Hypertension And Blood Pressure

Hypertension is a common and major cause of stroke and other cardiovascular disease. There are many causes of hypertension, including defined hormonal and genetic syndromes, renal disease and multifactorial racial and familial factors. It is one of the leading causes of morbidity and mortality in the world and will increase in worldwide importance as a public health problem by 2020 (Murray and Lopez 1997).

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Blood pressure (BP) is defined as the amount of pressure exerted, when heart contract against the resistance on the arterial walls of the blood vessels. In a clinical term high BP is known as hypertension. Hypertension is defined as sustained diastolic BP greater than 90 mmHg or sustained systolic BP greater than 140 mmHg. The maximum arterial pressure during contraction of the left ventricle of the heart is called systolic BP and minimum arterial pressure during relaxation and dilation of the ventricle of the heart when the ventricles fill with blood is known as diastolic BP (Guyton and Hall 2006).
Hypertension is commonly divided into two categories of primary and secondary hypertension. In primary hypertension, often called essential hypertension is characterised by chronic elevation in blood pressure that occurs without the elevation of BP pressure results from some other disorder, such as kidney disease. Essential hypertension is a heterogeneous disorder, with different patients having different causal factors that lead to high BP. Essential hypertension needs to be separated into various syndromes because the causes of high BP in most patients presently classified as having essential hypertension can be recognized (Carretero and Oparil 2000). Approximately 95% of the hypertensive patients have essential hypertension. Although only about 5 to 10% of hypertension cases are thought to result from secondary causes, hypertension is so common that secondary hypertension probably will be encountered frequently by the primary care practitioner (Beevers and MacGregor 1995).
In normal mechanism when the arterial BP raises it stretches baroceptors, (that are located in the carotid sinuses, aortic arch and large artery of neck and thorax) which send a rapid impulse to the vasomotor centre that resulting vasodilatation of arterioles and veins which contribute in reducing BP (Guyton and Hall 2006). Most of the book suggested that there is a debate regarding the pathophysiology of hypertension. A number of predisposing factors which contributes to increase the BP are obesity, insulin resistance, high alcohol intake, high salt intake, aging and perhaps sedentary lifestyle, stress, low potassium intake and low calcium intake. Furthermore, many of these factors are additive, such as obesity and alcohol intake (Sever and Poulter 1989).
The pathophysiology of hypertension is categorised mainly into cardiac output and peripheral vascular resistant, renin- angiotensin system, autonomic nervous system and others factors. Normal BP is determined and maintained the balance between cardiac output and peripheral resistant. Considering the essential hypertension, peripheral resistant will rise in normal cardiac output because the peripheral resistant is depend upon the thickness of wall of the artery and capillaries and contraction of smooth muscles cells which is responsible for increasing intracellular calcium concentration (Kaplan 1998). In renin-angiotensin mechanism endocrine system plays important role in maintain blood pressure; especially the juxtaglomerular cells of the kidney secrete renin in order to response glomerular hypo-perfusion. And also renin is released by the stimulation of the sympathetic nervous system which is later convert to angiotensin I then again it converts to angiotensin II in the lungs by the effect of angiotensin- converting enzyme (ACE). Angiotensin II is a potent vasoconstrictor and also it released aldosterone from the zona glomerulosa of the adrenal gland which is responsible for sodium and water retention. In this way, renin-angiotensin system increases the BP (Beevers et al 2001). Similarly, in autonomic nervous system sympathetic nervous system play a role in pathophysiology of hypertension and key to maintaining the normal BP as it constricts and dilates arteriolar. Autonomic nervous system considers as an important in short term changes in BP in response to stress and physical exercise. This system works together with renin-angiotensin system including circulating sodium volume. Although adrenaline and nor-adrenaline doesn’t play an important role in causes of hypertension, the drugs used for the treatment of hypertension block the sympathetic nervous system which had played proper therapeutic role (Beevers et al 2001). Others pathophysiology includes many vasoactive substance which are responsible for maintaining normal BP. They are enothelin bradikinin, endothelial derived relaxant factor; atrial natriuretic peptide and hypercoagulability of blood are all responsible in some way to maintain the BP (Lip G YH 2003).
The seventh report of the Joint National Committee (JNC-VII) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure defines some important goals for the evaluation of the patient with elevated BP which are detection and confirmation of hypertension; detection of target organ disease (e.g. renal damage, congestive heart failure); identification of other risk factors for cardiovascular disorders (e.g. diabetes mellitus, hyperlipidemia) and detection of secondary causes of hypertension (Chobanian et al 2003).
Most hypertensive patients remain asymptomatic until complications arise. Potential complications include stroke, myocardial infarction, heart failure, aortic aneurysm and dissection, renal damage and retinopathy (Zamani et al 2007).The drug selection for the pharmacologic treatment of hypertension would depend on the individual degree of elevation of BP and contradictions. Treatment of non-pharmacologic hypertension includes life-style, weight reduction, exercise, sodium, potassium, stop smoking and alcohol, relaxation therapy and dietary improvements, followed by pharmacology therapy.
Commonly used antihypertensive drugs include thiazide diuretics, β-blockers, ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, direct vasodilators and α-receptor antagonists which are shown in the following table.
Diuretics have been used for decades to treat hypertension and recommended as first-line therapy by JNC-VII guidelines after antihypertensive and lipid-lowering treatment to prevent heart attack trail (ALLHAT) success. They reduce circulatory volume, cardiac output and mean arterial pressure and are most effective in patients with mild-to- moderate hypertension who have normal renal function. Thiazide diuretics (e.g. hydrochlorothiazide) and potassium sparing diuretics (e.g. spironolactone) promote Na+ and Cl- excretion in the nephrone. Loop diuretics (e.g. furosemide) are generally too potent and their actions too short-lived, however, they are useful in lowering blood pressure in patients with renal insufficiency, who often does not respond to other diuretics. Diuretics may result in adverse metabolic side effects, including elevation of creatinine; glucose, cholesterol, triglyceride levels, hypokalemia, hyperuricemia and decreased sexual function are potential side effects. The best BP lowering response is seen from low doses of Thiazide diuretics (Kaplan 1998).
Β-blocker such as propranolol are believed to lower BP through several mechanisms, including reducing cardiac output through a decrease heart rate and a mild decrease in contractility and decreasing the secretion of renin, which lead to a decrease in total peripheral resistant. Adverse effects of b-blockers include bronchospam, fatigue, impotence, and hyperglycemia and alter lipid metabolism (Zamani et al 2007).
Centrally acting α2-adrenergic agonists such as methyldopa and clonidine reduce sympathetic outflow to the heart, blood vessels and kidneys. Methyldopa is safe to use during pregnancy. Side effect includes dry mouth, sedation, drowsiness is common; and in 20% of patients methyldopa causes a positive antiglobulin test, rarely haemolytic anaemia and clonidine causes rebound hypertension if the drug is suddenly withdrawn (Neal M J 2009). Systemic a1-antagonists such as prazosin, terazosin and doxazosin cause a decrease in total peripheral resistance through relaxation of vascular smooth muscle.
Calcium channel blockers (CCB) reduce the influx of Ca++ responsible for cardiac and smooth muscle contraction, thus reducing cardiac contractility and total peripheral resistant. Thus long-acting members of this group are frequently used to treat hypertension. There are two classes of CCB dihyropyridines and non- dihyropyridines. The main side effect of CCB is ankle oedema, but this can sometimes be offset by combining with β-blockers (Lip G YH 2003).
Direct vasodilators such as Hydralazine and minoxidil lower BP by directly relaxing vascular smooth muscle of precapillary resistance vessels. However, this action can result in a reflex increase heart rate, so that combined β-blocker therapy is frequently necessary (Neal M J 2009).
ACE inhibitors works by blocking the renin-angiotensin system thereby inhibiting the conversion of angiotensin I to angiotensin II. ACE inhibitors may be most useful for treating patients with heart failure, as well as hypertensive patients who have diabetes. Using ACE inhibitors can lead to increased levels of bradikinin, which has the side effect of cough and the rare, but severe, complication of angioedema. Recent study demonstrated that captopril was as effective as traditional thaizides and β-blockers in preventing adverse outcomes in hypertension (Lip G YH 2003).
Angiotensin II antagonists act on the renin-angiotensin system and they block the action of angiotensin II at its peripheral receptors. They are well tolerated and very rarely cause any significant side-effects (Zamani et al 2007).
Another helpful principle of antihypertensive drug therapy concerns the use of multiple drugs. The effects of one drug, acting at one physiologic control point, can be defeated by natural compensatory mechanism (e.g. diuretic decrease oedema occurring secondary to treatment with a CCB). By using two drugs with different mechanisms of action, it is more likely that BP and its complication are controlled and with the low dose range of combined drugs also help to reduce the side-effects as well (Frank 2008) . The following two-drug combinations have been found to be effective and well tolerated which are diuretic and β-blocker; diuretic and ACE inhibitor or angiotensin receptor antagonist; CCB (dihydropyridine) and β-blocker; CCB and ACE inhibitor or angiotensin receptor antagonist; CCB and b-diuretic; α-blocker and β-blocker and other combinations (e.g. with central agents, including α2-adrenoreceptor agonists and imidazoline- I2 receptor modulators, or between ACE inhibitors and angiotensin receptor antagonists) can be used (ESH and ESC 2003). If necessary, three or four drugs may be required in many cases for the treatment. The use of a single drug will lower the BP satisfactorily in up to 80% of patients with hypertension but combining two types of drugs will lower BP about 90%. If the diastolic pressure is above 130 mmHg then the hypertensive emergency is occurred. Although it is desirable to reduce the diastolic pressure below 120 mmHg within 24 hours in accelerated hypertension, it is usually unnecessary to reduce it more rapidly and indeed it may be dangerous to do so. This is because the mechanisms that maintain cerebral blood flow at a constant level independent of peripheral BP are impaired in hypertension. However, it is important to reduce the BP quickly by giving the intravenous drugs but caution should be taken to avoid cerebrovascular pressure inducing cerebral ischemia (Grahame-Smith and Aronson 2002).
In conclusion, hypertension emerges as an extremely important clinical problem because of its prevalence and potentially devastating consequences. The major classes of antihypertensive drugs: diuretics, β-blockers, CCB, ACE inhibitors and angiotensin receptor antagonists, are suitable for the initiation and maintenance of antihypertensive therapy which helps in reduction of cardiovascular morbidity and mortality.
 

Vascular Reactivity in Hypertension

Vascular Reactivity in Hypertension
Introduction
High blood pressure (hypertension) is one of the most important preventable causes of morbidity and premature death in the world. The major risk factor for ischemic and myocardial infarction, heart failure, chronic renal failure, premature death, cognitive decline and hemorrhagic stroke is hypertention. Untreated hypertension is usually associated with a progressive increase of blood pressure. Vascular and kidney it can cause lead to a was resistant to treatment

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Blood pressure is normally distributed in the population and not cut from the natural point above which “hypertension” is certainly and below which it is not. The associated risk with the increase in blood pressure is continuously, with each increase of 2 mmHg in systolic blood pressure associated with an increased risk of 7% of deaths from ischemic heart disease and 10% increased risk of stroke mortality. Hypertension is very common in the UK and prevalence is strongly influenced by age. In any individual, systolic and / or diastolic pressure can be high. Diastolic pressure increases more frequently in younger people 50. With age, systolic hypertension is becoming a bigger problem because of progressive stiffening and loss of performance of large arteries. At least a quarter of adults (And more than half of those over 60) have high blood pressure.
Hypertension’s clinical management is one of the most common interventions in primary education care, representing about 1 million pounds in just 2006 drug costs.
The guideline will accept that prescribers will use a summary of the drug product characteristics to inform decisions with individual patients.
This guide recommends drugs for indications where lack of marketing in the world approval on the date of publication, if there is good evidence to support this use. Where recommendations were made for the use of drugs outside their approved indications (“off label use ‘), these drugs are marked with a note in the recommendations.
What is hypertension?
Before understanding on hypertension, we must have a clear idea on blood pressure. It is the force exerted on artery walls when the heart pumps blood through the circulatory system. Rhythmic contractions of the left ventricle, results in cyclical changes in blood pressure. During ventricular systole, the heart pumps blood through the circulatory system, and the pressure in the arteries is at its highest level; this is called the systolic blood pressure. During diastole, the blood pressure in the system decreases and the diastolic blood pressure (1).
Systolic and mean diastolic pressure during the cardiac cycle is the weighted average blood pressure over time; this is called the mean arterial pressure.
The alternation of systolic and diastolic creates external and internal motions of the arterial walls, which are perceived as arterial pulsation. Pulse pressure is the difference between systolic and diastolic blood pressure.
Blood pressure is regulated by:
Central factors; the factors that affect the heart

Cardiac output.
Heart rate.

Peripheral factors: the factors that affect the blood vessels

Diameter of blood vessels- Blood pressure is inversely proportional to the diameter of blood vessels. When the diameter is reduced, the peripheral resistance of elevated blood pressure is increased. Blood vessels, especially arterioles are always in a state partially limited due to vasomotor tone.
Blood volume
Venous return
Velocity of blood flow
Elasticity of blood vessels
Peripheral resistance- Important that keeps this is the diastolic arterial pressure factor. Diastolic pressure is directly proportional to the peripheral resistance

Hypertension is high blood pressure. The force of the blood is blood pressure against the walls of arteries as it flows there through. Arteries are blood vessels that carry oxygenated blood from the heart to the body tissues.
A normal systolic blood pressure less than 140 mm Hg: normal diastolic blood pressure less than 90 mmHg
Persistent increase in systemic blood pressure is known as hypertension. Clinically, when systolic blood pressure is above 150 mmHg and diastolic blood pressure rises above 90 mmHg, assuming the pressure.(1)
Type of hypertension
Hypertension has two major types.

Primary hypertension
Secondary hypertension,

Primary hypertension
Primary (essential) hypertension is the most common form of hypertension, which represents 90 to 95% of all cases of hypertension. In almost all contemporary societies, the increase in blood pressure with age and the risk of becoming hypertensive adults is appreciable. Hypertension results from a complex interaction of genes and environmental factors.
Many common with little effect on genetic variations in blood pressure have been identified as well as some rare genetic variants with large effects on blood pressure but the genetic basis of hypertension is still poorly understood. Several environmental factors influence blood pressure. The lifestyle that lower blood pressure include reducing salt intake in the diet, increased consumption of fruit and low-fat (Dietary Approaches to Stop Hypertension (DASH)) exercise weight loss and reduced alcohol consumption. Stress seems to play a minor role with specific relaxation techniques not supported by the witness. The possible role of other factors such as caffeine, and vitamin D deficiency is less clear. Insulin resistance, which is common in obesity and is a component of Syndrome X (or Metabolic Syndrome), it is also believed to contribute to hypertension. Recent studies have also implicated in early life events (eg, low birth weight, maternal smoking and lack of breastfeeding) as risk factors for essential hypertension adults although the mechanisms linking this adult hypertension remain obscure exhibitions. Essential hypertension
Essential hypertension has a multifactorial etiology
Genetic factors
Blood pressure tends to run in families and children of hypertensive parents tend to have high blood pressure. Children and parents of the same age with normal blood pressure.
Fetal factors
Subsequent hypertension pressure associate with low birth weight
Environmental factors
Among the many environmental factors that have been proposed, the following seems to be the most important:

Obesity
Alcohol intake
Sodium intake
Stress

Humoral mechanisms
The renin-angiotensin system and the autonomic nervous system, and the natriuretic peptide system, kallikrein-kinin plays a role in the physiological regulation of short term Changes in blood pressure and have been implicated in the pathogenesis of essential hypertension.
Insulin resistance
An association between diabetes and hypertension has a long syndrome was recognized and described in hyperinsulinemia, glucose intolerance, reduced levels of HDL cholesterol hypertriglyceridemia and central obesity in association hypertension.
Secondary hypertension
Secondary hypertension is where the elevation of blood pressure is the result of a specific and potentially treatable cause. Secondary forms of hypertension are:
Endocrine hypertension:
This develops due to hyperactivity of endocrine glands as some

Conn’s syndrome
Cushing’s syndrome
adrenal hyperplasia

Neurogenic hypertension:
Disorders of the nervous system that produce hypertension are

Increased intracranial pressure
Sectioning of nerve fibers from carotid sinus

Renal hypertension:
Renal diseases that cause hypertension are

diabetic nephropathy
chronic glomerulonephritis
chronic tubulointerstitial nephritis

Hypertension during pregnancy:
The arterial blood pressure is increased by the low glomerular filtration rate and retention of sodium and water.
Cardiovascular hypertension:
This occurs due to cardiovascular disorders such as,

Atherosclerosis : hardening of blood vessels
coarctation of aorta : narrowing of aorta

Drugs:
There are many medications that cause or aggravate hypertension.
NSAIDs, oralcontraceptives, steroids, carbenoxolone, liquorice, sympathomimetic and vasopressin.
Experimental hypertension
Hypertension can be produced in practical animals by various methods. Can be produced by,

Clamping the renal artery
Denervation of baroreceptors in carotid sinus and aortic arch
Injections of corticosteroids
Infusion of salts with aldosterone

Manifestation of hypertension

Left ventricular failure
Renal failure
Cerebral hemorrhage
Retinal hemorrhage

Treatments for hypertension
Primary hypertension can be controlled but not cured. Secondary hypertension but is cured by treatment of hypertension in the cause of disease. Different types of antihypertensive drugs are given.

Diuretics: Cause diuresis and reduce the volume of extracellular fluid and blood. So blood pressure is decreased
Vasodilators: Cause vasodilation reducing the blood pressure.
Inhibitors of angiotensin converting enzyme: Blood pressure is reduced due to formation of angiotensin is blocked.
Beta blockers: Beta blockers block the sympathetic beta receptors. Thus, cardiac output is reduced. Inhibits vasoconstriction leading to drop in blood pressure.
Calcium channel blockers: Calcium channel in the myocardium are blocked by these drugs reduce myocardial contractility. Cardiac output to the drop in blood pressure is reduced (3).

What is the vascular reactivity?
Vascular reactivity is essential in vascular function that allows the circulatory system to respond to physiological and pharmacological stimuli which require adjustment of blood flow and the vascular tone and diameter. Vascular reactivity occurs in two modes. Reactivity are vasoconstrictor and vasodilator reactivity. These forms may be exposed to levels both microvascular and macrovascular.
Vascular reactivity in hypertension
Vascular reactivity in humans has been studied in many different conditions with a variety of methods. The most effective methods use either intra-arterial or intravenous infusion after inhibition of sympathetic outflow and interpret the changes in flow and pressure in terms of work instead of vasoconstriction of resistance.
Using these methods, the vascular reactivity to various substances, including norepinephrine and angiotensin II has been found to be increased in essential hypertension, but not in various types of renal hypertension.
Some studies have shown that alpha-methyldopa, guanethidine and increased vascular reactivity, although lower blood pressure. Glucocorticoids increase reactivity in normotensive subjects, but not in patients with essential hypertension. Aldosterone and salt increased vascular reactivity, especially in hypertensive patients, but slightly in normotensive individuals (2).
Vascular reactivity to different vasopressors has been extensively studied in different types of hypertension in experimental animals. The mechanisms underlying this hyper-responsiveness and its role in the development of hypertension are unclear. But, it has been suggested that high blood pressure may induce structural changes in the vessel wall adaptation, resulting in an increase of the wall: lumen ratio. This could responsible for the increase in vascular reactivity vasoconstrictors stimuli (4).
Increased vascular reactivity in hypertension occurs in response to a variety of vasoconstrictor agents, epinephrine, norepinephrine, posterior pituitary extracts, tyramine and renin.
Exposure to stress increases sympathetic outflow, and vasoconstriction induced stress can lead to vascular hypertrophy, which leads to progressive increases in peripheral resistance and blood pressure is repeated. People with a family history of hypertension and sympathetic vasoconstrictor obvious stressors increased laboratory tests such as cold and mental stress responses(5).
Vascular reactivity to endothelin in hypertensive patients
Endothelin is a potent vasoconstrictor substance as produced by the cardiovascular system. Therefore, a pathophysiological role of this peptide has been proposed under these conditions, such as hypertension, characterized by the increased vascular tone. The vasoconstrictor response to endothelin-1 is slightly higher in hypertensive patients than in normal subjects.
There is an increase of the activity of the vascular endothelin in patients with essential hypertension, which may be the pathophysiological relevance to their increased vascular tone (6). 
Vascular reactivity to catecholamine in hypertensive patients
In hereditary essential hypertension, vascular reactivity is increased to vasoactive substances which act on the vascular sympathetic neuronal receptor complex and. Since this increase in reactivity is present in early disease progression and even pre-essential hypertension and associated with certain abnormal metabolism of catecholamines, this is probably an etiological factor. Inherited hypertension is probably caused by an abnormal gene or genes produce an abnormal protein or proteins that directly or indirectly affect sympathetic neural and systemic vascular contractile receptor sites (7).
Established in human hypertension, baroreceptor mechanisms remain active. But the blood pressure is maintained at a high level again in place of the normal blood pressure. This process is known as “reset baroreceptor”. The upward adjustment of these baroreceptors occurs not only in the primary or essential hypertension, high blood pressure, but also secondary to renal disease or other types. In most patients with established hypertension, catecholamine excretion is within normal limits so that if the neurological part kept the blood pressure is increased in pressure, is probably the result of an increased effect activity nerve rather than an increase in the activity itself. This could occur by an increase in the sensitivity of the blood vessels to the endogenous norepinephrine produced by the sympathetic nerve endings.
The hypertensive patients have a significantly greater response to norepinephrine than normal subjects. There are a number of possible relationships between increased vascular reactivity and high blood pressure. An important preliminary to elucidating the significance of the altered vascular reactivity is to determine whether it represents a metabolic or a structural vascular abnormality, which causes high blood pressure, or whether it is one of the ways in which a rise in blood pressure, initiated by some other mechanism, becomes an established change (8).
After administrating norepinephrine to the patients with essential hypertension, it has been proven that the initial constriction of vessels is greater in hypertensive individuals than in normotensive individual. Hypertensive patients had a significantly higher response to norepinephrine than normal subjects. There are a number of possible relationships between increased vascular reactivity and high blood pressure. An important preliminary to elucidate the importance of altered vascular reactivity is whether it represents a metabolic abnormality or structural vascular, causing high blood pressure, or is one of the means by which an increase in blood pressure he started by another mechanism, becomes a set rate .
After the administration of norepinephrine in patients with essential hypertension, it has been shown that constriction of blood vessels is higher than initial hypertensive than in normotensive subjects(9) .
Reference

Paul A. Iaizzo. Hand book of cardiac anatomy, physiology, and devices. Totowa: Humana Press; 2005. p. 181-182
Kim E. Barrett, Susan M. Barman, Scott Boitano, Heddwen L. Brooks. Ganong’s review of medical physiology. 24th ed. New Delhi: McGraw-Hill; 2012. p. 590-592
Kumar & Clark Clinical medicine 6E (857-864)
A. E. Doyle, J. R. E. Fraser. Vascular reactivity in hypertension. Journal of the American heart association. 1961; vol 9: 755-761
Milton Mendlowitz. Vascular reactivity in essential and renal hypertension in man. American heart journal.1967; vol 73. Issue 1: 121-128 and Milton Mendlowitz. Vascular reactivity in systemic arterial hypertension. American heart journal.1973vol 85.issue 2: 252-259
B. K. Bhattacharya, N. K. Dadkar, A. N. Dohadwalla. Vascular reactivity of perfused vascular bed in spontaneously hypertensive and normotensive rats. Br. J. pharmac.1977;59:243-246
Carmine Cardillo, Crescence M. Kilcoyne, Myron Waclawiw, Richard O. Cannon, Julio A. Panza. Role of endothelin in the increased vascular tone of patients with essential hypertension. American heart association.1998.vol 65.
James Conway. Vascular reactivity in experimental hypertension measured after hexmethonium. Journal of the American heart association.1958; 17:807-810

 

Physiology and Pharmacology of Hypertension

Introduction
High blood pressure, or most usually termed as hypertension is one of the most common diseases that affects the human population and approximately 1 billion individuals are afflicted by it and around 7.1 million deaths per year can be affiliated with it. (Chobanian, et al., 2003). However all these deaths are caused mostly by cardiovascular disease and another disease, death does not occur b hypertension on its own but by many of the acute linked diseases like Myocardia Infraction, strokes and renal failures. (Rodriguez-Cruz, 2009). As it is the leading cause of mortality and morbidity, it possesses important health challenge as the cost associated with treating it and reducing other risk factors associated with it a lot of active research is being done to understand the causes and the pathophysiology.

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Classification
Normal blood pressure is considered to be 115/75 mmHg, whereas the 115 is the systolic pressure (occurs during contraction of the ventricles) and 75 is the diastolic pressure (occurs during the relaxation of ventricles). (Oparil & Weber, Hypertension: A Companion to Brenner and Rector’s The Kidney, 2005). An individual is treated with hypertension when their blood pressure is consistently over 140/90 mmHg, however doctors these days are becoming more cautious and start treatment when the pressure touches 130/80 mmHg . It is known that cardiovascular risk increases for every 20/11 mmHg increment. (Chobanian, et al., 2003)
Hypertension can be broadly classified into two groups; primary/essential and secondary hypertension. About 90 to 95% population diagnosed with hypertension has primary type, for which the cause is not full known and seems to be more prevalent as people age; it may increase up to 75% in people aged over 75. (Rodriguez-Cruz, 2009) (Carretero & Opari, 2000). Secondary hypertension is caused by an underlying medical condition which has altered the homeostatic pathway of regulating blood pressure. Secondary hypertension is more easily treatable as the underlying cause can be identified. Some commonly recognised diseases that may cause hypertension include Cushing’s disorder, kidney diseases and tumours. Another important cause is the genetic abnormality of the aorta. (Williams, 2010).
Signs and Symptoms
Moderate hypertension which starts from 140/90 is asymptomatic. Prolonged and sudden enhanced blood pressure is linked to headaches, sleepiness and visual disturbances; which in turn can cause nausea. (McPhee, Papadakis, & Tierney, 2008)While it is known hypertension is more prevalent in elderly, children can be affected as well in the children the symptoms may be as more acute like epistaxis, and bell palsy. (Rodriguez-Cruz, 2009). Children usually exhibit hypertension due to some other underlying cause, and thus most cases are of secondary nature. (Rodriguez-Cruz, 2009).The signs and symptoms of secondary hypertension are dependent upon the ailment that is causing it and thus the indicators for Cushing’s syndrome would be different from the genetic one or drug induced one. (Williams, 2010)
Pathophysiology
The exact cause of the primary hypertension is not known. There are many risk factors including age, genetics, metabolic, race and “sedentary lifestyle which can cause obesity” and it has been estimated that 85%of the cases of hypertension have a higher BMI than 25. (Haslam & James, 2005)
Figure 1: This figure shows the key elements of the pathophysiology of hypertension and all the risk factors which increase the likelihood of contracting the ailment. Abbreviations used here: AME- apparent mineralocorticoid excess; CNS – central nervous system; GRA – glucocorticoid-remediable aldosteronism. (Oparil, Zaman, & Calhoun, Pathogenesis of Hypertension, 2003)
The pathophysiologic mechanism and the vascular irregularities are speculative and it is actively being researched upon. Blood pressure is the combined consequence of cardiac output and vascular resistance thus either one can independently or in combination cause hypertension. (Dreisbach & Sharma, 2010). Different studies show that several factors may work independently or together to turn the neurohumoral systems on or off. In patients with a hyper-responsive system due to “changed vascular properties” an aggravated pressure flow is observed. (Randal, 1991). It has also been studied that there is a natural evolution of the disease thus man researchers suggest the one of the reason of the early elevations of the blood volume or the cardiac output may be the inadequate elimination of sodium by kidneys. Increased sodium levels can increase the osmotic pressure hence the blood volume. It chronic hypertension subjects the cardiac output and the blood volume is usually close to the normal. So it can be inferred that hypertension is maintained by the increase in vascular resistance by a decrease of elasticity of the walls as in aging or “by a reduction in lumen Diameter” (Khabunde, 2007) when the individual has been following a medically unhealthy lifestyle. These “changes in arterioles, which increase total peripheral resistance, result in an increase in diastolic and a secondary increase in systolic blood pressures” (Randal, 1991)
Another factor that different studies have showed relate the decrease in sensitivity of receptors of the receptors in the vessels The decrease in receptors sensitivity modifies central nervous system (CNS) manipulation of sympathetic nervous system (SNS) distribution, resulting in two expressions. First, having an insensitive receptor requires a larger change in blood pressure to produce the same response as the receptor doesn’t get activated. Secondly decreased receptors “sensitivity results in enhanced SNS activity for a given level of arterial blood pressure.” (Supiano, 2001)
In hypertension there is has been shown evidence that changes in vascular endothelial function (VEF) can hamper normal vascular tone of hypertensive patients. Vascular tone can be changed by increase circulation of angiotensin II, or by the increased sympathetic activity (as discussed above). The altered sympathetic activity can lead to a decrease in production of nitric oxide which is a vasodilator or endothelin production could increase, which is a vasoconstrictor. (Khabunde, 2007). Type 2 diabetes can causes endothelial dysfunction “by enhanced oxygen free radical-mediated damage and decreased nitric oxide bioavailability.” (Khabunde, 2007).
Other factors that maintain hypertension are caused by dysfunction in electrolyte homoeostasis especially deviations in sodium, calcium, and potassium concentrations. Sodium example has been already discussed above. In addition, calcium increases vascular contractility. It can also stimulate renin release; the same mechanism is thought to operate in obesity-mediated hypertension. Renin synthesis epinephrine, and activity of the sympathetic nervous system, which can be linked back to abnormalities seen in vascular tone. Potassium, however, helps decrease the blood pressure as it suppresses the release of renin. (Rodriguez-Cruz, 2009).
This figure explains the different factors that directly affect the blood pressure, which is later affected by other different factors. In hypertension cardiac output is usually normal and therefore peripheral resistance sustains hypertension by the dysfunction in vascular function or decreases in lumen by a sedentary lifestyle. The figure is taken from Wikipedia. (Wikipedia, 2009)
It can be seen the complexity of the system, as many mechanism works to sustain hypertension. In different individuals, it can be difficult to understand which systems are operational thus designing treatments can be difficult, and treatments are then usually more often designed to affect the regulatory factors rather than cause. (Randal, 1991)
Treatment
Treatment usually works to regulate the factors which maintain hypertension. Non-pharmacological treatments include lifestyle changes like decrease/halt in alcohol and cigarette consumption and if needed weight reduction with a more active lifestyle. Caffeine intake is also minimized as it increases the pulse rate. It is assessed that lifestyle interventions can reduce blood pressure by at least 10 mmHg in about 1 in 4 people with high blood pressure. (Association, 2009).Yet most of the times pharmacological interventions are used as they more affectively regulate blood pressure, there around 6 classes of pharmacological medications available which all perform at different levels to bring the blood pressure to normal. (Oparil & Weber, Hypertension: A Companion to Brenner and Rector’s The Kidney, 2005).

ACE inhibitors: inhibits the assembly of angiotensin II, as a result, the vessels expand improving the blood flow. The tension in the circulation is regulated to normalcy by increase filtration by the kidneys. The decrease in levels of fluids also helps reduce blood pressure. This medication is used only when other medications are not working.
Angiotensin-II receptor antagonists: they work in an analogous manner to ACE inhibitors. However, instead of stopping the production of angiotensin II, they prevent its action on the receptors. Again vessels are able to expand, improving blood flow and reducing blood pressure.
Beta-blockers block the effects of sympathetic nervous system and the hormone epinephrine. This decreases the cardiac output as it relaxes the heart so the pulse rate is slowed down, lowering the blood pressure.
Alpha-blockers: triggers the vessels to ease and expand. Giving them in combination with beta-blockers has a greater effect.
Calcium-channel blockers: expand the arteries to reduce the muscle tension and also decrease the cardiac output by relaxing the heart muscles so it pumps more slowly, reducing blood pressure.
Diuretics: help clear the unnecessary sodium and water thru kidneys, which decrease the osmotic pressure. They also relax the blood vessels reducing the strain on them. (Uren & Rutherford, 2004)

Treatment for hypertension is throughout one’s life as hypertension is not curable; however, all the drug classes above help maintain the blood pressure quite well within the normal range.
Summary
The complexity of pathophysiologic mechanisms that lead to high blood pressure is such that selective antihypertensive treatment is rarely possible and a number of drugs and lifestyle changes are required to bring any change. Hypertension is widespread among middle-aged and elderly and controlling their blood pressure is a challenge we face as we still have not properly understood the underlying causes of primary/essential hypertension. (Oparil, Zaman, & Calhoun, Pathogenesis of Hypertension, 2003).
Bibliography

Association, B. P. (2009, March 4). High Blood Pressure. Retrieved March 8, 2010, from Patients UK: http://www.patient.co.uk/health/High-Blood-Pressure-(Hypertension).htm
Carretero, O. A., & Opari, l. S. (2000, Jan 25). Essential hypertension. Part I: definition and aetiology. Circulation, 3(101), 329-335.
Chobanian, A. V., Bakris, G. L., Black, H. R., Cushman, W. C., Green, L. A., Izzo, J. L., et al. (2003, December 1). Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension, 42, 1206-1252.
Dreisbach, A. W., & Sharma, S. (2010, Feb 19). Hypertension and Kidney. Retrieved March 8, 2010, from Emedicine: http://emedicine.medscape.com/article/241381-overview
Haslam, D., & James, W. (2005). Obesity. The Lancet, 366, 1197-1209.
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Health Belief Model and Hypertension Treatment Compliance

The health belief model and compliance with hypertension treatment
Running title: Health Belief Model and Compliance in Hypertension
Pauline E. Osamor and Olanike A. Ojelabi
Pauline E. Osamor, Institute of Child Health, College of Medicine, University of Ibadan, Nigeria,
Olanike A. Ojelabi, Worcester State University, Urban Studies Department, Worcester, MA 01605, USA
Author contributions: Osamor PE, contributed to the conception and design of the study; all authors contributed to the writing and critical revision of the manuscript.
Biostatistics statement: The study was designed, analysed and data interpreted by the authors. Data available in this manuscript did NOT involve a biostatistician.
Conflict-of-interest statement: The author reports no conflicts of interest in this work.
Data sharing statement: No additional data are available
Abstract
AIM: To explore the use of the Health Belief Model (HBM) in evaluating care seeking and treatment compliance among hypertensive adults in south-west, Nigeria.
METHODS: A community-based cross-sectional study was conducted using a semi-structured questionnaire to obtain information from 440 hypertensive adults in an urban, low-socio-economic community, situated in south west Nigeria. Focus Group Discussions (FGDs) were conducted with a subset of the population. The relationship between treatment compliance and responses to questions that captured various components of the HBM was investigated using chi-square tests. Content analysis was used to analyze data from the FGD sessions and to provide context to the survey responses. Data entry and management was carried out using the Statistical Package for Social Sciences (SPSS) version 11.0.

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RESULTS: The components of the HBM reflecting Perceived Susceptibility components were significantly associated with treatment compliance. On the other hand, HBM Perceived Seriousness components were not significantly associated with compliance. The main HBM Perceived Benefit of Taking Action component that was prominent was the belief that hypertension could be cured by treatment, a theme that emerged from both the survey and the FGD.
CONCLUSION: Use of the HBM as a framework is helpful in identifying perceptions and behaviors associated with hypertension treatment compliance.
Key words: Health belief model; Compliance; Hypertension; Community-based; Nigeria
Core tip: Hypertension is a major health problem in developing and developed countries, and treatment compliance for such chronic conditions is often poor. In this study, the Health Belief Model (HBM) was used to evaluate care seeking and treatment compliance among hypertensive adults. HBM proved to be a valuable framework to develop and modify public health interventions and also serves to improve treatment compliance and reduce the risk of complications.
Osamor PE, Ojelabi OA. The health belief model and compliance with hypertension treatment. World J Hypertension 2017;
INTRODUCTION
Hypertension, otherwise known as high blood pressure, is a leading cause of cardiovascular disease (CVD) worldwide[1]. The proportion of the global burden of disease attributable to hypertension has significantly increased from about 4.5 percent (nearly 1 billion adults) in 2000 to 7 percent in 2010[2-9]. This makes hypertension a major global public health challenge and the single most important cause of morbidity and mortality globally. The prevalence of hypertension in Nigeria may form a substantial proportion of the total burden in Africa. This is because of the large population of the country currently estimated to be over 170 million[3,6,10]. In Nigeria, hypertension is the commonest non-communicable disease with over 4.3 million Nigerians above the age of 15 classified as being hypertensive using the erstwhile national guidelines (systolic BP > 160 mmHg and diastolic BP > 90 mmHg)[12-15].
Treatment of hypertension rests on a combination of lifestyle interventions and use of antihypertensive medication. However, poor compliance with treatment is often common in hypertension. Studies of treatment compliance have explored the role of various factors, including demographic and socio-behavioral features of patients, the type and source of therapeutic regimen, and the patient-provider relationship[16]. Yet, a common framework for evaluating such factors is often lacking. One such framework is the Health Belief Model (HBM),which has shown utility in evaluating compliance with antihypertensive medications[17-20].
Health Belief Model
The Health Belief Model (HBM) is an intrapersonal health behavior and psychological model. This model has been commonly applied to studying and promoting the uptake of health services and adoption of health behaviors[21]. Recently, a National Institutes of Health publication, “Theory at a Glance, A Guide for Health Promotion Practices” proposed that the HBM may be useful in the examination of inaction or noncompliance of persons with or at risk for heart disease and stroke[24], suggesting a natural fit for this study.
The HBM is a “value-expectancy” model [17]. It attempts to explain and predict health behaviors by focusing on the attitudes and belief patterns of individuals and groups. The modelconsists of six dimensions: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and modifying factors. While the HBM has been criticized for overemphasizing the logical order and rationality of one’s health behaviors[28], it is considered to be one of the most influential models in the history of health promotion practice[29], and has shown usefulness in predicting health behaviors among population with or at risk for developing cardiovascular disease.
With respect to care-seeking and treatment compliance, a hypertensive patient’s ability to see a physician and comply to medical treatment regimen is a function of a various factors. These include patient’s personal knowledge, benefit and perceptions, modifying factors, and cues to action[30]. Therefore, the goal of this study is to explore the use of the HBM as a framework for evaluating care-seeking and treatment compliance in hypertension in south-west Nigeria.
Rationale
Uncontrolled hypertension is caused by non-adherence to the antihypertensive medication, patients understanding their drug regimens and the necessity to adhere to this regimen will help to improve their adherence, thus help prevent the complications of hypertension that are debilitating and if not prevented can increase the burden of a disease that is already on the increase[31]. Knowledge and beliefs about hypertension have been frequently examined in efforts to better understand the disparities in blood pressure control[33,34]. Relatively few studies, however, have attempted to identify individual factors associated with the adoption of hypertension control behaviors using a health behavior model as the theoretical framework. Thus, this study aims to explore the use of the HBM- an intrapersonal health behavior and psychological model in evaluating care seeking and treatment compliance among hypertensive adults in south west Nigeria.
MATERIALS AND METHODS
This community-based cross-sectional study was carried out in an urban, low-socio-economic community in Nigeria. Most of the residents belong to the Yoruba ethnic group and the dominant religion is Islam. The health facilities in the community include an outreach clinic run by the Department of Preventive Medicine and Primary Care of the University of Ibadan, four private clinics and a small dental clinic. Other sources of health care in the community include Patent Medicine Vendors (PMVs) and three traditional healing homes. The study site was selected for three specific reasons: Firstly, the community has been the site of previous research studies where people were screened and therefore know of their hypertension status. Secondly, a community study approach (instead of a clinic-based approach) was chosen because selecting participants from a clinic or hospital will only select those who are attending clinic or complying, thereby introducing a selection bias and thirdly, the community has a variety of sources of healthcare located within the community, implying that residents have options when seeking healthcare.
The study is a community-based cross-sectional study which enrolled hypertensive adults (age 25 years and above) in the community. It utilized both the survey and Focus Group Discussion (FGD) to collect primary data from the respondents. The participants for this study were selected from a list of known hypertensive adults residing in the community that was developed from a previous hypertension study[35] and updated for the present study during home visits. Four hundred and forty (440) hypertensive subjects were enrolled using a consecutive sampling method.
After obtaining informed consent, subjects were administered a semi-structured questionnaire that had items on several issues, including knowledge on causes, prevention and severity of hypertension, healthcare seeking for hypertension, their beliefs and perception about hypertension and compliance with treatment including keeping clinic follow-up appointments and regularly taking their antihypertensive medications. Eight FGDs were conducted, each with 6-8 discussants. The dimensions of the HBM were operationalized as described in table 1, where each dimension was framed as a series of questions, which were asked in the survey and/or discussed as a topic in the FGD.
Data entry and management was carried out using the Statistical
Package for Social Sciences (SPSS) version 11.0[36]. Univariate analyses were employed in interpreting socio-demographic characteristics of the respondents, while a bivariate analysis was used in cross tabulating variables. The transcription of the qualitative data was carried out immediately after each FGD session. This was essential since the memory of the interviewer/note taker was still fresh and it was easier to reconcile written notes and the interview transcripts. Content analysis was used to analyze data from FGD sessions.
RESULTS
Socio-demographic characteristics
A total of 440 (including 287 women) respondents were studied. The ages of respondents ranged from 25 to 90 years, with a mean of 60 (SD 12) years. Most (71%) of the respondents were married and 61.4%, Muslims. Slightly over half of the respondents (51.1%) had no formal education. About half (50%) of the respondents were traders, while those who have retired and not working constituted 25.7%.
Prevalence of compliance with clinic visits and taking medication
The prevalence of self-reported compliance with clinic appointments was 77.5% and that of good compliance with treatment was 50.7% of respondents. 41.5% reported poor treatment compliance at different levels ranging from regularly missing taking their medication to fairly regularly, sometimes and rarely taking their medication.
Perceived Susceptibility to hypertension
In response to being asked what they understood by the disease “hypertension”, most respondents defined hypertension as an illness of anxiety and stress (60.9%). Nearly one in twelve (7.3%) said they did not know what hypertension meant. A few of the respondents (4.1%) believed that hypertension means “too much blood in the body”, thereby causing “tension in the blood”. Roughly two percent of respondents said hypertension “was in everybody’s blood”. A quote from one of the FGDs is illustrative:
Hypertension is in everybody’s body and blood. When we exert undue stress on our body, think too much and do a lot of wahala (stressful things), hypertension will start.
This statement clearly articulates the notion that everyone is predisposed to hypertension but the condition only becomes apparent or manifests itself when the person experiences a lot of stress. This could either mean that everyone is predisposed to having hypertension or that hypertension is hereditary.
Perceived Severity of hypertension
A large proportion 89.8% of the respondents knew that hypertension could lead to other serious health problems or complications. Only 1.1% did not affirm that it will lead to serious problem, while 9.1% did not know if hypertension could lead to other health problems. Other health problems that could result from hypertension mentioned by respondents include: stroke (47.5%); death (25.5%); severe headache (5.2%) and heart attack (5.0%). In the FGD sessions conducted, respondents were asked if they perceived hypertension to be a serious health problem. The general response was that hypertension is a serious health problem. One of the FGD discussants summed it this way:
Hypertension is a very serious sickness. It is not sickness we should take lightly. It can lead to quick death. One of my younger brothers who worked in the bank had hypertension. He suffered attacked from hypertension while in the office and before they got to the hospital, he died. Hypertension kills fast. But it has drugs that can control it and if one is not taking the drugs regularly, it will cause serious problem.
A fifty-two years old woman used her personal experience to buttress the magnitude of hypertension. She stated that:
This sickness they call hypertension is a very serious sickness. I was not taking any drugs because I did not have money to buy it and I was not worried because I was not feeling sick. In 2003, I was sick just for a week and before I knew what was happening I could not walk or move my body. I was rushed to the hospital and they told me my blood pressure was very high. I was in the hospital for almost a month and my children spent a lot of money. I am better now, but am still using walking stick because the hypertension made my body stiff. I am taking my medication always now so that I do not die quickly because it can kill.
The general perception of the respondents and focus group discussants on the complications from hypertension is that hypertension itself is a very serious health problem and that any complications arising from it could be very severe.
Perceived benefit of treatment compliance
Nearly three quarters (73.2%) of the respondents believed that hypertension could be cured with treatment. Most (72.0%) of the respondents reported that it is not good to wait until one feels sick before taking antihypertensive medication and the reason given by a large proportion (30%) of these respondents is that taking medication regularly will prevent reoccurrence of hypertension. Despite the fact that respondents believe they needed to take medication as prescribed (and not only when they are sick), only a relatively small proportion (a little above 50%) of the respondents did take their medication as prescribed.
Perceived barriers to complying with treatment
Among the respondents, 41.5% had poor compliance at different levels ranging from regularly missing taking their medication to fairly regularly, sometimes and rarely taking their medication. Of these respondents who were non-compliant with their medication, 11.4% said they felt better and therefore had no need to continue taking their medication. Only 0.5% said they were tired of taking drugs, while 6.8% stopped because of lack of funds to purchase drugs. Other factors included side effects of drugs (6.1%), forgetfulness (8.4%), busy schedule and limited medication (3.6%). A major theme from the survey and FGDs is that respondents were apprehensive of the long term effects from antihypertensive medication and the possibility of being stuck with it for the rest of one’s life or the medication causing other illness or complications. Negative feelings were elicited in some cases, as antihypertensive drugs were perceived as being damaging or “not good” for the body. The FGDs highlighted factors that hindered good compliance to treatment despite the general acceptance of the necessity to take antihypertensive medications. One of the discussant said:
I do not take my medicine every day. People do not always follow what doctor say. It is not only for hypertension, even for other sickness. If they say take medicine for five days, once we feel better by thethird day, the person will stop. Even the doctors themselves, will they swallow medicine every day?
A discussant in another session stated:
Let me tell you the truth … it is not easy to be taking drugs every day. Sometimes, we forget especially when you are rushing to go out. Sometimes we do not have the money to buy it.
Another respondent added details about what often happens as a result of the financial obstacles:
That is what we have all been trying to say. Money is the major problem. In the hospital, they will ask you to pay for ordinary card, before you see the doctor. When they write drugs for you there is no money to buy all. If you do not have money and you go to a private hospital, they will not even attend to you. That is why some people prefer to just go to chemist and buy what they can afford and some others prefer traditional medicine because you do not have to drink it every day and it is less expensive.
Cues to action
An important source of cues to action includes the individual’s cultural conditioning of available treatment options. In this study family and friends were a major source of cues to action. Overall, 19.3% of respondents reported that family members were very concerned about their hypertension while 74.8% said family members were extremely concerned about their hypertension. Also, 20.2% and 73.2% respectively reported that family members were very helpful or extremely helpful in reminding them about taking their medication. Regarding support from friends, 26.4% of respondents reported that friends were very concerned about their hypertension while 28.9% said friends were extremely concerned about their hypertension. Out of the 440 respondents, 91 and 150 (20.7% and 34.1%) respectively reported that friends were very helpful or extremely helpful in reminding them about taking their medication (Figure 1).
DISCUSSION
Hypertension is a condition of sustained high blood pressure which can only be confirmed after blood pressure measurements that meet the criteria for the condition. The cause of hypertension is not known in most cases[1] hence the term “essential hypertension”. In the present study, hypertension is perceived primarily as an illness of anxiety and stress. This finding is consistent with a previous study of hypertension in Nigeria[38] which revealed that over 60% of their respondents irrespective of the educational background believe that psychosocial stress is the main cause of hypertension. Similarly, Koslowsky et al[39] found that stress and tension were most commonly stated as causes of hypertension. Majority (more 90%) in this study believe hypertension is a serious condition and two-thirds (66%) believe that hypertension can be prevented. Contrary to findings and reports from previous studies[38,40,41], nearly three-quarters (73%) of respondents in the present study believe that hypertension is curable. Almost half of the respondents claim good compliance with respect to drug treatment and 86% claim good compliance with keeping their doctor’s appointment. Reasons for compliance to treatment include fear of the complications of hypertension and the desire to control blood pressure. Benson and Britten[42] reported that patients comply with medication regimen for a variety of reasons including perceived benefits of medication; fear of complications associated with hypertension and feeling better on medication. The latter reason is contrary to the generally held belief among physicians that hypertension is a largely asymptomatic disease[43].

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One central theme that runs through the data in this study is the issue of socio-economic status of the respondents. This suggests the importance of considering other variables that can help form individual’s perception including health care costs and some sort of lay consultation that takes place before they resolve to take a recommended health action[27]. Financial hardship is a barrier which should not be ignored as it is a contributory factor to noncompliance. This finding corroborates the observed association between poor compliance, ignorance and lack of funds for purchase of drugs[44]. Failure of patients to keep scheduled appointments is an important obstacle to the provision of effective healthcare. By missing appointments, individuals deprive themselves of professional services. Interestingly, 77.5% of the respondents in this study claim they comply with keeping their follow up clinic appointments every time. Several studies have investigated HBM and appointment-keeping for chronic disease management. Nelson et al[20] and also Landers et al[45] found HBM variables to be unrelated to keeping clinic appointments for hypertension.
Social support networks are important in the long-term management of chronic conditions such as hypertension, which require a radical and life-long change in the lifestyle of the affected person. In this study, those who had support from friends or family members (concerned about their illness, giving reminders about medication) showed better treatment compliance than those who did not, although this difference was greatest for those that had the support of friends. This is an important finding and is consistent with what has been reported for multiple chronic diseases in several parts of the world[46].
A summary of the major findings in this study in the context of interpreting compliance using the significant components of the HBM shown in Figure 1 suggests that HBM Perceived Susceptibility components tested were significant predictors of compliance. On the other hand, HBM Perceived Seriousness components were not significantly associated with compliance. The main HBM Perceived Benefit of Taking Action component that was prominent in this study is the belief that hypertension can be cured. This is a recurring theme in all the components of the study (survey and FGD) and most respondents believed that taking the medication for some time led to a “cure” and one could stop taking medication. This finding agrees with studies of Kamran et al[47], which showed a relationship between HBM constructs and treatment compliance. The constructs that were significantly showing relationship in their study were perceived susceptibility, perceived benefit of using the medicine and perceived barrier to treatment. This has major personal and public health implications because hypertension can only be controlled (not cured) and stopping medication can lead to complications. More importantly, it highlights the discrepancy between healthcare providers and their patients in the perceived goal of treatment since the former are working towards control while the latter believe compliance can lead to cure.
Most of the HBM Barriers to Taking Action components emerged during the FGD sessions. These barriers are practical issues that loom large and prevent the patients from making optimum use of the hospitals and medications that are available. In other words, the option of a university teaching hospital is available but is not accessible because of costs and inconvenience. Similarly, known medications that work well in hypertension are available but the costs are too high for the patients to comply with the prescriptions as written. It is noteworthy that believing that one can stop taking the medication after some time can also serve as a barrier to compliance because the individual now believes there is “no need” for more medication.
Another major finding from this study is that HBM Cues to Action are extremely important in predicting compliance with hypertension treatment in this community. These cues are centered on patients having family members and/or friends who are concerned about the individual’s health and treatment. This finding is important because, as noted by Harrison et al[48] in a meta-analysis, cues are often not included in Health Belief Model studies. Indeed, these authors limited their review to articles to the four major components of the HBM (susceptibility, severity, benefits and costs) because in their words: “Cues to action have received so little attention in empirical studies that we excluded this dimension”. However, the findings of this study shows that cues are an important dimension in these types of study. While the specific cues that are important may vary between locations, cultures, and environments, they emphasize the social context in which health behavior takes place. As expected, attending clinic regularly is an important predictor of compliance in the present study. It provides an opportunity for multiple cues that can improve compliance, including blood pressure checks, discussing actions to control blood pressure, and reminders to take medication.
CONCLUSION
Components of the HBM show variation in association with treatment compliance for hypertension in this Nigerian community. The findings provide useful baseline data for future studies of the Health Belief Model in hypertension and other chronic conditions in similar societies.
Strength and limitations of the study
Strengths of this study include: the use of both survey and FGD methods; inclusion of a large set of variables and focus on the components of the HBM to a non-communicable disease (hypertension) in a developing country context. A potential limitation is that the study did not formally investigate the modifying factors dimension of the HBM. Nonetheless, the findings provide clues to care-seeking and compliance issues, while suggesting potential intervention points (e.g. breaking the cost barrier, including social networks in treatment plans) that could be further studied and tested.
Ethical Approval
Ethical approval for the study was obtained from the Joint University of Ibadan /University College Hospital Ethical Committee.
Acknowledgment
The authors are grateful to the study participants and community leaders of Idikan community, Ibadan. The input of Dr. Bernard Owumi and Dr. Patricia Awa Taiwo of the Department of Sociology, University of Ibadan, is hereby acknowledged.  

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Persistent Pulmonary Hypertension of the Newborn (PPHN)

Persistent pulmonary hypertension of the newborn (PPHN) is the inability to relax the pulmonary circulation arrangement at birth, which leads to non-oxygenated blood bypassing around the lungs and into the systemic circulation. Therefore, blood that has not gone to the lungs, where the oxygen is picked up from, is pushed into the left side of the heart which then is pumped throughout the body and causes many symptoms. The blood is shunted through the foramen ovale (PFO) and ductus arteriosus (PDA). These passageways are developed in utero to bypass the lungs so that circulation is possible for the infant while the mother provides the oxygen. Failure of one or both of these closing is a primary factor for causing PPHN (Persistent Newborn Pulmonary Hypertension, 2018).

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The etiology of PPHN is varied and is accompanied by other neonatal diseases as well. According to Ostrea (2006), “any condition that leads to chronic hypoxia in utero or abnormal muscularization of the pulmonary vessels can lead to persistent pulmonary vasoconstriction and PPHN after birth” (Ostrea, 2006, p.179). Some of the conditions included in this category would be asphyxia, neonatal respiratory distress syndrome, and aspiration syndromes like meconium aspiration syndrome (MAS) (Raju, U., Sondhi, V., & Patnaik, S., 2010). Other conditions that are related to PPHN are ones that can result in declines in the pulmonary vascular bed such as pulmonary hypoplasia and congenital diaphragmatic hernia (CDH). Situations that can cause increases in pulmonary venous pressure such as a mitral obstruction, aortic stenosis, hypoplastic left heart syndrome, and endocardial fibroelastosis also are correlated with PPHN. With this information, it is now known that the diagnosis of PPHN can be problematic due to it being closely related with all the conditions listed. To properly diagnose PPHN, the condition must be fully understood through its pathophysiology.

Fetal circulation in utero has very distinguishing characteristics. Ostrea explains that some of those are (2006) “a high pulmonary vascular resistance, low systemic resistance in the placenta, and the presence of transient circulatory channels such as the ductus venosus, ductus arteriosus, and foramen ovale” (Ostrea, 2006, p. 180). Due to these structures, blood can bypass the lungs and move through the heart efficiently to provide systemic circulation. As an infant cannot breathe while in the womb, this is an important characteristic for the life of the infant. When the infant is birthed, an astonishing and scientific miracle takes place. These three pathways will constrict till closure over the first twenty-four hours after birth. The closure of these ducts forces the blood to begin moving through the lungs to become oxygenated and provide oxygen to the rest of the body. When an infant has PPHN, two of the pathways, such as the PFO and PDA, do not close during those first twenty-four hours. This creates a right to left shunt in the heart where deoxygenated blood moves from the right side of the heart to the left, bypassing the pulmonary system. That blood is then circulated throughout the body which limits perfusion into the tissues (Waknin, R.).

PPHN is most often seen in late preterm or term newborns. It consists of three different modalities: PPHN related to underdevelopment, mal-development, and mal-adaptation. All three types have numerous causes and risk factors, but according to Puthiyachirakkal and Mhanna (2013), “meconium aspiration syndrome is the most common cause of PPHN” (Puthiyachirakkal & Mhanna, 2013, p. 1). It is simply explained that PPHN in MAS results from obstructions in the airways, insufficient surfactant, and chemical pneumonitis (Greenspan, J. S., 2014). Some other risk factors include pneumothorax, asphyxia, and changes in the fetal heartbeat rhythm. With smooth muscle proliferation and adventitial thickening, the PVR rises which causes shunting from right-to-left through the PFO and PDA. The hypoxia and respiratory acidosis further exacerbate the constriction of the pulmonary vessels and generate a vicious cycle of shunting (Mhanna, Jean, M., & Ashraf, M., 2013).

Clinical manifestations for PPHN may differ with each case. Most patients diagnosed with PPHN are either term or late-term neonates, but it is not uncommon for preterm infants to also receive this same finding. Some patients may exhibit tachypnea, tachycardia, and low oxygen saturation levels. Another case might present with bradycardia, heart murmur, and cyanosis. A couple of instances might show meconium-stained amniotic fluid being discharged from the birthing canal. Not all symptoms need to be present for PPHN to be the diagnosis. Any combination or singular symptom could be the determining factor. The one thing the signs all have in common is that they tend to start presenting within the first 24 hours of life. Most have low APGAR scores and almost all the neonates received some sort of intervention in the delivery room such as oxygen therapy, bag and mask ventilation, and endotracheal intubation.

Most neonates will go through basic screenings and testing such as pulse oximetry, ABGs, and of course, chest radiographs. Although these tests can show the signs and symptoms for PPHN, the diagnosis of PPHN is primarily made by echocardiography. Echocardiography will show a normal cardiac structure with signs of pulmonary hypertension. That will be shown through a flattened or a displaced ventricular septum. It will also show ventricular function that is impaired. Echocardiography may also show the severity of PPHN that is present. Research by Stark and Eichenwald (2018) revealed, “the majority of infants also have other respiratory diagnoses associated with PPHN” (Stark & Eichenwald, 2018). MAS is seen in 41% of PPHN diagnoses. Another 14% goes to pneumonia and 13% to respiratory distress syndrome. A smaller percentage of the neonates are also associated with CDH at 10% and pulmonary hypoplasia at 4%. Only 17% of neonates with PPHN have no other respiratory condition association (Stark & Eichenwald, 2018).

The first steps in treating PPHN includes ventilation of the lungs, oxygenation of the lungs and tissues, maintaining proper blood pressure, and equilibrium of the body. Treating the underlying disease is critically important in the treatment of PPHN. The use of inhaled nitric oxide (iNO) was approved in 1999 for neonates diagnosed with PPHN (Inhaled nitric oxide, 2019), but only with near-term and term infants. Mortality in infants has significantly decreased with the use of iNO, although, about 40% of patients will not respond to it. Oxygen can be used as a vasodilator, but ventilating the lungs with 100% O2 has been linked with an uncertain reaction to iNO. Ventilation through a ventilator is used to maintain the PaCO2 between 40 and 60 mmHg to optimize lung volume. According to Lloyd and Smith (2016), “high-frequency oscillatory ventilation (HFOV) can minimize lung injury, but has not been proven to have a clear benefit over conventional ventilation, except when used in combination with iNO in the treatment of MAS” (Lloyd & Smith, 2016, p. 195).

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Surfactant therapy has had mixed results in treating PPHN. As surfactant has not shown impressive results with improving lung compliance, it has presented better results when it comes to pulmonary morbidity, lower length of hospital stays with neonates and air leakage. Numerous medications are also being used in the treatment of PPHN. Some of those medications may include calcium channel blockers, phosphodiesterase type (PDE) 5 inhibitors, endothelin receptor antagonists, phosphodiesterase (PDE) type 3 inhibitors, and magnesium sulfate. In Puthiyachirakkal and Mhanna’s research (2013), “… studies have shown that intravenous magnesium sulfate can cause a reduction in pulmonary artery pressures” (Puthiyachirakkal & Mhanna, 2013, p. 1), however, observational studies are the only thing available for neonates.

PPHN is an emergency that needs premature involvement and managing to avoid serious hypoxemia and more than a few short to long-term illnesses. The most important treatment is the handling of the underlying disorder. These therapies include numerous useful methods like oxygen therapy, mechanical ventilation, iNO, and PDE inhibitors. However, the ideal method of managing PPHN remains debatable. Future high classed random studies of current and innovative beneficial procedures are desired to advance solid, document-based approaches for the handling of PPHN. Infants with PPHN need continuing follow-ups, subsequently because they are at risk for developmental disabilities and long-lasting health situations (Teng, R., & Wu, T., 2013).

References

(n.d.). Retrieved January 6, 2019, from https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat/persistent-pulmonary-hypertension-newborn-pphn

Greenspan, J. S. (Ed.). (2014, October). Meconium Aspiration (for Parents). Retrieved January 6, 2019, from https://kidshealth.org/en/parents/meconium.html

Inhaled nitric oxide. (n.d.). Retrieved January 6, 2019, from https://docslide.us/documents/inhaled-nitric-oxide.html

Lloyd, L. G., & Smith, J. (2016). The management of persistent pulmonary hypertension of the newborn: A review. South African Journal of Child Health, 10(4), 194-198. doi:10.7196/sajch.2016.v10i4.1145

Meconium Aspiration Syndrome. (n.d.). Retrieved January 6, 2019, from https://www.dovemed.com/diseases-conditions/meconium-aspiration-syndrome/

Mhanna, Jean, M., & Ashraf, M. (2013, August 19). Pathophysiology, Management, and Outcome of Persistent Pulmonary Hypertension of the Newborn: A Clinical Review. Retrieved January 6, 2019, from https://www.frontiersin.org/articles/10.3389/fped.2013.00023/full

Ostrea, E. M., Villanueva-Uy, E. T., Natarajan, G., & Uy, H. G. (2006). Persistent Pulmonary Hypertension of the Newborn. Pediatric Drugs, 8(3), 179-188. doi:10.2165/00148581-200608030-00004

Persistent Newborn Pulmonary Hypertension. (2018, September 17). Retrieved January 6, 2019, from https://emedicine.medscape.com/article/898437-overview

Persistent Pulmonary Hypertension (PPHN). (n.d.). Retrieved January 6, 2019, from https://www.slhd.nsw.gov.au/rpa/neonatal/html/newprot/pphn.html

Persistent Pulmonary Hypertension of the Newborn | Pediatrics Central. (n.d.). Retrieved January 6, 2019, from https://peds.unboundmedicine.com/pedscentral/view/5-Minute-Pediatric-Consult/617614/all/Persistent_Pulmonary_Hypertension_of_the_Newborn

Persistent Pulmonary Hypertension of the Newborn (PPHN). (n.d.). Retrieved January 6, 2019, from https://www.abclawcenters.com/practice-areas/persistent-pulmonary-hypertension-of-the-newborn-pphn/

Persistent Pulmonary Hypertension of the Newborn (PPHN). (n.d.). Retrieved January 6, 2019, from https://www.nationwidechildrens.org/conditions/persistent-pulmonary-hypertension-of-the-newborn-pphn

Puthiyachirakkal, M., & Mhanna, M. J. (2013). Pathophysiology, Management, and Outcome of Persistent Pulmonary Hypertension of the Newborn: A Clinical Review. Frontiers in Pediatrics, 1. doi:10.3389/fped.2013.00023

Raju, U., Sondhi, V., & Patnaik, S. (2010). Meconium Aspiration Syndrome: An Insight. Medical Journal Armed Forces India, 66(2), 152-157. doi:10.1016/s0377-1237(10)80131-5

Stark, A. R., MD, & Eichenwald, E. C., MD. (2018). Persistent pulmonary hypertension of the newborn. UpToDate. Retrieved December 18, 2018, from https://www.uptodate.com/contents/persistent-pulmonary-hypertension-of-the-newborn.

Teng, R., & Wu, T. (2013). Persistent pulmonary hypertension of the newborn. Journal of the Formosan Medical Association, 112(4), 177-184. doi:10.1016/j.jfma.2012.11.007

Waknin, R. (n.d.). Persistent pulmonary hypertension of the newborn | Radiology Reference Article. Retrieved January 6, 2019, from https://radiopaedia.org/articles/persistent-pulmonary-hypertension-of-the-newborn

Hypertension (High Blood Pressure) Causes, Treatment and Complications

Hypertension

Hypertension (High Blood Pressure)

Hypertension is the condition in which force of the blood pushing against artery vessel walls is too high. It is measured in millimeters of mercury  (mmHg). Hypertension or high blood pressure (HTN) means the pressure in arteries is consistently above normal 140/90 mmHg, or high than it should be resulting in excessive pressure on the walls of the arteries. Hypotension is an abnormally low blood pressure, which may be caused by emotional or traumatic shock; hemorrhage and chronic wasting disease. Persistent reading of 90/60 mmHg or lower usually is considered hypotension orthostatic hypotension can cause patients to experience vertigo or syncope.

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Hypertension is the common life-threatening disease among American. It is estimated that one in four American has high blood pressure. The incidence of hypertension in the United States has increased as a result of an aging population and the increased incidence of obesity. Nearly half of the American Population over age 20 has hypertension, and many do not even know it. Not treating high blood pressure is dangerous. Hypertension increases the risk of heart attack and stroke.

Blood pressure is written as two numbers, such as 120/70 mmHg. The highest occurring persistent health disorder blood pressure. About 30% of the people, population around the globe has an increased blood pressure with systolic and diastolic equivalent or more than 140/90 mmHg. Blood pressure gently and continuously upswing with age growth. The escalation of the hypertension notice in the different age groups 20% of 20 years of age, 40% of 40 years of age, 60% of 60 years of age and 80% of 80 years of age. 

Etiology (Causes of hypertension)

In about 90% of cases, the precise cause of high blood pressure is unknown. This type of hypertension is known as essential or primary hypertension. High blood pressure caused by an underlying condition. This type of blood pressure is known as secondary hypertension, which tends to appear suddenly and cause high blood pressure, the condition such as obstructive sleep apnea, kidney disease, and medications. Certain factors seem to increase the risks of developing essential hypertension including.

Family history:  High blood pressure runs in families. Studies of twins have shown that inheritance accounts for 25% of the variability in blood pressure. Genetic factors play a role in the development of hypertension, and can, in particular, be expressed as the diminished ability of the kidney to excrete salt.

Weight:There is a significant association between obesity and hypertension that cannot be fully accounted for by an overestimation of blood pressure arising from the use of an inappropriately sized cuff. In clinical trials, weight loss almost always causes a fall in blood pressure.

Ethnicity: Research has shown that Black or African American have high risks or develop high blood pressure than white American.

Salt Intake:  this is the main element, which cause increase blood pressure due to extreme salt consumption.

Potassium intake: A high potassium intake protests against some of the effects of high salt intake on blood pressure and much epidemiological evidence also suggests that high dietary potassium intake is associated with lower blood pressure. Studies of black people in the United States of America have shown that, where salt intake is similar to that of white people the higher prevalence of increased blood pressure is associated with lower potassium intake.

Age: Blood pressure normally increases, as one grows older. Men are more likely to develop High blood pressure at the age 50 and above. Women are more likely to develop high blood pressure at the age 60 and above.

Chronic stress: Research indicates that people who are under continuous stress tend to develop more heart and circulatory problems than people who are not under stress. Acute stress causes an increase in blood pressure.

Smoking: Smoking tobacco constricts blood vessels thus cause an increase in high blood pressure.

Alcohol consumption:  Heavy alcohol consumption is associated with increased blood pressure. However, it appears that this relationship is quite transient because, if alcohol is withdrawn there is an immediate fall in blood pressure. It most likely that the alcohol-related rise in blood pressure results from either a direct vasoconstrictive effect or an increase in sympathetic tone as blood alcohol level rise.

Physical inactivity: In addition to contributing to the rapid increase in obesity in all developed countries, physical inactivity is associated with a high incidence of hypertension. Regular aerobic activity may lower blood pressure.

Signs and symptoms

Hypertension is largely symptomless or no sign is a silent killer. Hypertension often is discovered during medical treatment for other problems. Approximately one-third of people who have high blood pressure are unaware of it because there are few or no symptoms and as a result, an individual with hypertension may go undiagnosed for many years. If symptoms occur, they may include one or more of the following: 

Blurred or loss of vision

Severe headaches especially pounding headaches behind the eyes

Nausea and vomiting unrelated to indigestion or other food or medication-related causes.

Dizziness or syncope episodes

Tinnitus (a sensation of ringing or buzzing in the ears)

Flushed face, fatigue, epistaxis, excessive perspiration, heart palpitations, frequent urination, and cramping in the legs with walking. The only way to know whether you have hypertension is to have checked regularly.

Diagnosis

Hypertension affects more the 75 million people in the United States of America, many whom are not even aware they have the disease. In addition, the prevalence of hypertension is on the rise as a result of the growing obesity epidemic.  American Heart Association guideline for diagnosis and management of hypertension include three categories for diagnostic and treatment purposes. The diagnosis of hypertension may include the following.

Medical history will provide the physician with a significant proportion of the information needed to assess cardiovascular risk. Relevant past medical history includes evaluation for comorbid risk factors, including type 1 or types 2 diabetes mellitus, dyslipidemia, obesity, smoking history, diet and exercise regime, and presence of vascular disease, including coronary artery disease, congestive heart failure, chronic kidney disease, stroke, and cardiac arrhythmias. In addition, it is helpful to characterize non-cardiovascular disease that may either be associated with hypertension disease such as bronchial asthma, chronic lung disease psychiatric disease. Characterization of the family history is relevant for the assessment of the newly diagnosed hypertension patients.

Physical examination. A thorough physical examination is essential in the diagnosis of a patient with hypertension. The physical examination should include accurate measurement and recording of the blood pressure, evaluation of general appearance, height, weight, waist circumference calculation of the body mass index, fat distribution and skin changes.

Funduscopic examination is of utmost importance in assessing for target organs damage and for risk stratification.

The cardiovascular examination is essential in the evaluation of hypertension patients and includes determination of cardiac rate and rhythm, auscultation of the heart and evaluation of peripheral pulses. Auscultation of a loud brisk first heart sound associated with a brisk carotid upstroke also suggests the presence of a hyperdynamic and possibly enlarged left ventricle. 

Hypertension stages

Blood pressure category

Systolic (mmHg)

Diastolic (mmHg)

Prehypertension

120 – 139

80 – 89

Stage 1 hypertension (mild)

140 – 159

90 – 99

Stage 2 hypertension (Moderate)

160 – 179

100 – 109

Stage 3 hypertension (severe)

180 and above

110 and above

Treatment of hypertension

The overall aim when treating individuals with consistently raise blood pressure is to lower their blood pressure and maintain this for the rest of their lifetimes, whole keep them feeling complexly well. Given the modern therapeutic approach to high blood pressure, with both non-pharmacological advice and the large range of drugs available, it is possible to achieve this aim for the majority of people. All individuals should be properly assessed for sustained hypertension and overt secondary causes. In addition, all patients regardless of blood pressure level should be given non- pharmacological advice and attention should be paid to other cardiovascular risks factors.

Non-pharmacological treatments

Decrease too much consumption of table salt.  Examine the hardship of realizing remarkable body mass loss, minimizing too much uptake of salt will be the efficacious method or way of decreasing hypertension.

The overweight cutback is also one of the greatest ways of treating or controlling hypertension among people. Many people with hypertension are linked to body overweight for height. Cutting back or down the body weight may control hypertension.  Therefore, all hypertension people who obese or overweight should be advised to consider cutting down their weight to control hypertension.

Consider raising potassium consumption: high or moderate uptake of potassium is considering one of the best ways to treat or lower hypertension. Patients with hypertension should be encouraged to consume extra garden fresh fruits, bananas, beans and fish.  Healthy food has benefits not exclusively maximize potassium consumption. Healthier diet has the advantage only of increasing potassium intake, however, it also reduces high salt, drenches fat and excessive fiber.

Considering reducing too much alcohol consumption may help in controlling hypertension because there is some link between alcohol and hypertension but the effects are less. Average alcohol consumption can help to control cardiovascular consequences.

Physical activity: Regular physical activity (that is to say 30 minutes of aerobic exercise for four to five times a week) is also another way to treat or controlling hypertension. obviously, a person with hypertension condition or unhealthy person should begin with the moderate level of exercises such as walking or bike riding. Being physically active will help to reduce or control hypertension complication.

Hypertension patients should be encouraged to quit smoking cigar/tobacco and drugs this may help to treat or control hypertension with other related long-term complication such as thrombotic stroke and coronary heart disease.

Pharmacological treatment.

The patient’s blood pressure level will determine how quickly drug therapy is initiated. All those with mild to moderate hypertension should be encouraged for non-pharmacological treatment. The four principal drug classes currently used in the treatment of high blood pressure are:

Diuretics. There are three major groups of diuretics:

Thiazide diuretics (hydrochlorothiazide, bendroflumethiazide) act by inhibiting tubular sodium and chloride resorption, thereby causing loss of sodium chloride and a decrease in extracellular volume, resulting in a fall in blood pressure.

Calcium antagonists

Hypertension usually asymptomatic and treatment will need to be continued for a long time, usually for life.

Complications of hypertension

If hypertension is not brought under control, it can cause severe damage to vital organs, such as the heart, brain, kidneys, and eyes. This damage can result in a heart attack or heart failure, stroke, kidney damage, or damage vision.

Hypertension causes damage and complication to the blood vessels, heart, brain, and kidneys. This damage is either a direct consequence of high blood pressure or the result of accelerated atherosclerosis and destabilization of plaques that high blood pressure causes.

Abnormal enlargement (hypertrophy) of Ventricular, the labor of heart has to expand as blood pressure hike result to an expansion of the heart especially the left side of the ventricular.

Heart destruction (failure), due to extra work hypertension leave on the heart, the increase hypertension has been considered as one of the crucial source or cause of chronic heart disease.

Myocardial infarction (heart attack), when there is an increased demand due to hypertension the heart may not supply oxygen-rich blood to the heart muscle can block the blood may clot in a coronary artery.

Hypertension can lead to a stroke when the blood flow to the brain is unexpectedly blocked off because stroke occurs from the blocked or break a blood vessel in the brain.

Kidneys damage acute hypertension in the precipitate or cruel form can cause accelerating kidneys damage eventually lead to renal dysfunction or failure. 

Prognosis of hypertension

Hypertension is common and independent risk factors if it is untreated, it can lead to the development of chronic condition such as coronary artery disease, cerebrovascular disease, and heart failure. It plays a dominant role in the development and progression of atherosclerotic vascular disease. Hypertension predisposing risk factors that lead to the development of hypertension chronic kidney disease, coronary heart disease, and diabetes.  Everyone in the community is at risk to develop hypertension.

Conclusion:

Most patients with hypertension require two or more medication to achieve desired blood pressure levels. The goals of treatment are to maintain blood pressure below 140/90 mmHg or below 130/80 mmHg. A patient-centered treatment approach should be implemented to motivate patients and to maintain compliance with hypertension management. A medical assistant can play an active role in establishing a therapeutic relationship with the patients by providing ongoing health education. Your lifestyle is your health. Changing your lifestyle can go a long way toward controlling high blood pressure. Staying healthy has the best impact on our bodies and it also plays an important role in our daily activities. It is said, “your lifestyle is your health”. So, eat healthy food, do not consume too much alcohol, do not smoke, exercise daily, and always have a positive attitude

References

MacGregor, G. A., & Kaplan, N. K. (2010). Hypertension (Vol. 4th ed). Abingdon: Health Press. Retrievedhttp://search.ebscohost.com.asa.idm.oclc.org/login.aspx?direct=true&db=nlebk&AN=412341&site=ehost-live

Bakris, G. L., & Baliga, R. R. (2012). Hypertension. Oxford: Oxford University Press. Retrieved fromhttp://search.ebscohost.com.asa.idm.oclc.org/login.aspx?direct=true&db=nlebk&AN=502211&site=ehost-live

Lip, G. Y. H., & Nadar, S. (2009). Hypertension. Oxford: OUP Oxford. Retrieved from http://search.ebscohost.com.asa.idm.oclc.org/login.aspx?direct=true&db=nlebk&AN=467661&site=ehost-live

Effects of Dietary Management on Symptoms of Hypertension

Introduction
Hypertension is a cardiovascular condition continuously on the rise due to many modifiable and nonmodifiable risk factors. The effects of this condition are manageable yet can also lead to rapid decline. According to recent studies, hypertension (or high blood pressure) is the primary contributor to cardiovascular disease and is the leading cause of morbidity and mortality worldwide (Mohamed et al., 2018, p. 9). Jones, Forouhi, Khaw, Wareham, and Monsivais (2018) go on to say, “Cardiovascular disease (CVD) is the most common cause of death in the world and was estimated to account for 32% of all deaths in 2013 (p.235).” Sanuade, Boatemaa, & Kushitor (2018) studied hypertension prevalence, awareness, treatment and control in Ghanaian population and globally stating, “Recent evidence shows that between 1990 and 2015, there has been an increase in hypertension incidence, prevalence, and deaths globally [2]” (p.1).

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As a result of these statistics, lifestyle modifications were researched to learn how patients diagnosed with hypertension can control their condition and reduce their risk for health decline. Dietary management and its effect on hypertension were the focal points during research. The interventions of interest are shown by studies done to assess the effect and correlation of dietary management on symptoms of hypertension. 
The PICO question guiding this paper is, in patients with hypertension, how does dietary management compared to no dietary management affect the symptoms of this chronic illness? The intent of this paper is to address the effects of dietary management and no dietary management in patients who have hypertension. This issue will be addressed through evidence presented in research studies expanding on dietary management resulting in weight loss, decreased obesity, and decreased symptoms of hypertension. Nurses play an important role in the lives of patients diagnosed with hypertension because they encounter them every day.
Nurses, as health care professionals, are responsible for educating their patients. Patients with hypertension should be educated on the effects of poor dietary management with this condition and the benefits that proper nutrition can yield. This paper provides evidencbout the management of hypertension to provide nurses with additional knowledge, so they are more equipped to educate their patients.
Literature Review
The articles discussed provide evidence on the effects of dietary management compared to no dietary management in patients with hypertension. Three topics were identified while reading the evidenced based research. The first topic involved foods to be avoided in patients with hypertension and foods that should be consumed to decrease the risk of progression into cardiovascular disease. The second topic was how weight loss can benefit someone diagnosed with hypertension and the third expanded on how exercise effects patients with hypertension.  Therefore, all articles researched discuss the effects, benefits, and importance of dietary management and other aspects regarding hypertension.
Diet
According to the article written by Jones et. al (2018), prioritizing a healthy diet significantly benefits someone diagnosed with hypertension (p.325). In this study, two trials were done to test the effects of dietary management. In this article Jones et. al (2018) states,
A diet based around nutrient targets – specifically reduced fat intake – was found to be less effective at reducing risk of CVD events than a dietary pattern based around changing the consumption of fruit, vegetables, whole grains, fish, nuts, dairy products and vegetable oils, and reduced consumption of processed meats, sugars, desserts, alcohol, and fats (p. 236).
Most patients who have hypertension see a decline in their health due to poor dietary management. Neglected nutrition can cause a buildup of lipids which results in an elevation of blood pressure. This can further lead to an increased risk for cardiovascular disease. Foods that cause this decline include processed meats, sugars, desserts, alcohol, fats, and red meats (Jones et. al, 2018, p. 235). Conversely, Jones et al. (2018) states consuming a diet of fruit, vegetables, legumes, whole grains, and low-fat dairy as opposed to fatty alternatives, significantly lowers the risk for decline with hypertension (p. 235). However, when regarding dietary management, education and compliance are priority. One risk for gathering self-reported data is that the patient may withhold their entire daily intake, causing error in dietary regiment. This results in possible increased blood pressure and risk for cardiovascular disease. Thus, emphasizing the importance of dietary management for prevention of chronic disease. 
Weight Loss
Poorolajal, Hooshmand, Bahrami, and Amen (2017) reviewed the next topic found, being the association between weight loss and incidence rate of hypertension (p, 95). Hypertension is a condition not only associated with overweight or obese individuals, but in comparison to normal weight, overweight can increase the risk of hypertension (Poorolajal et. al, 2017, p. 95). Poorolajal et. al (2017) expands on this statistic in his article by stating, “Raised blood pressure is a major risk factor for cardiovascular disease and stroke (p. 95). Evidence has shown that raised blood pressure happens in individuals of all body sizes, ranging from lean to obese. However, people who are overweight or obese are greater risk of developing high blood pressure” (Poorolajal et. al, 2017, p. 95). Due to this risk factor, the purpose of this article was specifically to provide evidence on if weight loss is a beneficial method of controlling hypertension and decreasing risk for cardiovascular disease. This research specifically expanded on “the effect of overweight and obesity on the risk of raised blood pressure and estimated the amount of relative reduction in the incidence of hypertension that may occur if excess body weight is controlled” (Poorolajal et. al, 2017, p. 95). The eligibility criteria were clearly stated, including explanations as to what overweight and obesity are defined as.
The exposure of interest was overweight and obesity. Overweight refers to a BMI between 25 and 29.9 kg/m squared. Obesity refers to a BMI equal to or >30 kg/m squared. The outcome of interest was high blood pressure so called hypertension. Hypertension refers to a mean systolic/diastolic blood pressure at or above 140/90 mmHg (Poorolajial et. al, 2017, p. 95)
One measure utilized was Attributable Risk Fraction (AFR), which indicates how much of the relative prevalence of raised blood pressure will reduce per specified weight loss. Researchers determined the evidence presented by gathering a variety of data from studies and data extracted from other research articles, comparing weight loss to the effects on overweight and obese patients with hypertension. Through comparing data, researchers found that the effect of weight loss had a positive correlation on the reduction of incidence rate in hypertension and decreased risk for future cardiovascular disease. According to the results and statistics, the article’s conclusion was that weight loss can effectively reduce the incidence rate of hypertension, therefore, excess weight loss is a vital strategy for controlling hypertension and is sufficient for achieving the global target relative reduction in the incidence of raised blood pressure (Poorolajial et. al, 2017, p. 95).
Exercise
An article written by Pescatello, McDonald, Lamberti, and Johnson (2015, p. 87) specifically expands upon the topic of the effects of exercise on hypertension. Through a series of randomized controlled trials, researchers were able to administer a variety of amounts of exercise including acute and chronic aerobic, dynamic resistance, and concurrent exercise ranging from 30-60 minutes each day on patients who were diagnosed with hypertension. After these exercises were administered, blood pressure was taken and recorded.
Numerous randomized controlled trials (RTCs) have been conducted investigating the antihypertensive effects of exercise…These meta-analyses concluded that aerobic exercise training lowers blood pressure (BP) 5-7 mmHg, while dynamic resistance training lowers BP 2-3 mmHg among adults with hypertension. The magnitude of these BP reductions rivals the magnitude of those obtained with first-line antihypertensive medications and lower CVD risk by 20-30% (Pescatello, et. al, 2015, p. 87).
Based on the results of the study, it was concluded that practicing regular exercise significantly reduces blood pressure. Therefore, making exercise a key modifiable determinant of hypertension that should be prioritized to reduce the significance of hypertension and its effects to those who are diagnosed with this condition (Pescatello et. al, 2015, p. 87). 
The biopsychosocial aspects related to hypertension include obesity, depression, and cardiovascular disease. Most individuals who are diagnosed with hypertension often lack diet management and exercise, which results in overweight or obesity. Obesity becomes psychosocially problematic when body image and self-esteem significantly decline, which can lead to depression. In addition to the biological aspect of obesity, untreated hypertension or noncompliance to a treatment plan leads to an increased risk for cardiovascular disease. If untreated, hypertension can cause an overall decline, frequently leading to obesity, depression, and cardiovascular disease.
Discussion
A.D., a 73-year-old male diagnosed with hypertension about two years ago was the subject interviewed throughout this process. Research found suggested that to decrease symptoms of hypertension and prevent further decline, patients diagnosed should practice diet management, prioritize weight loss, and exercise frequently. If compliant to these lifestyle modifications, research proposes a decrease in blood pressure and risk for future cardiovascular disease.
Nursing interventions suggested in the literature include engaging in a healthy lifestyle including diet management, weight control, and exercise. As stated before, diet management regarding patients diagnosed with hypertension is crucial for preventing further decline. A.D. has been practicing diet management for the previous two years and currently states that he “tries to cut down on sodium and consume foods that promote healthy blood pressure”. From the time of being diagnosed with hypertension to now, A.D. has lost 30 pounds from diet management and exercise. A.D. currently weighs 228 pounds and is 6’1”, giving him a BMI of 30.1, which is obese. Although he is considered obese, A.D. plans to lose more weight in the future through the same type of healthy lifestyle. In addition to diet management and weight loss, A.D. regularly goes to the gym about three times a week. His current gym regimen involves him doing cardio and weights every time he attends. A.D stated, “I try to incorporate cardiovascular and weight training exercises into my workout”. Cardio either being the bike machine or treadmill, and weights involving body weight exercises or free weights. A.D. also stated that he plans to continue his exercise routine throughout the future to promote losing weight and preventing further decline.
Direct nursing care measures and patient teaching which have been utilized with A.D. was educating on exactly how to engage in a healthy lifestyle required to prevent further decline of hypertension. Instilling different types of diet management and emphasizing the importance of prioritizing diet management are essential for patient competence. This may include describing different dieting plans or explaining specifically what foods to avoid and what foods to prioritize in a diet geared towards those who are diagnosed with hypertension. The importance of weight loss in addition to diet management is essential to educate the patient on, due to its positive effects on lowering blood pressure and therefore reducing the risk of worsening hypertension. Further education on integrating exercise into someone’s life is also important when teaching a patient how to engage in a healthy lifestyle. Explaining outlets for working out and the variety of at home exercises is important regarding a patient who may be overwhelmed with the idea of working out in general. As well as explaining how to engage in a healthy lifestyle, it is crucial to educate the patient on how hypertension has the potential to turn into serious cardiovascular disease. This may prompt the patient to prioritize preventative measures more seriously. Literature suggests that with diet management, weight loss, and regular exercise, a patient’s blood pressure is likely to decrease, reducing the potential of their hypertension to turn into serious cardiovascular disease.
A.D. is receiving the best practice based on the evidence that literature indicated, yet more education on specific diet management could be given. Further education would be given to confirm that he is getting the nutrients that he needs while only ingesting foods that promote cardiovascular function.
Developing a teaching plan for this patient would include mapping out a specific diet management plan and weekly exercise regimen. As stated before, A.D. currently “tries to cut down on sodium and only eat foods that promote healthy blood pressure”. Although this statement indicates that A.D. prioritizes a heart healthy diet, providing a specific diet plan would be beneficial in creating structure and therefore increasing compliance. Proper nutrition should include a diet high in fruit, vegetables, legumes, whole grains, and low-fat dairy. This will ensure that A.D. gets the appropriate vitamins and minerals needed, yet also promoting healthy blood pressure. A key exercise regimen would include cardio and weight bearing exercises for a period of 30-60 minutes three times a week. Cardio would involve biking or running, and weight bearing exercises may include either body weight, or utilizing free weights. These dynamic range of aerobic, dynamic resistance, and concurrent exercises will allow the burning of fat in the body, which lowers blood pressure, in addition to strengthening muscles. The limitations of this teaching plan would be noncompliance from the patient. As healthcare workers, educating the patient is vital in preventing decline, yet it is ultimately up to the patient whether or not they choose to comply with the teaching plan. Appropriate related nursing diagnoses would include knowledge deficit related to lack of specific diet plan. Due to not being prescribed a strict diet plan, this results in lack of in dept knowledge of which foods to avoid and prioritize for proper nutrition.
To evaluate the effectiveness of this teaching plan, A.D. stated that he plans to check his weight every day at the same time each day and monitor his blood pressure to assess any changes. A.D. agreed to prioritize a structured diet regimen and frequent exercise to continue to lower his blood pressure. In the future regarding nutrition, A.D. plans to discontinue red meats, alcohol, and sugar from his diet. He also states that he will incorporate cardiovascular promoting exercises that specifically burn fat into his exercise plan. The effects of these strategies will therefore be monitored through the evaluation of his body weight and blood pressure. Strengths to this teaching plan include that A.D. was educated on exactly how to engage in a healthy lifestyle involving proper nutrition, promotion of weight loss, and exercise. He was also educated on the importance of prevention of further cardiovascular disease. Another strength is that he was given structured diet and exercise plans in attempts to increase compliance.
Some suggestions in the literature that can be used, as a nursing student, to change practice would be to familiarize yourself with proper nutrition and exercises regarding patients diagnosed with hypertension. Understanding what foods inhibit the promotion of healthy blood pressure and which foods and exercises benefit those with high blood pressure is crucial when educating about controlling blood pressure. 
The patient’s preferences, with regard to the care given, are to continue with his diet and exercise plan. A.D. states “I want to continue to avoid sodium and only eat foods that promote healthy blood pressure. I also want to continue to workout three times a week and keep up the exercises I do at the gym.” The patient has been improving his compliance to following the teaching plan given and continues to show improvement in his blood pressure and weight loss.
Summary Conclusion
Nursing responsibilities in caring for patients affected by hypertension involves providing the best holistic personalized care while educating the patient. Holistic care entails more than solely dealing with the physical aspect of hypertension. To help patients appropriately cope and manage this condition, nursing responsibilities include taking into consideration the psychological, social, and spiritual aspects that the patient may be dealing with. Patients diagnosed with hypertension also need individualized care, which impacts wellness and promotes the best outcome for their situation. This means providing education on specific diet and exercise plans available to the patient and encouraging compliance with those plans. Education and encouragement are vital factors that contribute to impacting patient compliance. As nurses, offering these attributes to care endorses an overall well experience when patients are working through a chronic illness or condition.
References
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