International Journal of Trend in Scientific Research and Development (IJTSRD)

Volume 5 Issue 4, May-June 2021 Available Online: www.ijtsrd.com e-ISSN: 2456 – 6470

A Review: Hypertension
Shweta Pawar1, Sujit Kakde2, Ashok Bhosale3
1Student, 2Giude, 3Principal,
1,2,3PDEA'S
Shankarrao Ursal College of Pharmaceutical
Science and Research Centre, Pune, Maharashtra, India

ABSTRACT How to cite this paper: Shweta Pawar |

Hypertension is a major public health problem and important area of research Sujit Kakde | Ashok Bhosale "A Review:
due to its high prevalence and being major risk factor for cardiovascular Hypertension"
diseases and other complications. Published in
International Journal
Objectives
of Trend in Scientific
1. To assess the prevalence of hypertension and its associated factors and
Research and
2. to estimate awareness, treatment, and adequacy of control of
Development (ijtsrd),
hypertension among study subjects.
ISSN: 2456-6470, IJTSRD42416
According to the Joint National Committee 7 (JNC7), normal blood pressure is Volume-5 | Issue-4,
a systolic BP < 120 mmHg and diastolic BP < 80 mm Hg. Hypertension is June 2021, pp.1320-1326, URL:
defined as systolic BP level of ≥140 mmHg and/or diastolic BP level ≥ 90 www.ijtsrd.com/papers/ijtsrd42416.pdf
mmHg.
Copyright © 2021 by author (s) and
A number of factors increase BP, including
International Journal of Trend in Scientific
(1) obesity, (2) insulin resistance, (3) high alcohol intake, (4) high salt intake
Research and Development Journal. This
(in salt-sensitive patients), (5) aging and perhaps (6) sedentary lifestyle, (7)
is an Open Access article distributed
stress, (8) low potassium intake, and (9) low calcium intake.
under the terms of
KEYWORDS: health problem, cardiovascular disease, systolic and diastolic, the Creative
factors Commons Attribution
License (CC BY 4.0)
(http: //creativecommons.org/licenses/by/4.0)

INTRODUCTION
Hypertension is a major public health problem due to its through which cities grow, and higher and higher
high prevalence all around the globe. Around 7.5 million percentages of the population comes to live in the
deaths or 12.8% of the total of all annual deaths worldwide city, mechanization, sedentary life, and dietary changes
occur due to high blood pressure. It is predicted to be act together as a web of risk factors which entangles people
increased to 1.56 billion adults with hypertension in 2025. in it and leads to several chronic diseases. In order to take
effective prevention measures, identification of the risk
Raised blood pressure causes many complications like
factors is an essential prerequisite.
chronic heart disease, stroke, and coronary heart disease.
Elevated BP is positively match up to the risk of stroke and DEFINITION OF HYPERTENSION:
coronary heart disease. Other than coronary heart disease The relationship Between BP and cardiovascular and renal
and stroke, its complications include heart failure, peripheral events is continuous, making the distinction between
vascular disease, renal impairment, retinal haemorrhage, normotension and hypertension, based on cut-off BP values,
and visual impairment. somewhat arbitrary. However, ‘hypertension’ is defined as
the level of BP at which the benefits of treatment (either with
There are several factors make liable to hypertension and
lifestyle interventions or drugs) unequivocally outweigh the
those factors vary from country to country even from some
risks of treatment.
place or region like urban or rural. By perceiving the effect of
urbanization on our collective health, World Health HYPERTENSION AND CARDIOVASCULAR RISK
Organization has chosen “Urbanization and Health” as the Several calculation modalities are used today for
theme for World Health Day 2010. Urbanization is cardiovascular risk assessment. Cardiovascular risk
considered a determinant of health and one of the key assessment should be performed in all hypertensive
drivers of non communicable diseases (NCDs), especially in patients. Risk assessment methods being based on the
low- and middle-income countries (LMICs). Urban people population in which the patient lives and the inclusion of
are more at risk of these diseases as compared to their rural factors such as ethnicity variations, socioeconomic status,
counterparts. As per the findings of National Family Health and medication use will contribute to improvements in risk
Survey (NFHS-4), the prevalence of hypertension, obesity, assessments. The results should be shared with the patient,
and blood glucose in urban area of Uttar Pradesh was 10.5%, and modifiable risk factors must be effectively treated.
23.9, and 9.9%, respectively. However, the prevalence of the Hypertension rarely occurs in isolation, and often clusters
same phenomenon was 8.3%, 10.8%, and 8.2%, respectively with other cardiovascular risk factors such as dyslipidaemia
in rural area. Thus comparatively it is seen that all the and glucose intolerance. This metabolic risk factor clustering
parameters are having higher prevalence in urban area as has a multiplicative effect on cardiovascular risk.
compared to rural area. Rapid Urbanization is the process Consequently, quantification of total cardiovascular risk (i.e.,

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the likelihood of a person developing a cardiovascular event Evaluation (SCORE) system because it is based on large,
over a defined period) is an important part of the risk representative European cohort data sets. The SCORE
stratification process for patients with hypertension. system estimates the 10-year risk of a first fatal
Since 2003, the European Guidelines on CVD prevention atherosclerotic event, in relation to age, sex, smoking habits,
have recommended use of the Systematic Coronary Risk total cholesterol level.
TABLE 01: Factors influencing cardiovascular risk in patients with hypertension
Source

There is also emerging evidence that an increase in serum RESULT: CVR assessment should be performed in all
uric acid to levels lower than those typically associated with hypertensive patients, the results shared with the patient,
gout is independently associated with increased and modifiable risk factors effectively treated. Risk
cardiovascular risk in both the general population and in assessment methods being based on the population in which
hypertensive patients. Measurement of serum uric acid is the patient lives and the inclusion of factors such as ethnicity
recommended as part of the screening of hypertensive variations, socioeconomic status, and medication use will
patients. contribute to the improvement of risk assessments.

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BLOOD PRESSURE MEASUREMENT: Take multiple readings and record the results. Each
Auscultatory or oscillometric semiautomatic or automatic time you measure, take two or three readings one
sphygmomanometers are the preferred method for minute apart and record the results. If your monitor has
measuring BP in the doctor's office. These devices should be built-in memory to store your readings, take it with you
validated according to standardized conditions and to your appointments. Some monitors may also allow
protocols. BP should initially be measured in both upper you to upload your readings to a secure website after
arms, using an appropriate cuff size for the arm you register your profile.
circumference. A consistent and significant SBP difference
Don't take the measurement over clothes. Several
between arms (i.e., >15 mmHg) is associated with an
studies have been done to determine what is a normal
increased cardiovascular risk, most likely due to
variation between right and left arm. In general, any
atheromatous vascular disease. Where there is a difference
difference of 10 mm Hg or less is considered normal and
in BP between arms, ideally established by simultaneous
is not a cause for concern.
measurement, the arm with the higher BP values should be
used for all subsequent measurements. WHITE-COAT HYPERTENSION:
White coat hypertension (WHT), more commonly known
In older people, people with diabetes, or people with other
as white coat syndrome, is a form of labile hypertension in
causes of orthostatic hypotension, BP should also be
which people exhibit a blood pressure level above the
measured 1 and 3 min after standing. Orthostatic
normal range, in a clinical setting, although they do not
hypotension is defined as a reduction in SBP of at least 20
exhibit it in other settings. Although the prevalence varies
mmHg or in DBP of at least 10 mmHg within 3 min of
between studies, white-coat hypertension can account for up
standing, and is associated with an increased risk of
to 30–40% of people (and >50% in the very old) with an
mortality and cardiovascular events. Heart rate should also
elevated office BP. It is more common with increasing age, in
be recorded at the time of BP measurements because resting
women, and in non-smokers. Its prevalence is lower in
heart rate is an independent predictor of cardiovascular
patients with HMOD, when office BP is based on repeated
morbid or fatal events, although heart rate is not included in
measurements, or when a doctor is not involved in the BP
any cardiovascular risk algorithm.
measurement. A significant white-coat effect can be seen at
HOME BLOOD PRESSURE MONITORING all grades of hypertension (including resistant
Home BP is the average of all BP readings performed with a hypertension), but the prevalence of white-coat
semiautomatic, validated BP monitor, for at least 3 days and hypertension is greatest in grade 1 hypertension.
preferably for 6–7 consecutive days before each clinic visit,
HMOD is less prevalent in white-coat hypertension than in
with readings in the morning and the evening, taken in a
sustained hypertension, and recent studies show that the
quiet room after 5 min of rest, with the patient seated with
risk of cardiovascular events associated with white-coat
their back and arm supported. Two measurements should be
hypertension is also lower than that in sustained
taken at each measurement session, performed 1–2 min
hypertension. Conversely, compared with true
apart.
normotensives, patients with white-coat hypertension have
Blood pressure was measured two times on the right arm of increased adrenergic activity, a greater prevalence of
the selected subject using automatic electronic device metabolic risk factors, more frequent asymptomatic cardiac
(OMRON HEM-7261). The average of two readings was used. and vascular damage, and a greater long-term risk of new-
onset diabetes and progression to sustained hypertension
It's recommended to use an upper arm blood pressure
and LVH.
monitor for the most accurate blood pressure reading
results. White-coat hypertension has also been shown to have a
greater cardiovascular risk in isolated systolic hypertension
HOW TO USE HOMEBLOOD PRESSURE MONITOR:
and older patients [91], and does not appear to be clinically
Be still. Don't smoke, drink caffeinated beverages or
innocent.
exercise within 30 minutes before measuring your blood
pressure. Empty your bladder and ensure at least 5 MASKED HYPERTENSION:
minutes of quiet rest before measurements. Masked hypertension is defined as a normal blood
pressure (BP) in the clinic or office (<140/90 mmHg), but
Sit correctly. Sit with your back straight and supported
an elevated BP out of the clinic (ambulatory daytime BP or
(on a dining chair, rather than a sofa). Your feet should
home BP>135/85 mmHg).
be flat on the floor and your legs should not be crossed.
Your arm should be supported on a flat surface (such as What causes masked hypertension? Masked
a table) with the upper arm at heart level. Make sure the hypertension can occur if your home or work environment
bottom of the cuff is placed directly above the bend of is more stressful than at your doctor's office. Use of alcohol,
the elbow. Check your monitor's instructions for an caffeine or cigarettes at home can
illustration or have your healthcare provider show you also cause increased blood pressure.
how.
Masked hypertension is associated with increased
Measure at the same time every day. It’s important to cardiovascular risk in both untreated and treated subjects. In
take the readings at the same time each day, such as contrast, white-coat hypertension is a cardiovascular risk
morning and evening. It is best to take the readings daily factor in untreated but not in treated subjects.
however ideally beginning 2 weeks after a change in
Masked hypertension can be found in approximately 15% of
treatment and during the week before your next
patients with a normal office BP. The prevalence is greater in
appointment.
younger people, men, smokers, and those with higher levels
of physical activity, alcohol consumption, anxiety and job

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stress. Obesity, diabetes, CKD, family history of hypertension, rise in BP during exercise predicts the development of
and high–normal office BP are also associated with an hypertension, independently from BP at rest.
increased prevalence of masked hypertension. Masked
Normally during exercise, blood pressure increases to
hypertension is associated with dyslipidaemia and
push the flow of oxygen-rich blood throughout the body.
dysglycaemia, HMOD, adrenergic activation, and increased
However, in some individuals, the response to exercise is
risk of developing diabetes and sustained hypertension.
exaggerated. Instead of reaching a systolic (upper
Meta-analyses and recent studies have shown that the risk of
number) blood pressure of around 200 mmHg at
cardiovascular events is substantially greater in masked
maximal exercise, they spike at 250 mmHg or higher.
hypertension compared with normotension, and close to or
greater than that of sustained hypertension. Masked Nevertheless, exercise testing is not recommended as part of
hypertension has also been found to increase the risk of the routine evaluation of hypertension because of various
cardiovascular and renal events in diabetes, especially when limitations, including a lack of standardization of
the BP elevation occurs during the night. methodology and definitions. Importantly, except in the
presence of very high BP values (grade 3 hypertension),
BLOOD PRESSURE DURING EXERCISE:
patients or athletes, with treated or untreated hypertension
It is important to recognize that BP increases during
should not be discouraged from regular exercise, especially
dynamic and static exercise, and that the increase is more
aerobic exercise, which is considered beneficial as part of
pronounced for SBP than for DBP, although only SBP can be
lifestyle changes to reduce BP.
measured reliably with non-invasive methods. There is
currently no consensus on normal BP response during Becoming more active can lower both your top and
exercise. The increase in SBP during exercise is related to bottom blood pressure numbers. How much lower isn't
pre-exercise resting BP, age, arterial stiffness and abdominal entirely clear, but studies show reductions from 4 to 12 mm
obesity, and is somewhat greater in women than in men and Hg diastolic and 3 to 6 mm Hg systolic. Regular exercise also
in unfit individuals. There is some evidence that an excessive helps you maintain a healthy weight — another important
way to control blood pressure.
FIGURE

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THE KIDNEY IN HYPERTENSION: by angioplasty, stenting, or surgery on the blood vessels of

Hypertension is the second most important cause of CKD the kidney.
after diabetes. Hypertension may also be the presenting
THE BRAIN IN HYPERTENSION:
feature of asymptomatic primary renal disease. An alteration
Hypertension increases the prevalence of brain damage, of
of renal function is most commonly detected by an increase
which transient ischaemic attack (TIA) and stroke are the
in serum creatinine. This is an insensitive marker of renal
most dramatic acute clinical manifestations. In the
impairment because a major reduction in renal function is
asymptomatic phase, brain damage can be detected by MRI
needed before serum creatinine rises. Furthermore, BP
as white matter hyperintensities, silent microinfarcts, (most
reduction by antihypertensive treatment often leads to an
of which are small and deep, i.e., lacunar infarctions),
acute increase in serum creatinine by as much as 20–30%,
microbleeds and brain atrophy. White matter
especially with renin–angiotensin system (RAS) blockers,
hyperintensities and silent infarcts are associated with an
which has a functional basis and does not usually reflect
increased risk of stroke and cognitive decline due to
manifest renal injury, but the long-term clinical significance
degenerative and vascular dementia. Availability and cost do
is unclear. The diagnosis of hypertension-induced renal
not permit the widespread use of brain MRI for the
damage is based on the finding of reduced renal function
evaluation of hypertensive patients, but white matter
and/or the detection of albuminuria. CKD is classified
hyperintensity and silent brain infarcts should be sought in
according to estimated glomerular filtration rate (eGFR),
all hypertensive patients with neurological disturbances,
calculated by the 2009 CKD-Epidemiology Collaboration
cognitive decline, and, particularly, memory loss.
formula.
A family history of cerebral haemorrhage at middle age and
The albumin: creatinine ratio (ACR) is measured from a spot
early-onset dementia should prompt MRI. Cognitive
urine sample (preferably early morning urine), and is the
impairment in older patients is, at least in part,
preferred method to quantify urinary albumin excretion. A
hypertension-related, and cognitive evaluation tests should
progressive reduction in eGFR and increased albuminuria
be considered in the clinical assessment of hypertensive
indicate progressive loss of renal function, and are both
patients with a history suggestive of early cognitive
independent and additive predictors of increased
impairment. The Mini-Mental State Examination has been
cardiovascular risk and progression of renal disease.
the most widely used method in clinical trials, but is now
Hypertensive kidney disease is a medical condition being superseded by more sophisticated cognitive tests that
referring to damage to the kidney due to chronic high are more suitable for routine clinic visits.
blood pressure. It manifests as hypertensive
High blood pressure (or “hypertension”) has been shown
nephrosclerosis (sclerosis referring to the stiffening
to damage the tiny blood vessels in the parts of your
of renal components).
brain responsible for cognition and memory, greatly
RENAL HYPERTENSION, also called renovascular increasing your risk of developing Alzheimer's disease or
hypertension, is elevated blood pressure caused by kidney another dementia.
disease. It can usually be controlled by blood pressure drugs.
Neurological regulation of blood pressure and flow
Some people with renal hypertension can be helped
depends on the cardiovascular centers located in the

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 International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470
medulla oblongata. This cluster of neurons responds to antiphospholipid syndrome, or with pre-existing
changes in blood pressure as well as blood concentrations hypertension, renal disease, or diabetes. It is often
of oxygen, carbon dioxide, and other factors such as pH. associated with foetal growth restriction due to
placental insufficiency and is a common cause of
GENETICS AND HYPERTENSION:
prematurity. The only cure for preeclampsia is delivery.
A positive family history is a frequent feature in
As proteinuria may be a late manifestation of
hypertensive patients, with the heritability estimated to vary
preeclampsia, it should be suspected when de-novo
between 35 and 50% in most studies. However,
hypertension is accompanied by headache, visual
hypertension is a highly heterogeneous disorder with a
disturbances, abdominal pain, or abnormal laboratory
multifactorial aetiology. Several genome-wide association
tests, specifically low platelets and/or abnormal liver
studies and their meta-analyses have identified 120 loci that
function.
are associated with BP regulation, but together these only
explain about 3.5% of the trait variance. Several rare, Antenatally unclassifiable hypertension: this term is used
monogenic forms of hypertension have been described such when BP is first recorded after 20 weeks of gestation and it
as glucocorticoid-remediable aldosteronism, Liddle's is unclear if hypertension was pre-existing. Reassessment 6
syndrome, and others, where a single gene mutation fully weeks postpartum will help distinguish pre-existing from
explains the pathogenesis of hypertension and dictates the gestational hypertension.
best treatment modality. There are also inherited forms of
CLINICAL MANAGEMENT OF HYPERTENSION IN
phaeochromocytoma and paraganglioma, which are also
PREGANANCY:
rare causes of hypertension. Outside of specialist clinics
Mild hypertension of pregnancy (BP 140–159/90–
evaluating patients for these rare causes of secondary
109 mmHg). The goal of drug treatment of hypertension in
hypertension, there is no role for genetic testing in
pregnancy is to reduce maternal risk; however, the agents
hypertension in routine clinical care.
selected must be safe for the fetus. The benefits of drug
Hypertension tends to run in families. Individuals whose treatment for mother and fetus in hypertension in pregnancy
parents have hypertension have an elevated risk of have not been extensively studied, with the best data from a
developing the condition, particularly if both parents are single trial using alpha-methyldopa, performed 40 years ago.
affected. However, the inheritance pattern is unknown. A further study suggested that tighter vs. less tight control of
Rare, genetic forms of hypertension follow the inheritance BP in pregnancy showed no difference in the risk of adverse
pattern of the individual condition. perinatal outcomes and overall serious maternal
complications. However, secondary analysis suggested that
Angiotensinogen (AGT) AGT was the first gene to show
tighter control of BP may reduce the risk of developing more
linkage with human essential or primary hypertension. In
severe hypertension and preeclampsia.
addition to linkage to the AGT locus, hypertension and
plasma angiotensinogen levels were both found to be High blood pressure during pregnancy poses various risks,
associated with the 235T and 174M variants of AGT. including: Decreased blood flow to the placenta. If the
placenta doesn't get enough blood, your baby might receive
HYPERTENSION AND PREGNANCY:
less oxygen and fewer nutrients. This can lead to slow
Hypertensive disorders in pregnancy affect 5–10% of
growth (intrauterine growth restriction), low birth weight or
pregnancies worldwide and remain a major cause of
premature birth.
maternal, foetal, and neonatal morbidity and mortality.
Maternal risks include placental abruption, stroke, multiple In the United States, high blood pressure happens in 1 in
organ failure, and disseminated intravascular coagulation. every 12 to 17 pregnancies among women ages 20 to
The fetus is at high risk of intrauterine growth retardation 44. High blood pressure in pregnancy has become more
(25% of cases of preeclampsia), prematurity (27% of cases common. However, with good blood pressure control, you
of preeclampsia), and intrauterine death (4% of cases of and your baby are more likely to stay healthy.
preeclampsia).
Most women with pre-existing hypertension and normal
The definition of hypertension in pregnancy is based on renal function will not have severe hypertension and are a
office BP values, SBP at least 140 mmHg and/or DBP at least low risk for developing complications during pregnancy.
90 mmHg, and is classified as mild (140–159/90–109 Indeed, some of these women may be able to withdraw their
mmHg) or severe (≥160/110 mmHg), in contrast to the medication in the first half of pregnancy because of the
conventional hypertension grading. physiological fall in BP. Despite the paucity of evidence,
European Guidelines have recommended initiating drug
1. Pre-existing hypertension: precedes pregnancy or
treatment:
develops before 20 weeks of gestation, and usually
persists for more than 6 weeks postpartum and may be 1. In all women with persistent elevation of BP at least
associated with proteinuria. 150/95 mmHg;
2. Gestational hypertension: develops after 20 weeks of 2. In women with gestational hypertension (with or
gestation and usually resolves within 6 weeks without proteinuria), pre-existing hypertension with the
postpartum. superimposition of gestational hypertension, or
hypertension with subclinical HMOD, when BP is more
3. Pre-existing hypertension plus superimposed
than 140/90 mmHg.
gestational hypertension with proteinuria.
CONCLUSION:
4. Preeclampsia: gestational hypertension with significant
Hypertension is a very important disorder in aged people
proteinuria (>0.3 g/24 h or ≥30 mg/mmol ACR). It
and is associated with higher risk of cardiovascular
occurs more frequently during the first pregnancy, in
morbidity and mortality. The fact of reducing blood
multiple pregnancy, in hydatidiform mole, in

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 International Journal of Trend in Scientific Research and Development (IJTSRD) @ www.ijtsrd.com eISSN: 2456-6470
pressure values decreases the risk for cardiac death as well pressures for stroke risk: the MOnica, Risk, Genetics,
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