Acknowledgement

I wish to express my sincere gratitude to

Mrs.SANTOSH ,for providing me an
opportunity to do my project work on
“HYPERTENSION”.This project bears on
imprint of many peoples. I sincerely thank to
my project guide for guidance and
encouragement in carrying out this project
work. I also wish to express my gratitude to the
officials and other staff members of R.M.S
PUBLIC SCHOOL who rendered their help
during the period of my project work. Last but
not least I wish to avail myself of this
opportunity, express a sense of gratitude and
love to my friends and my beloved parents for
their manual support, strength, help and for
everything.

SHILPA
Certificate
This is to certify that this project has been made
by SHILPA of class XII on the topic
“HYPERTENSION” under my guidence and
have been completed it successfully.

Mrs. SANTOSH

Contents
1 Classification
2 Signs and symptoms
2.1 Accelerated hypertension

2.2 Children

2.3 Pregnancy

3 Causes
3.1 Essential hypertension

3.2 Secondary hypertension

4 Pathophysiology
5 Diagnosis
6 Prevention
7 Treatment
7.1 Medications

8 Complications
9 Epidemiology
9.1 Pediatrics

10 History
11 Society and culture
11.1 Economics

11.2 Awareness

Hypertension
Classification and external resources

Automated arm blood pressure meter showing arterial hypertension (shown

a systolic blood pressure 158 mmHg, diastolic blood pressure 99 mmHg
and heart rate of 80 beats per minute).

Hypertension (HTN) or high blood pressure is a chronic medical condition

in which the systemic arterial blood pressure is elevated. It is the opposite
of hypotension. It is classified as either primary (essential) or secondary.
About 90–95% of cases are termed "primary hypertension", which refers to
high blood pressure for which no medical cause can be found.[1] The
remaining 5–10% of cases (Secondary hypertension) are caused by other
conditions that affect the kidneys, arteries, heart, or endocrine system.

Persistent hypertension is one of the risk factors for stroke, myocardial

infarction, heart failure and arterial aneurysm, and is a leading cause of
chronic kidney failure. Moderate elevation of arterial blood pressure leads
to shortened life expectancy. Dietary and lifestyle changes can improve
blood pressure control and decrease the risk of associated health
complications, although drug treatment may prove necessary in patients for
whom lifestyle changes prove ineffective or insufficient .

Classification
Blood pressure is usually classified based on the systolic and diastolic
blood pressures. Systolic blood pressure is the blood pressure in vessels
during a heart beat. Diastolic blood pressure is the pressure between
heartbeats. A systolic or the diastolic blood pressure measurement higher
than the accepted normal values for the age of the individual is classified
as prehypertension or hypertension.

Hypertension has several sub-classifications including, hypertension stage

I, hypertension stage II, and isolated systolic hypertension. Isolated systolic
hypertension refers to elevated systolic pressure with normal diastolic
pressure and is common in the elderly. These classifications are made
after averaging a patient's resting blood pressure readings taken on two or
more office visits. Individuals older than 50 years are classified as having
hypertension if their blood pressure is consistently at least 140 mmHg
systolic or 90 mmHg diastolic. Patients with blood pressures higher than
130/80 mmHg with concomitant presence of diabetes mellitus or kidney
disease require further treatment.

Hypertension is also classified as resistant if medications do not reduce

blood pressure to normal levels.

Exercise hypertension is an excessively high elevation in blood pressure

during exercise. The range considered normal for systolic values during
exercise is between 200 and 230 mm Hg.Exercise hypertension may
indicate that an individual is at risk for developing hypertension at rest.

Signs and symptoms

Mild to moderate essential hypertension is usually asymptomatic.

Accelerated hypertension
Accelerated hypertension is associated with headache, drowsiness,
confusion, vision disorders, nausea, and vomiting symptoms which are
collectively referred to as hypertensive encephalopathy.[12] Hypertensive
encephalopathy is caused by severe small blood vessel congestion and
brain swelling, which is reversible if blood pressure is lowered.

Children
Some signs and symptoms are especially important in newborns and
infants such as failure to thrive, seizures, irritability, lack of energy, and
difficulty breathing.[14] In children, hypertension can cause headache,
fatigue, blurred vision, nosebleeds, and facial paralysis.

Even with the above clinical symptoms, the true incidence of pediatric
hypertension is not known. In adults, hypertension has been defined due to
the adverse effects caused by hypertension. However, in children, similar
studies have not been performed thoroughly to link any adverse effects
with the increase in blood pressure. Therefore, the prevalence of pediatric
hypertension remains unknown due to the lack of scientific knowledge.

Pregnancy
Hypertension in pregnant women is one symptom of pre-eclampsia. Pre-
eclampsia can progress to a life-threatening condition called eclampsia,
which is the development of protein in the urine, generalized swelling, and
severe seizures. Other symptoms indicating that brain function is becoming
impaired may precede these seizures such as nausea, vomiting,
headaches, and vision loss.

In addition, the systemic vascular resistance and blood pressure decrease

during pregnancy. The body must compensate by increasing cardiac output
and blood volume to provide sufficient circulation in the utero-placental
arterial bed.
Causes
Essential hypertension
Essential hypertension is the most prevalent hypertension type, affecting
90–95% of hypertensive patients. Although no direct cause has been
identified, there are many factors such as sedentary lifestyle,smoking,
stress, visceral obesity, potassium deficiency (hypokalemia),obesity(more
than 85% of cases occur in those with a body mass index greater than 25),
salt (sodium) sensitivity, alcohol intake,and vitamin D deficiency that
increase the risk of developing hypertension. Risk also increases with
aging, some inherited genetic mutations, and having a family history of
hypertension. An elevated level of renin, a hormone secreted by the kidney,
is another risk factor, as is sympathetic nervous system overactivity.Insulin
resistance, which is a component of syndrome X (or the metabolic
syndrome), is also thought to contribute to hypertension. Recent studies
have implicated low birth weight as a risk factor for adult essential
hypertension.

Secondary hypertension
Secondary hypertension by definition results from an identifiable cause.
This type is important to recognize since it's treated differently to essential
hypertension, by treating the underlying cause of the elevated blood
pressure. Hypertension results in the compromise or imbalance of the
pathophysiological mechanisms, such as the hormone-regulating endocrine
system, that regulate blood plasma volume and heart function. Many
conditions cause hypertension, some are common and well recognized
secondary causes such as Cushing's syndrome,[36] which is a condition
where the adrenal glands overproduce the hormone cortisol.[36] In
addition, hypertension is caused by other conditions that cause hormone
changes such as hyperthyroidism, hypothyroidism (citation needed), and
certain tumors of the adrenal medulla (e.g., pheochromocytoma). Other
common causes of secondary hypertension include kidney disease,
obesity/metabolic disorder, pre-eclampsia during pregnancy, the congenital
defect known as coarctation of the aorta, and certain prescription and
illegal drugs.
Pathophysiolog
y
Most of the mechanisms associated with secondary hypertension are
generally fully understood. However, those associated with essential
(primary) hypertension are far less understood. What is known is that
cardiac output is raised early in the disease course, with total peripheral
resistance (TPR) 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 factors

such as Atrial Natriuretic Factor being secreted to promote salt excretion
with the side effect of raising total peripheral resistance.

An overactive Renin-angiotensin 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.

It is also known that hypertension is highly heritable and polygenic (caused

by more than one gene) and a few candidate genes have been postulated
in the etiology of this condition.

Recently, work related to the association between essential hypertension

and sustained endothelial damage has gained popularity among
hypertension scientists. It remains unclear however whether endothelial
changes precede the development of hypertension or whether such
changes are mainly due to long standing elevated blood pressures.

Diagnosis
Hypertension is generally diagnosed on the basis of a persistently high
blood pressure. Usually this requires three separate sphygmomanometer
(see figure) measurements at least one week apart (Often, this entails
three separate visits to the physician's office). Initial assessment of the
hypertensive patient should include a complete history and physical
examination. Exceptionally, if the elevation is extreme, or if symptoms of
organ damage are present then the diagnosis may be given and treatment
started immediately.

Once the diagnosis of hypertension has been made, physicians will attempt
to identify the underlying cause based on risk factors and other symptoms,
if present. Secondary hypertension is more common in preadolescent
children, with most cases caused by renal disease. Primary or essential
hypertension is more common in adolescents and has multiple risk factors,
including obesity and a family history of hypertension. Laboratory tests can
also be performed to identify possible causes of secondary hypertension,
and determine if hypertension has caused damage to the heart, eyes, and
kidneys. Additional tests for Diabetes and high cholesterol levels are also
usually performed because they are additional risk factors for the
development of heart disease require treatment. Tests typically performed
are classified as follows:

System Tests

Renal: Microscopic urinalysis, proteinuria, serum BUN (blood urea

nitrogen) and/or creatinine

Endocrine Serum sodium, potassium, calcium, TSH (thyroid-stimulating

hormone).

Metabolic Fasting blood glucose, total cholesterol, HDL and LDL

cholesterol, triglycerides

OtherHematocrit, electrocardiogram, and chest radiograph

Sources: Harrison's principles of internal medicine others

Creatinine (renal function) testing is done to determine if kidney disease is
present, which can be either the cause or result of hypertension. In
addition, it provides a baseline measurement of kidney function that can be
used to monitor for side-effects of certain antihypertensive drugs on kidney
function. Additionally, testing of urine samples for protein is used as a
secondary indicator of kidney disease. Glucose testing is done to
determine if diabetes mellitus is present. Electrocardiogram (EKG/ECG)
testing is done to check for evidence of the heart being under strain from
high blood pressure. It may also show if there is thickening of the heart
muscle (left ventricular hypertrophy) or has experienced a prior minor heart
distubance such as a silent heart attack. A chest X-ray may be performed
to look for signs of heart enlargement or damage to heart tissue.

Prevention
The degree to which hypertension can be prevented depends on a number
of features including current blood pressure level, sodium/potassium
balance, detection and omission of environmental toxins, changes in
end/target organs (retina, kidney, heart, among others), risk factors for
cardiovascular diseases and the age at diagnosis of prehypertension or at
risk for hypertension. A prolonged assessment in which repeated
measurements of blood pressure are taken provides the most accurate
assessment of blood pressure levels. Following this, lifestyle changes are
recommended to lower blood pressure, before the initiation of prescription
drug therapy. The process of managing prehypertension according the
guidelines of the British Hypertension Society suggest the following lifestyle
changes:

Weight reduction and regular aerobic exercise (e.g., walking): Regular

exercise improves blood flow and helps to reduce the resting heart rate and
blood pressure.

Reducing dietary sugar.

Reducing sodium (salt) in the body by disuse of condiment sodium and the
adoption of a high potassium diet which rids the renal system of excess
sodium. Many people use potassium chloride salt substitute to reduce their
salt intake.

Additional dietary changes beneficial to reducing blood pressure include

the DASH diet (dietary approaches to stop hypertension) which is rich in
fruits and vegetables and low-fat or fat-free dairy products. This diet has
been shown to be effective based on research sponsored by the National
Heart, Lung, and Blood Institute. In addition, an increase in dietary
potassium, which offsets the effect of sodium has been shown to be highly
effective in reducing blood pressure.

Discontinuing tobacco use and alcohol consumption has been shown to

lower blood pressure. The exact mechanisms are not fully understood, but
blood pressure (especially systolic) always transiently increases following
alcohol or nicotine consumption. Abstaining from cigarette smoking
reduces the risk of stroke and heart attack which are associated with
hypertension.

Limiting alcohol intake to less than 2 standard drinks per day can reduce
systolic blood pressure by between 2-4mmHg.

Reducing stress, for example with relaxation therapy, such as meditation

and other mindbody relaxation techniques, by reducing environmental
stress such as high sound levels and over-illumination can also lower blood
pressure. Jacobson's Progressive Muscle Relaxation and biofeedback are
also beneficial, such as device-guided paced breathing,although meta-
analysis suggests it is not effective unless combined with other relaxation
techniques.

Increasing omega 3 fatty acids can help lower hypertension. Fish oil is
shown to lower blood pressure in hypertensive individuals. The fish oil may
increase sodium and water excretion.

Treatment
Medications
Antihypertensive drug
Several classes of medications, collectively referred to as antihypertensive
drugs, are currently available for treating hypertension. Agents within a
particular class generally share a similar pharmacologic mechanism of
action, and in many cases have an affinity for similar cellular receptors. An
exception to this rule is the diuretics, which are grouped together for the
sake of simplicity but actually exert their effects by a number of different
mechanisms.

Reduction of the blood pressure by 5 mmHg can decrease the risk of

stroke by 34%, of ischaemic heart disease by 21%, and reduce the
likelihood of dementia, heart failure, and mortality from cardiovascular
disease. The aim of treatment should be reduce blood pressure to <140/90
mmHg for most individuals, and lower for individuals with diabetes or
kidney disease (some medical professionals recommend keeping levels
below 120/80 mmHg). If the blood pressure goal is not met, a change in
treatment should be made as therapeutic inertia is a clear impediment to
blood pressure control.Comorbidity also plays a role in determining target
blood pressure, with lower BP targets applying to patients with end-organ
damage or proteinuria.

Often multiple drugs are combined to achieve the goal blood pressure.
Commonly used prescription drugs include:

ACE inhibitors (e.g., captopril)

Alpha blockers (e.g., prazosin)

Angiotensin II receptor antagonists (e.g., losartan)

Beta blockers (e.g., propranolol)

Calcium channel blockers (e.g., verapamil)

Diuretics (e.g. hydrochlorothiazide)

Direct renin inhibitors (e.g., aliskiren)

Some examples of common combined prescription drug treatments

include:

A fixed combination of an ACE inhibitor and a calcium channel blocker.

One example of this is the combination of perindopril and amlodipine, the
efficacy of which has been demonstrated in individuals with glucose
intolerance or metabolic syndrome.

A fixed combination of an ACE inhibitor and a calcium channel blocker.

A fixed combination of a diuretic and an ARB.

Combinations of an ACE inhibitor or angiotensin II–receptor antagonist, a

diuretic and an NSAID (including selective COX-2 inhibitors and non-
prescribed drugs such as ibuprofen) should be avoided whenever possible
due to a high documented risk of acute renal failure. The combination is
known colloquially as a "triple whammy" in the Australian health industry.

Treating moderate to severe high blood pressure decreases death rates in

those under 80 years of age however there is no decrease in those over 80
years old. Even though there was no decrease in total mortality, the results
showed similarities between cardiovascular mortality and morbidity.

Complication
Hypertension is the most important risk factor for death in industrialized
countries.It increases hardening of the arteries thus predisposes individuals
to heart disease, peripheral vascular disease,and strokes. Types of heart
disease that may occur include: myocardial infarction,heart failure,and left
ventricular hypertrophy Other complications include:

Hypertensive retinopathy

Hypertensive nephropathy

If blood pressure is very high hypertensive encephalopathy may result.

Epidemiology
In the year 2000 it is estimated that nearly one billion people or ~26% of
the adult population have hypertension worldwide. It was common in both
developed (333 million ) and undeveloped (639 million) countries.[However
rates vary markedly in different regions with rates as low as 3.4% (men)
and 6.8% (women) in rural India and as high as 68.9% (men) and 72.5%
(women) in Poland.

In 1995 it is estimated that 43 million people in the United States had

hypertension or were taking antihypertensive medication, almost 24% of
the adult population.The prevalence of hypertension in the United States is
increasing and reached 29% in 2004. It is more common in blacks and
native americans and less in whites and Mexican Americans, rates
increase with age, and is greater in the southeastern United States.
Hypertension is more prevalent in men (though menopause tends to
decrease this difference) and those of low socioeconomic status.

Over 90–95% of adult hypertension is essential hypertension. The most

common cause of secondary hypertension is primary aldosteronism.The
incidence of exercise hypertension is reported to range from 1–10%.

Pediatrics
The prevalence of high blood pressure in the young is increasing. Most
childhood hypertension, particularly in preadolescents, is secondary to an
underlying disorder. Kidney disease is the most common (60–70%) cause
of hypertension in children. Adolescents usually have primary or essential
hypertension, which accounts for 85–95% of cases.[89]

History
Some cite the writings of Sushruta in the 6th century BC as being the first
mention of symptoms like those of hypertension. Others propose even
earlier descriptions dating as far as 2600 BCE. Main treatment for what
was called the "hard pulse disease" consisted in reducing the quantity of
blood in a subject by the sectioning of veins or the application of leeches.
Well known individuals such as The Yellow Emperor of China, Cornelius
Celsus, Galen, and Hipocrates advocated such treatments.

Our modern understanding of hypertension began with the work of

physician William Harvey (1578–1657), who was the first to describe
correctly the systemic circulation of blood being pumped around the body
by the heart in his book "De motu cordis". The basis for measuring blood
pressure were established by Stephen Hales in 1733. Initial descriptions of
hypertension as a disease came among others from Thomas Young in
1808 and specially Richard Bright in 1836.The first ever elevated blood
pressure in a patient without kidney disease was reported by Frederick
Mahomed (1849–1884). It was not until 1904 that sodium restriction was
advocated while a rice diet was popularized around 1940.

Studies in the 1920s demonstrated the public health impact of untreated

high blood pressure; treatment options were limited at the time, and deaths
from malignant hypertension and its complications were common. A
prominent victim of severe hypertension leading to cerebral hemorrhage
was Franklin D. Roosevelt (1882–1945). The Framingham Heart Study
added to the epidemiological understanding of hypertension and its
relationship with coronary artery disease. The National Institutes of Health
also sponsored other population studies, which additionally showed that
African Americans had a higher burden of hypertension and its
complications. Before pharmacological treatment for hypertension became
possible, three treatment modalities were used, all with numerous side-
effects: strict sodium restriction, sympathectomy (surgical ablation of parts
of the sympathetic nervous system), and pyrogen therapy (injection of
substances that caused a fever, indirectly reducing blood pressure).[91][93]

The first chemical for hypertension, sodium thiocyanate, was used in 1900
but had many side effects and was unpopular.[91] Several other agents
were developed after the Second World War, the most popular and
reasonably effective of which were tetramethylammonium chloride and its
derivative hexamethonium, hydralazine and reserpine (derived from the
medicinal plant Rauwolfia serpentina). A randomized controlled trial
sponsored by the Veterans Administration using these drugs had to be
stopped early because those not receiving treatment were developing more
complications and it was deemed unethical to withhold treatment from
them. These studies prompted public health campaigns to increase public
awareness of hypertension and the advice to get blood pressure measured
and treated. These measures appear to have contributed at least in part of
the observed 50% fall in stroke and ischemic heart disease beween 1972
and 1994.

A major breakthrough was achieved with the discovery of the first well-
tolerated orally available agents. The first was chlorothiazide, the first
thiazide and developed from the antibiotic sulfanilamide, which became
available in 1958 ; it increased salt excretion while preventing fluid
accumulation. In 1975, the Lasker Special Public Health Award was
awarded to the team that developed chlorothiazide. The British physician
James W. Black developed beta blockers in the early 1960s; these were
initially used for angina, but turned out to lower blood pressure. Black
received the 1976 Lasker Award and in 1988 the Nobel Prize in Physiology
or Medicine for his discovery. The next class of antihypertensives to be
discovered was that of the calcium channel blockers. The first member was
verapamil, a derivative of papaverine that was initially thought to be a beta
blocker and used for angina, but then turned out to have a different mode
of action and was shown to lower blood pressure. ACE inhibitors were
developed through rational drug design; the renin-angiotensin system was
known to play an important role in blood pressure regulation, and snake
venom from Bothrops jararaca could lower blood pressure through
inhibition of ACE. In 1977 captopril, an orally active agent, was described;
[96] this led to the development of a number of other ACE inhibitors.
Society and
culture
Economics
The National Heart, Lung, and Blood Institute (NHLBI) estimated in 2002
that hypertension cost the United States $47.2 billion.

High blood pressure is the most common chronic medical problem

prompting visits to primary health care providers, yet it is estimated that
only 34% of the 50 million American adults with hypertension have their
blood pressure controlled to a level of <140/90 mm Hg[citation needed].
Thus, about two thirds of Americans with hypertension are at increased risk
for heart disease. The medical, economic, and human costs of untreated
and inadequately controlled high blood pressure are enormous. Adequate
management of hypertension can be hampered by inadequacies in the
diagnosis, treatment, and/or control of high blood pressure. Health care
providers face many obstacles to achieving blood pressure control from
their patients, including resistance to taking multiple medications to reach
blood pressure goals. Patients also face the challenges of adhering to
medicine schedules and making lifestyle changes. Nonetheless, the
achievement of blood pressure goals is possible, and most importantly,
lowering blood pressure significantly reduces the risk of death due to heart
disease, the development of other debilitating conditions, and the cost
associated with advanced medical care.,
Awareness

The World Health Organization attributes hypertension, or high blood

pressure, as the leading cause of cardiovascular mortality. The World
Hypertension League (WHL), an umbrella organization of 85 national
hypertension societies and leagues, recognized that more than 50% of the
hypertensive population worldwide are unaware of their condition. To
address this problem, the WHL initiated a global awareness campaign on
hypertension in 2005 and dedicated May 17 of each year as World
Hypertension Day (WHD). Over the past three years, more national
societies have been engaging in WHD and have been innovative in their
activities to get the message to the public. In 2007, there was record
participation from 47 member countries of the WHL. During the week of
WHD, all these countries – in partnership with their local governments,
professional societies, nongovernmental organizations and private
industries – promoted hypertension awareness among the public through
several media and public rallies. Using mass media such as Internet and
television, the message reached more than 250 million people. As the
momentum picks up year after year, the WHL is confident that almost all
the estimated 1.5 billion people affected by elevated blood pressure can be
reached.
References
SITES :
 WWW.WIKIPEDIA.COM
 WWW.WIKIPEDIA.ORG

 RELATED BOOKS

SUBMITTED TO: Mrs. SANTOSH

SUBMITTED BY: SHILPA