High blood pressure, or hypertension, is a major bugbear of modern, or stressful, living. It entails a big price we pay for our own flawed ‘being under the pump’ lifestyle, or frenzied existence. There is adequate evidence to show that adult hypertension begins to ‘evolve’ during the first twenty years of life. The testimony is also clear just as well: genetic and environmental factors influence blood pressure during childhood. This, in turn, may encourage the development of essential hypertension — high blood pressure with no identifiable cause — as one ‘comes of age.’
Hypertension is one of the commonest health problems confronting us today. Its understanding, therefore, has improved considerably, thanks to increased awareness in the general population. Yet, healthy control of the disorder has been dismally poor. Reports suggest that just 15-20 per cent of individuals with high blood pressure [hypertensives] manage to adequately control the problem — even in the developed world, despite its advanced healthcare apparatus. Worse still, a plethora of hypertension dangers arises not from the few with severe high blood pressure, but from individuals with mild hypertension.
Despite continued efforts hypertension will almost never be conquered, because it is one disease as The Lancet, the respected medical journal, puts it, "[That] afflict us from the middle age onwards. It might simply represent unfavourable genes that have accumulated to express themselves in the second-half of our lives. This could never be corrected by any ‘evolutionary pressure’ since such pressures act only during the first-half of our lives: once we have reproduced, it does not greatly matter that we grow 'sans teeth, sans eyes, sans taste, sans everything.’”
New studies have found that blood pressure levels often equate with low birth weight, body mass, maternal age, racial factors, childhood obesity, insulin levels, or elevated blood pressure during childhood, aside from a positive family history. As a matter of fact, children from hypertensive families, by and large, tend to have higher blood pressure levels than kids from ‘normotensive’ [normal blood pressure] families. Besides, there is a strong association in blood pressure levels between fathers and their offspring. This is not all — there are superimposed environmental factors, like stress, excess salt intake, alcohol, smoking, sedentary lifestyle, caffeine, temperature changes, altitude, exposure to drugs having ‘pressor,’ or ‘nephrotoxic — heart-stimulating, or kidney damaging — properties that could lead to the hypertensive state.
"Blood pressure," as Dr V K Verma, a Navi Mumbai-based super-specialist in cardiology, puts it, "is a measurable end-product of an exceedingly complex series of factors, including elements which control blood vessel calibre and responsiveness – or, factors which control fluid volume both within and outside the vascular compartment. It also includes factors that control heart output. However this may be, none of the factors are independent; they interact with each other and also respond to changes in blood pressure. It is not easy, therefore, to dissect the cause and effect at the ‘drop’ of a symptom.”
Factors that play a significant role in blood pressure control are ironically normal in hypertension; indeed, this normality would require explanation as it would indicate a lack of responsiveness to increased pressure. All the same, normal blood pressure, is defined as systolic — when the heart contracts — and, diastolic, when the heart refills with blood. In adults, a blood pressure of 120/80mmHg is considered normal or optimal; a blood pressure of 130/85mmHg as a tad high and any blood pressure more than 140/90mmHg as high.
The variability of blood pressure measurements, both during a single visit and on separate occasions, is also much greater than envisaged. As researchers Haydee Marie Perry Jr, and J Philip Miller explain, "Perhaps, only one-third to two-third of people whose measured diastolic pressures exceed 95mmHg on a single occasion actually have average pressures that high. In the general population, single measurements of diastolic pressure exceed 95mmHg in approximately an equal number of normotensive, borderline and hypertensive patients.” What does this signify? That hypertension should be diagnosed preferably after elevated blood pressure readings are recorded, and confirmed, on at least three separate or consecutive examinations one week apart. During each of the occasions, blood pressure should be measured at least twice, and if the readings are more than 5 mm Hg apart, further readings are necessary to establish the diagnosis.
There are a host of guidelines recommended for measuring blood pressure while using a standard sphygmomanometer, viz., 1. Initial readings should be taken after five minutes in supine position, immediately on and after two minutes on standing. For routine follow-up, measurements can be taken with the patient sitting in a chair with a back-rest. 2. No pressure should be exerted through the stethoscope during the examination; this may lower diastolic readings. 2. To note both the fourth [muffling] and fifth [disappearance] of Korotkoff's sounds — or, resonance that your physician listens to while taking blood pressure — or, what clinicians and physicians acknowledge the fifth sound as diastolic. 3. The cuff should be of proper fit. False, or elevated, levels may be obtained if the cuff is too small; if it is too large, false low blood pressure recordings are recorded. 4. Blood pressure should be measured in both the arms initially, while using the arm with higher blood pressure for all future readings.
Most importantly, blood pressure readings should be taken by age three and yearly thereafter. Most clinicians, however, suggest that regular auscultation — or, listening to the sounds of the body during examination — is not viable in infants, or young children, because of problems related to non-co-operation and apprehension, more so with Korotkoff's sounds being soft. Yet, knowing one’s blood pressure levels would be immensely helpful; also practical. The reason is simple. It is evidenced that a secondary, or accompanying, cause is often found in 50 per cent of infants with hypertension. For example — umbilical artery catheterisation, intraventricular haemorrhage [bleeding into the ventricle], patent ductus arteriosus [a congenital heart defect], and bronchopulmonary dysplasia [a chronic lung disorder]. What’s more, in children belonging to the 1-10 age group, an ‘associated’ cause may frequently be related to vascular and renal disease [coarctation of, or ‘narrowed,’ aorta and renal artery stenosis, or narrowing], not to speak of a number of other less common causes. This is precisely the raison d'être why electronic, or automated, ultrasound devices are used in most clinical settings today — for accuracy of diagnosis and also reliability.
Hypertension may also sometimes present as acute distress in infants with signs and/or symptoms of congestive heart failure, justifying aggressive treatment rather than diagnosis. Such patients may be reviewed by way of screening studies: blood haematocrit, serum electrolytes, serum lipid levels, blood urea nitrogen, creatinine, and renal ultrasonography — especially during the initial evaluation. It may also be highlighted, in the context, that primary hypertension — triggered by genetic or environmental factors — happens to be the most common cause in all age groups — infants, children, and adults. This is yet again related directly to the level of blood pressure and conversely to the age of the patient. Mild elevations, as most clinicians evidence, are unlikely to be associated with secondary disease.
Primary hypertension in childhood and adolescence — as in adults — is usually asymptomatic, or no apparent signs. It is often detected during a routine physical examination. The most frequent symptom is usually a headache. Symptoms like seizures, nosebleed, dizziness, and syncope, or loss of consciousness, typically point towards severe secondary hypertension, or the concomitant use of certain medications, or emotional crises.
History and physical examination may, likewise, reveal evidence of a derivative cause of hypertension. In pre-pubertal children, aggressive attempts are made to rule out the most common resultant causes sequentially. In infants, due to their poor general condition in which they usually present with symptoms, treatment takes precedence over diagnosis. Invasive diagnostic studies are often postponed till the infant is stable, normotensive, and relatively well.
Notes Dr Verma, “The aim of any treatment plan is to reduce blood pressure to its acceptable level —according to one’s age. In adults, the target blood pressure is 130/85mmHg, or lower. The risk factors for cardiovascular disease are equally important in children too. Management of primary hypertension, in young children and adolescents alike, without pharmacological intervention, is often effective, probably more so. This is primarily because most children with early essential hypertension respond to weight control, diet, exercise, and stress-control measures. It is also, likewise, appropriate to reduce salt intake, especially in individuals with primary hypertension, because they are often salt-sensitive.”
In addition, a hypertensive child, or teenage athlete, more so if one is into active sport, should be asked to undergo formal exercise testing, as Dr Verma explains, to decipher if the blood pressure peak is so high that pharmacological [medicinal] treatment is indicated. If exercise levels reveal a systolic elevation [>180mmHg], or high diastolic increase [>120mmHg], drug therapy would be recommended. Children should be recommended to participate in sports involving dynamic exercises; however, isometric exercises should be curtailed. Drug therapy needs to be initiated, anyway, if non-pharmacological management gives no benefit, or when the individual has additional risk factors for cardiovascular disease [CVD].
Pharmacological therapy today includes a large number of drugs in the conventional armamentarium: beta-blockers, calcium channel blockers, ace inhibitors, diuretics, and angiotensin-II receptor blockers. Each of the drugs has its indication and side-effect profile — this, therefore, allows the clinician to individualise the therapy from patient to patient. The older drugs, such as the centrally-acting alpha blockers, sympathetic blockers and peripheral vasodilators are seldom used today. The preference is keyed, at present, towards drugs that can be given once a day to improve compliance and optimal control, low cost, and also protect people from sudden death, heart attack, and stroke, due to unexpected elevations in blood pressure, after awakening from overnight sleep. A combination of two drugs, of different classes, having low dosages, as is the current practice, provides for additional healthy and augmentative benefit with fewer side-effects.
As far as high blood pressure that has been well-controlled for at least one year is concerned, your cardiologist would often endeavour to decrease the number and dosage of drugs in a slow, tapering, progressive and controlled manner, while keeping a close watch through regular follow-ups. This is effective, of course, in patients who are following modifications, or are young with mild hypertension and can without difficulty control their blood pressure on a single drug. The rest would probably require select drugs all through life.
The main underlying dilemma, as research sums-up, is the asymptomatic nature of hypertension. This requires a lifetime of therapy, although it provides no immediate, or complete, benefit and unleashes troublesome side-effects and considerable financial costs. Yet, the import is simple, also profound —because, both cardiologists and their patients would be more likely to achieve better success if untreated hypertension played the spoilsport, not a great deal, but just enough, to remind one of the essential need to take medicines — along with exercise, meditation, appropriate diet and nutritional supplements, such as coenzyme Q10, magnesium, omega-3 fatty acids, vitamin C and D, and niacin [vitamin B3], for the most part — to derive adequate, sustained relief and also lead a healthy, wealthy and optimal life.