Dr Narender Goel MD (Internal Medicine and Nephrology) Financial Disclosure: None, Conflict of Interest: None

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1 Dr Narender Goel MD (Internal Medicine and Nephrology) Financial Disclosure: None, Conflict of Interest: None 12 th December 2013, New York Visit us at: What is Blood pressure? While heart contracts blood is pumped in to major arteries. Thereby a pressure in exerted on vessel wall which is also known as systolic blood pressure; represented by upper number in a blood pressure reading. While heart relaxes, volume of blood present in the circulation exerts pressure on vessel wall which is also known as diastolic blood pressure; represented by lower number in a blood pressure reading. What is Hypertension? High blood pressure also known as hypertension (HTN) is very common in western countries. It is estimated that one in every 3 adult person in the United States has HTN. Blood pressure is checked manually using sphygmomanometer or using electronic machines. Most instruments use arm or wrist cuff. HTN is defined as blood pressure 140/90 mmhg (measured at rest) measured over 3 consecutive visits. What are stages of HTN? 7 th Joint national committee has proposed and revised stages of HTN in 2003 Normotension: BP <120/80 mmhg

2 Prehypertension: BP / mmhg HTN Stage I: BP /90-99 mmhg HTN Stage II: BP 160/100 mmhg Why it is important to be aware about HTN? It is a very common condition in western adult population, patients with chronic kidney disease, end-stage renal disease on dialysis or kidney transplantation. It is 2 nd most common cause of end-stage renal disease. HTN is also significantly associated with stroke, peripheral vascular disease, congestive heart failure, heart attack and death. Patients often don t feel any symptoms from HTN unless BP is very high which can cause headache, chest pain, shortness of breath; which could be signs of life threatening complications. Untreated and undiagnosed HTN is detrimental to health and early intervention can reduce the risk of associated complications (KNOW YOUR BLOOD PRESSURE). What are the causes of HTN? It is not very clear that what causes hypertension. It appears that multiple factors contribute to development of HTN such as genetic predisposition; impaired handling of sodium and chloride by kidney and environmental factors, sedentary lifestyle and aging further contributes. Chronic kidney disease, excess hormones, over the counter and herbal medications containing mahuang, ephedra, amphetamines, pseudoephedrine and licorice (mulethi) can cause HTN. Substance abuse with cocaine, amphetamines can also cause high blood pressure. What are the tests usually done for patients with HTN? Your doctor will first attempt to identify any reversible or curable causes of HTN such as hormonal excess which can be evaluated using several different blood tests.

3 Besides urinalysis, complete blood count, kidney function test and electrolytes should be routinely checked. Eye examination (fundoscopy) can suggest extent of HTN damage. Electrocardiogram and echocardiogram may show changes of HTN on heart. How can HTN be managed? First step is lifestyle modifications which include weight loss, exercise (for 30 minutes for 5 times per week), smoking cessation, moderation of alcohol consumption and low sodium (salt) diet [2 gram sodium]. DASH (dietary approach to stop hypertension) is known to be the best dietary regimen to reduce blood pressure. Components of DASH diet are 1) Low fat/cholesterol 2) Diet rich in fiber, vegetables, whole grains and low fat dairy products Learn more about DASH diet at U.S Department of Health and Human Services. What are different classes of medications which can be used? There are several classes of medications which can be used to control blood pressure. It is very common for patients to need 2-3 medications to control blood pressure. Compliance to medication and low salt diet is of utmost importance. Taking medications at bedtime instead of in morning has been shown to achieve better blood pressure control. Choice of medication will depend upon clinical status, level of kidney function, electrolytes and other medical conditions. 1) ACE Inhibitors: There are several medications belonging to this class such as ramipril, lisinopril, fosinopril, captopril etc. (note: all name ends in pril). These are very good and effective antihypertensive medications and often a leading choice medication.

4 Major adverse effects are as follows: rise in serum potassium, dry cough, temporary & slight decrease in kidney function, serious allergic reaction causing tongue and lip swelling (angioedema). You must stop ACE Inhibitors and immediately report to healthcare provider if you develop angioedema. 2) Angiotensin receptor blockers (ARB): There are several medications belonging to this class such as valsartan, telmisartan, losartan, olmesartan etc. (note: all name ends in sartan). These are very good and effective antihypertensive medications and often a leading choice medication along with ACE Inhibitors. Major adverse effects are as follows: rise in serum potassium, temporary & slight decrease in kidney function, serious allergic reaction causing tongue and lip swelling (angioedema). You must stop ARB and immediately report to healthcare provider if you develop angioedema. Combination of ACE Inhibitors and ARB is harmful and should be avoided. 3) Diuretics or water pill: These medications help your kidney to excrete excess water and salt in to the urine. Hydrochlorothiazide (HCTZ), furosemide (Lasix), metolazone, triamterene, spironolactone and amiloride are commonly used medications. Discuss individual medication adverse effects with your doctor. 4) Calcium Channel Blockers (CCB): Commonly used medications among this class are amlodipine (Norvasc), nifedipine XL, diltiazem and verapamil. These are also among preferred class of prescribed antihypertensive.

5 Amlodipine can cause ankle swelling while diltiazem and verapamil can slow down your heart. CCBs tend to cause constipation. Discuss individual medication adverse effects with your doctor. 5) Beta blockers: Commonly used medications among this class are atenolol, metoprolol (Lopressor, Toprol XL), carvedilol, nevibolol, bisoprolol (note: all name ends in olol). This class is commonly prescribed for patients with heart failure or coronary artery disease. It is suggested that this class of medication be used with caution in patients with asthma, peripheral vascular disease or diabetics. 6) Clonidine, Hydralazine and minoxidil are less commonly used medications It would be helpful to have some information about these medications as it will enable you to have an informed discussion with your healthcare providers. Disclosure and Disclaimer: This is a Not for profit website and not endorsed by any other society, institution or organization. We do not receive any funding from any sources for this website. All information provided herein is either a personal opinion or from other education resources. Views expressed here are personal and not of any institution or employer. Views expressed here shall not replace your physicians opinion. Articles, commentaries and other opinion expressed here may not have formal peer review hence users are recommended to use the information at their own discretion. We do not take any responsibility for any adverse event following opinion expressed here or on other websites connected via links provided herein and will not be liable under any circumstance. We do not take any responsibility or endorse any information provided on the websites connected via links provided herein, for their accuracy, completeness, content, data or any product. We do not receive any financial or economic incentive from links to website provided. By clicking on links, you leave our website and enter another website. This site should not be used as a medical advice source but merely as an information resource. Patients or families should get any advice from their medical professional. We do not recommend posting any patient related protected or identifiable health information on this public website. Information provided here is as an educational resource and shall not be used to violate any law of copyrights or privacy.