, a lower mark of ?130/80 mmHg is recommended.
Nature of drug therapy,
Most of the hypertensive patients require a combination of drugs to accomplish recommended marks. In most patients therapy with lipid-lowering medicines and acetylsalicylic acid is added to cut down the overall cardiovascular hazard. Harmonizing to the degree of blood force per unit area decrease following intervention, patient should be recommended to give particular drug therapies. But this specific drug therapy should be made merely after a careful period of appraisal of about 6 months with repeated blood force per unit area measurings.
Make consciousness of patients,
Patient should be explained about the purpose of the intervention that is to cut down the hazard of complications of high blood pressure and about the alterations of drugs. They should be given under the understanding of the patient. It is of import to cognize that all of the drugs used for intervention have side effects. And besides the consequences of the drug intervention are non instantly looking 1s. ( 2 )
Diuretic drugs ;
Diuretic drugs have prompt natriuretic consequence ( 3 ) , which increases the elimination of Na salts in the piss. Through this contraction of plasma and extracellular fluid ( ECF ) occur. Thiazide water pills and some cringle agents act as mild carbonaceous anhydrase inhibitors ensuing cut down formation of HCO3_ . And besides they cut down resorption of Na+ , HCO3_ , Cl_ and H2O in proximal convoluted tubule of uriniferous tubule.
20 % of Na+ resorption occurs in Loop of Henle. Loop water pills inhibit this action. Some agents inhibit the active conveyance of Cl_ ions at the go uping limb of Henle cringle. Some water pills competitively bind to aldosterone receptors in distal convoluted tubule and suppress the action of aldosterone on increasing permeableness to Na+ in that tubule. As this they cut down plasma Na+ concentration ensuing lessening in fluid volume. This contraction of plasma and ECF volume causes a decrease of preload on the bosom. It may do decrease of cardiac end product and arterial force per unit area. In this instance blood force per unit area is reduced without altering entire peripheral opposition. These drugs besides cut down the hazard of shot.
Angiotensin II receptor adversaries ;
These drugs selectively block the receptors for angiotonin II ( 2 ) . Angiotensin II is a powerful vasoconstrictive ( 1,2 ) and it besides stimulates increased secernment of aldosterone by adrenal cerebral mantle. Aldosterone increase the permeableness to Na+ in distal convoluted tubule and roll uping tubule and cause Na+ and H2O keeping. It increases unstable volume ensuing addition in blood force per unit area. It mediates those actions by adhering to specific membrane edge receptors. There are two types of receptors, AT1 and AT2. AT1 is responsible for major action on Renin Angiotensin System ( RAS ) ( 4 ) . These drugs include peptide parallels and besides antibodies of angiotonin II. Through them they block the receptor adhering action of it, ensuing suppression of its action. These effects are independent of age and sex. Action of drugs is potentiated by negative salt balance and attenuated by positive salt balance.
Angiotensin Converting Enzyme ( ACE ) inhibitors ;
These drugs block the transition of angiotonin I to angiotensin II. It mediates RAS as above description. So, barricading its synthesis those actions are inhibited and may take down the blood force per unit area. And besides they block the debasement of bradykinin ( 2 ) . It is a powerful vasodilative ( 2 ) . By distending vass it help to cut down blood force per unit area.
Renin inhibitors ;
These drugs straight inhibit the plasma renin activity. Renin is released from kidney in response to lessening of nephritic perfusion force per unit area and contribute to increase blood force per unit area by exciting the transition of angiotensinogen to angiotensin I. By suppressing this reaction RAS is interrupted cut downing arterial force per unit area occurs.
Beta adrenoceptor blockers ;
Blood force per unit area cut downing action of these drugs is depended on diminishing entire peripheral opposition and cardiac end product. Using ?1 selective adversaries is more effectual than non-selective drugs ( 5 ) . They target ?1 sympathomimetic receptor messenger RNA with antisense oligodeoxynucleotides ( ?1-AS-ODN ) . Main mechanism is to cut down motorial sympathetic activity underlying lessening in plasma noradrenaline degree. Decrease of sympathetic activity significantly decreases cardiac contractility exposing a negative inotropic consequence ( 1 ) . Harmonizing to Starling ‘s jurisprudence of the bosom, force of contraction is relative to stroke volume. When the contractility is reduced stroke volume and cardiac end product lessening. As this blood force per unit area lowers. As a 2nd mechanism they inhibit RAS to bring forth sustained antihypertensive consequence. Newer ? barricading drugs besides cut down blood force per unit area through NO mediated vasodilatation.
Calcium channel blockers ;
They efficaciously cut down blood force per unit area by arteriolar distension and some agents besides cut down the force of cardiac contraction. Ca2+ and Ca channels are more of import in contraction of cardiac musculus. Contraction occurs due to motion of actin and myosin fibrils ( 1 ) . When action possible spreads to cardiac musculus membrane, Ca channels are opened. Large sums of Ca2+ release from cross tubules and ECF. They diffuse into sarcostyles and bind to troponin c. It consequences in exposing of adhering sites for myosin caputs on actin. Myosin caputs bind to actin and power shot occur doing cardiac contraction. When these drugs block the Ca2+ channels, let go ofing Ca2+ is reduced. Above mechanism slows and force of contraction reduces. It may do lessening in cardiac end product and blood force per unit area.
L/N type Ca channel blockers inhibit aldosterone production which induced by angiotonin II.
Alpha blockers ;
? sympathomimetic receptors are present in peripheral vascular system and besides in Central Nervous System ( CNS ) . All in vascular system are innervated by sympathetic nervous system. These agents block postsynaptic ?1 receptors. Sympathetic activity causes peripheral vasoconstriction. By barricading them, this action is reduced and blood force per unit area take downing occurs. But of import thing is that ? receptors in CNS have opposing action. So, by barricading them increase in blood force per unit area may happen. Because of that selective vascular ? adrenoceptor blockers should be used. ( 3 )
Other vasodilatives ;
These drugs act straight on vascular smooth musculus and loosen up them without part of cell receptors. By loosen uping smooth musculus, vasodilatation occurs. This reduces entire peripheral opposition and venous return to the bosom is reduced through it. As this, lowers the blood force per unit area. This antihypertensive consequence is independent from the sympathetic tone.
Some vasodilating agents inhibit sympathetic nervous signals to the kidneys or barricade the action of sympathetic sender substance on nephritic vasculature. These drugs besides straight relax the smooth musculus of nephritic vasculature and through it block the RAS. ( 3 )
Centrally moving drugs ;
These drugs act by cardinal ordinance of sympathetic nervous system.
Using drug combinations ;
Majority of hypertensive patients need at least two drugs to command blood force per unit area under the degree of 140/90 mmHg. Better combinations of antihypertensive drugs use agents from different categories with different primary actions. So, that hypotensive effects are obtained by usage of low doses. By combination of drugs we can detect greater blood force per unit area decreases than single-channel drug therapy. It may do fewer side effects than one drug therapy because of utilizing little doses of two drugs. Improved coherence to intervention and therapy can be taken in low cost are the other advantages of drug combination. Normally utilizing combinations are water pills and ? blockers, ACE inhibitors and angiotonin II receptor adversaries and every bit good as ACE inhibitors and Ca channel blockers.
Management of terrible or malignant high blood pressure ;
Treatment should originate instantly for patients who have terrible high blood pressure, malignant high blood pressure or patients with terrible hypertensive complications such as cardiac failure. But it is non recommended to cut down blood force per unit area excessively quickly because it may do intellectual, nephritic and retinal harm and myocardial infarction. Blood force per unit area response to those therapies must be carefully conducted. In most instances the intervention is aimed to cut down the diastolic blood force per unit area to 100-110 over 24 hours. It can be normalized over 2-3 yearss merely with unwritten medicine. But in really terrible instances rapid control of blood force per unit area is required. Intravenous Na nitroprusside is used to such types of interventions. ( 2 )
Management of high blood pressure in gestation ;
Though cardiac end product is increased in gestation, greater autumn in entire peripheral opposition occurs. So, blood force per unit area is reduced than normal. But in 8-10 % of pregnant adult females are reported as gestation induced hypertensive patients. Pre- eclampsia is a syndrome consisting of gestation induced high blood pressure and albuminuria. Decrease of uteroplacental circulation causes high blood pressure ( 2 ) . Placental ischemia leads to disfunction of maternal vascular endothelium that consequence in increased formation of endothelin and thromboxane and increased in vascular sensitiveness to angiotensin II. And besides causes decreased formation of vasodilatives such as NO and prostacyclin. Maternal blood volume is about 30 % above normal. This increases during latter half of gestation. Increasing aldosterone and oestrogen cause increased unstable keeping by kidneys ( 6 ) . And besides bone marrow produces excess ruddy blood cells ( 6 ) . Those things cause unstable overload in gestation may take to high blood pressure.
Many antihypertensive drugs are contraindicated in gestation. When blood force per unit area is increased to & A ; gt ; 160/110 mmHg, intervention is responsible for protection of the female parent. Labetalol and alpha methyl dopas are safety utilizing drugs for mild high blood pressure. Pre-eclamsic high blood pressure can be treated by same agents or Procardia. More terrible high blood pressure or eclampsic high blood pressure require endovenous Apresoline and may necessitate expiration of gestation ( 2 ) .
Non pharmacological intervention: –
Non pharmacological intervention of high blood pressure is used to all hypertensive patients and marginal hypertensive. Lifestyle alteration through weight decrease, attention of dietetic consumption, cut downing smoke and intoxicant ingestion and dynamic exercising is aid to forestall the hazard of high blood pressure.
Weight decrease ;
As the first measure of lifestyle alteration is aimed at increasing physical activity and weight decrease in more patients. Obesity is a major cause for indispensable high blood pressure. Cardiac end product is increased because of excess demand of blood flow to the excess adipose tissue in corpulent 1s ( 6 ) . And besides endocrines like leptin that are secreted from fat cells may excite hypothalamus ensuing stimulation of Vasomotor Centre ( VMC ) ( 6 ) . It may do increased activity of sympathetic nervous system in fleshy patients. It increases the activity of RAS. These things cause addition in blood force per unit area. By weight decrease, sum of excess adipose tissue is reduced and above mechanisms are lowered. Controling Body Mass index ( BMI ) & A ; lt ; 25kg/m2 ( 2 ) may bespeak a healthy person.
During exercising blood force per unit area rises by several mechanisms such as addition in sympathetic activity, cardiac end product and bosom rate. As this blood force per unit area rises as immediate consequence of exercising. But as a long term consequence blood force per unit area is reduced by exercising. Aerobic exercising that is intended to increase O ingestion is recommended for take downing blood force per unit area in hypertensive patients. Antihypertensive effects of exercising are mediated through several mechanisms.
NO degree is increased by exercising. It plays a major function in modulating vascular tone and antiatherosclerotic effects. NO is produced by vascular endothelial cells. It is a powerful vasodilative metabolite. Plasma NO2_ and NO3_ concentration addition significantly by aerophilic exercising. And besides cGMP concentration which helps to bring forth NO is increased. As this NO additions and vasodilatation occurs. This causes decrease of vascular opposition and so decrease of blood force per unit area. NO is sensitive to inactivation of superoxide groups. Relationship between blood force per unit area take downing consequence and NO bioactivity remains unknown.
Exercise needs high degree of energy. So, inordinate adipose tissue that accumulates in corpulent 1s is used to derive energy. It helps to cut down fleshiness. Because of the decrease of adipose tissue, demand of blood flow to them is reduced. This helps to take down cardiac end product and blood force per unit area.
Body temperature rises during exercising. To modulate the organic structure temperature, compensatory mechanisms are activated. They increase heat loss by increasing airing, radiation, distension of tegument blood vass and sudating vasodilatation decreases peripheral opposition and diminishing blood force per unit area occurs. By sudating, loss of organic structure fluids includes H2O and electrolytes such as Na+ are increased. It causes decrease of blood volume and blood force per unit area. As this exercising benefits low blood force per unit area for hypertensive patients.
Dietary control ;
Taking a controlled diet is used in non pharmacological therapy in high blood pressure. Reducing consumption of entire fat, saturated fat and salt in diet and taking veggies, fruits, K and fish oil included diet is recommended for hypertensive patients. In add-on to that high consumptions of vitamin D, protein, aminic acid, tea, dark cocoa and nutrients high in NO3_ aid to cut down blood force per unit area.
Entire fat, saturated fat and unsaturated fat –
Dietary fat specially unsaturated fatty acids have an consequence of increasing go arounding lipoproteins. They increase the degree of Low Density Lipoprotein ( LDL ) . They may do increased hazard of fleshiness and coronary artery disease. They besides increase arterial stiffness and cause oxidative emphasis. Those things contribute to increase blood force per unit area. So cut downing intake those things help to cut down blood force per unit area. Unsaturated fatty acids which are in fish oil besides contribute to cut down blood force per unit area.
Vegetables, fruits –
Oxidative emphasis, which is known as bioavailability of Reactive Oxygen Species ( ROS ) causes high blood pressure. It is due to extra ROS coevals, decreased NO production and decreased antioxidant capacity in cardiovascular, nephritic and nervous systems. It amplifies blood force per unit area lift in the presence of other prohypertensive factors. Major beginning of cardiovascular ROS is household of non phagocytic NADPH oxidase and AT1 receptors. Antioxidants prevent those free groups. Increase ingestion of antioxidants such as vitamin C, E……… . aid to forestall oxidative emphasis and diminish the hazard of high blood pressure. Vegetables and fruits which include those things cut down the degree of ROS. And besides antioxidants decrease degree of entire cholesterin, triglycerides, LDL, VLDL and they increase HDL and NO degrees. These things cut down the hazard of coronary artery disease and high blood pressure.
Salt intake –
Excessive salt intake can do lift of arterial force per unit area chiefly by increasing Extracellular Fluid ( ECF ) volume. Though pure H2O is excreted by kidney every bit quickly as it is taken, salt is non excreted easy. Excessive salt accretion of the organic structure increases ECF volume by two basic causes.
Osmolality ( osmoles per kilogram ) is increased because of extra salt. And besides it stimulates the Centre in the encephalon doing the individual to imbibe excess sum of H2O to rectify the Na+ concentration in ECF to normal. This increases the ECF volume ( 6 ) .
Addition in osmolality besides stimulates the hypothalamic posterior pituitary secretory organ secretary mechanism to release increased sum of antidiuretic endocrine. It stimulates the kidney to resorb greater measure of H2O from nephritic cannular fluid ( 6 ) . By this, volume that excretes as piss is diminished and ECF volume is increased.
As this sum of salt that accumulate in the organic structure is the major component that determines the ECF volume. A small addition in ECF and blood volume can greatly increase the arterial force per unit area. So, even a little sum of excess salt in the diet can take to important addition in arterial force per unit area. So, hypertensive patients are recommended to take diet with low salt content & A ; lt ; 6g NaCl per twenty-four hours ( 2 ) .
Reduce smoke ;
Chronic smoke and secondhand fume exposure are major hazard factors of cardiovascular disease. Substances in baccy and coffin nail fume adversely change the structural and mechanical belongingss of arterias ( 7 ) . Structural characteristics such as wall thickness and functional characteristics as NO production and bioactivity and endothelin 1 degrees may be altered ( 7 ) . Smoke reduces NO bioactivity as a consequence of oxidative emphasis. These things acutely increase arterial stiffness ( 7 ) . Complaisance of the arterias is reduced and hard to distend. Entire peripheral opposition is increased and besides bosom is reduced during smoke. This consequences increase in cardiac end product and blood force per unit area. So, halting smoking benefits more healthy life than tobacco users.
Reducing intoxicant ingestion ;
Excessive consumption of intoxicant can take to high blood pressure. Excessive intoxicant causes arterial stiffness. And besides it has psychological effects that lead to increase in blood force per unit area. So, cut downing consumption of intoxicant benefits decrease of blood force per unit area.
High blood pressure may caused by many causings and it may do many serious upsets. Treatment of high blood pressure is based on age, sex, cultural beginning and physiological position. Both pharmacological and non pharmacological therapies are used to interventions. Pharmacological therapy is conducted by utilizing one drug or drug combinations. But the job is all antihypertensive drugs may do side effects. Non pharmacological therapy is used with the association of drug therapy. Weight decreases, dietetic control, cut down smoke and intoxicant ingestion aid to decrease the hazard of high blood pressure.