Hypertension or high blood pressure is the most common chronic disease in the developed world, affecting up to 25 per cent of the adult population.
It remains to be the most important modifiable risk factor for coronary heart disease, stroke, congestive heart failure, renal disease and peripheral vascular disease. Sub-optimal blood pressure control is responsible for 62 per cent of cerebrovascular disease, 49 per cent of ischemic heart disease and leads to an estimated 7.1 million deaths a year.
The overall prevalence of hypertension in adults is around 30 to 45 per cent.
Based on recently published data from the UAE, the prevalence was found to be 30 per cent among the adult population in this part of the world. Although the risk of developing hypertension starts to increase after a person turns 18, it is progressively higher with advancing age - with a prevalence of more than 60 per cent in people aged over 60 years, and more than 75 per cent in people aged over 75 years. A sedentary lifestyle, increased body weight and poor dietary habits play a major role in the statistics.
Lowering one's blood pressure (BP) to normal target levels can significantly reduce premature morbidity and mortality. A number of proven, highly effective and well-tolerated lifestyle and drug treatment strategies are available to achieve this reduction in BP.
Despite this, BP control rates remain unacceptably high worldwide due to lack of awareness and patient and physician inertia. Consequently, hypertension remains a major yet preventable cause of cardiovascular disease and all-cause death globally.
Screening and diagnosis
Hypertension is a predominantly asymptomatic condition (without symptoms) and, therefore, all adults must regularly measure and should be aware of their blood pressure. People are considered healthy if their BP is less than 120/80mmHg, but this should be measured at least every five years.
In patients with a normal BP (120-129/80-84mmHg), BP should be measured at least every three years. Patients with high-normal BP (130-139/85-89mmHg), on the other hand, should have their BP recorded annually because of the high rates of progression of high-normal BP to hypertension. It is not uncommon to have high readings of BP in the medical facilities due to an effect called 'White Coat Hypertension', which happens due to anxiety, apprehension and fatigue associated with the visit to the facility.
There are ways to confirm the true readings of blood pressure in such situations, and they include ambulatory blood pressure monitoring or if the condition permits, home blood pressure monitoring.
Home BP is the average of all readings performed with a semiautomatic, validated BP monitor for at least three days, twice in a day and preferably for six to seven consecutive days.
It is worth mentioning here that finger-based instruments are not recommended, and wrist-based instruments may be less accurate in some patients depending on the wrist size and other factors.
When to initiate anti-hypertensive treatment
Up to certain levels of blood pressure, lifestyle interventions like dietary advice and exercise along with regular monitoring may be sufficient. But in significantly high BP readings or in the presence of features that suggest harmful effects of high blood pressure on the body, pharmacological treatment need to be initiated along with lifestyle interventions.
The initiation of treatment in most patients is done with a single-pill combination comprising two drugs. In some patients, however, an adequate dose of optimally chosen single drug may be sufficient.
The recommended lifestyle measures that have been shown to reduce blood pressure are salt restriction (permissible salt intake of less than 5gm/day), high consumption of vegetables and fruits, maintaining a healthy body mass index (about 20-25 kg/m2), and waist circumference values (less than 94cm in men and less than 80cm in women), and regular physical activity (at least 30 minutes of moderate dynamic exercise, five to seven days per week). Quitting smoking is highly recommended.
Follow-up of hypertensive patients
After the initiation of anti-hypertensive drug therapy, it is important to evaluate the patient's condition at least once within the first two months to review the effects on BP and assess side effects, until the BP is under control. The frequency of review will depend on the severity of hypertension, the urgency to achieve BP control, and the patient's co-morbidities.
Single-pill combination drug therapy should reduce BP within one to two weeks and may continue to lower it over the next two months. Once the BP target is reached, a visit interval of a few months is reasonable. Subsequently, no difference exists in BP control between three and six-month intervals.
Can anti-hypertensive medications be stopped?
In some patients, whom the treatment leads to effective BP control for a prolonged period, it may be possible to reduce the number and/or dosage of drugs. This may particularly be the case if BP control is accompanied by healthy lifestyle changes such as weight loss, exercise habit and a low-fat and low-salt diet. A reduction of medications should be made gradually, and the patient should be checked frequently because reappearance of hypertension can occur quickly.
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