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By Lahle Wolfe

Sources

Wikipedia.com

High Blood Pressure and Kidney Disease from The National Kidney and Urologic Diseases Information Clearinghouse

Patient UK.com


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A vegetable-rich diet can help to reduce blood pressure, researchers say.
 
BCC News, January 10, 2006


Hypertension & Women

(LifeClinic.com Links)

Does menopause affect blood pressure?

Do oral contraceptives raise blood pressure?

High blood pressure and bone weakening.

High Blood Pressure Isn't Well Controlled in Older Women.


Symptoms of High Blood Pressure

(LifeClinic.com Links)

How do I know when my blood pressure is high?

What are the symptoms of high blood pressure?


Headaches & High Blood Pressure

(LifeClinic.com Links)

Is Headache Related to Increases of Blood Pressure?

Study Proves Headaches Are Not Related to Blood Pressure


Measuring High Blood Pressure

(LifeClinic.com Links)

What are Korotkoff sounds?

What is an electrocardiogram?

Do You Have 'White Coat Hypertension'?


Stress & High Blood Pressure

(LifeClinic.com Links)

Panic attacks more common in people with high blood pressure.

Does stress cause hypertension?

'Fight or flight' response raises blood pressure -- even while you're asleep


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More Links

The Framingham Heart Study

Information on ALLHAT

A guide to lowering high blood pressure from the National Heart, Lung, and Blood Institute

The DASH diet from the National Heart, Lung, and Blood Institute

High Blood Pressure (from the American Heart Association)

High Blood Pressure from MedlinePlus

 

Diabetes Medical Library                     back to main "Complications" page
Diabetes Complications

High Blood Pressure (Hypertension) and Diabetes
Risks, Causes, Treatment & Prevention


Mini Site Index
What is blood pressure?
-- Systolic Pressure
-- Diastolic Pressure
What is normal blood pressure?
(Chart) Blood Pressure Values
What do the numbers mean?
Signs and Symptoms
Causes  (Etiology & Pathophysiology)
Complications and Emergencies
Diabetes and High Blood Pressure
Pregnancy
When is hypertension diagnosed?
Distinguishing Between Primary vs. Secondary Hypertension
Treatment - Lifestyle Modifications and Medication
Epidemiology and Prevalence

What is Blood Pressure?

The heart pumps blood throughout the body in vessels called arteries.  Blood pressure is the measure of how much force (or pressure) pushes against the walls of your arteries.  

There are two numbers used to measure blood pressure, systolic and diastolic pressure.  They will be shown as one number over another, with the systolic number always listed first.  For example, the number 120/80 would mean:

(Systolic Pressure) 120   over    (Diastolic Pressure) 80


Systolic Pressure

This measures how much pressure is put on atery walls when the heart pumps (the most pressure is present when the heart pumps.)  The average, normal heart rate is 60-70 pumps per minute when a person is at rest.  


Diastolic Pressure

This measures how much pressure is put on the arteries when the heart rests between beats.  Your pressure will fall briefly in between each heart beat.  


What is normal blood pressure for nondiabetics?

It is normal for blood pressure to fluctuate a little through the night and day.  For example, it is lowest when you sleep and rises when you get up.  It also can rise when you are excited, nervous, or active, and certain medications can either increase or decrease blood pressure.

But for most of your waking hours, your blood pressure stays pretty much the same when you are sitting or standing still. A normal blood pressure level would be lower than 120/80.  When the level stays high (140/90 or higher), you have high blood pressure.

High blood pressure makes the heart work harder and your arteries take a beating.  High blood pressure (hypertension) increases your chances of a stroke, heart attack, and kidney problems.

Blood Pressure Values

Classification

Systolic
(top number)

Diastolic
(bottom number)

Normal

Less than 120

Less than 80

Prehypertension

120-139

80-89

Hypertension Stage 1

140-159

90-99

Hypertension Stage 2

160 or higher

100 or higher

 

   


What do the Numbers Mean?

If you have diabetes without kidney problems the usual target is to reduce blood pressure to 140/80 mmHg or below. Some experts advise the target should be even lower at 130/80 mmHg or below. Your own doctor will advise on what target you should aim for.

If you have a complication of diabetes called diabetic nephropathy (kidney damage) - The target is then to reduce blood pressure even lower - to 135/75 mmHg or below. Again, some experts would advise even lower, to 130/75 mmHg or below. Your own doctor will advise what target you should aim for.

For people with diabetes:

  • Mildly high blood pressure is above the target level, but below 160/100 mmHg.
     
  • Moderate to severe high blood pressure is 160/100 mmHg or above.

High blood pressure can also be:

  • just a high systolic pressure, for example, 170/70 mmHg.
  • just a high diastolic pressure, for example, 128/104 mmHg.
  • or both, for example, 170/110 mmHg.

Note: it can be confusing as the definition of high blood pressure in the general population is 140/90 mmHg or above. However, for people with diabetes, bringing blood pressure down to the lower target levels described above is beneficial to reduce the increased health risks associated with diabetes.

   


Signs and Symptoms of Hypertension

Hypertension is usually found incidentally - "case finding" by healthcare professionals. It normally produces no symptoms but sometimes may evidence in malignant hypertension (or accelerated hypertension, a late stage 2 in the condition) and may present with headaches, blurred vision, and end-organ damage.

Hypertension is often confused with mental tension, stress and anxiety.  While chronic anxiety is associated with poor outcomes in people with hypertension, it alone does not cause it.  

   


Causes of Hypertension

Essential hypertension

  • Age. Over time, the number of collagen fibres in artery and arteriole walls increases, making blood vessels stiffer. With the reduced elasticity comes a smaller cross-sectional area in systole, and so a raised mean arterial blood pressure.
  • High salt intake
  • Sedentarylifestyle
  • Tobacco smoking
  • Alcohol abuse
  • High levels of saturated fat in the diet
  • Obesity. In obese subjects, losing a kilogram of mass generally reduces blood pressure by 2 mmHg.
  • Stress
  • Low birth-weight
  • Diabetes mellitus
  • Various genetic causes

Secondary hypertension

Main article: Secondary hypertension

While most forms of hypertension have no known underlying cause (and are thus known as "essential hypertension" or "primary hypertension", in about 5% of the cases, there is a known cause, and thus the hypertension is secondary hypertension.

Pathophysiology

The mechanisms behind the factors associated with inessential hypertension are generally fully understood, and are outlined at secondary hypertension. However, those associated with essential hypertension are far less understood. What is known is that cardiac output is raised early in the disease course, with total peripheral resistance normal; over time cardiac output drops to normal levels but TPR is increased. Three theories have been proposed to explain this:

  • Inability of the kidneys to excrete sodium, resulting in natriuretic factor (note: the existence of this substance is theoretical) being secreted to promote salt excretion with the side-effect of raising total peripheral resistance.
     
  • An overactive renin / angiotension system leads to vasoconstriction and retention of sodium and water. The increase in blood volume leads to hypertension.
     
  • An overactive sympathetic nervous system, leading to increased stress responses.  

   


Complications and Emergencies

Emergencies

Hypertension is rarely severe enough to cause symptoms. These only surface with a systolic blood pressure over 240 mmHg and/or a diastolic blood pressure over 120 mmHg. These pressures without signs of end-organ damage (such as renal failure) are termed accelerated hypertension. When end-organ damage is possible or already ongoing, but in absence of raised intracranial pressure, it is called hypertensive emergency. Hypertension under this circumstance needs to be controlled, but prolonged hospitalization is not necessarily required. When hypertension causes increased intracranial pressure, it is called malignant hypertension. Increased intracranial pressure causes papilledema, which is visible on ophthalmoscopic examination of the retina.

Complications

While elevated blood pressure alone is not an illness, it often requires treatment due to its short- and long-term effects on many organs. The risk is increased for:

  • Cerebrovascular accident (CVAs or strokes)
  • Myocardial infarction (heart attack)
  • Hypertensive cardiomyopathy (heart failure due to chronically high blood pressure)
  • Hypertensive retinopathy - damage to the retina (people with hypertension, especially when retinopathy is present, may not be able to perform pressure-related exercise like weight lifting)
  • Hypertensive nephropathy - chronic renal failure due to chronically high blood pressure  

   


Diabetes and Hypertension

If you have diabetes you should try to keep your blood pressure below certain levels to reduce the risk of developing complications of diabetes such as heart disease, stroke, and eye problems. As a rule, the higher the pressure, the greater the health risk. Treatment of high blood pressure includes a change in lifestyle factors where these can be improved - losing weight if you are overweight, regular exercise, a healthy diet, drinking alcohol in moderation, and a low salt intake. If needed, medication can lower blood pressure

Diabetes kidney disease may cause hypertension.  A complication which develops in some people with diabetes is called diabetic nephropathy. In this condition the kidneys are damaged which can cause high blood pressure. This is more common in people with type 1 diabetes.  

Note: it can be confusing as the definition of high blood pressure in the general population is 140/90 mmHg or above. However, for people with diabetes, bringing blood pressure down to the lower target levels described above is beneficial to reduce the increased health risks associated with diabetes.

For people with diabetes:

  • Mildly high blood pressure is above the target level, but below 160/100 mmHg.
     
  • Moderate to severe high blood pressure is 160/100 mmHg or above.

High blood pressure can also be:

  • just a high systolic pressure, for example, 170/70 mmHg.
  • just a high diastolic pressure, for example, 128/104 mmHg.
  • or both, for example, 170/110 mmHg.

   


Pregnancy

See the main article: hypertension of pregnancy

Although few women of childbearing age have high blood pressure, up to 10% develop hypertension of pregnancy. While generally benign, it may herald three complications of pregnancy: pre-eclampsia, HELLP syndrome and eclampsia. Follow-up and control with medication is therefore often necessary.  

   


Diagnosing Hypertension

You are said to have 'high blood pressure' (hypertension) if you have several blood pressure readings which are high, and which are taken on different occasions, and when you are relaxed.

How is high blood pressure diagnosed?

A one-time blood pressure reading which is high does not mean that you have high blood pressure. Your blood pressure varies throughout the day. It may be high for a short time if you are anxious, stressed, or have just been exercising.  In patients with diabetes mellitus or kidney disease studies have shown that blood pressure over 130/80 mmHg should be considered a risk factor and may warrant treatment.  Hypertension is usually diagnosed on finding blood pressure of 140/90 mmHg or above, measured on both arms on three occasions over a few weeks.

Measuring Blood Pressure

Obtaining reliable blood pressure measurements relies on following several rules and being cognizant of the many factors that influence blood pressure reading.  For example, measurements should be at least 1 hour after caffeine, 30 minutes after smoking and without any stress. Cuff size is also important. The cuff bladder should encircle and cover two-thirds of the length of the arm. The patient should be sitting for a minimum of five minutes. The patient should not be on any adrenergic stimulants, such as those found in many cold medications.

When taking manual measurements, the person taking the measurement should be careful to inflate the cuff at least 30 mmHg greater than systolic pressure. A stethoscope should be placed lightly over the brachial artery. The arm should be at the level of the heart and the cuff should be deflated at a rate of 2 to 3 mmHg/s. Systolic pressure is the pressure reading at the onset of the sounds described by Korotkoff (Phase one). Diastolic pressure is then defined as the pressure at which the sounds disappear (K5) or sometimes the K4 point, where the sound is abruptly muffled. Two measurements should be made at least 5 minutes apart and if there is a discrepancy of more than 5 mmHg, a third reading should be done. The readings should then be averaged. An initial measurement should include both arms. Also, in elderly patients, it is recommended to measure pressures in multiple postures as they are at risk for orthostatic hypotension (low blood pressure).

   


Distinguishing Primary vs. Secondary Hypertension

Once the diagnosis of hypertension has been made it is important to attempt to exclude or identify reversible (secondary) causes.

Diabetes kidney disease may causes hypertension.  A complication which develops in some people with diabetes is called diabetic nephropathy. In this condition the kidneys are damaged which can cause high blood pressure. This is more common in people with type 1 diabetes.

Rarely, high blood pressure is caused by other conditions.  It is then called 'secondary hypertension'. For example, certain kidney or hormone problems can cause high blood pressure.

  • Essential/Primary Hypertension.  Over 90% of adult hypertension has no clear cause and is therefore called essential/primary hypertension. Often, it is part of the metabolic "syndrome X" in patients with insulin resistance: it occurs in combination with diabetes mellitus (type 2), combined hyperlipidemia and central obesity.
     
  • Secondary Hypertension.  In hypertensive children most cases are secondary hypertension, and the cause should be pursued diligently.

Blood Tests Commonly Performed in a Newly Diagnosed Hypertension Patient

  • Creatinine (renal function)
  • Electrolytes ( sodium, potassium)
  • Glucose (to identify diabetes mellitus)
  • Cholesterol  

   


Treatment for Hypertension

Lifestyle Modification

Mild hypertension is usually treated by diet, exercise, and quitting smoking (if you smoke).  A diet rich in fruits and vegetables and fat-free dairy foods and low in fat and sodium can lower blood pressure in people with hypertension. Dietary sodium (salt) causes hypertension in some people and reducing salt intake decreases blood pressure in a third of people.

IOH Health Tip:  Regular mild exercise improves blood flow, and helps to lower blood pressure.

Things you can do to Lower High Blood Pressure

Lose weight if you are overweight.  Losing some excess weight can make a big difference. Blood pressure can fall by up to 2.5/1.5 mmHg for each excess kilogram which is lost. Losing excess weight has other health benefits too.

Exercise regularly.  If possible, aim to do some exercise on five or more days of the week, for at least 30 minutes. For example, brisk walking, swimming, cycling, dancing, etc. Regular exercise can lower blood pressure in addition to giving other health benefits. If you previously did little exercise, and change to doing regular exercise five times a week, it can reduce systolic blood pressure by 2-10 mmHg.

Limit Salt Intake.  The amount of salt that we eat can have an effect on our blood pressure. Government guidelines recommend that we should have no more than 5-6 grams of salt per day. (Most people currently have more than this because salt is hidden in many pre-packaged and prepared foods.)

Tips on how to reduce salt include:

  • Use herbs and spices to flavour food rather than salt.
  • Limit the amount of salt used in cooking, and do not add salt to food at the table.
  • Choose foods labelled 'no added salt', and avoid processed foods as much as possible.

Follow a Healthy Diabetes-Friendly Diet

If you have diabetes you will normally be given a lot of advice about a healthy diet that may include advice such as:

  • Have at least 5 portions, and ideally 7-9 portions, of a variety of fruit and vegetables per day.
  • Most of your meals should be starch-based foods (such as cereals, wholegrain bread, potatoes, rice, pasta), plus fruit and vegetables.
  • Limit fatty food such as fatty meats, cheeses, full-cream milk, fried food, butter, etc. Use low fat, mono-, or poly-unsaturated spreads.
  • Include 2-3 portions of fish per week. At least one of which should be 'oily' such as herring, mackerel, sardines, kippers, pilchards, salmon, or fresh (not tinned) tuna.
  • If you eat meat it is best to eat lean meat, or poultry such as chicken.
  • If you do fry, choose a vegetable oil such as sunflower, rapeseed or olive oil.
  • Keep your diet low in salt.

A healthy diet provides health benefits in different ways and if you have diabetes you should follow the advice of a registered dietitian who understands the unique dietary needs for a person with diabetes and high blood pressure.  A healthy diet can lower cholesterol and control your weight.  Your diet, as recommended by a health professional, should include vitamins, fiber, and other nutrients which help to prevent certain diseases.

Some aspects of a healthy diet also directly affect blood pressure. For example, if you have a poor diet and change to a diet which is low-fat, low-salt, and high in fruit and vegetables, it can lower systolic blood pressure by up to 11 mmHg.

Medications

There are many classes of medications for treating hypertension, together called antihypertensives, which—by varying means—act by lowering blood pressure. Evidence suggests that reduction of the blood pressure by 5-6 mmHg can decrease the risk of stroke by 40%, of coronary heart disease by 15-20%, and reduces the likelihood of dementia, heart failure, and mortality from vascular disease.

Which type of medication to use initially for hypertension has been the subject of several large studies. The JNC7 (The Seventh Report of the Joint National Committee on Prevention of Detection, Evaluation and Treatment of High Blood Pressure) recommends starting with a thiazide diuretic if single therapy is being initiated and another medication is not indicated. This is based on a slightly better outcome for chlorothiazide in the ALLHAT study versus other anti-hypertensives and because thiazide diuretics are relatively cheap. Another large study (ANBP2) published after the JNC7 did not show this small difference in outcome and actually showed a slightly better outcome for ACE-inhibitors.

Physicians may start with non-thiazide antihypertensive medications if there is a compelling reason to do so. An example is the use of ACE-inhibitors in diabetic patients as they have been shown to both reduce blood pressure and prevent diabetic nephropathy (kidney problems). In patients with coronary artery disease or a history of a heart attack, beta blockers and ACE-inhibitors both lower blood pressure and protect heart muscle over a lifetime, leading to reduced mortality.

Commonly used drugs include:

  • Beta blockers: eg, metoprolol (Lopressor), atenolol, labetolol, carvedilol (Coreg)
  • ACE inhibitors: eg, lisinopril (Zestril), quinapril,monopril, captopril, enalapril
  • Angiotension receptor blockers (ARBs): eg, losartan (Cozaar), valsartan (Diovan), irbesartan (Avapro)
  • Calcium channel blockers: e.g. amlodipine (Norvasc), verapamil
  • Diuretics: eg, hydrochlorothiazide (also called HCTZ)
  • Combination products (which usually contain HCTZ and one other drug)

The aim of treatment should be blood pressure control (<140/90, lower in certain contexts). Each added drug may reduce the systolic blood pressure by 5-10 mmHg, so often multiple drugs are necessary to achieve blood pressure control.

   


Epidemiology and Prevalence

The level of blood pressure regarded as deleterious has been revised down during years of epidemiological studies. A widely quoted and important series of such studies is the Framingham Heart Study carried out in an American town: Framingham, Massachusetts. The results from Framingham and of similar work in Busselton, Western Australia have been widely applied. To the extent that people are similar this seems reasonable, but there are known to be genetic variations in the most effective drugs for particular sub-populations. Recently (2004) the Framingham figures have been found to overestimate risks for the UK population considerably. The reasons are unclear. Nevertheless the Framingham work has been an important element of UK health policy.

How common is high blood pressure?

In the UK, about half of people over 65, and about 1 in 4 middle aged adults, have high blood pressure. It is less common in younger adults. Most cases are mildly high (up to 160/100 mmHg). However, at least 1 in 20 adults have blood pressure of 160/100 mmHg or above. High blood pressure is more common in people:

  • with diabetes (about 3 in 10 people with type 1 diabetes, and about 7 in 10 people with type 2 diabetes, eventually develop high blood pressure)
  • from African-Caribbean origin.
  • from the Indian sub-continent.
  • with a family history of high blood pressure.
  • with certain lifestyle factors (those who are overweight, eat a lot of salt, don't eat much fruit and vegetables, don't take much exercise, or drink a lot of alcohol).  

   

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Page Updated 03/17/2006