Hypertension, also referred to as arterial hypertension or high blood pressure, refers to a chronic bodily condition characterized by the constant elevated blood pressure in the arteries. The disease is always asymptomatic during its onset. If the condition persists for a long time, then it predisposes one to the risk of developing other fatal conditions, such as stroke, hypertensive heart disease, aneurysm, peripheral heart disease, coronary heart disease, and chronic kidney disease (Scisney-Matlock et al., 2009).
Hypertension has been identified under the Healthy People 2020 Objective as a condition that should be managed effectively. According to this health objective, there is a need to reduce the prevalence of the condition to as low as 10%, particularly in children and adolescents (Demede et al., 2011). However, there is no comprehensive and universal guideline to guide the management of the disease. This paper aims to analyze all the published literature on hypertension management strategies in order to develop comprehensive, current, and universal guidelines on how to manage the condition. An all-inclusive overview of the disease pathophysiology will also be provided because understanding disease progression is fundamental to the development of management strategies.
Hypertension is described as a disease of the vascular regulatory system, which occurs due to a malfunction in one of the control mechanisms of arterial pressure, such as the central nervous system, extracellular fluid volume control system, or the renin-angiotensin-aldosterone system. There is still no clear explanation of the exact pathophysiology of the condition. Multiple factors play a role in the regulation of blood pressure; therefore, it is believed that hypertension results when there is a failure in one of these regulatory systems. However, it is still not possible to single out a particular factor as a confirmed cause of the condition. For instance, a small proportion of hypertension patients, between 2 and 5%, always have adrenal or renal infection as the underlying causes of the condition. However, even in such patients, no single cause can be identified, and the disease is eventually termed as essential hypertension (Demede et al., 2011).
It is also thought that interrelated factors play a significant role in the onset of hypertension. However, the role played by each of the factors is unknown, and may differ between different patients. Obesity and consumption of salt are thought to increase the risk of hypertension. Persons who have insulin resistance are also at a higher risk of getting the disease. A faulty renin-angiotensin system equally predisposes one to the development of hypertension. Other factors implicated in the onset of hypertension include genetics, low birth weight, endothelial malfunction, neurovascular abnormalities, and intrauterine nutrition (Demede et al., 2011). The primary physiological mechanisms involved in the development of hypertension include, peripheral resistance to blood flow, cardiac output, autoimmune nervous system, rennin-angiotensin-aldosterone system, and other factors, such as endothelin, bradykinin, nitric acid or endothelial derived relaxing factor (EDRF), quabain, and atrial natriuretic peptide (ANP) (Jonovich & Bisognano, 2009).
Adequate maintenance of blood pressure depends wholly on the balance between the cardiac output and the resistance to blood flow in the periphery. Persons suffering from essential hypertension present with normal cardiac output. Instead, it is the peripheral resistance in the blood vessels that is high (Demede et al., 2011). Some studies have shown that some children and adolescents who suffer from pre-hypertension have a raised heart rate, elevated cardiac output, but normal peripheral resistance; a condition referred to as hyperkinetic borderline hypertension. Persons suffering from this condition have been shown to develop essential hypertension in adulthood, given that peripheral resistance to blood flow usually increases with age (Jonovich & Bisognano, 2009).
Anatomically narrow arterioles are seen in cases of high peripheral resistance in hypertension that is established. The narrowing can result from multiple factors, such as over the deposition of fat molecules in the arterial walls. In elderly people, the raised arterial resistance is associated with arterial stiffness, which typically accompanies aging (James et al., 2013). Apart from arteriole factors, hypertension is also brought by a reduction in the compliance of the peripheral nervous system. This may eventually result in elevated cardiac preload, raised venous return, and eventual diastolic malfunction (Demede et al., 2011).
Diagnosis mainly entails measuring the levels of blood pressure in mmHg. The following values are then used to determine the hypertension status:
Normal Blood Pressure: One is considered normal if the pressure in below 120/80 mmHg. However, levels of 115/75 mmHg are preferred. Any pressure beyond this value puts one at risk of developing cardiovascular disease.
Pre-hypertension: One is considered pre-hypertensive when the systolic pressure continuously ranges between 120 and 139 mmHg, while the diastolic pressure ranges between 80 and 89 mmHg.
Stage 1 Hypertension: It is characterized by a systolic pressure of between 140 and 159 mmHg and a diastolic pressure of between 90 and 99 mmHg.
Stage 2 Hypertension: Hypertension is classified as stage 2 when the systolic pressures attain 160 mmHg and above, while diastolic pressure is at 100 mmHg and above (Jonovich & Bisognano, 2009).
The risk of one developing hypertension increases with age due to physiological changes that accompany aging. Aging is associated with sclerosis and hypertrophy of muscular arterioles and arteries, loss of elasticity of the blood vessels, and elevated atherosclerotic disease of the arteries. A combination of these factors results in the stiffening of the arteriole walls and increased pressure. Aging is also associated with increased renal and total vascular resistance and a reduction in plasma renin activities. The ability of one’s kidneys to excrete salts also decreases with an increase in age. A combination of these factors increases the risk of developing hypertension in old age (Logan, 2011).
Genetic Issues and Hypertension
Several studies have shown that genetic factors contribute to the development of hypertension. On some occasions, a single gene or genetic factors have been shown to result in primary hypertension. However, it has been suggested that a combination of various genetic factors or genes play different roles in the onset of hypertension in any given individual (Rana et al., 2007). However, it is very difficult and almost impossible to isolate the individual genes responsible for the disease and distinguish the role each of the genes play. Specific mutations, though very rare, can result in hypertension, even in the absence of other predisposing factors, such as the Liddle’s syndrome (Lifton, Gharavi & Geller, 2001).
The percentage of hypertension that has been shown to result from a monogenic mechanism is relatively small. In most cases, the disease has been shown to result from a combination of various genetic and physiological factors that play a complex role in the onset of the disease. Efforts to isolate and characterize genes or genetic factors responsible for hypertension have been fruitless (Rana et al. 2007). Furthermore, some genes that have been linked to the onset of hypertension have been shown to have antihypertensive effects, such as in Gitelman’s syndrome. For these reasons, the association of genetics and hypertension has not been fully described. Researchers have argued that, probably, genetic factors exert their effect on other physiological parameters, which play a primary role in the onset of hypertension (Taal et al., 2012).
Literature Search Strategy
A thorough literature search was conducted to retrieve the relevant sources that formed part of the information to be analyzed, from which a guideline was developed. A two-step literature search strategy was employed in order to get as much literature as possible. The first step entailed an electronic literature search to retrieve any data available online. The online database search included searching the Medline database, as well as the PubMed database. A further online literature search was performed by the aid of available search engines, such as Google Scholar using the following keywords: Hypertension management strategies, pathophysiology of hypertension, current management strategies for hypertension, global guidelines for the management of hypertension, and prevention, control, and treatment of hypertension.
After searching the literature electronically, a manual literature search was performed in the library to identify any relevant material that may have been missed during the online search process. The manual search was conducted with the aid of the library catalog. All the retrieved literature was then subjected to the inclusion and exclusion criteria to ensure that only relevant literature was included in the analysis. For a research paper to be included in the analysis, it had to be published less than seven years ago. It must have analyzed at least one or compared at least two hypertension management strategies. The retrieved paper also ought to have used human subjects only as the study participants. Finally, the advocacy and recommendation for a particular guideline or strategy should only have been based on scientific work and not personal feelings at any level. Once the literature was retrieved, a comparison of the various management strategies evaluated by different researchers was done, and a single comprehensive guideline for managing hypertension was developed.
Prevalence and Obstacles to Effective Management
Hypertension is ranked as a major co-morbidity worldwide. Heart failure, a major syndrome that results from hypertension, is one of the significant causes of morbidity and mortality worldwide. There is a strong link between hypertension and numerous health conditions that are of public health importance. Both hypertension and its associated heart failure are described as progressive diseases. Globally, their prevalence is also very high (Demede et al., 2011). For instance, in the United States of America (USA), the prevalence of hypertension between the years of 2005 and 2008 was 30.9% among adults aged above 18 years, with the peak prevalence being 69.7% among persons aged above 65 years. The prevalence also seems to vary with race, as the prevalence was higher in non-Hispanic blacks, who had a prevalence rate of 44%. However, the genetic factors determining the hypertension race discrimination is not known (Roger et al., 2011).
The overall and effective management of the condition is also very expensive. For instance, the US spends approximately $93.5b annually to manage hypertension. Furthermore, the US spends approximately 17% of its entire health expenditure on the management of stroke and other cardiovascular diseases primarily caused by stroke. Although the treatment of hypertension has been described, the majority of the patients affected are not aware of this fact, most go untreated, and those who are privileged to access treatment are not treated adequately (Roger et al., 2011).
The ineffective treatment of hypertension occurs primarily due to the lack of a unified and comprehensive treatment approach, with most clinicians being at crossroads on which strategy to employ. The fact that the etiology of hypertension is not clearly known also contributes to the ineffective management of the condition. In most cases, the disease does not present at all, with identifiable symptoms only manifesting at a later, critical stage (Demede et al., 2011).
Risk factors that predispose one to hypertension have been identified and can help in designing the best management strategies. Such factors include being a black, old age, overweight, familial history of the disease, having sleep apnea, and smoking of cigarettes, diabetes mellitus, and a living sedentary type of lifestyle. Hypertension is sometimes as a ‘silent killer’ because clear symptoms do not accompany the onset of this disease. Resultantly, there is a need to develop a proper and effective methodology for the diagnosis and management of the condition (Ehret et al., 2011).
Hypertension can be managed effectively. Effective management of hypertension has also been shown to reduce the incidence of heart disease onset by up to 50%. Several advances have been made recently regarding the management of the condition. Efforts have been geared towards creating public awareness of the condition and effective control of blood pressure. Treatment mainly involves two strategies; lifestyle modification and the use of therapeutic agents. Some researchers argue that lifestyle changes are sufficient to control effectively the condition, while other scholars advocate the use of drugs. Several clinical trials have demonstrated that specific categories of therapeutic agents are sufficient to control effectively the disease (Palatini & Julius, 2009).
Abandoning a sedentary lifestyle is an effective way of lowering blood pressure, which eventually leads to reduced chances of having a cardiovascular condition. It also enhances the efficacy of therapeutic agents that the patient is using. Lifestyle changes have been identified in a long-term strategy for mitigating hypertension. Weight reduction is vital in managing hypertension, as weight loss has been shown to reduce effectively cases of hypertension by almost 21% (Scisney-Matlock et al., 2009). Dietary modification that has been shown to be effective in the management of hypertension includes reducing the intake of saturated fats, low consumption of salts, such as sodium, magnesium, and potassium, reduced alcohol intake, and cessation of cigarette smoking (Scisney-Matlock et al., 2009).
Lifestyle intervention has been shown to be very effective if it is combined with thorough education and adequate training. Recurrent cardiac adverse events have been shown to reduce after regular and aerobic exercises on a daily basis. Regular exercise has been shown to reduce incidences of over-accumulation of fats in the blood vessels, a fundamental factor in the control of hypertension. However, even in developing and designing such lifestyle modifications for a particular population, research has shown that strategies that are culturally oriented are effective in the disease control, as they pay attention to the specific needs of a particular population (Scisney-Matlock et al., 2009).
Even with lifestyle modifications, some patients need to be given therapeutic agents to control their levels of hypertension. The drugs used to control this condition are mainly referred to as antihypertensive drugs, which are grouped in different categories. Studies have shown that effective treatment is achieved when the drug of choice is selected after a thorough analysis of the status of the patient classification of the patient into a given disease stage, and the possibility of the drug reducing the mortality or rate of hospitalization for that particular patient (James et al., 2013). Most studies have identified a low dosage of diuretics as the first-line treatment option for hypertension and other cardiovascular diseases. The clinical outcome is similar to that of Angiotensin Converting Enzyme Inhibitors (ACEI) and calcium channel blockers (Demede et al., 2011).
The use of diuretics is limited due to their side effects, such as urecemia and electrolyte abnormalities, particularly in Africans. However, the drugs’ effectiveness can be improved when used in combination with other drugs, such as neurohormonal blockade whenever there is a justifiable cause. Beta blockers have recently been placed under scrutiny regarding their effectiveness. Nevertheless, beta-blockers are used in combination with the ACEIs if the patient has reached stage B and C hypertension. The use of drugs that act as aldosterone antagonists can be helpful in such circumstances. Studies have provided sufficient evidence for the use of ACEIs in all hypertensive patients. If the ACEIs are not bearable, then drugs that compete for the angiotensin receptors, also known as ARBs, should be considered. Beta Blockers (BB) have also been shown to be effective in reducing mortality and morbidity in hypertension, as well as improving hypertension symptoms (Demede et al., 2011).
Treatment of the Disease
From the analysis of the retrieved literature, it is clear that several drugs are available for the management of hypertension. However, there are varying guidelines on which drug of choice to use for a particular hypertensive patient. From the data, I recommend that lifestyle modifications and dietary changes be adopted as the primary management strategy for long term management of hypertension. People should adopt healthy lifestyles, including regular physical exercises and reducing saturated fat and salt intake to lower the incidences of overweight and obesity, which are vital predisposing factors in hypertension.
For patients who are diagnosed with hypertension, the primary medication should entail diuretics because the drugs have been proven to be effective; they produce the desired clinical outcome in most of the patients. The resulting side effects are also manageable. The ACEIs should be considered where diuretics are not effective. However, such a choice should be based on a comprehensive analysis of the patient, including identifying the stage of infection, cultural differences, and the underlying risk factors. Any other drugs, such as the BB, calcium channel blockers, aldosterone blockers and ARB, should only be used if the patient cannot tolerate the ACEIs and after a careful evaluation of the patient.
Referral and Follow Up
The patient should be referred for specialized and patient-specific treatment if the above measures or strategies fail to achieve their goal. Special attention should be accorded to patients below the age of 40 years who are suffering from Stage 1 hypertension, yet without associated organ damage. This specialized evaluation will help provide a comprehensive assessment of the risk of developing cardiovascular diseases, as well as exclude other secondary causes of hypertension. Referral should be made if the patient is in need of urgent specialized treatment due to severe hypertension and other impending complications. After treatment, follow-up should be made mainly to evaluate the patient’s response to treatment, adherence to the treatment regime, and adoption of healthy living. The follow-up can be done three months after discharge from hospital, and then six months until the patient attains stability.
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Ehret, G. B., Munroe, P. B., Rice, K. M., Bochud, M… & Johnson A. D. et al. (2011). Genetic variants in novel pathways influence blood pressure and cardiovascular disease risk. Nature, 478(7367), 103-109.
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