Hoy es el día más hermoso de nuestra vida, querido Sancho; los obstáculos más grandes, nuestras propias indecisiones; nuestro enemigo más fuerte, el miedo al poderoso y a nosotros mismos; la cosa más fácil, equivocarnos; la más destructiva, la mentira y el egoísmo; la peor derrota, el desaliento; los defectos más peligrosos, la soberbia y el rencor; las sensaciones más gratas, la buena conciencia, el esfuerzo para ser mejores sin ser perfectos, y sobretodo, la disposición para hacer el bien y combatir la injusticia dondequiera que esté.

Don Quijote de la Mancha.

11 de agosto de 2015

Hypertension (A review)

Sep 30, 2014

Hypertension affects approximately 75 million adults in the United States and is a major risk factor for stroke, myocardial infarction, vascular disease, and chronic kidney disease. See the image below.
Anteroposterior x-ray from a 28-year old woman who

Anteroposterior x-ray from a 28-year old woman who presented with congestive heart failure secondary to her chronic hypertension, or high blood pressure. The enlarged cardiac silhouette on this image is due to congestive heart failure due to the effects of chronic high blood pressure on the left ventricle. The heart then becomes enlarged, and fluid accumulates in the lungs, known as pulmonary congestion.

Signs and symptoms

Hypertension is defined as a systolic blood pressure (SBP) of 140 mm Hg or more, or a diastolic blood pressure (DBP) of 90 mm Hg or more, or taking antihypertensive medication.[2]
Based on recommendations of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the classification of BP for adults aged 18 years or older has been as follows[3] :
  • Normal: Systolic lower than 120 mm Hg, diastolic lower than 80 mm Hg
  • Prehypertension: Systolic 120-139 mm Hg, diastolic 80-89 mm Hg
  • Stage 1: Systolic 140-159 mm Hg, diastolic 90-99 mm Hg
  • Stage 2: Systolic 160 mm Hg or greater, diastolic 100 mm Hg or greater
Hypertension may be primary, which may develop as a result of environmental or genetic causes, or secondary, which has multiple etiologies, including renal, vascular, and endocrine causes. Primary or essential hypertension accounts for 90-95% of adult cases, and secondary hypertension accounts for 2-10% of cases.
See Clinical Presentation for more detail.

Patients may have undiagnosed hypertension for years without having had their BP checked. Therefore, a careful history of end-organ damage should be obtained. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) identifies the following as targets of end-organ damage[3] :
  • Heart: left ventricular hypertrophy, angina/previous myocardial infarction, previous coronary revascularization, and heart failure
  • Brain: stroke or transient ischemic attack, dementia
  • Chronic kidney disease
  • Peripheral arterial disease
  • Retinopathy
The JNC 7 identifies the following as major cardiovascular risk factors[3] :
  • Hypertension: component of metabolic syndrome
  • Tobacco use, particularly cigarettes, including chewing tobacco
  • Elevated LDL cholesterol (or total cholesterol ≥240 mg/dL) or low HDL cholesterol: component of metabolic syndrome
  • Diabetes mellitus: component of metabolic syndrome
  • Obesity (BMI ≥30 kg/m 2): component of metabolic syndrome
  • Age greater than 55 years for men or greater than 65 years for women: increased risk begins at the respective ages; the Adult Treatment Panel III used earlier age cut points to suggest the need for earlier action
  • Estimated glomerular filtration rate less than 60 mL/min
  • Microalbuminuria
  • Family history of premature cardiovascular disease (men < 55 years; women < 65 years)
  • Lack of exercise


The evaluation of hypertension involves accurately measuring the patient’s blood pressure, performing a focused medical history and physical examination, and obtaining results of routine laboratory studies.[3, 4] A 12-lead electrocardiogram should also be obtained. These steps can help determine the following[3, 4, 5] :
  • Presence of end-organ disease
  • Possible causes of hypertension
  • Cardiovascular risk factors
  • Baseline values for judging biochemical effects of therapy
Other studies may be obtained on the basis of clinical findings or in individuals with suspected secondary hypertension and/or evidence of target-organ disease, such as CBC, chest radiograph, uric acid, and urine microalbumin.[3]
See Workup for more detail.


Many guidelines exist for the management of hypertension. Most groups, including the JNC, the American Diabetes Associate (ADA), and the American Heart Association/American Stroke Association (AHA/ASA) recommend lifestyle modification as the first step in managing hypertension.
Lifestyle modifications
JNC 7 recommendations to lower BP and decrease cardiovascular disease risk include the following, with greater results achieved when 2 or more lifestyle modifications are combined[3] :
  • Weight loss (range of approximate systolic BP reduction [SBP], 5-20 mm Hg per 10 kg)
  • Limit alcohol intake to no more than 1 oz (30 mL) of ethanol per day for men or 0.5 oz (15 mL) of ethanol per day for women and people of lighter weight (range of approximate SBP reduction, 2-4 mm Hg)
  • Reduce sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride; range of approximate SBP reduction, 2-8 mm Hg) [6]
  • Maintain adequate intake of dietary potassium (approximately 90 mmol/day)
  • Maintain adequate intake of dietary calcium and magnesium for general health
  • Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health
  • Engage in aerobic exercise at least 30 minutes daily for most days (range of approximate SBP reduction, 4-9 mm Hg)
The AHA/ASA recommends a diet that is low in sodium, is high in potassium, and promotes the consumption of fruits, vegetables, and low-fat dairy products for reducing BP and lowering the risk of stroke. Other recommendations include increasing physical activity (30 minutes or more of moderate intensity activity on a daily basis) and losing weight (for overweight and obese persons).
webmd.ads2.defineAd({id:'ads-pos-420',pos: 420}); The 2013 European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) guidelines recommend a low-sodium diet (limited to 5 to 6 g per day) as well as reducing body-mass index (BMI) to 25 kg/m2 and waist circumference (to < 102 cm in men and < 88 cm in women).[7, 8]
Pharmacologic therapy
If lifestyle modifications are insufficient to achieve the goal BP, there are several drug options for treating and managing hypertension. Thiazide diuretics are the preferred agents in the absence of compelling indications.[3]
Compelling indications may include high-risk conditions such as heart failure, ischemic heart disease, chronic kidney disease, and recurrent stroke, or those conditions commonly associated with hypertension, including diabetes and high coronary disease risk. Drug intolerability or contraindications may also be factors.[3]

An angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB), calcium channel blocker (CCB), and beta-blocker are all acceptable alternative agents in such compelling cases.
The following are drug class recommendations for compelling indications based on various clinical trials[3] :
  • Heart failure: Diuretic, beta-blocker, ACE inhibitor, ARB, aldosterone antagonist
  • Postmyocardial infarction: Beta-blocker, ACE inhibitor, aldosterone antagonist
  • High coronary disease risk: Diuretic, beta-blocker, ACE inhibitor, CCB
  • Diabetes: Diuretic, beta-blocker, ACE inhibitor, ARB, CCB
  • Chronic kidney disease: ACE inhibitor, ARB
  • Recurrent stroke prevention: Diuretic, ACE inhibitor
See Treatment and Medication for more detail.



Recommendations of the new ESH and ESC guidelines include[7, 8] :
  • In patients younger than 80 years, the systolic BP target should be 140 to 150 mm Hg, but physicians can go lower than 140 mm Hg if the patient is fit and healthy; the same advice applies to octogenarians—however, the patient's mental capacity and physical heath should also be considered if targeting to less than 140 mm Hg
  • Patients with diabetes should be treated to below 85 mm Hg diastolic BP
  • Salt intake should be limited to approximately 5 to 6 g per day
  • Body-mass index (BMI) should be reduced to 25 kg/m 2 and waist circumferences should be reduced to less than 102 cm in men and less than 88 cm in women
  • Ambulatory BP monitoring (ABPM) should be incorporated into the assessment of risk
  • Effective combination therapies include thiazide diuretics with ARBs, calcium-channel antagonists, or ACE inhibitors; or, calcium-channel antagonists with ARBs or ACE inhibitors
  • Dual renin-angiotensin system blockade (ie, ARBs, ACE inhibitors, and direct renin inhibitors) is not recommended because of the risks of hyperkalemia, low BP, and kidney failure
  • Although additional data is needed, renal denervation is a promising therapy in the treatment of resistant hypertension

ADA 2011 standard of medical care

The ADA 2011 standard of medical care states that in individuals with diabetes and mild hypertension, it may be reasonable to begin treatment with a trial of nonpharmacologic therapy (diet, exercise, and other lifestyle modifications.) Mild hypertension as defined by the ADA guideline (systolic BP 130-139 mm Hg or diastolic BP 80-89 mm Hg) may be classified as prehypertension by other organizations.[61]
pos-420',pos: 420}); The ADA 2011 standards of medical care in diabetes also indicate that a majority of patients with diabetes mellitus have hypertension. In patients with type 1 diabetes, nephropathy is often the cause of hypertension, whereas in type 2 diabetes, hypertension is one of a group of related cardiometabolic factors.[61, 62] Hypertension remains one of the most common causes of congestive heart failure (CHF). Antihypertensive therapy has been demonstrated to significantly reduce the risk of death from stroke and coronary artery disease.
Other studies have demonstrated that a reduction in BP may result in improved renal function. Therefore, earlier detection of hypertensive nephrosclerosis (using means to detect microalbuminuria) and aggressive therapeutic interventions (particularly with ACE inhibitor drugs) may prevent progression to end-stage renal disease.[12]


Key messages of the JNC 7 were as follows[3] :
  • The goals of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality, with the focus on controlling the systolic BP, as most patients will achieve diastolic BP control when the systolic BP is achieved
  • Prehypertension (systolic 120-139 mm Hg, diastolic 80-89 mm Hg) requires health-promoting lifestyle modifications to prevent the progressive rise in BP and cardiovascular disease
  • In uncomplicated hypertension, a thiazide diuretic, either alone or combined with drugs from other classes, should be used for the pharmacologic treatment of most cases
  • In specific high-risk conditions, there are compelling indications for the use of other antihypertensive drug classes (eg, angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], beta blockers, calcium channel blockers)
  • Two or more antihypertensive medications will be required to achieve goal BP (< 140/90 mm Hg or < 130/80 mm Hg) for patients with diabetes and chronic kidney disease
  • For patients whose BP is more than 20 mm Hg above the systolic BP goal or more than 10 mm Hg above the diastolic BP goal, initiation of therapy using 2 agents, one of which usually will be a thiazide diuretic, should be considered
  • Regardless of therapy or care, hypertension will be controlled only if patients are motivated to stay on their treatment plan

Lifestyle modifications

Lifestyle modifications are essential for the prevention of high BP, and these are generally the initial steps in managing hypertension. As the cardiovascular disease risk factors are assessed in individuals with hypertension, pay attention to the lifestyles that favorably affect BP level and reduce overall cardiovascular disease risk. A relatively small reduction in BP may affect the incidence of cardiovascular disease on a population basis. A decrease in BP of 2 mm Hg reduces the risk of stroke by 15% and the risk of coronary artery disease by 6% in a given population. In addition, a prospective study showed a reduction of 5 mm Hg in the nocturnal mean BP and a possibly significant (17%) reduction in future adverse cardiovascular events if at least one antihypertensive medication is taken at bedtime.

Surgical intervention

Aortorenal bypass using a saphenous vein graft or a hypogastric artery is a revascularization technique for renovascular hypertension that has become much less common since the advent of renal artery angioplasty with stenting. Surgical resection is the treatment of choice for pheochromocytoma and for patients with a unilateral solitary aldosterone-producing adenoma, because hypertension is cured by tumor resection. In patients with fibromuscular renal disease, angioplasty has a 60-80% success rate for improvement or cure of hypertension. A promising therapy for resistant hypertension is renal denervation via a percutaneous approach. This catheter-based intervention is currently in the clinical trial phase.


Consultations with a nutritionist and exercise specialist are often helpful in changing lifestyle and initiating weight loss. Consultations with an appropriate consultant are indicated for management of secondary hypertension attributable to a specific cause.
Next Section: Nonpharmacologic Therapy



Drugs such as angiotensin converting enzyme (ACE) inhibitors, calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs), beta-blockers, and diuretics are all considered acceptable alternative therapies in patients with hypertension.

Diuretics, Thiazide


Diuretic, Potassium-Sparing


Diuretics, Loop


ACE Inhibitors (Angiotensin converting enzyme)


ARBs (angiotensin receptor blockers)


Beta-Blockers, Beta-1 Selective


Beta-Blockers, Alpha Activity


Beta-Blockers, Intrinsic Sympathomimetic


Calcium Channel Blockers


Aldosterone Antagonists, Selective


Alpha2-agonists, Central-acting


Renin Inhibitors/Combos


Alpha-Blockers, Antihypertensives


Antihypertensives, Other


Antihypertensive Combinations


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