What is high blood pressure

High blood pressure is medically known as hypertension, means your blood pressure is consistently higher-than-normal pressures and that also means your heart has to work harder to pump blood around your body. Your blood pressure is made up of two numbers given in millimeters of mercury (mm Hg): systolic pressure and diastolic pressure. Systolic pressure is the blood pressure when the heart ventricles pump blood out of your heart. Systolic pressure is represented by the top, higher number. Diastolic pressure measures the blood pressure in your arteries between heartbeats when your heart is at rest and is filling with blood and blood is not moving out of your heart. Diastolic pressure is represented by the bottom, lower number. For example, if your blood pressure is “140 over 90” or 140/90 mmHg, it means you have a systolic pressure of 140 mmHg and a diastolic pressure of 90 mmHg. The definition and categories of hypertension have been evolving over the years, high blood pressure is defined as systolic blood pressure 130 mmHg or higher and/or diastolic blood pressure 80 mmHg or higher ¹. Your blood pressure is considered high when you have consistent systolic readings of 130 mm Hg or higher or diastolic readings of 80 mm Hg or higher ². Everyone’s blood pressure will be slightly different. What’s considered low or high for you may be normal for someone else. As a general guide high blood pressure is considered to be 140/90mmHg or higher (or 150/90mmHg or higher if you’re over the age of 80). Readings above 180/120 mm Hg are dangerously high and require immediate medical attention. An ideal blood pressure is usually considered to be between 90/60mmHg and 120/80mmHg. Research have shown that systolic blood pressure greater than 120 mm Hg can be increasingly harmful to health ³, ⁴. You can have high blood pressure for years without any symptoms. Nearly half of American adults have high blood pressure and are not being treated to control their blood pressure. High blood pressure usually has no symptoms and many people don’t even know they have it ⁵. So the only way to find out if you have high blood pressure is to get regular blood pressure checks at least once a year from your health care provider. Your doctor will use a gauge, a stethoscope or electronic sensor, and a blood pressure cuff. He or she will take two or more readings at separate appointments before making a diagnosis.

Table 1. Blood pressure classification

Systolic blood pressure (mmHg)	and/or	Diastolic blood pressure(mmHg)	Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure	American College of Cardiology/American Heart Association 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
<120	and	<80	Normal blood pressure	Normal blood pressure
120–129	and	<80	Prehypertension	Elevated blood pressure
130–139	or	80–89	Prehypertension	Stage 1 hypertension
140–159	or	90–99	Stage 1 hypertension	Stage 2 hypertension
≥160	or	≥100	Stage 2 hypertension	Stage 2 hypertension

Footnotes: Blood pressure should be based on an average of ≥2 careful readings on ≥2 occasions. Adults with systolic blood pressure or diastolic blood pressure in 2 categories should be designated to the higher blood pressure category.

[Sources ⁶, ⁷ ]

The National Heart, Lung, and Blood Institute of the National Institutes of Health has determined 2 levels of high blood pressure for adults (for individuals aged 18 years and above):

• Stage 1 hypertension
  • 130 mm Hg to 139 mm Hg systolic pressure
  • OR
  • 80 mm Hg to 89 mm Hg diastolic pressure
• Stage 2 hypertension
  • 140 mm Hg to 159 mm Hg systolic pressure
  • OR
  • 90 mm Hg to 99 mm Hg diastolic pressure
• Stage 2 hypertension
  • Higher than 160 mm Hg systolic pressure
  • OR
  • Higher than 100 mm Hg diastolic pressure
• Hypertensive crisis
  • A blood pressure measurement higher than 180/120 mm Hg is an emergency situation that requires urgent medical care. If you get this result when you take your blood pressure at home, wait five minutes and retest. If your blood pressure is still this high, contact your doctor immediately. If you also have chest pain, vision problems, numbness or weakness, breathing difficulty, or any other signs and symptoms of a stroke (this is when blood flow to your brain stops) or heart attack (also called myocardial infarction), call your local emergency medical number.

The National Heart, Lung, and Blood Institute defines “prehypertension” or “elevated blood pressure” as:

• 120 mm Hg to 129 mm Hg systolic pressure
• AND
• Less than 80 mm Hg diastolic pressure

The National Heart, Lung, and Blood Institute guidelines define “normal blood pressure” as follows:

• Less than 120 mm Hg systolic pressure
• AND
• Less than 80 mm Hg diastolic pressure

Low blood pressure is define as:

• Less than 90 mm Hg systolic pressure
• AND
• Less than 60 mm Hg diastolic pressure

The recent European Society of Cardiology and European Society of Hypertension guidelines for individuals aged 16 years and above came out in 2018 and defined hypertension as ⁸:

• Optimal: systolic blood pressure less than 120 mmHg and diastolic blood pressure less than 80 mmHg
• Normal: systolic blood pressure 120 to 129 mmHg and/or diastolic blood pressure 80 to 84 mmHg
• High normal: systolic BP 130 to 139 mmHg and/or diastolic BP 85 to 89 mmHg
• Grade 1 hypertension: systolic BP 140 to 159 mmHg and/or diastolic BP 90 to 99 mmHg
• Grade 2 hypertension: systolic BP 160 to 179 mmHg and/or diastolic BP 100 to 109mmHg
• Grade 3 hypertension: systolic BP greater than or equal to 180 mmHg and/or diastolic BP greater than or equal to 110 mmHg
• Isolated systolic hypertension: systolic BP greater than or equal to 140 mmHg and diastolic BP less than 90 mmHg (further classified into Grades as per above ranges of systolic blood pressure)

European Society of Cardiology and European Society of Hypertension recommendations also shed light on home and ambulatory BP measurements and following cut-offs were given ⁸:

• Daytime (or awake) mean systolic blood pressure greater than or equal to 135mmHg and/or diastolic BP greater than or equal to 85 mmHg
• Night-time (or asleep) mean systolic blood pressure greater than or equal to 120mmHg and/or diastolic BP greater than or equal to 70 mmHg
• 24 hr mean systolic blood pressure greater than or equal to 130mmHg and/or diastolic BP greater than or equal to 80 mmHg
• Home BP mean systolic blood pressure greater than or equal to 135mmHg and/or diastolic BP greater than or equal to 85 mmHg

Isolated systolic hypertension is a condition in which the diastolic pressure is normal (less than 80 mm Hg) but systolic pressure is high (greater than or equal to 130 mm Hg). This is a common type of high blood pressure among people older than 65.

White coat hypertension is an office BP 130/80 mmHg or more but less than 160/100mmHg which comes down to 130/80mmHg or less after at least 3 months of anti-hypertensive therapy ⁹. Ambulatory or home blood pressure measurement is usually necessary for this diagnosis.

Masked hypertension is an elevated office systolic BP 120 to 129mmHg, and diastolic BP less than 80mmHg but raised BP on ambulatory or home measurements (130/80mmHg or more) ⁹.

Use these numbers as a guide only. Both numbers in a blood pressure reading are important. But after age 50, the systolic reading is even more important. A single elevated blood pressure measurement is not necessarily an indication of a problem. Because blood pressure normally varies during the day and may increase during a doctor visit (white coat hypertension), your doctor will likely take multiple blood pressure measurements over several days or weeks before making a diagnosis of high blood pressure and starting treatment. If you normally run a lower-than-usual blood pressure, you may be diagnosed with high blood pressure with blood pressure measurements lower than 140/90.

Uncontrolled high blood pressure increases your risk of serious health problems and need urgent treatment in hospital to reduce the risk of a stroke or heart attack. High blood pressure can also cause kidney failure, heart failure, problems with your sight and vascular dementia. Your blood pressure is important because if it is too high, it affects the blood flow to your organs. Over the years, this increases your chances of developing heart disease, stroke, kidney failure, diabetes, eye disease, erectile dysfunction and other conditions. Fortunately, high blood pressure can be easily detected. And once you know you have high blood pressure, you can work with your doctor to control it.

To control or lower high blood pressure, your doctor may recommend that you adopt a heart-healthy lifestyle. This includes choosing heart-healthy foods such as those in the DASH (Dietary Approaches to Stop Hypertension) eating plan. You may also need to take medicines. Controlling or lowering blood pressure can help prevent or delay serious health problems such as chronic kidney disease, heart attack, heart failure, stroke, and possibly vascular dementia.

High blood pressure can often be prevented or reduced by eating healthily, maintaining a healthy weight, taking regular exercise, drinking alcohol in moderation and not smoking.

What is blood pressure?

Blood pressure is the pressure of blood in your arteries or the force of blood pushing against your artery walls – the vessels that carry your blood from your heart to your brain and the rest of your body ¹⁰. You need a certain amount of pressure to get the blood moving around your body. Your blood pressure is determined both by the amount of blood your heart pumps and the amount of resistance to blood flow in your arteries. The size and elasticity of the artery walls affect blood pressure. The more blood your heart pumps and the narrower your arteries, the higher your blood pressure. High blood pressure, sometimes called hypertension, happens when this force is too high. A blood pressure reading is given in millimeters of mercury (mm Hg). This recording represents how high the mercury column in the blood pressure cuff is raised by the pressure of your blood. Mercury was used in the first accurate pressure gauges and is still used in medicine today as the standard unit of measurement for pressure. Health care workers check blood pressure readings the same way for children, teens, and adults. They use a gauge, stethoscope or electronic sensor, and a blood pressure cuff.

Your blood pressure naturally goes up and down throughout the day and night, and it’s normal for it to go up while you’re moving about. It’s when your overall blood pressure is consistently high, even when you are resting, that you need to do something about it.

Blood pressure is measured in millimeters of mercury (mmHg) and is given as two figures:

• Systolic pressure (the upper number) – the pressure when your heart pushes blood out. The systolic pressure (higher number) is the force at which your heart pumps blood around your body.
• Diastolic pressure (the lower number)– the pressure when your heart rests between beats. The diastolic pressure (lower number) is the resistance to the blood flow in the blood vessels.

For example, if your blood pressure is “140 over 90” or 140/90mmHg, it means you have a systolic pressure of 140mmHg and a diastolic pressure of 90mmHg. Normal blood pressure for adults is defined as a systolic pressure below 120 mmHg and a diastolic pressure below 80 mmHg. It is normal for blood pressures to change when you sleep, wake up, or are excited or nervous. When you are active, it is normal for your blood pressure to increase. However, once the activity stops, your blood pressure returns to your normal baseline range.

Both numbers in a blood pressure reading are important. Typically, more attention is given to systolic blood pressure (the first number) as a major risk factor for cardiovascular disease for people over 50. In most people, systolic blood pressure rises steadily with age due to the increasing stiffness of large arteries, long-term buildup of plaque and an increased incidence of cardiac and vascular disease. However, either an elevated systolic or an elevated diastolic blood pressure reading may be used to make a diagnosis of high blood pressure. According to recent studies, the risk of death from ischemic heart disease and stroke doubles with every 20 mm Hg systolic or 10 mm Hg diastolic increase among people from age 40 to 89. But after age 60, the systolic reading is even more significant. Isolated systolic hypertension is a condition in which the diastolic pressure is normal (less than 90 mm Hg) but systolic pressure is high (greater than 140 mm Hg). This is a common type of high blood pressure among people older than 60.

Your doctor will likely take two to three blood pressure readings each at three or more separate appointments before diagnosing you with high blood pressure. This is because blood pressure normally varies throughout the day, and sometimes specifically during visits to the doctor, a condition called white coat hypertension. Your blood pressure generally should be measured in both arms to determine if there is a difference. It’s important to use an appropriate-sized arm cuff. Your doctor may ask you to record your blood pressure at home and at work to provide additional information.

Blood pressure normally rises with age and body size. Newborn babies often have very low blood pressure numbers that are considered normal for babies, while older teens have numbers similar to adults.

Table 2. Blood Pressure Levels – Adults

Classification	Systolic and diastolic readings
Normal	Systolic: less than 120 mm Hg AND Diastolic: less than 80 mm Hg
Elevated	Systolic: 120–129 mm Hg AND Diastolic: less than 80 mm Hg
High blood pressure (Stage 1 hypertension)	Systolic: 130–139 mm Hg OR Diastolic: 80–89 mm Hg
High blood pressure (Stage 2 hypertension)	Systolic: 140 mm Hg or higher OR Diastolic: 90 mm Hg or higher
Hypertensive crisis (you should call your local emergency services number and see a doctor immediately)	Systolic: Higher than 180 mm Hg AND/OR Diastolic: Higher than 120 mm Hg

Footnote: Healthy and unhealthy blood pressure ranges. A blood pressure reading between 120/80mmHg and 140/90mmHg could mean you’re at risk of developing high blood pressure if you don’t take steps to keep your blood pressure under control. A hypertensive crisis (high blood pressure crisis) is when blood pressure rises quickly and severely with readings of 180/120 or greater.  If your blood pressure reading is 180/120 or greater and you are experiencing any other associated symptoms of target organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision, or difficulty speaking then this would be considered a hypertensive emergency. Do not wait to see if your pressure comes down on its own, call your local emergency number immediately.

The consequences of uncontrolled blood pressure in this range can be severe and include:

• Stroke
• Loss of consciousness
• Memory loss
• Heart attack
• Damage to the eyes and kidneys
• Loss of kidney function
• Aortic dissection
• Angina (unstable chest pain)
• Pulmonary edema (fluid backup in the lungs)
• Eclampsia

An elevated reading may or may not be accompanied by one or more of the following symptoms:

• Severe headache
• Shortness of breath
• Nosebleeds
• Severe anxiety

[Source ¹¹, ¹² ]

Table 3. Blood Pressure Categories and Stages – Children

For children aged 1–13 years	For children aged ≥ 13 years
Normal BP: < 90th percentile	Normal BP: < 120/< 80 mm Hg
Elevated blood pressure: ≥ 90th percentile to < 95th percentile or 120/80 mm Hg to < 95th percentile (whichever is lower)	Elevated blood pressure: 120/< 80 to 129/< 80 mm Hg
Stage 1 hypertension: ≥ 95th percentile to < 95th percentile + 12 mm Hg, or 130/80 to 139/89 mm Hg (whichever is lower)	Stage 1 hypertension: 130/80 to 139/89 mm Hg
Stage 2 hypertension: ≥ 95th percentile + 12 mm Hg, or ≥ 140/90 mm Hg (whichever is lower)	Stage 2 hypertension: ≥ 140/90 mm Hg

[Source ¹³ ]

What is normal blood pressure?

For most adults, a normal blood pressure is less than 120/80 mmHg ². An ideal blood pressure is usually considered to be between 90/60mmHg and 120/80mmHg. See your healthcare provider if your blood pressure readings are consistently higher than 120/80 mmHg. Blood pressure readings between 120/80mmHg and 140/90mmHg could mean you’re at risk of developing high blood pressure if you do not take steps to keep your blood pressure under control. For children younger than 13, blood pressure readings are compared with readings common for children of the same, age, sex, and height. In children younger than 13 years, elevated blood pressure is defined as blood pressure in the 90th percentile or higher for age, height, and sex, and hypertension is defined as blood pressure in the 95th percentile or higher ¹⁴. In adolescents 13 years and older, elevated blood pressure is defined as blood pressure of 120 to 129 mm Hg systolic and less than 80 mm Hg diastolic, and hypertension is defined as blood pressure of 130/80 mm Hg or higher.

High blood pressure signs and symptoms

Most people with high blood pressure have no symptoms, and may feel quite well. This is why it’s important to see your doctor and have your blood pressure checked regularly, especially if you have one or more of the risk factors listed above.

A few people with high blood pressure may experience headaches, dizziness, shortness of breath or nosebleeds, or the sudden effects of diseases of the arteries such as chest pain or stroke. But these signs and symptoms aren’t specific and usually don’t occur until high blood pressure has reached a severe or life-threatening stage.

Types of hypertension

There are two types of high blood pressure (hypertension).

Primary (essential) hypertension

For most adults, there’s no identifiable cause (idiopathic) of high blood pressure. This type of high blood pressure, called primary hypertension or essential hypertension, tends to develop gradually over many years. It has long been suggested that an increase in salt intake increases the risk of developing hypertension ¹⁵. One of the described factors for the development of essential hypertension is the patient genetic ability to salt response ¹⁶. About 50 to 60% of the patients are salt sensitive and therefore tend to develop hypertension ¹⁷.

High blood pressure has many risk factors, including:

• are over the age of 65. The risk of high blood pressure increases as you age. Through early middle age, or about age 45, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
• are overweight or obese. The more you weigh the more blood you need to supply oxygen and nutrients to your tissues. As the volume of blood circulated through your blood vessels increases, so does the pressure on your artery walls.
• are of African or Caribbean descent. Serious complications, such as stroke, heart attack and kidney failure, also are more common in blacks.
• have a relative with high blood pressure. High blood pressure tends to run in families.
• eat too much salt and don’t eat enough fruit and vegetables. Too much sodium in your diet can cause your body to retain fluid, which increases blood pressure.
• too little potassium in your diet. Potassium helps balance the amount of sodium in your cells. If you don’t get enough potassium in your diet or retain enough potassium, you may accumulate too much sodium in your blood.
• don’t do enough exercise. People who are inactive tend to have higher heart rates. The higher your heart rate, the harder your heart must work with each contraction and the stronger the force on your arteries. Lack of physical activity also increases the risk of being overweight.
• drink too much alcohol or coffee (or other caffeine-based drinks)
• drinking too much alcohol. Over time, heavy drinking can damage your heart. Having more than two drinks a day for men and more than one drink a day for women may affect your blood pressure. If you drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger. One drink equals 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.
• smoke. Not only does smoking or chewing tobacco immediately raise your blood pressure temporarily, but the chemicals in tobacco can damage the lining of your artery walls. This can cause your arteries to narrow, increasing your blood pressure. Secondhand smoke also can increase your blood pressure.
• don’t get much sleep or have disturbed sleep
• too little vitamin D in your diet. It’s uncertain if having too little vitamin D in your diet can lead to high blood pressure. Vitamin D may affect an enzyme produced by your kidneys that affects your blood pressure.
• Stress. High levels of stress can lead to a temporary increase in blood pressure. If you try to relax by eating more, using tobacco or drinking alcohol, you may only increase problems with high blood pressure.
• certain chronic conditions. Certain chronic conditions also may increase your risk of high blood pressure, such as kidney disease, diabetes and sleep apnea.

Making healthy lifestyle changes can help reduce your chances of getting high blood pressure and help lower your blood pressure if it’s already high.

Secondary hypertension

Some people have high blood pressure caused by an underlying condition. This type of high blood pressure, called secondary hypertension, tends to appear suddenly and cause higher blood pressure than does primary hypertension. Various conditions and medications can lead to secondary hypertension, including:

• Obstructive sleep apnea (OSA)
• Kidney disease
• Adrenal gland tumors
• Thyroid problems
• Certain defects you’re born with (congenital) in blood vessels
• Certain medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers and some prescription drugs
• Illegal drugs, such as cocaine and amphetamines

Known causes of high blood pressure

In about 1 in 20 cases, high blood pressure occurs as the result of an underlying condition, medication or drug.

Conditions that can cause high blood pressure include:

• kidney disease
• diabetes
• long-term kidney infections
• obstructive sleep apnea – a condition in which the walls of the throat relax and narrow during sleep, interrupting normal breathing
• glomerulonephritis – damage to the tiny filters inside the kidneys
• narrowing of the arteries supplying the kidneys
• hormone problems – such as an underactive thyroid, an overactive thyroid, Cushing’s syndrome, acromegaly, increased levels of the hormone aldosterone (hyperaldosteronism) and phaeochromocytoma
• lupus – a condition in which the immune system attacks parts of the body such as the skin, joints and organs
• scleroderma – a condition that causes thickened skin, and sometimes problems with organs and blood vessels

Medicines and drugs that can increase your blood pressure include:

• the combined oral contraceptive pill
• steroid medication
• non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen and naproxen
• some over-the-counter cough and cold remedies
• some herbal remedies – particularly those containing liquorice
• some recreational drugs – such as cocaine and amphetamines
• some selective serotonin-noradrenaline reuptake inhibitor (SSNRI) antidepressants – such as venlafaxine

In these cases, your blood pressure may return to normal once you stop taking the medicine or drug.

Isolated systolic hypertension

Isolated systolic hypertension is the predominant form of hypertension in the elderly population ¹⁸. Based on data from the National Health and Nutrition Examination Survey 1999-2010, approximately 30% of persons aged 60 years and above have untreated isolated systolic hypertension, as compared with 6% in adults aged 40 to 50 years and 1.8% in young adults aged 18 to 39 years ¹⁹. As per the Framingham Heart Study, a person aged 65 years with normal blood pressure has a 90% lifetime risk of developing hypertension. Among the elderly group, women and non-Hispanic Blacks have a higher prevalence of hypertensive disorders.

Isolated systolic hypertension is traditionally defined as systolic blood pressure above 140 mmHg with diastolic blood pressure of less than 90 mmHg ²⁰. It is estimated that 15% of people aged 60 years and above have isolated systolic hypertension. Per the 2017 American College of Cardiology/American Heart Association Blood Pressure guidelines, however, a systolic blood pressure of 130 mmHg is now considered hypertensive at all ages ⁷. The new definition of hypertension will lead to an increased number of elderly being diagnosed with high blood pressure. Isolated systolic hypertension remains an important public health concern as chronically untreated high systolic blood pressure patients carry significant mortality and morbidity.

Most patients with isolated systolic hypertension have primary hypertension, which is also known as essential hypertension. Rarely, isolated systolic hypertension is attributed to other causes of secondary hypertension such as hypothyroidism/hyperthyroidism, chronic kidney disease, peripheral vascular disease, diabetes mellitus, aortic insufficiency, arteriovenous fistula, anemia, Paget disease, and atherosclerotic renal artery stenosis ²¹.

Isolated systolic hypertension, in most cases, develops as a result of the reduced elasticity of the arterial system ²⁰. This is commonly seen among the elderly as there is increased deposition of calcium and collagen to the arterial wall ²². Hence, this may result in reduced compliance of the arterial vessels, decreased lumen-to-wall ratio, and increased thickening and fibrotic remodeling of the vascular intima and media. As a result, these stiffened conduit arteries lead to an increase in pulse pressure and pulse wave velocity, causing an elevation in systolic blood pressure and a further decline in diastolic blood pressure. Similarly, chronic diseases such as the above causes of secondary hypertension may contribute to the same pathological process by accelerating the deposition of calcium and collagen to the arterial system and the fibrotic remodeling of the vascular walls ²³.

Malignant hypertension

Malignant hypertension also known as hypertensive crisis, is a term that has been used to describe patients with elevated blood pressure and multiple complications (end organ damage) with a poor prognosis. Today, the term malignant hypertension or hypertensive crisis is used to describe patients who present with severe BP elevations as follow ²⁴:

• Systolic blood pressure greater than 180 mm Hg
• Diastolic blood pressure greater than 120 mm Hg

To make a diagnosis of malignant hypertension, papilledema has to be present ²⁴. The diagnosis can be further classified as a hypertensive emergency when severe elevation in BP is associated with end-organ damage or hypertensive urgency when severe hypertension occurs without it. Prompt treatment of BP can prevent a hypertensive emergency and, consequently, serious life-threatening complications ²⁵.

There are multiple causes of malignant hypertension (hypertensive crisis), including the following ²⁴:

• Medication noncompliance
• Renovascular diseases, such as renal artery stenosis, polyarteritis nodosa, and Takayasu arteritis
• Renal parenchymal disease including glomerulonephritis, tubulointerstitial nephritis, systemic sclerosis, hemolytic-uremic syndrome, systemic lupus erythematosus
• Endocrine dysfunction, such as pheochromocytoma, Cushing disease, primary hyperaldosteronism, renin-secreting tumor
• Coarctation of aorta; drugs or other exposures, including cocaine, phencyclidine, sympathomimetics, erythropoietin, cyclosporine
• Antihypertensive medication withdrawal
• Amphetamines
• Central nervous system disorders, such as head injury, cerebral infarction, and cerebral hemorrhage

The prognosis of patients with malignant hypertension is guarded. Five-year survivals of 75% to 84% have been reported with treatment; without treatment, the life expectancy is less than 24 months. Most deaths are a result of heart failure, stroke, or renal failure.

Multiple complications can arise from hypertensive crisis when target organs are affected, including encephalopathy, intracerebral hemorrhage, acute myocardial infarction, acute heart failure, pulmonary edema, unstable angina, dissecting aortic aneurysm, acute kidney injury, and vision loss. Fortunately, most patients with malignant hypertension have no acute end-organ damage (hypertensive urgency). Nevertheless, some patients have signs and symptoms of acute, ongoing injury, which is recognized as hypertensive emergency.

In malignant hypertension (hypertensive emergency), the key is to lower the blood pressure within a few hours. However, it is not recommended to decrease the blood pressure too fast or too much, as ischemic damage can occur in vascular territories that have become habituated with the elevated level of blood pressure ²⁴. For most hypertensive emergencies, mean arterial pressure (MAP) should be reduced by approximately 10 to 20% within the first hour and by another 5% to 15% over the next 24 hours ²⁴. This often results in a target blood pressure of less than 180/120 mm Hg for the first hour and less than 160/110 mm Hg for the next 24 hours, but rarely less than 130/80 mm Hg during that time frame.

Common intravenous (IV) medications and doses used to treat malignant hypertension (hypertensive emergencies) include:

• Nicardipine, initial infusion rate 5 mg per hour, increasing by 2.5 mg per hour every 5 minutes to a maximum of 15 mg per hour
• Sodium nitroprusside, 0.3 to 0.5 mcg/kg/minute, increases by 0.5 mcg/kg per minute every few minutes as needed to a maximum dose of 10 mcg/kg per minute.
• Labetalol 10 to 20 mg IV followed by bolus doses of 20 to 80 mg at 10-minute intervals until a target blood pressure is reached to a maximum 300-mg cumulative dose
• Esmolol, initial loading dose 500 mcg/kg/minute over 1 minute, then 50 to 100 mcg/kg/minute to a maximum dose of 300 mcg/kg per minute.

If there is any possibility of over or underestimating BP using frequent noninvasive cuff measurements or if the end-organ damage is life-threatening, consider arterial catheterization for precise, second-to-second measurements allowing for more careful medication titration.

The major exceptions to gradual BP lowering over the first day are:

• Acute phase of an ischemic stroke: The BP is usually not treated unless it is greater than 185/110 mmHg in patients whose reperfusion therapy could be an option or greater than 220/120 mm Hg in patients who might not qualify for it. Consider labetalol or nicardipine infusion.
• Acute aortic dissection: The SBP should be lowered to 120 mm Hg within 20 minutes, and a target heart rate around 60 beats per minute to reduce aortic shearing forces. Treatment usually requires a beta-blocker and a vasodilator. Options include esmolol, nicardipine, or nitroprusside.
• An intracerebral hemorrhage: The goals of therapy are different and depend on the location and surgical approach.
• Acute myocardial ischemia: Nitroglycerin is the drug of choice; do not use if the patient has taken phosphodiesterase inhibitors, including sildenafil or tadalafil, within the past 48 hours.

After a suitable period, often 8 to 24 hours of BP control at a target, oral medications are usually given, and the initial intravenous therapy is tapered and discontinued.

Renovascular hypertension

Renovascular hypertension is one of the most common causes of secondary hypertension and often leads to resistant hypertension. Renovascular hypertension is defined as systemic hypertension that manifests secondary to the compromised blood supply to the kidneys, usually due to an occlusive lesion in the main renal artery ²⁶. It is important to realize that any condition that compromises blood flow to the kidneys can contribute to renovascular hypertension ²⁷. The underlying mechanism in renovascular hypertension involves decreased perfusion to the kidney and activation of the renin-angiotensin-aldosterone (RAAS) pathway. Renin secretion by the kidneys is stimulated by three main pathways, 1) renal baroreceptors that sense decreased perfusion to the kidney, 2) low sodium chloride levels detected by the macula densa and 3) beta-adrenergic stimulation. Prolonged kidney ischemia also increases the number of renin expressing cells in the kidney in a process called ‘juxtaglomerular (JG) recruitment’ ²⁸. When renin is secreted into the blood, it acts on angiotensinogen (produced by the liver). Renin cleaves angiotensinogen to angiotensin 1, which is then converted to angiotensin 2 by angiotensin-converting enzyme (ACE) that is primarily found in the vascular endothelium of lungs and kidney. Angiotensin 2 raises blood pressure by multiple mechanisms, which include:

• Vasoconstriction, mostly in the heart, kidney, and vascular smooth muscle ²⁹
• Sympathetic nervous stimulation causing a presynaptic release of norepinephrine
• Stimulates secretion of aldosterone by the adrenal cortex, which in turn causes sodium and water retention, thereby raising blood pressure.
• It also causes the increased synthesis of collagen type I and III in fibroblasts, leading to thickening of the vascular wall and myocardium, and fibrosis
• It has been shown to have a growth effect on renal cells, which has been implicated in the development of glomerulosclerosis and tubulointerstitial fibrosis

The most common causes of renovascular hypertension include ²⁶:

• Renal artery stenosis (RAS), mostly secondary to atherosclerosis
• Fibromuscular dysplasia (FMD)
• Arteritides such as Takayasu’s arteritis, antiphospholipid antibody (APLA), or mid aortic syndrome ³⁰
• Extrinsic compression of a renal artery
• Renal artery dissection or infarction
• Radiation fibrosis
• Obstruction from aortic endovascular grafts

The dominant cause (at least 85%) of renovascular hypertension in western countries is atherosclerotic renal artery stenosis (ARAS) and is mostly seen in older adults (>65 years) ²⁷. This often develops as part of systemic atherosclerotic disease affecting multiple vascular beds, including coronary, cerebral and peripheral vessels. Community based studies suggest that up to 6.8% of individuals older than 65 have atherosclerotic renal artery stenosis (ARAS) more than 60% occlusion ³¹. Renal artery stenosis secondary to atherosclerosis has a higher prevalence in patients with known atherosclerotic disease (such as those with coronary artery disease, peripheral artery disease, or carotid artery stenosis) and autopsy studies have revealed that “greater than 25% of all patients who die of cardiovascular disease have some degree of renal artery stenosis” ³². Screening studies indicate rising prevalence of detectable atherosclerotic renal artery stenosis (ARAS) in hypertensive subjects from 3% (ages 50-59) to 25% (above age 70) with older ages ³³. Clinically significant atherosclerotic renovascular disease often is manifest by worsening or accelerating blood pressure elevations in older individuals with pre-existing hypertension.

Fibromuscular dysplasia (FMD) is usually seen in young women and accounts for around 10% of renovascular hypertension and 5.8% of secondary hypertension ³⁴. Fibromuscular dysplasia (FMD) can affect any arterial bed but most commonly affects the distal two-thirds of the renal artery ³⁵.

Salient points in the history that suggest the presence of renovascular hypertension include:

• Resistant hypertension: Uncontrolled blood pressure necessitating the use of 2 or 3 antihypertensive agents of different classes, one of which is a diuretic
• Trial of multiple medications to control blood pressure
• History of multiple hospital admissions for hypertensive crisis
• Elevation in creatinine of more than 30% after starting an angiotensin-converting enzyme inhibitor (ACE-I)
• Patients with renal artery stenosis secondary to atherosclerosis are usually older and might have the presence of other atherosclerotic diseases such as carotid artery stenosis, peripheral artery stenosis, or coronary artery disease
• A premenopausal female (15-50 years) with hypertension is most likely to have fibromuscular dysplasia (FMD) ³⁰
• Long term history of smoking
• Patients with systemic vasculitis can develop vasculitis of renal arteries and present with renovascular hypertension
• Recurrent episodes of flash pulmonary edema and/or unexplained congestive heart failure
• Unexplained azotemia
• Elevation in serum creatinine upon starting angiotensin-converting enzyme (ACE) inhibitor, which occurs due to interference with autoregulation and post glomerular arterial tone
• Unexplained hypokalemia and metabolic alkalosis
• Unilateral small or atrophic kidney

Physical examination may reveal an abdominal bruit, indicating the presence of renal artery stenosis.

Patients with renovascular hypertension often undergo an extensive evaluation to find a cause for uncontrolled hypertension.

Laboratory Tests include:

• Urine analysis: To check for proteinuria, hematuria, and casts. The presence of proteinuria (protein in urine) indicates the presence of renal parenchymal disorder, whereas the presence of hematuria (blood in urine) or red blood cell (RBC) casts indicates the presence of glomerulonephritis.
• Blood urea nitrogen and serum creatinine: To assess baseline kidney function.
• Basal metabolic profile: To assess for electrolyte disturbances and acid-base balance.
• Complement levels and autoimmune profile: In suspected cases of autoimmune diseases affecting the renal vasculature.
• Plasma free metanephrines or 24-hour urinary fractionated metanephrines and normetanephrine to rule out pheochromocytoma
• Plasma renin-aldosterone ratio to rule out hyperaldosteronism
• 24 hour urinary free cortisol or low dose dexamethasone suppression test to rule out Cushing’s syndrome

Imaging studies

There are multiple imaging modalities available to evaluate renovascular hypertension. Since the most common cause of renovascular hypertension is renal artery stenosis, renal arteriography remains the gold standard diagnostic test ³⁵. However, catheter angiography is invasive, costly, time-consuming, and can lead to complications such as renal artery dissection or cholesterol embolization. Other imaging tests that can be done to evaluate the renal vessels include duplex ultrasonography, computed tomography with angiography (CTA), and magnetic resonance angiography (MRA). The type of imaging test used often depends on the suspicion for high-grade lesions, and the need for intervention ³⁰.

Duplex ultrasonography is the initial imaging test of choice to evaluate the renal arteries. It is relatively inexpensive, non-invasive, and does not involve administration of contrast or exposure to radiation. A duplex scan has been shown to have an excellent correlation with contrast-enhanced angiography ³⁶. Though there are several criteria to assess the presence of renal artery stenosis, the most important sign is peak systolic velocity (PSV). A peak systolic velocity (PSV) higher than 180 cm/s suggests the presence of stenosis of greater than 60% ³⁷.

Duplex ultrasonography can also measure the resistive index (RI), which is calculated as (PSV-End diastolic velocity)/PSV. A value of more than 0.7 indicates the presence of pathological resistance to flow, and studies have shown that a value >0.8 predicts poor response to revascularization treatments ³⁷. The most significant setbacks for duplex ultrasonography are its reduced sensitivity in obese patients, hindrance by overlying bowel gas, and operator dependence.

CT angiography (CTA) involves the administration of intravenous contrast and acquiring detailed images of blood vessels or tissues by moving the beam in a helical manner across the area being studied. In a study by Wittenberg et al ³⁸, the sensitivity and specificity for hemodynamically significant renal artery stenosis (>50%) by CTA was found to be 96% and 99%. Computed tomography with angiography (CTA) also has a comparable negative predictive value to magnetic resonance angiography (MRA) in ruling out renal artery stenosis ³⁹.
It can also diagnose extrinsic compression of renal arteries, fibromuscular dysplasia (FMD), arterial dissection, and help in evaluating surrounding structures. However, CT angiography (CTA) can only provide an anatomical assessment of the lesion and is not able to evaluate the degree of obstruction to renal blood flow. Exposure to radiation, allergy to contrast, and acute kidney injury are other downfalls of CT angiography (CTA).

Magnetic resonance angiography (MRA) uses a powerful magnetic field, pulses of radio waves, and intravenous gadolinium to evaluate the renal blood vessels and surrounding structures. Several studies have shown the sensitivity and specificity of magnetic resonance angiography (MRA) to be around 97% and 92% in diagnosing renal artery stenosis ³⁹. MRA does not involve radiation, and gadolinium contrast is less likely to cause an allergic reaction as compared to the iodine contrast used in CTA. However, MRA has been shown to overestimate the grade of stenosis and is often affected by motion artifacts or opacification of renal veins, leading to difficulty visualizing the renal arteries ³⁹. Also, gadolinium has been shown to induce a rare, progressively fatal disease called nephrogenic systemic fibrosis (NSF). NSF can affect the skin, joints, and multiple organs leading to progressive, irreversible fibrosis and eventual death. This occurs due to a transmetalation reaction that displaces gadolinium ion from its chelate, resulting in the deposition of gadolinium in the skin and soft tissues. The 1-year incidence of NSF has been reported to be around 4.6% and almost all cases occurred in patients with a glomerular filtration rate < 30 mL/min/1.73 m² ⁴⁰.

In comparative studies, the positive predictive value of MRA was found to be higher than CTA due to increased false-positive rates with CTA. Negative predictive values are high for both CTA and MRA (>98% for both) ³⁹. Both modalities can exclude significant renal artery lesions with a high degree of certainty. Both MRA and CTA have also shown to be effective for the diagnosis of FMD, with the sensitivity of CTA being the best (84.2%) when compared to angiography ⁴¹.

Nuclear medicine ACE-inhibitor (ACE-I) renography is another non-invasive, relatively safe imaging method that uses radioactive material, a special camera, and a computer to evaluate for renovascular hypertension. It involves the administration of an ACE-inhibitor (ACE-I) to determine if the cause of hypertension is due to the narrowing of the renal arteries. The sensitivity and specificity of this test have shown to be variable, with values between 74% – 94% for sensitivity and 59% – 95% for specificity ⁴². It is a time-consuming procedure, and there is a risk of radiation exposure and irritation or pain from the injection of the radiotracer. The sensitivity of ultrasound has shown to be higher than captopril renography which makes it a better choice for an initial diagnostic test ⁴³.

Catheter angiography is the gold standard test to evaluate for renovascular hypertension and provides the best temporal and spatial resolution. Catheter angiography has the added advantage of measuring translesional pressure gradients to assess the hemodynamic significance of anatomically severe lesions ⁴⁴. Catheter angiography is most useful in:

• Patients with a disparity between imaging modalities
• Patients with a high index of suspicion and negative imaging findings
• Patients anticipated of needing an intervention

Catheter angiography can also evaluate anatomical abnormalities of the kidney, renal arteries, aorta, and can be followed by endovascular intervention for the treatment of significant lesions. Also, the surrounding tissues and bones can be removed or subtracted from the final image revealing only the arterial framework. This method is known as digital subtraction angiography (DSA). However, the radiation doses are higher than CTA, and because it is an invasive procedure, there are risks of complications such as arterial dissection, tear, rupture, or thromboembolic phenomenon ⁴⁴.

The management of renovascular hypertension aims to treat the underlying cause. Several options are available, which include pharmacological and invasive therapy. Renovascular hypertension due to atherosclerotic renal artery stenosis should be primarily managed medically as multiple studies have failed to show renal or cardiovascular benefits with invasive management.

Pharmacological therapy entails the use of antihypertensive medications to control blood pressure. The American College of Cardiology and the American Heart Association advocates pharmacological therapy as the first-line treatment for renal artery stenosis ⁴⁵. Since renin-angiotensin-aldosterone (RAAS) is the most prominent pathway contributing to hypertension in these disorders, ACE-inhibitors (ACE-Is) and angiotensin II receptor blockers (ARBs) form the cornerstone of managing renovascular hypertension. Often more than one medication will be needed to control the blood pressure. Calcium channel blockers, thiazides, beta-blockers, and hydralazine have been shown to be effective to control blood pressure in patients with renal artery stenosis ⁴⁶. Direct renin inhibitors such as aliskiren have been studied as monotherapy or in combination with ACE-inhibitors (ACE-Is) and angiotensin 2 receptor blockers (ARBs) to treat hypertension. Though it has been shown to be effective for the treatment of hypertension there is not enough data to prove its efficacy in treating renovascular hypertension ⁴⁷.

ACE-inhibitors (ACE-Is) and angiotensin II receptor blockers (ARBs) inhibit the action of angiotensin II, thereby causing vasodilation and promote sodium and water excretion. However, these medications are contraindicated in patients with a single functioning kidney or bilateral lesions as they can cause efferent arteriolar vasodilatation leading to interruption in autoregulation and thereby decreasing glomerular filtration. While these medications are effective in controlling blood pressure, they can also lead to worsening renal function.

Percutaneous angioplasty is the treatment of choice for renovascular hypertension due to fibromuscular dysplasia (FMD) and for patients with atherosclerotic renal artery stenosis that is not controlled with medications ⁴⁸. The American College of Cardiology and the American Heart Association guidelines recommend revascularization for renal artery disease in the following scenarios ⁴⁶:

• Patients with hemodynamically significant renal artery stenosis and recurrent, unexplained congestive heart failure or sudden, unexplained pulmonary edema
• Hemodynamically significant renal artery stenosis and accelerated hypertension, resistant hypertension, malignant hypertension or hypertension with an unexplained unilateral small kidney, and hypertension with intolerance to medication
• Patients with bilateral renal artery stenosis and progressive chronic kidney disease or a renal artery stenosis to a solitary functioning kidney
• Patients with hemodynamically significant renal artery stenosis and unstable angina
• Asymptomatic bilateral or solitary viable kidney with hemodynamically significant renal artery stenosis
• Patients with renal artery stenosis and chronic renal insufficiency with unilateral renal artery stenosis
• In addition to angioplasty, renal stent placement is indicated for patients with ostial atherosclerotic lesions

Patients with fibromuscular dysplasia (FMD) and renovascular hypertension are also treated with percutaneous intervention with or without a stent ⁴⁸. Multiple studies have shown a decrease in baseline blood pressure after intervention for fibromuscular dysplasia (FMD) ⁴⁹. However, there remains an ongoing debate about the benefit of revascularization when compared to medical management in patients with atherosclerotic renal artery stenosis (ARAS). Several studies have failed to show a significant decrease in blood pressure or the number of antihypertensive agents between angioplasty and medical treatment groups. A meta-analysis of 7 trials by Zhu et al. ⁵⁰ revealed that medical management is as effective as percutaneous revascularization in the treatment of renal artery stenosis. Three recent trials: the Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) ⁵¹, Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) ⁵², and STAR ⁵³ found no difference between stenting and medical therapy in patients with atherosclerotic renal artery stenosis. Thus it can be established that revascularization does not reverse renal damage or decrease blood pressure in patients with atherosclerotic renal artery stenosis.

In the case of recurrent renal artery stenosis or blood pressure not controlled with medication and or/angioplasty, renal bypass surgery may be an option. In this procedure, the surgeon uses a vein or synthetic tube to connect the kidney to the aorta, to create an alternate route for blood to flow around the blocked artery into the kidney. This is a complex procedure and rarely used. The American College of Cardiology and the American Heart Association guidelines recommend surgery for renal artery stenosis in ⁴⁶:

• Patients with renal artery stenosis secondary to fibromuscular dysplasia (FMD), especially those with complex disease and/or those having microaneurysms
• Patients with atherosclerotic renal artery stenosis involving multiple vessels or involvement of early primary branch of the main renal artery
• Patients with atherosclerotic renal artery stenosis who require pararenal aortic reconstructions (such as with aortic aneurysms or severe aortoiliac obstruction)

Several studies have also evaluated the role of unilateral nephrectomy in patients with renovascular hypertension and have shown improvement in blood pressure control, renal function, and a decrease in the use of anti-hypertensives ⁵⁴. However, this is an invasive procedure with inherent risks and the long-term consequences of such a procedure are unclear.

Untreated renovascular hypertension can also lead to end-stage renal failure with a median survival time of 25 months and a 4-year mortality rate of 35% ²⁶.

Hypertension in pregnancy

Some women have high blood pressure before they get pregnant. Others have high blood pressure for the first time during pregnancy. About 8 in 100 women (8 percent) have some kind of high blood pressure during pregnancy. If you have high blood pressure, talk to your health care provider. Managing your blood pressure can help you have a healthy pregnancy and a healthy baby.

Two kinds of high blood pressure that can happen during pregnancy:

1. Chronic hypertension. Chronic hypertension is high blood pressure that you have before you get pregnant or that develops before 20 weeks of pregnancy. Chronic hypertension doesn’t go away once you give birth. Chronic hypertension is diagnosed per American College of Cardiology and the American Heart Association and American College of Obstetricians and Gynecologists guidelines as an in-office measurement with systolic blood pressure greater than 140 mmHg or diastolic blood pressure greater than 90mmHg confirmed with either ambulatory blood pressure monitoring, home blood pressure monitoring, or blood pressure evaluation with serial office visits, with elevated pressures at least 4 hours apart prior to 20 weeks gestation ⁵⁵, ⁵⁶, ⁵⁷. About 1 in 4 women with chronic hypertension (25 percent) has preeclampsia during pregnancy. If you’re at high risk for preeclampsia, your health care provider may treat you with low-dose aspirin to prevent it. Your health care provider will check your blood pressure and urine at each prenatal care visit. You may need to check your blood pressure at home, too. Your health care provider may also use ultrasound and fetal heart rate testing to check your baby’s growth and health. Your health care provider also checks for signs of preeclampsia. If you were taking medicine for chronic hypertension before pregnancy, your health care provider makes sure it’s safe to take during pregnancy. If it’s not, he/she switches you to a safer medicine. Some blood pressure medicines, called ACE inhibitors (ACE-I) and angiotensin II receptor blockers (ARBs), can harm your baby during pregnancy. During the first half of pregnancy, blood pressure often falls. If you have mild hypertension and took medicine for it before pregnancy, your health care provider may lower the dose of medicine you take. Or you may be able to stop taking medicine during pregnancy. Don’t stop taking any medicine before you talk to your health care provider. Even if you didn’t take blood pressure medicine in the past, you may need to start taking it during pregnancy.
2. Gestational hypertension. Gestational hypertension is high blood pressure that only pregnant women can get. Gestational hypertension is defined per American College of Obstetricians and Gynecologists guidelines as blood pressure greater than or equal to 140 mmHg systolic or 90mmHg diastolic on two separate occasions at least four hours apart after 20 weeks of pregnancy when previous blood pressure was normal with no excess protein in their urine or other signs of organ damage. Alternatively, a patient with systolic blood pressure greater than 160 mmHg or diastolic blood pressure greater than 110 mmHg can be confirmed to have gestational hypertension if they have a similar pressure after a short interval. This is in order to ensure timely antihypertensive treatment. Gestational hypertension starts after 20 weeks of pregnancy and usually goes away after you give birth. It usually causes a small rise in blood pressure, but some women develop severe hypertension and may be at risk for more serious complications later in pregnancy, like preeclampsia.
3. Chronic hypertension with superimposed preeclampsia. This condition occurs in women who have been diagnosed with chronic high blood pressure before pregnancy, but then develop worsening high blood pressure and protein in the urine or other health complications during pregnancy.

Hypertensive disorders of pregnancy includes chronic hypertension, with or without superimposed pre-eclampsia/eclampsia, gestational hypertension, HELLP syndrome, preeclampsia with or without severe features or eclampsia present a significant risk of morbidity to both mother and fetus. HELLP stands for hemolysis (H), elevated liver enzymes (EL), low platelet count (LP) syndrome.

High blood pressure in pregnancy can cause problems for you and your baby during pregnancy, including ⁵⁸:

• Problems for moms include:
  • Preeclampsia. Preeclampsia is a complication of pregnancy in which affected women develop high blood pressure (hypertension); they can also have abnormally high levels of protein in their urine (proteinuria) and signs of damage to another organ system, most often the liver and kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in women whose blood pressure had been normal or after giving birth (called postpartum preeclampsia). Signs and symptoms of preeclampsia include having protein in the urine, changes in vision and severe headaches. Preeclampsia can be a serious medical condition. Even if you have mild preeclampsia, you need treatment to make sure it doesn’t get worse. Without treatment, preeclampsia can cause serious health problems, including kidney, liver and brain damage. In rare cases, it can lead to life-threatening conditions called eclampsia and HELLP syndrome. Eclampsia causes seizures and can lead to coma. HELLP syndrome stands for hemolysis (H) which is the destruction of red blood cells, elevated liver enzymes (EL), low platelet count (LP) syndrome. HELLP syndrome is a more severe form of preeclampsia, and can rapidly become life-threatening for both you and your baby. Left untreated, preeclampsia can lead to serious — even fatal — complications for both you and your baby. If you have preeclampsia, the most effective treatment is delivery of your baby. Even after delivering the baby, it can still take a while for you to get better.
  • Gestational diabetes. This is a kind of diabetes that only pregnant women get. It’s a condition in which your body has too much sugar (also called glucose). Most women get a test for gestational diabetes at 24 to 28 weeks of pregnancy.
  • Heart attack (also called myocardial infarction).
  • Kidney failure. This is a serious condition that happens when the kidneys don’t work well and allow waste to build up in the body.
  • Placental abruption. This is a serious condition in which the placenta separates from the wall of the uterus before birth. If this happens, your baby may not get enough oxygen and nutrients in the womb. You also may have serious bleeding from the vagina. The placenta grows in the uterus and supplies the baby with food and oxygen through the umbilical cord.
  • Postpartum hemorrhage (PPH). This is when a woman has heavy bleeding after giving birth. It’s a serious but rare condition. It usually happens 1 day after giving birth, but it can happen up to 12 weeks after having a baby.
  • Pulmonary edema. This is when fluid fills the lungs and leads to shortness of breath.
  • Stroke. This is when blood flow to your brain stops. Stroke can happen if a blood clot blocks a vessel that brings blood to the brain or when a blood vessel in the brain bursts open.
  • Pregnancy related death. This is when a woman dies during pregnancy or within 1 year after the end of her pregnancy from health problems related to pregnancy.

If you have high blood pressure during pregnancy, you’re also more likely have a cesarean birth (also called c-section). This is surgery in which your baby is born through a cut that your doctor makes in your belly and uterus.

• Problems for babies include:
  • Premature birth. This is birth that happens too early, before 37 weeks of pregnancy. Even with treatment, a pregnant woman with severe high blood pressure or preeclampsia may need to give birth early to avoid serious health problems for her and her baby.
  • Fetal growth restriction. High blood pressure can narrow blood vessels in the umbilical cord. This is the cord that connects the baby to the placenta. It carries food and oxygen from the placenta to the baby. If you have high blood pressure, your baby may not get enough oxygen and nutrients, causing him to grow slowly.
  • Low birthweight. This is when a baby is born weighing less than 5 pounds, 8 ounces.
  • Fetal death. When a baby dies spontaneously in the womb at any time during pregnancy.
  • Neonatal death. This is when a baby dies in the first 28 days of life.

To manage high blood pressure during pregnancy:

• Go to all your prenatal care checkups, even if you’re feeling fine.
• If you need medicine to control your blood pressure, take it every day. Your doctor can help you choose one that’s safe for you and your baby.
• If you have severe preeclampsia or HELLP syndrome, corticosteroid medications can temporarily improve liver and platelet function to help prolong your pregnancy. Corticosteroids can also help your baby’s lungs become more mature in as little as 48 hours — an important step in preparing a premature baby for life outside the womb.
• If your preeclampsia is severe, your doctor may prescribe an anticonvulsant medication, such as magnesium sulfate, to prevent a first seizure.
• Do not take any extra vitamins, calcium, aspirin, or other medicines without talking with your doctor first.
• Check your blood pressure at home. Ask your doctor what to do if your blood pressure is high.
• Eat healthy foods. Don’t eat foods that are high in salt, like soup and canned foods. They can raise your blood pressure.
• Stay active. Being active for 30 minutes each day can help you manage your weight, reduce stress and prevent problems like preeclampsia.
• Don’t smoke, drink alcohol or use street drugs or abuse prescription drugs.
• Contact your doctor immediately or go to an emergency room if you have severe headaches, blurred vision or other visual disturbance, severe pain in your abdomen, or severe shortness of breath. Because headaches, nausea, and aches and pains are common pregnancy complaints, it’s difficult to know when new symptoms are simply part of being pregnant and when they may indicate a serious problem — especially if it’s your first pregnancy. If you’re concerned about your symptoms, contact your doctor.

Pulmonary hypertension

Pulmonary hypertension is a potentially life-threatening condition caused by high blood pressure in the arteries of the lungs (pulmonary arteries), which leads to damage to the right side of the heart. In pulmonary hypertension the walls of the pulmonary arteries become thick and stiff, and cannot expand as well to allow blood to flow through. The reduced blood flow into your lungs makes it harder for the right side of your heart to pump blood through the pulmonary arteries. This increase in pressure can damage your heart. If the right side of your heart has to continually work harder, it can gradually become weaker. This can lead to heart failure. Pulmonary hypertension can also cause other symptoms such as shortness of breath, chest pain, tiredness, a racing heartbeat (palpitations), swelling (edema) in the legs, ankles, feet or tummy (abdomen) and lightheadedness. These symptoms often get worse during exercise, which can limit your ability to take part in physical activities.

Pulmonary hypertension can occur alone or be caused by another disease or condition ⁵⁹:

• One type of pulmonary hypertension is pulmonary arterial hypertension (PAH). Pulmonary arterial hypertension (PAH) is caused by changes in the smaller branches of the pulmonary arteries.
• Left heart diseases, such as left heart failure, which may be caused by high blood pressure throughout your body or coronary heart disease
• Other heart and blood vessel diseases such as congenital (inherited) heart defects
• Lung diseases or a shortage of oxygen in the body (hypoxia)
• Blood clots that cause narrowing or a blockage in the pulmonary arteries
• Other medical conditions such as liver disease, sickle cell disease or connective tissue disorders like scleroderma

Several factors can increase your risk of developing pulmonary hypertension:

• Age: Pulmonary hypertension can occur at any age, but your risk increases as you get older. The condition is usually diagnosed between ages 30 and 60.
• Environment: You may be at an increased risk of pulmonary hypertension if you have or are exposed to asbestos or certain infections caused by parasites.
• Family history and genetics: Certain genetic disorders, such as Down syndrome, congenital heart disease, and Gaucher disease, can increase your risk of pulmonary hypertension. A family history of blood clots also increases your risk.
• Lifestyle habits: Unhealthy lifestyle habits such as smoking and illegal drug use can raise your risk of developing pulmonary hypertension.
• Medicine: Some prescribed medicines used to treat cancer and depression may increase your risk of pulmonary hypertension.
• Sex: Pulmonary hypertension is more common in women than in men. Pulmonary hypertension with certain types of heart failure is also more common in women.

In the United States, the most common cause of pulmonary hypertension is left heart disease, such as left heart failure. There are several other medical conditions and environmental factors that can increase the risk of developing pulmonary hypertension. As a disease on its own pulmonary hypertension is rare – affecting between 10 and 57 people per million – but it leads to heart damage. Pulmonary hypertension can lead to death from heart failure within a few years. Some patients will need a lung transplant, or heart-lung transplant.

To diagnose pulmonary hypertension, your doctor may ask you questions about your medical history and do a physical exam. Based on your symptoms and risk factors, your doctor may refer you to a lung specialist (pulmonologist) or a heart and blood vessel specialist (cardiologist). Your doctor will diagnose you with pulmonary hypertension if tests show higher-than-normal pressure in the arteries of the lungs (pulmonary arteries).

The most common tests that doctors use to diagnose pulmonary hypertension is to measure the pressure in your pulmonary arteries using cardiac catheterization and echocardiography. Normal pressure in the pulmonary arteries is between 11 and 20 mm Hg. If the pressure is too high, you may have pulmonary hypertension. A pressure of 25 mmHg or greater measured by cardiac catheterization or 35 to 40 mmHg or greater on echocardiography suggests pulmonary hypertension.

Other tests use to diagnose pulmonary hypertension may include:

• Blood tests look for blood clots, stress on the heart, or anemia.
• Heart imaging tests, such as cardiac MRI, take detailed pictures of the structure and functioning of the heart and surrounding blood vessels.
• Lung imaging tests, such as chest X-ray, looks at the size and shape of the heart and surrounding blood vessels, including the pulmonary arteries.
• Electrocardiogram (ECG or EKG) looks for changes in the electrical activity of your heart. This can help detect if certain parts of the heart are damaged or working too hard. In pulmonary hypertension, the heart can become overworked due to damage or changes in the pulmonary arteries.

Pulmonary hypertension treatment

Treatments for pulmonary hypertension will depend on the cause of the condition. Pulmonary hypertension usually gets worse over time. Left untreated, it may cause heart failure, which can be fatal, so it’s important treatment is started as soon as possible.

Many times, there is not a cure for pulmonary hypertension, but your healthcare provider can work with you to manage the symptoms and help you manage your condition. This may include medicine or healthy lifestyle changes.

If another condition is causing pulmonary hypertension, the underlying condition should be treated first. This can sometimes prevent the pulmonary arteries being permanently damaged.

Medicines to treat pulmonary hypertension may include:

• Anticoagulant medicines or blood thinners to prevent blood clots in people whose pulmonary hypertension is caused by chronic blood clots in the lungs. These blood thinners also can help some people who have pulmonary arterial hypertension (PAH), heart failure, or other risk factors for blood clots.
• Digitalis or digoxin to control the rate blood is pumped throughout the body. Digoxin can improve your symptoms by strengthening your heart muscle contractions and slowing down your heart rate
• Vasodilator therapy to relax blood vessels and lower blood pressure in the pulmonary artery most affected in people who have pulmonary arterial hypertension. This includes calcium channel blockers such as nifedipine, diltiazem, nicardipine and amlodipine, as well as newer groups of medicines called endothelin receptor antagonists (bosentan, ambrisentan and macitentan), phosphodiesterase type 5 inhibitors (sildenafil and tadalafil), prostaglandins (epoprostenol, iloprost and treprostinil) and soluble guanylate cyclase stimulators (riociguat).
• Diuretics (water tablets) to remove excess fluid as a result of heart failure

Home oxygen treatment may also be prescribed if the level of oxygen in your blood is low.

Your doctor may recommend a procedure or surgery to treat pulmonary hypertension:

• Pulmonary endarterectomy – a surgery to remove old blood clots from the pulmonary arteries in the lungs of people with chronic thromboembolic pulmonary hypertension.
• Balloon pulmonary angioplasty – a new procedure where a tiny balloon is guided into the pulmonary arteries and inflated for a few seconds to push the blockage aside and restore blood flow to the lung; it may be considered if pulmonary endarterectomy is not suitable, and has been shown to lower blood pressure in the lung arteries, improve breathing, and increase the ability to exercise.
• Atrial septostomy to decrease pressure in the right heart chambers and improve the output of the left heart and oxygenation of the blood. In this procedure, a small hole is made in the wall between the right and left atria to allow blood to flow from the right to the left atrium.
• Transplant surgery – in severe cases, a lung transplant or a heart-lung transplant may be needed; this type of surgery is rarely used because effective medicine is available

Your doctor may also recommend medicines or procedures to treat the condition that is causing your pulmonary hypertension:

• Blood pressure medicines such as angiotensin-converting enzymes inhibitors (ACE-I), beta blockers, or calcium channel blockers (CCB) when left heart disease is the cause
• Blood transfusions or hydroxyurea to treat sickle cell disease
• Heart valve repair
• Iron supplements to increase blood iron levels and improve anemia

The outlook for pulmonary hypertension varies, depending on factors such as:

• what’s causing it
• how quickly it’s diagnosed
• how advanced your symptoms are
• whether you have another underlying health condition

The specialist in charge of your care will be able to give you more detailed information.

Having pulmonary hypertension can affect your ability to carry out everyday activities. Your doctor may recommend the following to monitor your condition and treatment response:

• Six-minute walk test to monitor your ability to exercise
• Blood tests to check hemoglobin, iron, and electrolyte levels; kidney, liver, and thyroid function; your blood’s ability to clot; and signs of stress on the heart
• Cardiac catheterization
• Cardiac MRI to monitor your heart’s size and how well it is working
• Chest X-ray
• Echocardiography to monitor your heart’s size and how well it is working, and measure the pressure in your right heart chambers
• Electrocardiogram to check for irregular heartbeats
• Lung function tests to check for any change in your lung function

If your pulmonary hypertension is severe or does not respond to treatment, your doctor may talk to you about a lung transplant or a heart and lung transplant.

Portal hypertension

Portal hypertension is abnormally high blood pressure in the portal vein (the large vein that brings blood from the intestine to the liver) and its branches. The portal vein receives blood from the entire intestine and from the spleen, pancreas, and gallbladder and carries that blood to the liver. After entering the liver, the portal vein divides into right and left branches and then into tiny channels that run through the liver. When blood leaves the liver, it flows back into the general circulation through the hepatic vein.

Portal hypertension is a common complication of cirrhosis and, less commonly, alcoholic hepatitis. When the liver becomes severely scarred, it’s harder for blood to move through it. This leads to an increase in the pressure of blood around the intestines.

The blood must also find a new way to return to your heart. It does this by using smaller blood vessels. Most often it goes through blood vessels in your stomach, esophagus, or intestines. But these blood vessels are not designed to carry the weight of blood, so they can become stretched out and weakened. These weakened blood vessels are known as varices. If the blood pressure rises to a certain level, it can become too high for the varices to cope with, causing the walls of the varices to split and bleed. Bleeding from esophageal varices is a medical emergency and can be fatal. The bleeding can be rapid and massive, causing you to vomit blood and pass stools that are very dark or tar-like. Alternatively, long-term bleeding can lead to anemia.

Usually, doctors can recognize portal hypertension based on symptoms and findings during the physical examination. Doctors can usually feel an enlarged spleen when they examine the abdomen. They can detect fluid in the abdomen by noting abdominal swelling and by listening for a dull sound when tapping (percussing) the abdomen.

Ultrasonography may be used to examine blood flow in the portal vein and nearby blood vessels and to detect fluid in the abdomen. Ultrasonography, magnetic resonance imaging (MRI), or computed tomography (CT) can be used to look for and examine collateral vessels.

Less commonly, a catheter is inserted through an incision in the neck and threaded through blood vessels into the liver to measure pressure in the portal blood vessels.

Treatment of portal hypertension

• For bleeding from esophageal varices, drugs to slow bleeding, blood transfusions, and/or endoscopy. Drugs such as vasopressin or octreotide may be given intravenously to make the bleeding veins contract and thus slow the bleeding. Blood transfusions are given to replace lost blood. Doctors usually use a flexible viewing tube (endoscope), inserted through the mouth into the esophagus to confirm that the bleeding is from varices. Working through the endoscope, doctors can use rubber bands to tie off the veins or hardened chemicals in the swollen blood vessels to block them off. To reduce the risk of bleeding from esophageal varices, doctors may try to reduce pressure in the portal vein. One way is to give beta-blocker drugs, such as timolol, propranolol, nadolol, or carvedilol.
• Sometimes surgery to reroute blood flow (portosystemic shunting). Portosystemic shunting may be done to connect the portal vein or one of its branches to a vein in the general circulation. This procedure reroutes most of the blood that normally goes to the liver so that it bypasses the liver. This bypass (called a shunt) lowers pressure in the portal vein because pressure is much lower in the general circulation. There are various types of portosystemic shunt procedures. In one type, called transjugular intrahepatic portosystemic shunting (TIPS), doctors, using x-rays for guidance, insert a catheter with a needle into a vein in the neck and thread it to veins in the liver. The catheter is used to create a passage (shunt) that connects the portal vein (or one of its branches) directly with one of the hepatic veins. Less commonly, portosystemic shunts are created surgically.
• If surgery doesn’t work or you have liver failure, you may need a liver transplant.

Intracranial hypertension

Intracranial hypertension is a general term for the neurological disorders in which cerebrospinal fluid (CSF) pressure within the skull is too high. “Intracranial” means “within the skull.” “Hypertension” means “high fluid pressure.” Intracranial hypertension in adults is generally defined as intracranial pressure that reaches 250 millimeters of water (mm H2O) or above. Old names for intracranial hypertension include Benign Intracranial Hypertension and Pseudotumor Cerebri ⁶⁰.

For adults:

• Normal intracranial pressure readings are generally below 200 mm H2O
• Borderline high intracranial pressure readings are between 200-250 mm H2O
• Anything above 250 mm H2O is considered a high pressure reading.

For young children:

• Anything above 200 mm H2O is considered a high pressure reading.

Cerebrospinal fluid (CSF) is one of three major components inside the skull; the other two are the blood supply (the arteries and veins known as the vasculature) that the brain requires to function and the brain itself. Cerebrospinal fluid (CSF) has several important functions. It cushions the brain within the skull, transports nutrients to brain tissue and carries waste away. CSF is produced at a site within the brain called the choroid plexus, which generates about 400-500 ml (one pint) of the fluid each day or approximately 0.3 cc per minute. The total volume of CSF in the skull at any given time is around 140 ml. That means the body produces, absorbs and replenishes the total volume of CSF about 3-4 times daily.

Cerebrospinal fluid (CSF) flows from the choroid plexus through the brain’s four, interconnecting ventricles before finally entering the sub-arachnoid space, which surrounds the brain and spinal cord. The fluid then flows over the brain and spinal cord and is eventually absorbed into the venous blood system through tiny, one-way channels called arachnoid granulations or villi. When this continuous cycle of CSF production, circulation and absorption functions normally, it regulates the volume of CSF in the skull and the fluid pressure remains at a constant level. In other words, the CSF production rate remains equal to the CSF absorption rate. Intracranial pressure is determined by the three main components within the skull —brain tissue, blood and cerebrospinal fluid (CSF)— working together. Under normal circumstances, these three components maintain a dynamic equilibrium. In order for this balance to be maintained, it is believed that CSF, which is produced at approximately 0.3 cc per minute, must also exit the skull at the same rate. But when the body cannot effectively absorb or drain CSF, intracranial pressure increases within the skull, which is made of bone and cannot expand. And since the brain and the vasculature can only be compressed so far, intracranial pressure must rise. Intracranial hypertension in adults is defined as CSF pressure at 250 mmH2O or above. In chronic intracranial hypertension, the exiting (or egress) of CSF is thought to be impaired while simultaneously the CSF productions continues, which leads to elevated intracranial pressure.

Intracranial hypertension can be divided into two categories:

1. Acute intracranial hypertension
2. Chronic intracranial hypertension

Acute intracranial hypertension often occurs as the result of severe head injury or intracranial bleeding from an aneurysm or a stroke. It is characterized by a very rapid onset after the initial injury and extremely high intracranial pressure that can be fatal. The underlying cause of acute intracranial hypertension is brain-swelling or intracranial bleeding into the sub-arachnoid space that surrounds the brain. In many cases, a piece of skull is surgically removed to accommodate brain swelling and lower intracranial pressure. This can be life-saving.

In contrast, chronic intracranial hypertension is a neurological disorder in which the increased cerebrospinal fluid (CSF) pressure has generally arisen and remains elevated over a sustained period of time. It can either occur without a detectable cause (idiopathic intracranial hypertension or pseudotumor cerebri) or be triggered by an identifiable cause such as an underlying disease or disorder, injury, drug or cerebral blood clot (secondary intracranial hypertension). Chronic intracranial hypertension is frequently a life-long illness with significant physical, financial and emotional impact. Chronic intracranial hypertension can cause both rapid and progressive changes in vision. Vision loss and blindness due to chronic intracranial hypertension are usually related to optic nerve swelling (papilledema), which is caused by high CSF pressure on the nerve and its blood supply. In addition, individuals with chronic intracranial hypertension often suffer severe pain. The most common form is a chronic headache, which is generally unresponsive to the most potent pain medication.

Anyone can develop chronic intracranial hypertension, regardless of age, gender, ethnicity, race or body type. While the chronic form of intracranial hypertension is not usually fatal, current treatments for the disorder can result in serious, sometimes life-threatening complications.

Researchers are eager to identify the mechanism that underlies chronic intracranial hypertension. While no one is sure why intracranial hypertension happens, some researchers believe that the answer may involve resistance or obstruction of CSF outflow through the exiting pathways from the brain.

Symptoms of chronic intracranial hypertension can include ⁶¹:

• Constant throbbing headaches that are generally nonspecific in location, type and frequency and can be associated with nausea and vomiting. Headaches may be worse in the morning, or when coughing or straining; it may improve when standing up
• Pulsatile tinnitus is a rhythmic or pulsating ringing heard in one or both ears.
• Horizontal double vision can be a sign of pressure on the 6th cranial nerve(s).
• Nonspecific radiating pain in the arms or legs (radicular pain).
• Transient obscurations of vision, which are temporary dimming or complete blacking out of vision. Your vision may become dark or “greyed out” for a few seconds at a time; this can be triggered by coughing, sneezing or bending down
• Visual field defects. These defects can occur in the central as well as the peripheral vision.
• Loss of color vision.
• Feeling and being sick
• Feeling sleepy
• Feeling irritable

Chronic intracranial hypertension can sometimes result in permanent vision loss, although treatment can help to reduce the chances of this happening.

The cause of chronic intracranial hypertension is usually not known (idiopathic intracranial hypertension). A common explanation for increased intracranial pressure is a problem with the reabsorption of cerebrospinal fluid (CSF) back into the body, which causes the pressure to increase. Sometimes the cause is found and then it is called secondary intracranial hypertension.

Possible causes of chronic intracranial hypertension include:

• a blood clot on the surface of your brain, known as a chronic subdural hematoma
• a brain tumor
• an infection in your brain, such as meningitis or encephalitis
• hydrocephalus, where fluid builds up around and inside your brain
• abnormal blood vessel, such as an arteriovenous fistula or arteriovenous malformation
• a blood clot in one of the veins of your brain, known as a venous sinus thrombosis

Rare causes include a blockage in the circulation of fluid at the bottom of the skull (Chiari malformation), inflammation of the blood vessels in the brain (vasculitis) and abnormal skull growth in children (craniosynostosis).

Causes of secondary intracranial hypertension include:

• Certain medications such as oral contraceptives, steroids, vitamin A, Isotretinoin, lithium, growth hormone, nitrofurantoin, phenytoin, sulfa drugs, minocycline, Tamoxifen, naladixic acid, thyroid replacement, tetracycline, and some chemotherapeutic drugs.
• Medical conditions such as dural venous sinus thrombosis, kidney disease, head injuries, Lyme disease, lupus, acute sinusitis or mastoiditis, measles, blood clotting disorders, anemia, leukemia, periodic fever and meningitis.

In many cases, the cause of chronic intracranial hypertension is unclear. This is known as idiopathic intracranial hypertension or benign intracranial hypertension (pseudotumor cerebri). It mainly affects women in their 20s and 30s, and has been associated with:

• being overweight or obese – most cases happen in overweight women, although it’s not clear why
• hormone problems such as Cushing’s syndrome, hypoparathyroidism, an underactive thyroid (hypothyroidism) or an overactive thyroid (hyperthyroidism)
• certain medicines including some antibiotics, steroids and the combined contraceptive pill
• a lack of red blood cells (iron deficiency anaemia) or too many red blood cells (polycythaemia)
• chronic kidney disease
• lupus – a problem with the immune system

But these are only linked with idiopathic intracranial hypertension, they’re not necessarily causes.

A doctor may suspect you have intracranial hypertension if you have symptoms of increased pressure on your brain, such as vision problems and headaches.

You may have several different tests to diagnose intracranial hypertension, such as:

• an examination to check functions such as your muscle strength, reflexes and balance. Any problems could be a sign of an issue with your brain or nerves
• an assessment of your eyes and vision
• a CT scan or MRI scan of your brain
• a lumbar puncture, where a needle is inserted into your spine to check for high pressure in the fluid that surrounds your brain and spinal cord. The typical position for a spinal tap is to lie on your side, with knees slightly bent forward. Local anesthesia is given to numb the lower back. Sometimes, an x-ray (fluoroscopy) may be used to help guide the needle connected to the manometer, the device used to measure intracranial pressure, into the subarachnoid space. Once the spinal needle is inserted, the physician may have you extend your legs and ask you to relax in order to obtain an accurate reading. Holding your breath, bearing down (Valsalva maneuver), or sitting, rather than lying on your side, can produce an inaccurate reading. The opening pressure must be measured before any CSF is removed. The amount of CSF drained during a spinal tap depends on several factors: the opening pressure, the desired closing pressure and the amount of CSF the physician requires for lab studies. Many find that the headache and pulse synchronous tinnitus associated with intracranial hypertension disappears during a spinal tap. While spinal taps can provide important diagnostic information, their therapeutic effects are temporary since spinal fluid regenerates quickly.

Idiopathic intracranial hypertension may be diagnosed if you have increased pressure on your brain and no other cause can be found.

The Modified Dandy Criteria for Idiopathic Intracranial Hypertension is the official criteria used to diagnose idiopathic intracranial hypertension (benign intracranial hypertension). According to the Dandy criteria, an idiopathic intracranial hypertension diagnosis is appropriate if a person ⁶²:

• has signs and symptoms of increased intracranial pressure, such as papilledema and headache;
• has no localizing findings on neurological examination. Localizing findings are findings that point to injury of specific brain areas. For instance, a localizing finding could be the inability to move a certain muscle;
• has a normal MRI/CT scan with no evidence of venous obstructive disease;
• has high intracranial pressure of 250mm/H2O or above on a spinal tap, with no abnormalities of cerebrospinal fluid;
• is awake and alert;
• has no other cause of increased intracranial pressure found.

Chronic intracranial hypertension can be life threatening if it remains undiagnosed and the causes are not treated. You should be referred to a specialist (neurologist) as soon as possible if a your healthcare provider suspects it.

Treatment for intracranial hypertension depends on the cause, if this is known.

The main treatments for idiopathic intracranial hypertension are:

• losing weight if you’re overweight. This can often help to reduce your symptoms and may sometimes relieve them altogether
• stopping any medicine that may be causing your symptoms, including contraception methods. You will need to use a barrier form of contraception as an alternative, such as condoms
• medicine to remove excess fluid from the body (diuretics)
• medicine to reduce the production of cerebrospinal fluid in your brain
• a short course of steroid medicine to relieve headaches and reduce the risk of vision loss
• regular lumbar punctures to remove excess fluid from your spine and help reduce the pressure on your brain

Surgery

Surgery may be considered if other treatments do not help.

The main types of surgery for chronic intracranial hypertension are:

• shunt surgery – a thin, flexible tube is inserted into the fluid-filled space in your skull or spine to divert excess fluid to another part of your body
• optic nerve sheath fenestration – the protective layer surrounding your optic nerve (the nerve connecting the eye to the brain), is opened up to relieve pressure on it and allow fluid to drain away

These procedures can provide relief from your symptoms, but they also carry a risk of potentially serious complications. Talk to the surgeon about what your operation involves and what the risks are.

While many people find their symptoms are relieved with treatment, but the symptoms can come back and can have a significant impact on your life. There’s also a risk that you could lose your vision, even though treatment can help reduce this risk. Permanent vision loss is estimated to happen to 1 in every 5 to 20 people with idiopathic intracranial hypertension.

Complications of high blood pressure

If your blood pressure is too high, it puts extra strain on your blood vessels, heart and other organs, such as the brain, kidneys and eyes. The higher your blood pressure and the longer it goes uncontrolled, the greater the damage.

Persistent high blood pressure can increase your risk of a number of serious and potentially life-threatening health conditions, such as:

• Heart disease
• Coronary heart disease
• Heart attacks. High blood pressure can cause hardening and thickening of the arteries (atherosclerosis), which can lead to a heart attack, stroke or other complications.
• Strokes
• Aneurysm. Increased blood pressure can cause your blood vessels to weaken and bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.
• Heart failure. To pump blood against the higher pressure in your vessels, the heart has to work harder. This causes the walls of the heart’s pumping chamber to thicken (left ventricular hypertrophy). Eventually, the thickened muscle may have a hard time pumping enough blood to meet your body’s needs, which can lead to heart failure.
• Peripheral arterial disease
• Aortic aneurysms
• Atrial fibrillation
• Kidney disease. Weakened and narrowed blood vessels in your kidneys. This can prevent your kidneys from functioning normally.
• Eye disease. Thickened, narrowed or torn blood vessels in the eyes. This can result in vision loss.
• Metabolic syndrome. This syndrome is a group of disorders of your body’s metabolism, including increased waist size, high triglycerides, decreased high-density lipoprotein (HDL) cholesterol (the “good” cholesterol), high blood pressure and high insulin levels. These conditions make you more likely to develop diabetes, heart disease and stroke.
• Vascular dementia. Narrowed or blocked arteries can limit blood flow to the brain, leading to a certain type of dementia (vascular dementia). A stroke that interrupts blood flow to the brain also can cause vascular dementia.
• Trouble with memory or understanding (hypertensive encephalopathy). Uncontrolled high blood pressure may also affect your ability to think, remember and learn. Trouble with memory or understanding concepts is more common in people with high blood pressure.
• Death (usually due to coronary heart disease, vascular disease, stroke-related)

If you have high blood pressure, reducing it even a small amount can help lower your risk of these health conditions.

What is considered high blood pressure?

High blood pressure also known as hypertension, is a common disease that develops when blood flows through your arteries at higher-than-normal pressures. Your blood pressure is made up of two numbers: systolic and diastolic. Systolic pressure is the pressure when the ventricles pump blood out of the heart. Diastolic pressure is the pressure between heartbeats when the heart is filling with blood.

Your blood pressure changes throughout the day based on your activities. For most adults, a normal blood pressure is less than 120 over 80 millimeters of mercury, which is written as your systolic pressure reading over your diastolic pressure reading—120/80 mm Hg. Your blood pressure is considered high when you have consistent systolic readings of 130 mm Hg or higher or diastolic readings of 80 mm Hg or higher.

As a general guide ⁵:

• HYPERTENSIVE CRISIS is considered to be 180 mmHg (systolic) and/or 120 mmHg (diastolic) – your need to see your doctor immediately
• High blood pressure (Hypertension stage 2) is considered to be 160 – 179 mmHg (systolic) or 100-109 mmHg (diastolic)
  
• High blood pressure (Hypertension stage 1) is considered to be 140 – 159 mmHg (systolic) or 90-99 mmHg (diastolic)
• Prehypertension is considered to be 120-139 mmHg (systolic) and/or 80-89 mmHg (diastolic)
  
• Normal blood pressure is considered to be 120/80 mmHg or lower
• Low blood pressure is considered to be 90/60 mmHg or lower

Prehypertension. Prehypertension is a relatively new category of blood pressure identified by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Prehypertension is defined as a systolic blood pressure of 120 to 139 mm Hg and/or a diastolic blood pressure of less than 80 to 89 mm Hg ⁶³. Prehypertension tends to get worse over time and could mean you’re at risk of developing high blood pressure if you don’t take steps to keep your blood pressure under control.

Stage 1 hypertension. Stage 1 hypertension is a systolic pressure ranging from 140 to 159 mm Hg or a diastolic pressure ranging from 90 to 99 mm Hg.

Stage 2 hypertension. More severe hypertension, stage 2 hypertension is a systolic pressure of 160 mm Hg or higher or a diastolic pressure of 100 mm Hg or higher.

Hypertensive Crisis. If your blood pressure reading is 180/120 or greater and you are experiencing any other associated symptoms of target organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision, or difficulty speaking then this would be considered a hypertensive emergency. Do not wait to see if your pressure comes down on its own, call your local emergency number immediately.

A hypertensive (high blood pressure) crisis is when blood pressure rises quickly and severely with readings of 180/120 or greater ⁶⁴.

The consequences of uncontrolled blood pressure in this range can be severe and include:

• Stroke
• Loss of consciousness
• Memory loss
• Heart attack
• Damage to the eyes and kidneys
• Loss of kidney function
• Aortic dissection
• Angina (unstable chest pain)
• Pulmonary edema (fluid backup in the lungs)
• Eclampsia

An elevated reading may or may not be accompanied by one or more of the following symptoms:

• Severe headache
• Shortness of breath
• Nosebleeds
• Severe anxiety

You usually don’t have symptoms from high blood pressure until it has caused serious health problems. About 1 in 3 U.S. adults with high blood pressure aren’t even aware they have it and are not being treated to control their blood pressure. In fact, that is why it is important to have your blood pressure checked at least once a year.

How blood pressure is diagnosed?

High blood pressure (hypertension) doesn’t usually have any symptoms, so the only way to find out if you have it is to get your blood pressure checked.

A device called a sphygmomanometer will be used to measure your blood pressure.

This usually consists of a stethoscope, arm cuff, pump and dial, although automatic devices that use sensors and have a digital display are also commonly used nowadays.

• All adults over 40 are advised to have their blood pressure checked at least every five years. Getting this done is easy and could save your life.
• If you’re at an increased risk of high blood pressure, you should have your blood pressure checked more often – ideally once a year.

It’s best to sit down with your back supported and legs uncrossed for the test. You’ll usually need to roll up your sleeves or remove any long-sleeved clothing, so the cuff can be placed around your upper arm. Try to relax and avoid talking while the test is carried out.

During the test:

• you hold out one of your arms so it’s at the same level as your heart, and the cuff is placed around it – your arm should be supported in this position, such as with a cushion or arm of a chair
• the cuff is pumped up to restrict the blood flow in your arm – this squeezing may feel a bit uncomfortable, but only lasts a few seconds
• the pressure in the cuff is slowly released while a stethoscope is used to listen to your pulse (digital devices use sensors to detect vibrations in your arteries)
• the pressure in the cuff is recorded at two points as the blood flow starts to return to your arm – these measurements are used to give your blood pressure reading

You can usually find out your result straight away, either from the healthcare professional carrying out the test or on the digital display.

If your blood pressure is high, you may be advised to record your blood pressure at home to confirm whether you have high blood pressure.

Home blood pressure monitoring

Blood pressure tests can also be carried out at home using your own digital blood pressure monitor.

This can give a better reflection of your blood pressure, as being tested in somewhere like a doctor surgery can make you feel anxious and can affect the result. It can also allow you to monitor your condition more easily in the long term.

You can buy a variety of low-cost monitors so you can test your blood pressure at home or while you’re out and about.

Ambulatory blood pressure monitoring

In some cases, your doctor may recommend 24-hour or ambulatory blood pressure monitoring.

This is where your blood pressure is tested automatically around every 30 minutes over a 24-hour period using a cuff attached to a portable device worn on your waist.

Ambulatory blood pressure monitoring can help to give a clear picture of how your blood pressure changes over the course of a day.

You should continue with your normal daily activities during the test, although you must avoid getting the equipment wet.

What causes high blood pressure?

In most cases, it’s not clear exactly what causes high blood pressure, but there are things that can increase your risk.

You might be more at risk of high blood pressure if you:

• Are overweight or obese. The more you weigh, the more blood you need to supply oxygen and nutrients to your tissues. As the amount of blood flow through your blood vessels increases, so does the pressure on your artery walls.
• Eat too much salt (sodium) and do not eat enough fruit and vegetables. Too much sodium in your diet can cause your body to retain fluid, which increases blood pressure.
• Have too little potassium in your diet. Potassium helps balance the amount of sodium in your cells. A proper balance of potassium is critical for good heart health. If you don’t get enough potassium in your diet, or you lose too much potassium due to dehydration or other health conditions, sodium can build up in your blood.
• Do not do enough exercise. People who are inactive tend to have higher heart rates. The higher your heart rate, the harder your heart must work with each contraction and the stronger the force on your arteries. Lack of physical activity also increases the risk of being overweight.
• Drink too much alcohol or coffee (or other caffeine-based drinks). Over time, heavy drinking can damage your heart. Having more than one drink a day for women and more than two drinks a day for men may affect your blood pressure. If you drink alcohol, do so in moderation. For healthy adults, that means up to one drink a day for women and two drinks a day for men. One drink equals 12 ounces of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.
• Smoke or use tobacco. Not only does smoking or chewing tobacco immediately raise your blood pressure temporarily, but the chemicals in tobacco can damage the lining of your artery walls. This can cause your arteries to narrow and increase your risk of heart disease. Secondhand smoke also can increase your heart disease risk.
• Use illegal drugs such as cocaine, “bath salts,” and methamphetamine.
• Do not get much sleep or have disturbed sleep
• Have certain chronic conditions. Certain chronic conditions also may increase your risk of high blood pressure, including kidney disease, diabetes, sleep apnea, metabolic syndrome, thyroid problems and certain tumors.
• Age over 65. The risk of high blood pressure increases as you age. Until about age 64, high blood pressure is more common in men. Women are more likely to develop high blood pressure after age 65.
• Have a relative or family history with high blood pressure. High blood pressure tends to run in families.
• Are of African American or Hispanic descent. High blood pressure is particularly common among people of African heritage, often developing at an earlier age than it does in whites. Serious complications, such as stroke, heart attack and kidney failure, also are more common in people of African heritage.
• Experience stress in your life. High levels of stress can lead to a temporary increase in blood pressure. Stress-related habits such as eating more, using tobacco or drinking alcohol can lead to further increases in blood pressure.
• Use medicines. Some prescription and over-the-counter medicines can make it more difficult for your body to control your blood pressure. Antidepressants, decongestants (medicines to relieve a stuffy nose), hormonal birth control pills, and non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen can all raise your blood pressure.
• Live in a deprived area. Research now shows that factors such as income, your education, where you live, and the type of job you have may contribute to your risk of high blood pressure. Working early or late shifts is one example of a social factor that can raise your risk. Additionally, some research has shown that experiencing danger, harm, or trauma as a child has links to a higher risk of developing high blood pressure.
  
• Sometimes pregnancy contributes to high blood pressure as well. During pregnancy, African American women are more likely than white women to develop preeclampsia. Preeclampsia is a pregnancy disorder that causes sudden high blood pressure and problems with the kidneys and liver. Women who have high blood pressure during pregnancy are more likely to have high blood pressure later in life.
• Men are more likely than women to develop high blood pressure throughout middle age. But in older adults, women are more likely than men to develop high blood pressure.

In about 1 in 20 cases, high blood pressure happens as the result of an underlying health condition or taking a certain medicine.

• Health conditions that can cause high blood pressure include:
  • kidney disease
  • diabetes
  • long-term kidney infections
  • obstructive sleep apnea – where the walls of the throat relax and narrow during sleep, interrupting normal breathing
  • glomerulonephritis – damage to the tiny filters inside the kidneys
  • narrowing of the arteries supplying the kidneys
  • hormone problems – such as an underactive thyroid, an overactive thyroid, Cushing’s syndrome, acromegaly, increased levels of the hormone aldosterone (hyperaldosteronism), and pheochromocytoma
  • lupus – a condition in which the immune system attacks parts of the body, such as the skin, joints and organs
  • scleroderma – a condition that causes thickened skin, and sometimes problems with organs and blood vessels
• Medicines that can increase your blood pressure include:
  • the contraceptive pill
  • steroids
  • non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen and naproxen
  • some pharmacy cough and cold remedies
  • some herbal remedies – particularly those containing liquorice
  • some recreational drugs – such as cocaine and amphetamines
  • some selective serotonin-noradrenaline reuptake inhibitor (SSNRI) antidepressants – such as venlafaxine

In these cases, your blood pressure may return to normal once you stop taking the medicine or drug.

Although high blood pressure is most common in adults, children may be at risk, too. For some children, high blood pressure is caused by problems with the kidneys or heart. But for a growing number of kids, poor lifestyle habits — such as an unhealthy diet and lack of exercise — contribute to high blood pressure.

Making healthy lifestyle changes can sometimes help reduce your chances of getting high blood pressure and help lower your blood pressure if it’s already high.

Risk factors for high blood pressure

Nearly one-third of all Americans have high blood pressure, but it is particularly prevalent in:

• People who have diabetes, gout, or kidney disease
• African Americans (particularly those who live in the southeastern U.S.)
• People in their early to middle adult years; men in this age group have higher blood pressure more often than women in this age group
• People in their middle to later adult years; women in this age group have higher blood pressure more often than men in this age group (more women have high blood pressure after menopause than men of the same age)
• Middle-aged and elderly people; more than half of all Americans age 60 and older have high blood pressure
• People with a family history of high blood pressure
• People consuming a high salt diet
• Overweight or obese people
• Heavy drinkers of alcohol
• Women who are taking oral contraceptives
• People with depression
• A lack of exercise and physical activity

High blood pressure Prevention

High blood pressure can often be prevented or reduced by eating healthily, maintaining a healthy weight, taking regular exercise, drinking alcohol in moderation and not smoking.

Healthy diet

Cut down on the amount of salt in your food and eat plenty of fruit and vegetables. The Healthy Eating highlights the different types of food that make up our diet, and shows the proportions we should eat them in to have a well-balanced and healthy diet.

Salt raises your blood pressure. The more salt you eat, the higher your blood pressure. Aim to eat less than 1.5 g (1500 mg) of salt a day, which is about half a teaspoonful. A lower sodium level — 1,500 milligrams (mg) a day — is appropriate for people 51 years of age or older, and individuals of any age who are black or who have hypertension, diabetes or chronic kidney disease.

Otherwise healthy people can aim for 2,300 mg a day or less. While you can reduce the amount of salt you eat by putting down the saltshaker, you generally should also pay attention to the amount of salt that’s in the processed foods you eat, such as canned soups or frozen dinners.

Eating a low-fat diet that includes lots of fiber – such as wholegrain rice, bread and pasta – and plenty of fruit and vegetables also helps lower blood pressure. Aim to eat five portions of fruit and vegetables every day.

Tips for a lower-salt diet

Too much salt can raise your blood pressure, which puts you at increased risk of health problems such as heart disease and stroke. But a few simple steps can help you to cut your salt intake.

Salt (Sodium) Equivalents

Sodium chloride or table salt is approximately 40 percent sodium. It’s important to understand just how much sodium is in salt so you can take measures to control your intake. These amounts are approximate.

• 1/4 teaspoon salt = 575 mg sodium
• 1/2 teaspoon salt = 1,150 mg sodium
• 3/4 teaspoon salt = 1,725 mg sodium
• 1 teaspoon salt = 2,300 mg sodium

Sodium Sources

Sodium can be sneaky. Taking control of your sodium means checking labels and reducing preservatives. Other foods to be aware of include:

• Processed foods
• Natural foods with a higher-than-average sodium content, including cheese, seafood, olives and some legumes
• Table salt, sea salt and kosher salt (sodium chloride)
• Some over-the-counter drugs
• Some prescription medications

You don’t have to add salt to food to be eating too much – 75% of the salt we eat is already in everyday foods such as bread, breakfast cereal and ready meals.

A diet that is high in salt can cause raised blood pressure, which currently affects more than one third of adults in the US.

High blood pressure often has no symptoms, and it is estimated that in America about one in every three people who have high blood pressure don’t know it. But if you have it, you are more likely to develop heart disease or have a stroke.

How to lower high blood pressure

Simple lifestyle changes can often help reduce high blood pressure (hypertension), although some people may need to take medication as well.

Your doctor can advise you about changes you can make to your lifestyle and discuss whether they think you would benefit from medication.

Your doctor may recommend that you make lifestyle changes including:

• Eating a heart-healthy diet with less salt
• Getting regular physical activity
• Maintaining a healthy weight or losing weight if you’re overweight or obese
• Limiting the amount of alcohol you drink

But sometimes lifestyle changes aren’t enough. If diet and exercise don’t help, your doctor may recommend medication to lower your blood pressure. Have your blood pressure checked routinely and see your healthcare provider to monitor your blood pressure.

Eighth Joint National Committee (JNC 8) recommends the following ⁶⁵:

• Starting pharmacological therapy for individuals with diabetes mellitus and chronic kidney disease (CKD) with blood pressure greater than or equal to 140/90 mmHg to therapeutic target blood pressure less than 140/90 mmHg
• Starting pharmacological therapy for individuals 60 years of age and over with blood pressure greater than or equal to 150/90 mmHg to therapeutic target blood pressure less than 150/90mmHg
• Starting pharmacological therapy for individuals 18 to 59 years of age with systolic blood pressure greater than or equal to 140mmHg to therapeutic target systolic blood pressure less than 140mmHg
• Individuals with diabetes mellitus and non-black population, treatment should include a thiazide diuretic, calcium channel blocker, and an angiotensin-converting enzyme inhibitors/angiotensin receptor blocker
• Individuals in the black population, including those with diabetes mellitus, treatment should include a thiazide diuretic and calcium channel blocker
• Individuals with chronic kidney disease, treatment should be started with or include angiotensin-converting enzyme inhibitors/angiotensin receptor blocker, and this applies to all chronic kidney disease patients irrespective of race or diabetes mellitus status

American College of Cardiology recommends the following ⁶⁶:

• Ten-year atherosclerotic cardiovascular disease risk should be estimated
• Anti-hypertensive medications are usually initiated when blood pressure readings are persistently greater than or equal to 140/90 mmHg
• High-risk population (diabetics, chronic kidney disease, individuals with atherosclerotic cardiovascular disease) or in those individuals with 10-year atherosclerotic cardiovascular disease risk greater than or equal to 10%, therapy can be initiated at lower blood pressure cutoffs
• The goal of treatment is to keep blood pressures in as close to normal range as possible, i.e., blood pressure less than or equal to 130/80 mmHg

European Society of Cardiology and European Society of Hypertension recommends the following ⁸:

• Starting pharmacological therapy for grade 2 or 3 hypertension regardless of the level of risk
• Starting pharmacological therapy for grade 1 hypertension when there is hypertension mediated end-organ damage
• Grade 1 hypertension in the absence of hypertension mediated end-organ damage requires either high risk for cardiovascular disease or failure of lifestyle interventions, for initiating pharmacological therapy
• Starting pharmacological therapy for individuals greater than or equal to 80 years of age with blood pressure greater than or equal to 160/90mmHg to therapeutic target less than 160/90mmHg regardless of diabetes mellitus, chronic kidney disease, coronary artery disease or transient ischemia attack (TIA)/ stroke (cerebrovascular accident)
• Starting pharmacological therapy for individuals 18 to 79 years of age with blood pressure greater than or equal to 140/90mmHg to therapeutic target less than 140/90 mmHg regardless of diabetes mellitus, chronic kidney disease, coronary artery disease or transient ischemia attack (TIA)/ stroke (cerebrovascular accident)

Figure 1. Eighth Joint National Committee (JNC 8) Hypertension Guideline Algorithm

Abbreviations: CKD = chronic kidney disease; BP = blood pressure; HTN = hypertension

[Source ⁶⁵ ]

When treatment is recommended

Everyone with high blood pressure is advised to make healthy lifestyle changes.

Whether medication is recommended depends on your blood pressure reading and your risk of developing problems such as heart attacks or strokes.

Your doctor will carry out some blood and urine tests, and ask questions about your health to determine your risk of other problems:

• if your blood pressure is consistently above 140/90mmHg (or 135/85mmHg at home) but your risk of other problems is low – you’ll be advised to make some changes to your lifestyle
• if your blood pressure is consistently above 140/90mmHg (or 135/85mmHg at home) and your risk of other problems is high – you’ll be offered medication to lower your blood pressure, in addition to lifestyle changes
• if your blood pressure is consistently above 160/100mmHg – you’ll be offered medication to lower your blood pressure, in addition to lifestyle changes

Table 4. Blood pressure treatment goals*

*Although 120/80 mm Hg or lower is the ideal blood pressure goal, doctors are unsure if you need treatment (medications) to reach that level.
Less than 150/90 mm Hg	If you’re a healthy adult age 60 or older
Less than 140/90 mm Hg	If you’re a healthy adult younger than age 60
Less than 140/90 mm Hg	If you have chronic kidney disease, diabetes or coronary artery disease or are at high risk of coronary artery disease

• If you’re age 60 or older, and use of medications produces lower systolic blood pressure (such as less than 140 mm Hg), your medications won’t need to be changed unless they cause negative effects to your health or quality of life.
• Also, people older than 60 commonly have isolated systolic hypertension — when diastolic pressure is normal but systolic pressure is high.

The category of medication your doctor prescribes depends on your blood pressure measurements and your other medical problems.

Home remedies for high blood pressure

There are some changes you could make to your lifestyle to reduce high blood pressure. Some of these will lower your blood pressure in a matter of weeks, while others may take longer.

These include:

• cutting your salt intake to less than 1.5 g (1500 mg) a day. A lower sodium level — 1,500 milligrams (mg) a day — is appropriate for people 51 years of age or older, and individuals of any age who are black or who have hypertension, diabetes or chronic kidney disease. Otherwise healthy people can aim for 2,300 mg a day or less. While you can reduce the amount of salt you eat by putting down the saltshaker, you generally should also pay attention to the amount of salt that’s in the processed foods you eat, such as canned soups or frozen dinners.
• eating a low-fat, balanced diet – including plenty of fresh fruit and vegetables
• being active by getting more exercise
• cutting down on alcohol
• losing weight
• drinking less caffeine – found in coffee, tea and cola
• quitting smoking and get help quitting
• getting at least 8 hours of sleep a night if you can
• manage stress. Reduce stress as much as possible. Practice healthy coping techniques, such as muscle relaxation, deep breathing or meditation. Getting regular physical activity and plenty of sleep can help, too.
• Practice relaxation or slow, deep breathing. Practice taking deep, slow breaths to help relax. There are some devices available that promote slow, deep breathing. However, it’s questionable whether these devices have a significant effect on lowering your blood pressure.
• Monitor your blood pressure at home. Home blood pressure monitoring can help you keep closer tabs on your blood pressure, show if medication is working, and even alert you and your doctor to potential complications. Home blood pressure monitoring isn’t a substitute for visits to your doctor, and home blood pressure monitors may have some limitations. Even if you get normal readings, don’t stop or change your medications or alter your diet without talking to your doctor first. If your blood pressure is under control, you may be able to make fewer visits to your doctor if you monitor your blood pressure at home.

You can take these steps today, regardless of whether or not you’re taking blood pressure medication. In fact, by making these changes early on you may be able to avoid needing medication.

High blood pressure medication

Several medications can be used to help control high blood pressure. Many people need to take a combination of different medicines.

The medication recommended for you at first will depend on your age and ethnicity:

• if you’re under 55 years of age – you’ll usually be offered an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-2 receptor blocker
• if you’re aged 55 or older, or you’re any age and of African or Caribbean origin – you’ll usually be offered a calcium channel blocker

You may need to take blood pressure medication for the rest of your life. But your doctor might be able to reduce or stop your treatment if your blood pressure stays under control for several years.

It’s really important to take your medications as directed. If you miss doses, it won’t work as effectively. The medication won’t necessarily make you feel any different, but this doesn’t mean it’s not working.

Medications used to treat high blood pressure can have side effects, but most people don’t experience any. If you do, changing medication will often help.

Figure 2. High blood pressure medicine

[Source ⁶⁵ ]

ACE inhibitors

Angiotensin-converting enzyme (ACE) inhibitors reduce blood pressure by relaxing your blood vessels by blocking the formation of a natural chemical that narrows blood vessels. People with chronic kidney disease may benefit from having an angiotensin-converting enzyme inhibitor as one of their medications.

Common examples are enalapril, lisinopril, perindopril and ramipril.

The most common side effect is a persistent dry cough. Other possible side effects include headaches, dizziness and a rash.

Angiotensin-2 receptor blockers

Angiotensin-2 receptor blockers work to relax blood vessels by blocking the action, not the formation, of a natural chemical that narrows blood vessels. They’re often recommended if angiotensin-converting enzyme (ACE) inhibitors cause troublesome side effects. People with chronic kidney disease may benefit from having an angiotensin-2 receptor blockers as one of their medications.

Common examples are candesartan, irbesartan, losartan, valsartan and olmesartan.

Possible side effects include dizziness, headaches, and cold or flu-like symptoms.

Calcium channel blockers

Calcium channel blockers reduce blood pressure by widening your blood vessels. Some slow your heart rate. Calcium channel blockers may work better for blacks and older people than do ACE inhibitors alone.

Common examples are amlodipine, felodipine and nifedipine. Other medicines such as diltiazem and verapamil are also available.

Possible side effects include headaches, swollen ankles and constipation.

Drinking grapefruit juice while taking some calcium channel blockers can increase your risk of side effects. Talk to your doctor or pharmacist if you’re concerned about interactions.

Diuretics

Sometimes known as water pills, diuretics work by flushing excess water and salt from the body through urine, reducing blood volume. They’re often used if calcium channel blockers cause troublesome side effects.

If you’re not taking a diuretic and your blood pressure remains high, talk to your doctor about adding one or replacing a drug you currently take with a diuretic. Diuretics or calcium channel blockers may work better for black and older people than do angiotensin-converting enzyme (ACE) inhibitors alone. A common side effect of diuretics is increased urination.

Common examples are indapamide, hydrochlorothiazide (Microzide), chlorthalidone and bendroflumethiazide.

Possible side effects include dizziness when standing up, increased thirst, needing to go to the toilet frequently, and a rash.

Low potassium level (hypokalaemia) and low sodium level (hyponatraemia) may also be seen after long-term use.

Beta-blockers

Beta-blockers can reduce blood pressure by reducing the workload on your heart and open your blood vessels, causing your heart to beat slower and with less force.

They used to be a popular treatment for high blood pressure, but now only tend to be used when other treatments haven’t worked.

When prescribed alone, beta blockers don’t work as well, especially in black and older people, but may be effective when combined with other blood pressure medications.

This is because beta-blockers are considered less effective than other blood pressure medications.

Common examples are atenolol (Tenormin), acebutolol (Sectral) and bisoprolol.

Possible side effects include dizziness, headaches, tiredness, and cold hands and feet.

Renin inhibitors

Aliskiren (Tekturna) slows down the production of renin, an enzyme produced by your kidneys that starts a chain of chemical steps that increases blood pressure.

Tekturna works by reducing the ability of renin to begin this process. Due to a risk of serious complications, including stroke, you shouldn’t take aliskiren with ACE inhibitors or angiotensin II receptor blockers.

Additional medications sometimes used to treat high blood pressure

If you’re having trouble reaching your blood pressure goal with combinations of the above medications, your doctor may prescribe:

• Alpha blockers. These medications reduce nerve impulses to blood vessels, reducing the effects of natural chemicals that narrow blood vessels. Alpha blockers include doxazosin (Cardura), prazosin (Minipress) and others.
• Alpha-beta blockers. In addition to reducing nerve impulses to blood vessels, alpha-beta blockers slow the heartbeat to reduce the amount of blood that must be pumped through the vessels. Alpha-beta blockers include carvedilol (Coreg) and labetalol (Trandate).
• Central-acting agents. These medications prevent your brain from signaling your nervous system to increase your heart rate and narrow your blood vessels. Examples include clonidine (Catapres, Kapvay), guanfacine (Intuniv, Tenex) and methyldopa.
• Vasodilators. These medications, including hydralazine and minoxidil, work directly on the muscles in the walls of your arteries, preventing the muscles from tightening and your arteries from narrowing.
• Aldosterone antagonists. Examples are spironolactone (Aldactone) and eplerenone (Inspra). These drugs block the effect of a natural chemical that can lead to salt and fluid retention, which can contribute to high blood pressure.

To reduce the number of daily medication doses you need, your doctor may prescribe a combination of low-dose medications rather than larger doses of one single drug. In fact, two or more blood pressure drugs often are more effective than one. Sometimes finding the most effective medication or combination of drugs is a matter of trial and error.

High blood pressure diet

Eating a heart-healthy diet is important for managing your blood pressure and reducing your risk of heart attack, stroke and other health threats.

Get quality nutrition from healthy food sources.

Aim to eat a diet that’s rich in:

• Fruits
• Vegetables
• Whole-grains
• Low-fat dairy products
• Skinless poultry and fish
• Nuts and legumes
• Non-tropical vegetable oils

Limit:

• Saturated and trans fats
• Sodium
• Red meat (if you do eat red meat, compare labels and select the leanest cuts available)
• Sweets and sugar-sweetened beverages.

The DASH Diet

DASH stands for Dietary Approaches to Stop Hypertension is similar to a Mediterranean-type diet ⁶⁷. It is an eating plan that is based on research studies sponsored by the National Heart, Lung, and Blood Institute ⁶⁸. The DASH diet eating plan includes vegetables, whole grains, poultry, fish, and nuts, and has low amounts of fats, red meats, sweets, and sugared beverages. It is also high in potassium, calcium and magnesium, as well as protein and fiber. This dietary approach has been shown to lower blood pressure, but little has been published regarding weight loss ⁶⁷. In fact, a systematic review and meta-analysis on observational prospective studies on the effects of Dietary Approaches to Stop Hypertension (DASH)-style diet, showed that the DASH diet can significantly protect against cardiovascular diseases, coronary heart disease, stroke, and heart failure risk by 20%, 21%, 19% and 29%, respectively ⁶⁹, ⁷⁰.

The DASH Diet

• Emphasizes vegetables, fruits, and fat-free or low-fat dairy products.
• Includes whole grains, fish, poultry, beans, seeds, nuts, and vegetable oils.
• Limits sodium, sweets, sugary beverages, and red meats. The American Heart Association recommends 1,500 mg a day of sodium as an upper limit for all adults.

You can make your meals lower in calories by replacing high-calorie foods with more fruits and vegetables and that also will make it easier for you to reach your DASH eating plan goals.

What Foods To Eat

• Fruits
• Vegetables
• Whole-grains
• Low-fat dairy products
• Skinless poultry and fish
• Nuts and legumes
• Non-tropical vegetable oils

What Foods to Reduce or Avoid

• Saturated and trans fats
• Sodium (salt)
• Red meat (if you do eat red meat, compare labels and select the leanest cuts available)
• Sweets and sugar-sweetened beverages
• Alcohol and caffeine
• Processed foods, which are often high in fat, salt, and sugar

One teaspoon of table salt has 2,325 mg of sodium. When you read food labels, you may be surprised at just how much sodium some processed foods contain. Even low-fat soups, canned vegetables, ready-to-eat cereals and sliced turkey from the local deli — foods you may have considered healthy — often have lots of sodium.

Most of the salt (sodium) Americans eat comes from processed and prepared foods, such as breads, cold cuts, pizza, poultry, soups, sandwiches and burgers, cheese, pasta and meat dishes, and salty snacks. Therefore, healthier choices when shopping and eating out are particularly important.

Along with DASH, other lifestyle changes can help lower your blood pressure. They include staying at a healthy weight, exercising, and not smoking.

The DASH diet is a lifelong approach to healthy eating that’s designed to help treat or prevent high blood pressure (hypertension). The DASH diet encourages you to reduce the sodium in your diet and eat a variety of foods rich in nutrients that help lower blood pressure, such as potassium, calcium and magnesium and eating foods that are low in saturated fat, total fat, and cholesterol, and high in fruits, vegetables, and low fat dairy foods ⁷¹.

The original DASH trial ⁷² consisted of 459 subjects with systolic blood pressures <160 mm Hg and diastolic blood pressures between 80 and 95 mm Hg. For three weeks, all participants were fed a control diet low in fruits, vegetables, and dairy products, and with a fat content typical of an American diet (37% of daily caloric intake). During the following eight weeks, the participants were randomized to one of three diets: the control diet, a diet rich in fruits and vegetables, or the DASH Diet.

The DASH Diet was not low in sodium (salt), but still reduced blood pressure. A meta-analysis of 56 randomized, controlled trials that included over 3,500 participants did not support universal sodium restriction, but instead only recommended dietary sodium restriction in the elderly ⁷³.

The DASH Diet reduced systolic blood pressure by 5.5 mm Hg and diastolic blood pressure by 3.3 mm Hg, as compared with controls. Subgroup analysis showed that African Americans and those with hypertension had the greatest reduction in blood pressure ⁷² . The DASH diet results might be applied to a larger group due to the heterogeneous population: half of the participants were women, 60% were African American, and 37% had household incomes of <$30,000 per year. One limitation of applying the DASH Diet to the general population is that the study was carried out in a very controlled setting, where all the meals were prepared for the subjects, and thus no comments may be made regarding attrition rates for the diet.

By following the DASH diet, you may be able to reduce your blood pressure by a few points in just two weeks. Over time, your systolic blood pressure could drop by eight to 14 points, which can make a significant difference in your health risks.

Table 5. Daily Nutrient Goals Used in the DASH Studies (for a 2,100 Calorie Eating Plan)

Total fat: 27% of calories	Sodium: 2,300 mg*
Saturated fat: 6% of calories	Potassium: 4,700 mg
Protein: 18% of calories	Calcium: 1,250 mg
Carbohydrate: 55% of calories	Magnesium: 500 mg
Cholesterol: 150 mg	Fiber: 30 g

Footnote: 1,500 mg sodium* was a lower goal tested and found to be even better for  lowering blood pressure. It was particularly effective for middle-aged and older individuals, African Americans, and those who already had high blood pressure.

Abbreviation: g = grams; mg = milligrams

[Source ⁷⁴ ]

Most Americans should consume no more than 2.4 grams (2,400 milligrams) of sodium a day. That equals 6 grams (about 1 teaspoon) of table salt a day. The 6 grams includes all salt and sodium consumed, including that used in cooking and at the table. African Americans and the elderly, are especially sensitive to salt and sodium and should be particularly careful about how much they consume.

Another DASH diet called DASH-Sodium — calls for cutting back sodium (salt) to 1,500 milligrams a day (about 2/3 teaspoon). Studies of people on the DASH-Sodium plan lowered their blood pressure as well.

To further investigate the effects of sodium restriction, the DASH-Sodium Trial ⁷⁵ looked at the effect on blood pressure of a reduced dietary sodium intake as participants followed either the DASH eating plan or an eating plan typical of what many Americans consume. This second study involved 412 participants. Participants were randomly assigned to one of the two eating plans and then followed for a month at each of the three sodium levels. The three sodium levels were a higher intake of about 3,300 milligrams per day (the level consumed by many Americans), an intermediate intake of about 2,300 milligrams per day, and a lower intake of about 1,200 milligrams per day. Results showed that reducing dietary sodium lowered blood pressure for both eating plans. At each sodium level, blood pressure was lower on the DASH eating plan than on the other eating plan. Additionally, there was no significant difference between high (3,300 milligrams per day) and intermediate sodium (2,300 milligrams per day) intake on diastolic blood pressure for those on the DASH Diet. The greatest blood pressure reductions were for the DASH eating plan at the sodium intake of 1,200 milligrams per day. Those with high blood pressure saw the greatest reductions, but those with prehypertension also had large decreases ⁷⁵. The DASH Diet can reduce systolic blood pressure by 5.5 mm Hg and diastolic blood pressure by 3.3 mm Hg. However, the effect of sodium reduction on hypertension remains controversial. Lowering sodium to the levels of 1.2 g/day, as achieved in the lowest sodium intake group of the DASH-Sodium Trial, would be nearly impossible without changes in the food industry, as 75% of sodium intake comes from additions made in processing ⁷⁶.

Detailed analysis showed that the DASH diet and reduced sodium intake reduced blood pressure for all the population subgroups studied. The following list shows the average blood pressure reduction for key subgroups:

• For those with hypertension: 12/6 mm Hg (systolic/diastolic); for those without hypertension, 7/4 mm Hg.
• For those over age 45, 12/6 mm Hg; for those 45 or younger, 6/3 mm Hg.
• For women, 11/5 mm Hg; for men, 7/4 mm Hg.
• For African Americans, 10/5 mm Hg; for non-African Americans, 8/4 mm Hg.

Other results include:

• Compared with the typical American diet, the DASH diet alone (at the higher sodium level) reduced blood pressure by about 6/3 mm Hg for African Americans, and 6/2 mm Hg for other races.
• For those with hypertension, reductions from the DASH diet alone were 7/3 mm Hg; and for those without hypertension, the reductions were 5/3 mm Hg. The effects of sodium reduction appeared in all subgroups and were greater for those who ate the typical American diet, compared with those on the DASH diet.
• The effects from sodium reduction were particularly great for those with hypertension, African Americans, women, and those over age 45. Sodium reduction in those eating the control diet resulted in lower systolic and diastolic pressures by 8.3 mm Hg and 4.4 mm Hg, respectively, in hypertensives, and 5.4 and 2.8 mm Hg, respectively, in non-hypertensives.

“The blood pressure reductions achieved from this combination came in only 4 weeks and persisted through the duration of the study”, said Dr. Denise Simons-Morton, Leader of the NHLBI Prevention Scientific Research Group and a DASH coauthor ⁷⁷.

Both versions of the DASH diet include lots of whole grains, fruits, vegetables and low-fat dairy products. The DASH diet also includes some fish, poultry and legumes, and encourages a small amount of nuts and seeds a few times a week.

The DASH diet generally includes about 2,000 calories a day. If you’re trying to lose weight, you may need to eat fewer calories. You may also need to adjust your serving goals based on your individual circumstances — something your health care team can help you decide.

Studies showed that DASH lowers high blood pressure and improves levels of cholesterol. This reduces your risk of getting heart disease.

Because the DASH diet is a healthy way of eating, it offers health benefits besides just lowering blood pressure. The DASH diet is also in line with dietary recommendations to prevent osteoporosis, cancer, heart disease, stroke and diabetes.

While the DASH diet is not a weight-loss program, you may indeed lose unwanted pounds because it can help guide you toward healthier food choices. A recent study showed that people can lose weight while following the DASH eating plan and lowering their sodium intake. In a randomized trial of 810 participants called the PREMIER Study ⁷⁸, ⁷⁹, who were placed into three groups to lower blood pressure, lose weight, and improve health. The groups included:

1. Advice-only group received a 30-minute individual session with a nutritionist, which did not include counseling on how to make behavior changes.
2. Established treatment plan, including counseling for 6 months to keep track of their diet, including calorie and sodium consumption, and their physical activity.
3. Established treatment plan, plus counseling and use of the DASH diet.

After 6 months, blood pressure levels declined in all three groups. The two groups that received counseling and followed a treatment plan had more weight loss than the advice-only group. However, participants in the established treatment plan who followed the DASH diet had the greatest improvement in their blood pressure ⁷⁸, ⁷⁹.

By paying close attention to food labels when you shop, you can consume less sodium. Sodium is found naturally in many foods. But processed foods account for most of the salt and sodium that Americans consume. Processed foods that are high in salt include regular canned vegetables and soups, frozen dinners, lunch meats, instant and ready-to-eat cereals, and salty chips and other snacks.

Table 6. DASH Diet Eating Plan—Number of Food Servings by Calorie Level

Food Group	1,200 Calories	1,400 Calories	1,600 Calories	1,800 Calories	2,000 Calories	2,600 Calories	3,100 Calories
Grains a	4–5	5–6	6	6	6–8	10–11	12–13
Vegetables	3–4	3–4	3–4	4–5	4–5	5–6	6
Fruits	3–4	4	4	4–5	4–5	5–6	6
Fat-free or low-fat dairy products b	2–3	2–3	2–3	2–3	2–3	3	3–4
Lean meats, poultry, and fish	3 or less	3–4 or less	3–4 or less	6 or less	6 or less	6 or less	6–9
Nuts, seeds, and legumes	3 per week	3 per week	3–4 per week	4 per week	4–5 per week	1	1
Fats and oils c	1	1	2	2–3	2–3	3	4
Sweets and added sugars	3 or less per week	3 or less per week	3 or less per week	5 or less per week	5 or less per week	≤2	≤2
Maximum sodium limit d	2,300 mg/day	2,300 mg/day	2,300 mg/day	2,300 mg/day	2,300 mg/day	2,300 mg/day	2,300 mg/day

Footnotes:

^a Whole grains are recommended for most grain servings as a good source of fiber and nutrients.

^b For lactose intolerance, try either lactase enzyme pills with dairy products or lactose-free or lactose-reduced milk.

^c Fat content changes the serving amount for fats and oils. For example, 1 Tbsp regular salad dressing = one serving; 1 Tbsp low-fat dressing = one-half serving; 1 Tbsp fat-free dressing = zero servings.

^d The DASH diet eating plan has a salt (sodium) limit of either 2,300 mg or 1,500 mg per day. 1,500 milligrams (mg) sodium lowers blood pressure even further than 2,300 mg sodium daily.

Table 7. Tips for Lowering Salt (Sodium) When Shopping, Cooking, and Eating Out

Shopping	Cooking	Eating Out
Read food labels, and choose items that are lower in sodium and salt, particularly for convenience foods and condiments.* Choose fresh poultry, fish, and lean meats instead of cured food such as bacon and ham. Choose fresh or frozen versus canned fruits and vegetables. Avoid food with added salt, such as pickles, pickled vegetables, olives, and sauerkraut. Avoid instant or flavored rice and pasta.	Don’t add salt when cooking rice, pasta, and hot cereals. Flavor your foods with salt-free seasoning blends, fresh or dried herbs and spices, or fresh lemon or lime juice. Rinse canned foods or foods soaked in brine before using to remove the sodium. Use less table salt to flavor food.	Ask that foods be prepared without added salt or MSG, commonly used in Asian foods. Avoid choosing menu items that have salty ingredients such as bacon, pickles, olives, and cheese. Avoid choosing menu items that include foods that are pickled, cured, smoked, or made with soy sauce or broth. Choose fruit or vegetables as a side dish, instead of chips or fries.

Footnote: *Examples of convenience foods are frozen dinners, prepackaged foods, and soups; examples of condiments are mustard, ketchup, soy sauce, barbecue sauce, and salad dressings.

Increasing Daily Potassium

The DASH diet eating plan is designed to be rich in potassium, with a target of 4,700 mg potassium daily, to enhance the effects of reducing sodium on blood pressure. The following are examples of potassium-rich foods.

Table 8. Sample Foods and Potassium Levels

Food Groups	Potassium (mg)
Vegetables
Potato, 1 medium	926
Sweet Potato, 1 medium	540
Spinach, cooked, 1/2 cup	290
Zucchini, cooked, 1/2 cup	280
Tomato, fresh, 1/2 cup	210
Kale, cooked, 1/2 cup	150
Romaine lettuce, 1 cup	140
Mushrooms, 1/2 cup	110
Cucumber, 1/2 cup	80
Fruit
Banana, 1 medium	420
Apricots, 1/4 cup	380
Orange, 1 medium	237
Cantaloupe chunks, 1/2 cup	214
Apple, 1 medium	150
Nuts, seeds, and legumes
Cooked soybeans, 1/2 cup	440
Cooked lentils, 1/2 cup	370
Cooked kidney beans, 1/2 cup	360
Cooked split peas, 1/2 cup	360
Almonds, roasted, 1/3 cup	310
Walnuts, roasted, 1/3 cup	190
Sunflower seeds, roasted, 2 Tbsp	124
Peanuts, roasted, 1/3 cup	120
Low-fat or fat-free milk and milk products
Milk, 1 cup	380
Yogurt, 1 cup	370
Lean meats, fish, and poultry
Fish (cod, halibut, rockfish, trout, tuna), 3 oz	200-400
Pork tenderloin, 3 oz	370
Beef tenderloin, chicken, turkey, 3 oz	210

Footnote: Before you increase the potassium in your diet or use salt substitutes (which often contain potassium), check with your doctor. People who have kidney problems or who take certain medicines must be careful about how much potassium they consume.

[Source ⁸⁰ ]

Based on these recommendations, the following tables shows examples of daily and weekly servings that meet DASH diet eating plan targets for a 2,000-calorie-a-day diet.

Table 9. Daily and Weekly DASH Diet Eating Plan Goals for a 2,000-Calorie-a-Day Diet

Food Group	Daily Servings	Serving Sizes	Examples and Notes	Significance of Each Food Group to the DASH Eating Pattern
Grains*	6-8	1 slice bread 1 oz dry cereal** 1/2 cup cooked rice, pasta, or cereal	Whole wheat bread and rolls, whole wheat pasta, English muffin, pita bread, bagel, cereals, grits, oatmeal, brown rice, unsalted pretzels and popcorn	Major sources of energy and fiber
Vegetables	4-5	1 cup raw leafy vegetable 1/2 cup cut-up raw or cooked vegetable 1/2 cup vegetable juice	Broccoli, carrots, collards, green beans, green peas, kale, lima beans, potatoes, spinach, squash, sweet potatoes, tomatoes	Rich sources of potassium, magnesium, and fiber
Fruits	4-5	1 medium fruit 1/4 cup dried fruit 1/2 cup fresh, frozen, or canned fruit 1/2 cup fruit juice	Apples, apricots, bananas, dates, grapes, oranges, grapefruit, grapefruit juice, mangoes, melons, peaches, pineapples, raisins, strawberries, tangerines	Important sources of potassium, magnesium, and fiber
Fat-free or low-fat milk and milk products	2-3	1 cup milk or yogurt 1 1/2 oz cheese	Fat-free (skim) or low-fat (1%) milk or buttermilk, fat-free, low-fat, or reduced-fat cheese, fat-free or low-fat regular or frozen yogurt	Major sources of calcium and protein
Lean meats, poultry, and fish	6 or less	1 oz cooked meats, poultry, or fish 1 egg***	Select only lean; trim away visible fats; broil, roast, or poach; remove skin from poultry	Rich sources of protein and magnesium
Nuts, seeds, and legumes	4-5 per week	1/3 cup or 1 1/2 oz nuts 2 Tbsp peanut butter 2 Tbsp or 1/2 oz seeds 1/2 cup cooked legumes (dry beans and peas)	Almonds, hazelnuts, mixed nuts, peanuts, walnuts, sunflower seeds, peanut butter, kidney beans, lentils, split peas	Rich sources of energy, magnesium, protein, and fiber
Fats and oils****	2-3	1 tsp soft margarine 1 tsp vegetable oil 1 Tbsp mayonnaise 2 Tbsp salad dressing	Soft margarine, vegetable oil (such as canola, corn, olive, or safflower), low-fat mayonnaise, light salad dressing	The DASH study had 27 percent of calories as fat, including fat in or added to foods
Sweets and added sugars	5 or less per week	1 Tbsp sugar 1 Tbsp jelly or jam 1/2 cup sorbet, gelatin 1 cup lemonade	Fruit-flavored gelatin, fruit punch, hard candy, jelly, maple syrup, sorbet and ices, sugar	Sweets should be low in fat

Footnotes:

* Whole grains are recommended for most grain servings as a good source of fiber and nutrients.

** Serving sizes vary between 1/2 cup and 11/4 cups, depending on cereal type. Check the product’s Nutrition Facts label.

*** Since eggs are high in cholesterol, limit egg yolk intake to no more than four per week; two egg whites have the same protein content as 1 oz of meat.

**** Fat content changes serving amount for fats and oils. For example, 1 Tbsp of regular salad dressing equals one serving; 1 Tbsp of a low-fat dressing equals one-half serving; 1 Tbsp of a fat-free dressing equals zero servings.

[Source ⁸¹ ]

When following the DASH diet eating plan, it is important to choose foods that are:

• Low in saturated and trans fats
• Rich in potassium, calcium, magnesium, fiber, and protein
• Lower in sodium

Table 10. DASH Diet Eating Plan—Number of Daily Servings for Other Calorie Levels

	Servings/Day
Food Groups	1,600 calories/day	2,600 calories/day	3,100 calories/day
Grains*	6	10-11	12-13
Vegetables	3-4	5-6	6
Fruits	4	5-6	6
Fat-free or lowfat milk and milk products	2-3	3	3-4
Lean meats, poultry, and fish	3-6	6	6-9
Nuts, seeds, and legumes	3/week	1	1
Fats and oils	2	3	4
Sweets and added sugars	0	less than 2	less than 2

Footnote: * Whole grains are recommended for most grain servings as a good source of fiber and nutrients.

[Source ⁸¹ ]

Resistant hypertension

Resistant hypertension is defined as above-goal elevated blood pressure in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic ⁸². If your blood pressure remains stubbornly high despite taking at least three different types of high blood pressure drugs, one of which usually should be a diuretic, you may have resistant hypertension. People who have controlled high blood pressure but are taking four different types of medications at the same time to achieve that control also are considered to have resistant hypertension. The possibility of a secondary cause of the high blood pressure generally should be reconsidered.

The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses ⁸². Resistant hypertension also includes patients whose blood pressure achieves target values on ≥4 antihypertensive medications ⁸². The diagnosis of resistant hypertension requires assurance of antihypertensive medication adherence and exclusion of the “white-coat effect” (office blood pressure above goal but out-of-office blood pressure at or below target). The importance of resistant hypertension is underscored by the associated risk of adverse outcomes compared with non-resistant hypertension. Once antihypertensive medication adherence is confirmed and out-of-office blood pressure recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of resistant hypertension includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if blood pressure remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower blood pressure ⁸². If blood pressure remains uncontrolled, referral to a hypertension specialist is advised.

Having resistant hypertension doesn’t mean your blood pressure will never get lower. In fact, if you and your doctor can identify what’s behind your persistently high blood pressure, there’s a good chance you can meet your goal with the help of treatment that’s more effective.

Your doctor or hypertension specialist can evaluate whether the medications and doses you’re taking for your high blood pressure are appropriate. You may have to fine-tune your medications to come up with the most effective combination and doses. Adding an aldosterone antagonist such as spironolactone (Aldactone) often leads to control of resistant hypertension. Some experimental therapies such as catheter-based radiofrequency ablation of renal sympathetic nerves (renal denervation) and electrical stimulation of carotid sinus baroreceptors are being studied.

In addition, you and your doctor can review medications you’re taking for other conditions. Some medications, foods or supplements can worsen high blood pressure or prevent your high blood pressure medications from working effectively. Be open and honest with your doctor about all the medications or supplements you take.

If you don’t take your high blood pressure medications exactly as directed, your blood pressure can pay the price. If you skip doses because you can’t afford the medications, because you have side effects or because you simply forget to take your medications, talk to your doctor about solutions. Don’t change your treatment without your doctor’s guidance.

Resistant hypertension prognosis

Observational studies using the 2008 criteria have shown that patients with resistant hypertension are at higher risk for poor outcomes compared with patients without resistant hypertension ⁸³. In a retrospective study of >200,000 patients with incident hypertension, those with resistant hypertension were 47% more likely to suffer the combined outcomes of death, myocardial infarction, heart failure, stroke, or chronic kidney disease over the median 3.8 years of follow-up ⁸⁴. Differences in cardiovascular disease events in this study were driven largely by a higher risk for the development of chronic kidney disease ⁸⁴. In another study of >400,000 patients, compared with patients without resistant hypertension, patients with resistant hypertension had a 32% increased risk of developing end-stage renal disease, a 24% increased risk of an ischemic heart event, a 46% increased risk of heart failure, a 14% increased risk of stroke, and a 6% increased risk of death ⁸³. Prospective studies using ambulatory BP monitoring have suggested an almost 2-fold increased risk of cardiovascular disease events in patients with true resistant hypertension compared with those with hypertension responsive to treatment ⁸⁵. Together, these studies suggest that resistant hypertension is associated with an increased risk of adverse outcomes and represents an important public health problem.

Resistant hypertension is associated with worse outcomes among patients with some comorbid conditions. In patients with chronic kidney disease, resistant hypertension is associated with higher risk of myocardial infarction, stroke, peripheral arterial disease, heart failure, and all-cause mortality compared with patients without resistant hypertension ⁸⁶. Similarly, in patients with ischemic heart disease, resistant hypertension is associated with higher rates of adverse events, including death, myocardial infarction, and stroke ⁸⁷. Conversely, resistant hypertension is not associated with increased adverse clinical events in patients with heart failure with reduced ejection fraction and may lower the risk for heart failure-related rehospitalization ⁸⁸.

Among patients with resistant hypertension, lower blood pressure is associated with reduced risk for some cardiovascular events ⁸⁹. In the REGARDS study (Reasons for Geographic and Racial Differences in Stroke), uncontrolled resistant hypertension was associated with a 2-fold increased risk of coronary heart disease compared with controlled resistant hypertension. Control status was not associated with differences in stroke or mortality ⁹⁰. In another study of >118,000 treated hypertensive adults, including >40,000 individuals with resistant hypertension and 460,000 observation-years, blood pressure control was associated with significantly lower rates of incident stroke and coronary heart disease with no difference in rates of incident heart failure ⁸⁹. Blood pressure control reduced the risk of incident stroke, coronary heart disease, or heart failure by 13% among those with resistant hypertension compared with a 31% lower risk of these outcomes among patients without resistant hypertension ⁸⁹. Although blood pressure control is associated with a lower risk for some cardiovascular disease outcomes, it is possible that the benefit of blood pressure lowering may be less in patients with resistant hypertension compared with patients with non-resistant hypertension.

Pulmonary hypertension

Pulmonary hypertension is high blood pressure in the blood vessels that supply the lungs (pulmonary arteries). It’s a serious condition that can damage the right side of the heart.

The walls of the pulmonary arteries become thick and stiff, and can’t expand as well to allow blood through. The reduced blood flow makes it harder for the right-hand side of the heart to pump blood through the arteries. If the right-hand side of your heart has to continually work harder, it can gradually become weaker. This can lead to heart failure.

Pulmonary hypertension is a rare condition that can affect people of all ages, but it’s more common in people who have another heart or lung condition.

In one form of pulmonary hypertension, tiny arteries in your lungs, called pulmonary arterioles, and capillaries become narrowed, blocked or destroyed. This makes it harder for blood to flow through your lungs, and raises pressure within your lungs’ arteries. As the pressure builds, your heart’s lower right chamber (right ventricle) must work harder to pump blood through your lungs, eventually causing your heart muscle to weaken and fail.

Some forms of pulmonary hypertension are serious conditions that become progressively worse and are sometimes fatal. Although some forms of pulmonary hypertension aren’t curable, treatment can help lessen symptoms and improve your quality of life.

Symptoms of pulmonary hypertension

The signs and symptoms of pulmonary hypertension in its early stages might not be noticeable for months or even years. As the disease progresses, symptoms become worse.

Symptoms of pulmonary hypertension include:

• Shortness of breath (dyspnea), initially while exercising and eventually while at rest
• Fatigue and tiredness
• Feeling faint or dizzy
• Chest pain (angina)
• A racing heartbeat (palpitations)
• Swelling (edema) in the legs, ankles, feet and eventually in your abdomen (ascites)
• Dizziness or fainting spells (syncope)
• Bluish color to your lips and skin (cyanosis)

The symptoms often get worse during exercise, which can limit your ability to take part in physical activities.

If you have a type of pulmonary hypertension known as pulmonary arterial hypertension (PAH), you may not have any symptoms until the condition is quite advanced.

Pulmonary Hypertension in Children

Some children with congenital heart disease have high blood pressure in their lungs. This is called pulmonary hypertension. Many times after surgery is done to correct the congenital heart defect, the blood pressure in the lungs becomes normal. In other cases the pressure may remain higher than normal, making it harder for the heart to pump. In rare cases, the pressure may be high enough that surgery becomes too risky.

Oxygen or medications may be used to try to relax the blood vessels and reduce the blood pressure after surgery or if surgery is not possible.

Cyanosis due to Pulmonary Hypertension with Congenital Heart Disease

When there is a communication between the right and left heart (see ASD, VSD, PDA and atrioventricular septal defect) in congenital heart disease, blood goes from the low oxygen chamber or vessel to the high oxygen chamber or vessel. An example would be shunting from the right atrium to the left atrium in patients with atrial septal defect (ASD) and pulmonary arterial hypertension. The patient who was once acyanotic becomes cyanotic. One way the body compensates is to increase the ability of the blood to carry oxygen by increasing the number of red blood cells, a condition called secondary erythrocytosis, sometimes referred to as polycythemia. It is now recognized that removing blood with a procedure called phlebotomy is only rarely needed. Symptoms that may prompt a doctor to recommend it are headaches, excessive fatigue and worsening exercise tolerance. Before this is performed, it is important that the doctors tests for iron deficiency. Phlebotomy is preferably performed in a center with experience in adult congenital disease as special precautions are required.

Types of pulmonary hypertension

Pulmonary hypertension is classified into five groups, depending on the cause.

Group 1: Pulmonary arterial hypertension

• Cause unknown, known as idiopathic pulmonary arterial hypertension
• A specific gene mutation that can cause pulmonary hypertension to develop in families, also called heritable pulmonary arterial hypertension
• Certain drugs — such as certain prescription diet drugs or illegal drugs such as methamphetamines — or certain toxins
• Heart abnormalities present at birth (congenital heart disease)
• Other conditions, such as connective tissue disorders (scleroderma, lupus, others), HIV infection or chronic liver disease (cirrhosis)

Group 2: Pulmonary hypertension caused by left-sided heart disease

• Left-sided valvular heart disease, such as mitral valve or aortic valve disease
• Failure of the lower left heart chamber (left ventricle)

Group 3: Pulmonary hypertension caused by lung disease

• Chronic obstructive pulmonary disease, such as emphysema
• Lung disease such as pulmonary fibrosis, a condition that causes scarring in the tissue between the lungs’ air sacs (interstitium)
• Sleep apnea and other sleep disorders
• Long-term exposure to high altitudes in people who may be at higher risk of pulmonary hypertension

Group 4: Pulmonary hypertension caused by chronic blood clots

• Chronic blood clots in the lungs (pulmonary emboli)

Group 5: Pulmonary hypertension associated with other conditions that have unclear reasons why the pulmonary hypertension occurs

• Blood disorders
• Disorders that affect several organs in the body, such as sarcoidosis
• Metabolic disorders, such as glycogen storage disease
• Tumors pressing against pulmonary arteries

Eisenmenger syndrome and pulmonary hypertension

Eisenmenger syndrome, a type of congenital heart disease, causes pulmonary hypertension. It’s most commonly caused by a large hole in your heart between the two lower heart chambers (ventricles), called a ventricular septal defect.

This hole in your heart causes blood to circulate abnormally in your heart. Oxygen-carrying blood (red blood) mixes with oxygen-poor blood (blue blood). The blood then returns to your lungs instead of going to the rest of your body, increasing the pressure in the pulmonary arteries and causing pulmonary hypertension.

Pulmonary hypertension classifications

Once you’ve been diagnosed with pulmonary hypertension, your doctor might classify the severity of your disease into one of several classes, including:

• Class I. Although you’ve been diagnosed with pulmonary hypertension, you have no symptoms with normal activity.
• Class II. You don’t have symptoms at rest, but you experience symptoms such as fatigue, shortness of breath or chest pain with normal activity.
• Class III. You’re comfortable at rest, but have symptoms when you’re physically active.
• Class IV. You have symptoms with physical activity and while at rest.

Causes of pulmonary hypertension

Your heart has two upper chambers (atria) and two lower chambers (ventricles). Each time blood passes through your heart, the lower right chamber (right ventricle) pumps blood to your lungs through a large blood vessel (pulmonary artery).

In your lungs, the blood releases carbon dioxide and picks up oxygen. The oxygen-rich blood then flows through blood vessels in your lungs (pulmonary arteries, capillaries and veins) to the left side of your heart. Ordinarily, the blood flows easily through the vessels in your lungs, so blood pressure is usually much lower in your lungs.

With pulmonary hypertension, the rise in blood pressure is caused by changes in the cells that line your pulmonary arteries. These changes can cause the walls of the arteries to become stiff and thick, and extra tissue may form. The blood vessels may also become inflamed and tight.

These changes in the pulmonary arteries can reduce or block blood flow through the blood vessels. This makes it harder for blood to flow, raising the blood pressure in the pulmonary arteries.

Risk factors for pulmonary hypertension

Your risk of developing pulmonary hypertension may be greater if:

• You’re a young adult, as idiopathic pulmonary arterial hypertension is more common in younger adults
• You’re overweight
• You have a family history of the disease
• You have one of various conditions that can increase your risk of developing pulmonary hypertension
• You use illegal drugs, such as cocaine
• You take certain appetite-suppressant medications
• You have an existing risk of developing pulmonary hypertension, such as a family history of the condition, and you live at a high altitude

Complications of pulmonary hypertension

Pulmonary hypertension can lead to a number of complications, including:

• Right-sided heart enlargement and heart failure (cor pulmonale). In cor pulmonale, your heart’s right ventricle becomes enlarged and has to pump harder than usual to move blood through narrowed or blocked pulmonary arteries.

At first, the heart tries to compensate by thickening its walls and expanding the chamber of the right ventricle to increase the amount of blood it can hold. But this thickening and enlarging works only temporarily, and eventually the right ventricle fails from the extra strain.

• Blood clots. Clots help stop bleeding after you’ve been injured. But sometimes clots form where they’re not needed. A number of small clots or just a few large ones dislodge from these veins and travel to the lungs, leading to a form of pulmonary hypertension that can generally be reversible with time and treatment.

Having pulmonary hypertension makes it more likely you’ll develop clots in the small arteries in your lungs, which is dangerous if you already have narrowed or blocked blood vessels.

• Arrhythmia. Irregular heartbeats (arrhythmias) from the upper or lower chambers of the heart are complications of pulmonary hypertension. These can lead to palpitations, dizziness or fainting and can be fatal.

• Bleeding. Pulmonary hypertension can lead to bleeding into the lungs and coughing up blood (hemoptysis). This is another potentially fatal complication.

Diagnosis for pulmonary hypertension

Pulmonary hypertension is hard to diagnose early because it’s not often detected in a routine physical exam. Even when the condition is more advanced, its signs and symptoms are similar to those of other heart and lung conditions.

To diagnose your condition, your doctor may review your medical and family history, discuss your signs and symptoms, and conduct a physical examination. Doctors may order several tests to diagnose pulmonary hypertension, determine the severity of your condition and find out the cause of your condition. Tests may include:

• Echocardiogram. Sound waves can create moving images of the beating heart. An echocardiogram can help your doctor to check the size and functioning of the right ventricle, and the thickness of the right ventricle’s wall. An echocardiogram can also show how well your heart chambers and valves are working. Doctors may also use this to measure the pressure in your pulmonary arteries.

In some cases, your doctor will recommend an exercise echocardiogram to help determine how well your heart and lungs work under stress. In this test, you’ll have an echocardiogram before exercising on a stationary bike or treadmill and another test immediately afterward. This could be done as an oxygen consumption test, in which you may have to wear a mask that assesses the ability of your heart and lungs to deal with oxygen and carbon dioxide.

Other exercise tests may also be done. These tests can help determine the severity and cause of your condition. They may also be done at follow-up appointments to check that your treatments are working.

• Chest X-ray. A chest X-ray can show images of your heart, lungs and chest. This test can show enlargement of the right ventricle of the heart or the pulmonary arteries, which can occur in pulmonary hypertension. This test can also be used to identify other conditions that may be causing pulmonary hypertension.
• Electrocardiogram (ECG). This noninvasive test shows your heart’s electrical patterns and can detect abnormal rhythms. Doctors may also be able to see signs of right ventricle enlargement or strain.
• Right heart catheterization. After you’ve had an echocardiogram, if your doctor thinks you have pulmonary hypertension, you’ll likely have a right heart catheterization. This test can often help confirm that you have pulmonary hypertension and determine the severity of your condition.

During the procedure, a cardiologist places a thin, flexible tube (catheter) into a vein in your neck or groin. The catheter is then threaded into your right ventricle and pulmonary artery.

Right heart catheterization allows your doctor to directly measure the pressure in the main pulmonary arteries and right ventricle. It’s also used to see what effect different medications may have on your pulmonary hypertension.

• Blood tests. Your doctor might order blood tests to check for certain substances in your blood that might show you have pulmonary hypertension or its complications. Blood tests can also test for certain conditions that may be causing your condition.

Your doctor might order additional tests to check the condition of your lungs and pulmonary arteries and to determine the cause of your condition, including:

• Computerized tomography (CT) scan. During a CT scan, you lie on a table inside a doughnut-shaped machine. CT scanning generates X-rays to produce cross-sectional images of your body. Doctors may inject a dye into your blood vessels that helps your arteries to be more visible on the CT pictures (CT angiography).

Doctors may use this test to look at the heart’s size and function and to check for blood clots in the lungs’ arteries.

• Magnetic resonance imaging (MRI). This test may be used to check the right ventricle’s function and the blood flow in the lung’s arteries. In this test, you lie on a movable table that slides into the tunnel. An MRI uses a magnetic field and pulses of radio wave energy to make pictures of the body.
• Pulmonary function test. This noninvasive test measures how much air your lungs can hold, and the airflow in and out of your lungs. During the test, you’ll blow into a simple instrument called a spirometer.
• Polysomnogram. This test detects your brain activity, heart rate, blood pressure, oxygen levels and other factors while you sleep. It can help diagnose a sleep disorder such as obstructive sleep apnea.
• Ventilation/perfusion (V/Q) scan. In this test, a tracer is injected into a vein in your arm. The tracer maps blood flow and air to your lungs. This test can be used to determine whether blood clots are causing symptoms of pulmonary hypertension.
• Open-lung biopsy. Rarely, a doctor might recommend an open-lung biopsy. An open-lung biopsy is a type of surgery in which a small sample of tissue is removed from your lungs under general anesthesia to check for a possible secondary cause of pulmonary hypertension.

Genetic tests

If a family member has had pulmonary hypertension, your doctor might screen you for genes that are linked with pulmonary hypertension. If you test positive, your doctor might recommend that other family members be screened for the same genetic mutation.

Pulmonary hypertension Treatment

Once pulmonary hypertension has been diagnosed, often more medical therapy is needed. You’ll require regular follow-up with a cardiologist or pulmonologist trained in caring for patients with this condition.

Pulmonary hypertension can’t be cured, but doctors can help you manage your condition. Treatment may help improve your symptoms and slow the progress of pulmonary hypertension.

It often takes some time to find the most appropriate treatment for pulmonary hypertension. The treatments are often complex and require extensive follow-up care. Your doctor might also need to change your treatment if it’s no longer effective.

When pulmonary hypertension is caused by another condition, your doctor will treat the underlying cause whenever possible.

Medications for Pulmonary hypertension

• Blood vessel dilators (vasodilators). Vasodilators open narrowed blood vessels. One of the most commonly prescribed vasodilators for pulmonary hypertension is epoprostenol (Flolan, Veletri). The drawback to epoprostenol is that its effects last only a few minutes.

This drug is continuously injected through an intravenous (IV) catheter via a small pump that you wear in a pack on your belt or shoulder. Potential side effects of epoprostenol include jaw pain, nausea, diarrhea and leg cramps, as well as pain and infection at the IV site.

Another form of the drug, iloprost (Ventavis), can be inhaled six to nine times a day through a nebulizer, a machine that vaporizes your medication. Because it’s inhaled, it goes directly to the lungs. Side effects associated with iloprost include chest pain — often accompanied by a headache and nausea — and breathlessness.

Treprostinil (Tyvaso, Remodulin, Orenitram), another form of the drug, can be given four times a day. It can be inhaled, taken as oral medication or administered by injection. It can cause side effects such as a headache, nausea and diarrhea.

• Endothelin receptor antagonists. These medications reverse the effect of endothelin, a substance in the walls of blood vessels that causes them to narrow. These drugs may improve your energy level and symptoms. However, these drugs shouldn’t be taken if you’re pregnant. Also, these drugs can damage your liver and you may need monthly liver monitoring.

These medications include bosentan (Tracleer), macitentan (Opsumit), and ambrisentan (Letairis).

• Sildenafil and tadalafil. Sildenafil (Revatio, Viagra) and tadalafil (Cialis, Adcirca) are sometimes used to treat pulmonary hypertension. These drugs work by opening the blood vessels in the lungs to allow blood to flow through more easily. Side effects can include an upset stomach, headache and vision problems.
• High-dose calcium channel blockers. These drugs help relax the muscles in the walls of your blood vessels. They include medications such as amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others) and nifedipine (Procardia, others). Although calcium channel blockers can be effective, only a small number of people with pulmonary hypertension respond to them.
• Soluble guanylate cyclase (SGC) stimulator. Soluble guanylate cyclase (SGC) stimulators (Adempas) interact with nitric oxide and help relax the pulmonary arteries and lower the pressure within the arteries. These medications should not be taken if you’re pregnant. They can sometimes cause
• dizziness or nausea.
• Anticoagulants. Your doctor is likely to prescribe the anticoagulant warfarin (Coumadin, Jantoven) to help prevent the formation of blood clots within the small pulmonary arteries. Because anticoagulants prevent normal blood coagulation, they increase your risk of bleeding complications.

Take warfarin exactly as prescribed, because warfarin can cause severe side effects if taken incorrectly. If you’re taking warfarin, your doctor will ask you to have periodic blood tests to check how well the drug is working. Many other drugs, herbal supplements and foods can interact with warfarin, so be sure your doctor knows all of the medications you’re taking.

• Digoxin. Digoxin (Lanoxin) can help the heart beat stronger and pump more blood. It can help control the heart rate if you experience arrhythmias.
• Diuretics. Commonly known as water pills, these medications help eliminate excess fluid from your body. This reduces the amount of work your heart has to do. They may also be used to limit fluid buildup in your lungs.
• Oxygen. Your doctor might suggest that you sometimes breathe pure oxygen, a treatment known as oxygen therapy, to help treat pulmonary hypertension, especially if you live at a high altitude or have sleep apnea. Some people who have pulmonary hypertension eventually require continuous oxygen therapy.

Surgeries for Pulmonary hypertension

Atrial septostomy. If medications don’t control your pulmonary hypertension, this open-heart surgery might be an option. In an atrial septostomy, a surgeon will create an opening between the upper left and right chambers of your heart (atria) to relieve the pressure on the right side of your heart.

Atrial septostomy can have serious complications, including heart rhythm abnormalities (arrhythmias).

Transplantation. In some cases, a lung or heart-lung transplant might be an option, especially for younger people who have idiopathic pulmonary arterial hypertension.

Major risks of any type of transplantation include rejection of the transplanted organ and serious infection, and you must take immunosuppressant drugs for life to help reduce the chance of rejection.

Home remedies for Pulmonary hypertension

Although medical treatment can’t cure pulmonary hypertension, it can lessen symptoms. Lifestyle changes also can help improve your condition. Consider these tips:

• Get plenty of rest. Resting can reduce the fatigue that might come from having pulmonary hypertension.
• Stay as active as possible. Even the mildest forms of activity might be too exhausting for some people who have pulmonary hypertension. For others, moderate exercise such as walking might be beneficial — especially when done with oxygen. But first, talk to your doctor about specific exercise restrictions. In most cases, it’s recommended that you not lift heavy weights. Your doctor can help you plan an appropriate exercise program.
• Don’t smoke. If you smoke, the most important thing you can do for your heart and lungs is to stop. If you can’t stop smoking by yourself, ask your doctor to prescribe a treatment plan to help you quit. Also, avoid secondhand smoke if possible.
• Avoid pregnancy and birth control pills. If you’re a woman of childbearing age, avoid pregnancy. Pregnancy can be life-threatening for both you and your baby. Also avoid using birth control pills, which can increase your risk of blood clots. Talk to your doctor about alternative forms of birth control. If you do become pregnant, it’s important to consult with your doctor as pulmonary hypertension can cause serious complications to both you and the fetus.
• Avoid traveling to or living at high altitudes. High altitudes can worsen the symptoms of pulmonary hypertension. If you live at an altitude of 8,000 feet (2,438 meters) or higher, your doctor might recommend that you move to a lower altitude.
• Avoid situations that can excessively lower blood pressure. These include sitting in a hot tub or sauna or taking long hot baths or showers. These activities lower your blood pressure and can cause fainting or even death. Also avoid activities that cause prolonged straining, such as lifting heavy objects or weights.
• Follow a nutritious diet and stay at a healthy weight. Aim to eat a healthy diet of whole grains, a variety of fruits and vegetables, lean meats and low-fat dairy products. Avoid saturated fat, trans fat and cholesterol. It’s likely your doctor will recommend limiting the amount of salt in your diet. Aim to maintain a healthy weight.
• Ask your doctor about medications. Take all your medications as prescribed. Ask your doctor about any other medications before taking them, as some can interfere with your medication or worsen your condition.
• See your doctor at follow-up appointments. Your doctor may recommend regular follow-up appointments. Let your doctor know if you have any questions about your condition or medications you’re taking, or if you have any symptoms or side effects from your medications. If pulmonary hypertension is affecting your quality of life, ask your doctor about options that could improve your quality of life.
• Get vaccines. Your doctor may recommend getting an influenza and pneumonia vaccine, as these conditions can cause serious issues for people with pulmonary hypertension.
• Get support. If you’re feeling stressed or worried due to your condition, get support from family or friends. Or, consider joining a support group with others who have pulmonary hypertension.
• Pregnancy and ContraceptionPregnancy is not recommended in women with pulmonary hypertension. The changes associated with pregnancy and delivery produce changes that can seriously endanger the life of the mother and baby. Therefore it is important for women with pulmonary hypertension to use a more permanent but safe form of contraception. Because estrogen can aggravate pulmonary hypertension, it’s important to avoid any contraception containing estrogen. Progesterone forms of contraception are preferable. It is generally recommended that women with pulmonary hypertension have tubal ligation or use the Mirena IUD.
• Preventing EndocarditisPeople with pulmonary hypertension and certain underlying congenital heart defects may need antibiotics before certain dental procedures to prevent endocarditis. As the endocarditis recommendations have changed, please discuss with your cardiologist.

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