Complications of hypertension

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Main complications of persistent high blood pressure Main complications of persistent high blood pressure.svg
Main complications of persistent high blood pressure

Complications of hypertension are clinical outcomes that result from persistent elevation of blood pressure. [1] Hypertension is a risk factor for all clinical manifestations of atherosclerosis since it is a risk factor for atherosclerosis itself. [2] [3] [4] [5] [6] [7] It is an independent predisposing factor for heart failure, [8] [9] coronary artery disease, [10] [11] stroke, [1] kidney disease, [12] [13] [14] and peripheral arterial disease. [15] [16] It is the most important risk factor for cardiovascular morbidity and mortality, in industrialized countries. [17]

Contents

Complications affecting the heart

Left ventricular hypertrophy Heart left ventricular hypertrophy sa.jpg
Left ventricular hypertrophy

Hypertensive heart disease is the result of structural and functional adaptations [18] leading to left ventricular hypertrophy, [19] [20] [21] diastolic dysfunction, [18] [20] CHF (Congestive Heart Failure), abnormalities of blood flow due to atherosclerotic coronary artery disease [18] and microvascular disease, [10] [19] and cardiac arrhythmias. [19] Individuals with left ventricular hypertrophy are at increased risk for, stroke, [22] CHF, [22] and sudden death. [22] Aggressive control of hypertension can regress or reverse left ventricular hypertrophy and reduce the risk of cardiovascular disease. [23] [24] [25] [26] left ventricular hypertrophy are seen in 25% of the hypertensive patients and can easily be diagnosed by using echocardiography. [27] Underlying mechanisms of hypertensive left ventricular hypertrophy are of 2 types: firstly, mechanical (mainly leading to myocyte hypertrophy) and secondly, neuro-hormonal(mainly resulting in a fibroblastic proliferation). [27]

Abnormalities of diastolic function, ranging from asymptomatic heart disease [28] [29] [30] to overt heart failure, [31] [32] are common in hypertensive patients. Patients with diastolic heart failure have a preserved ejection fraction, which is a measure of systolic function. [33] [34] Diastolic dysfunction is an early consequence of hypertension-related heart disease and is exacerbated by left ventricular hypertrophy [20] [34] and ischemia.

Complications affecting the brain

Hypertension is an important risk factor for brain infarction and hemorrhage. [1] [10] [35] [36] [37] [38] [39] [40] [ excessive citations ] Approximately 85% of strokes are due to infarction and the remainder are due to hemorrhage, either intracerebral hemorrhage or subarachnoid hemorrhage. [41] The incidence of stroke rises progressively with increasing blood pressure levels, particularly systolic blood pressure in individuals >65 years. Treatment of hypertension convincingly decreases the incidence of both ischemic and hemorrhagic strokes. [41]

Hypertension is also associated with impaired cognition in an aging population. [42] [43] [44] [45] Hypertension-related cognitive impairment and dementia may be a consequence of a single infarct due to occlusion of a "strategic" larger vessel [46] [47] or multiple lacunar infarcts due to occlusive small vessel disease resulting in subcortical white matter ischemia. [43] [45] [48] Several clinical trials suggest that antihypertensive therapy has a beneficial effect on cognitive function, although this remains an active area of investigation. [49] [50] [51]

Cerebral blood flow remains unchanged over a wide range of arterial pressures (mean arterial pressure of 50–150 mmHg) through a process termed autoregulation of blood flow. [52] Signs and symptoms of hypertensive encephalopathy may include severe headache, nausea and vomiting (often of a projectile nature), focal neurologic signs, and alterations in mental status. Untreated, hypertensive encephalopathy may progress to stupor, coma, seizures, and death within hours. [53] [54] [55] [56] It is important to distinguish hypertensive encephalopathy from other neurologic syndromes that may be associated with hypertension, e.g., cerebral ischemia, hemorrhagic or thrombotic stroke, seizure disorder, mass lesions, pseudotumor cerebri, delirium tremens, meningitis, acute intermittent porphyria, traumatic or chemical injury to the brain, and uremic encephalopathy. [41]

Complications affecting the eye

Hypertensive retinopathy with AV nicking and mild vascular tortuosity Hypertensiveretinopathy.jpg
Hypertensive retinopathy with AV nicking and mild vascular tortuosity

Hypertensive retinopathy is a condition characterized by a spectrum of retinal vascular signs in people with elevated blood pressure. [57] It was first described by Liebreich in 1859. [58] The retinal circulation undergoes a series of pathophysiological changes in response to elevated blood pressure. [59] In the initial, vasoconstrictive stage, there is vasospasm and an increase in retinal arteriolar tone owing to local autoregulatory mechanisms. This stage is seen clinically as a generalized narrowing of the retinal arterioles. Persistently elevated blood pressure leads to intimal thickening, hyperplasia of the media wall, and hyaline degeneration in the subsequent, sclerotic, stage. This stage corresponds to more severe generalized and focal areas of arteriolar narrowing, changes in the arteriolar and venular junctions, and alterations in the arteriolar light reflex (i.e., widening and accentuation of the central light reflex, or "copper wiring"). [60]

This is followed by an exudative stage, in which there is disruption of the blood–retina barrier, necrosis of the smooth muscles and endothelial cells, exudation of blood and lipids, and retinal ischemia. These changes are manifested in the retina as microaneurysms, hemorrhages, hard exudates, and cotton-wool spots. Swelling of the optic disk may occur at this time and usually indicates severely elevated blood pressure (i.e., malignant hypertension). Because better methods for the control of blood pressure are now available in the general population, malignant hypertension is rarely seen. In contrast, other retinal vascular complications of hypertension, such as macroaneurysms and branch-vein occlusions, are not uncommon in patients with chronically elevated blood pressure. These stages of hypertensive retinopathy however, may not be sequential. [59] [61] For example, signs of retinopathy that reflect the exudative stage, such as retinal hemorrhage or microaneurysm, may be seen in eyes that do not have features of the sclerotic stage, [59]

Complications affecting the kidneys

Hypertension is a risk factor for chronic kidney disease and end-stage kidney disease (ESKD). [62] [63] [64] [65] [66] [67] [68] [ excessive citations ] Kidney risk appears to be more closely related to systolic than to diastolic blood pressure, [69] [70] and black men are at greater risk than white men for developing ESRD at every level of blood pressure. [71] [72] [73] [74] [75]

The atherosclerotic, hypertension-related vascular lesions in the kidney primarily affect the preglomerular arterioles, [69] [76] [77] resulting in ischemic changes in the glomeruli and postglomerular structures. [41] Glomerular injury may also be a consequence of direct damage to the glomerular capillaries due to glomerular hyperperfusion. Glomerular pathology progresses to glomerulosclerosis, [78] [79] and eventually the kidney tubules may also become ischemic and gradually atrophic. The kidney lesion associated with malignant hypertension consists of fibrinoid necrosis of the afferent arterioles, [80] [81] [82] [83] [84] [85] [86] [ excessive citations ] sometimes extending into the glomerulus, and may result in focal necrosis of the glomerular tuft. [82] [87] [88]

Clinically, macroalbuminuria (a random urine albumin/creatinine ratio > 300 mg/g) or microalbuminuria (a random urine albumin/creatinine ratio 30–300 mg/g) are early markers of kidney injury. These are also risk factors for kidney disease progression and for cardiovascular disease. [41]

Complications associated to diabetes and hypertension

Diabetes has several complications of which one is hypertension or high blood pressure. Data indicate that at least 60-80 percent of individuals whom develop diabetes will eventually develop high blood pressure. The high blood pressure is gradual at early stages and may take at least 10–15 years to fully develop. Besides diabetes, other factors that may also increase high blood pressure include obesity, insulin resistance and high cholesterol levels. In general, fewer than 25 percent of diabetics have good control of their blood pressure. The presence of high blood pressure in diabetes is associated with a 4 fold increase in death chiefly from heart disease and strokes. [89] It has also been shown in recent epidemiological studies that variability of blood pressure, independent of mean blood pressure level, contributes to microvascular and macrovascular complications [90] in those with diabetes, including heart failure. [91] These variability associations may be especially deleterious in persons with either particularly high or particularly low blood pressures. [92]

The chief reason why people with diabetes develop high blood pressure is hardening of the arteries. Diabetes tends to speed up the process of atherosclerosis. The other fact about diabetes is that it affects both large and small blood vessels in the body. Over time, blood vessels become clogged with fatty depots, become non-compliant and lose their elasticity. The process of atherosclerosis is a lot faster in diabetic individuals whom do not have good control of their blood sugars. The high blood pressure eventually leads to heart failure, strokes, heart attacks, blindness, kidney failure, loss of libido and poor circulation of blood in the legs. When the blood supply to the feet is compromised, the chances of infections and amputations also increases. All diabetics should know that even mild elevations in blood pressure can be detrimental to health. Studies have shown that diabetics with even a slight elevation in blood pressure have 2-3 times the risk of heart disease compared to individuals without diabetes. [93]

Blood pressure readings do vary but experts recommend that blood pressure should not range above 140/80. Secondly, high blood pressure is a silent disease and thus it is vital for all diabetics to regularly check their blood pressure or have it checked at a doctor's office on a regular basis. The American Diabetes Association recommends that all diabetics get their blood pressure measured by a health care professional at least 2-5 times a year. [94]

Treatment for diabetic patients with hypertension

Once blood pressure is found to be high in diabetics, there are ways to treat it:

Medications like the Angiotensin-converting enzyme inhibitors (ACEI) are widely used to control blood pressure in diabetics. These medications not only control blood pressure but also delay or prevent the development of kidney disease in diabetes. Many studies have shown that ACEI should be the drugs of first choice in diabetics with high blood pressure.[ citation needed ] Other medications used to treat high blood pressure include water pills. Sometimes, a combination of medications is used to treat high blood pressure. All diabetics should quit smoking. The combination of diabetes and smoking usually leads to amputations of the toes and feet. Measure your blood sugars regularly, and make sure that they are well balanced as the majority of complications of diabetes can be prevented by ensuring such blood sugars stay within normal limits. [95] It is also recommended to eat a healthy diet and avoid sugary foods and limit the intake of salt. Also, ensure that your cholesterol levels are under control. Exercise is a must for all diabetics. Walking twice a day for 30 minutes can be a fair substitute for those not engaged in intense gym activities. Losing weight is also beneficial as this has been shown to improve blood sugar control, increase insulin sensitivity and reduce blood pressure. [96]

Related Research Articles

<span class="mw-page-title-main">ACE inhibitor</span> Class of medications used primarily to treat high blood pressure

Angiotensin-converting-enzyme inhibitors are a class of medication used primarily for the treatment of high blood pressure and heart failure. This class of medicine works by causing relaxation of blood vessels as well as a decrease in blood volume, which leads to lower blood pressure and decreased oxygen demand from the heart.

<span class="mw-page-title-main">Cardiology</span> Branch of medicine dealing with the heart

Cardiology is the study of the heart. Cardiology is a branch of medicine that deals with disorders of the heart and the cardiovascular system. The field includes medical diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease, and electrophysiology. Physicians who specialize in this field of medicine are called cardiologists, a sub-specialty of internal medicine. Pediatric cardiologists are pediatricians who specialize in cardiology. Physicians who specialize in cardiac surgery are called cardiothoracic surgeons or cardiac surgeons, a specialty of general surgery.

<span class="mw-page-title-main">Blood pressure</span> Pressure exerted by circulating blood upon the walls of arteries

Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" refers to the pressure in a brachial artery, where it is most commonly measured. Blood pressure is usually expressed in terms of the systolic pressure over diastolic pressure in the cardiac cycle. It is measured in millimeters of mercury (mmHg) above the surrounding atmospheric pressure, or in kilopascals (kPa). The difference between the systolic and diastolic pressures is known as pulse pressure, while the average pressure during a cardiac cycle is known as mean arterial pressure.

<span class="mw-page-title-main">Hypertension</span> Long-term high blood pressure in the arteries

Hypertension, also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms itself. It is, however, a major risk factor for stroke, coronary artery disease, heart failure, atrial fibrillation, peripheral arterial disease, vision loss, chronic kidney disease, and dementia. Hypertension is a major cause of premature death worldwide.

<span class="mw-page-title-main">Microangiopathy</span> Medical condition

Microangiopathy is a disease of the microvessels, small blood vessels in the microcirculation. It can be contrasted to macroangiopathies such as atherosclerosis, where large and medium-sized arteries are primarily affected.

<span class="mw-page-title-main">Pulse pressure</span> Difference between systolic and diastolic blood pressure

Pulse pressure is the difference between systolic and diastolic blood pressure. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. Healthy pulse pressure is around 40 mmHg. A pulse pressure that is consistently 60 mmHg or greater is likely to be associated with disease, and a pulse pressure of 50 mmHg or more increases the risk of cardiovascular disease. Pulse pressure is considered low if it is less than 25% of the systolic. A very low pulse pressure can be a symptom of disorders such as congestive heart failure.

Antihypertensives are a class of drugs that are used to treat hypertension. Antihypertensive therapy seeks to prevent the complications of high blood pressure, such as stroke, heart failure, kidney failure and myocardial infarction. Evidence suggests that reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34% and of ischaemic heart disease by 21%, and can reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease. There are many classes of antihypertensives, which lower blood pressure by different means. Among the most important and most widely used medications are thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers or antagonists (ARBs), and beta blockers.

Essential hypertension is a form of hypertension without an identifiable physiologic cause. It is the most common type affecting 85% of those with high blood pressure. The remaining 15% is accounted for by various causes of secondary hypertension. Essential hypertension tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors. Hypertension can increase the risk of cerebral, cardiac, and renal events.

<span class="mw-page-title-main">Mean arterial pressure</span> Average blood pressure in an individual during a single cardiac cycle

In medicine, the mean arterial pressure (MAP) is an average calculated blood pressure in an individual during a single cardiac cycle. Although methods of estimating MAP vary, a common calculation is to take one-third of the pulse pressure, and add that amount to the diastolic pressure. A normal MAP is about 90 mmHg.

<span class="mw-page-title-main">Hypertensive emergency</span> Very high blood pressure and signs of organ damage

A hypertensive emergency is very high blood pressure with potentially life-threatening symptoms and signs of acute damage to one or more organ systems. It is different from a hypertensive urgency by this additional evidence for impending irreversible hypertension-mediated organ damage (HMOD). Blood pressure is often above 200/120 mmHg, however there are no universally accepted cutoff values.

<span class="mw-page-title-main">Arteriolosclerosis</span> Hardening of small arteries (arterioles)

Arteriolosclerosis is a form of cardiovascular disease involving hardening and loss of elasticity of arterioles or small arteries and is most often associated with hypertension and diabetes mellitus. Types include hyaline arteriolosclerosis and hyperplastic arteriolosclerosis, both involved with vessel wall thickening and luminal narrowing that may cause downstream ischemic injury. The following two terms whilst similar, are distinct in both spelling and meaning and may easily be confused with arteriolosclerosis.

<span class="mw-page-title-main">Hypertensive heart disease</span> Medical condition

Hypertensive heart disease includes a number of complications of high blood pressure that affect the heart. While there are several definitions of hypertensive heart disease in the medical literature, the term is most widely used in the context of the International Classification of Diseases (ICD) coding categories. The definition includes heart failure and other cardiac complications of hypertension when a causal relationship between the heart disease and hypertension is stated or implied on the death certificate. In 2013 hypertensive heart disease resulted in 1.07 million deaths as compared with 630,000 deaths in 1990.

<span class="mw-page-title-main">Perindopril</span> High blood pressure medication

Perindopril is a medication used to treat high blood pressure, heart failure, or stable coronary artery disease. As a long-acting ACE inhibitor, it works by relaxing blood vessels and decreasing blood volume. As a prodrug, perindopril is hydrolyzed in the liver to its active metabolite, perindoprilat. It was patented in 1980 and approved for medical use in 1988.

The Dietary Approaches to Stop Hypertension or the DASH diet is a diet to control hypertension promoted by the U.S.-based National Heart, Lung, and Blood Institute, part of the National Institutes of Health (NIH), an agency of the United States Department of Health and Human Services. The DASH diet is rich in fruits, vegetables, whole grains, and low-fat dairy foods. It includes meat, fish, poultry, nuts, and beans, and is limited in sugar-sweetened foods and beverages, red meat, and added fats. In addition to its effect on blood pressure, it is designed to be a well-balanced approach to eating for the general public. DASH is recommended by the United States Department of Agriculture (USDA) as a healthy eating plan. The DASH diet is one of three healthy diets recommended in the 2015–20 U.S. Dietary Guidelines, which also include the Mediterranean diet and a vegetarian diet. The American Heart Association (AHA) considers the DASH diet "specific and well-documented across age, sex and ethnically diverse groups."

Arterial stiffness occurs as a consequence of biological aging and arteriosclerosis. Inflammation plays a major role in arteriosclerosis development, and consequently it is a major contributor in large arteries stiffening. Increased arterial stiffness is associated with an increased risk of cardiovascular events such as myocardial infarction, hypertension, heart failure, and stroke, two of the leading causes of death in the developed world. The World Health Organization predicts that in 2010, cardiovascular disease will also be the leading killer in the developing world and represents a major global health problem.

In medicine, systolic hypertension is defined as an elevated systolic blood pressure (SBP). If the systolic blood pressure is elevated (>140) with a normal (<90) diastolic blood pressure (DBP), it is called isolated systolic hypertension. Eighty percent of people with systolic hypertension are over the age of 65 years old. Isolated systolic hypertension is a specific type of widened pulse pressure.

<span class="mw-page-title-main">Diabetic cardiomyopathy</span> Medical condition

Diabetic cardiomyopathy is a disorder of the heart muscle in people with diabetes. It can lead to inability of the heart to circulate blood through the body effectively, a state known as heart failure(HF), with accumulation of fluid in the lungs or legs. Most heart failure in people with diabetes results from coronary artery disease, and diabetic cardiomyopathy is only said to exist if there is no coronary artery disease to explain the heart muscle disorder.

<span class="mw-page-title-main">Pathophysiology of hypertension</span>

Pathophysiology is a study which explains the function of the body as it relates to diseases and conditions. The pathophysiology of hypertension is an area which attempts to explain mechanistically the causes of hypertension, which is a chronic disease characterized by elevation of blood pressure. Hypertension can be classified by cause as either essential or secondary. About 90–95% of hypertension is essential hypertension. Some authorities define essential hypertension as that which has no known explanation, while others define its cause as being due to overconsumption of sodium and underconsumption of potassium. Secondary hypertension indicates that the hypertension is a result of a specific underlying condition with a well-known mechanism, such as chronic kidney disease, narrowing of the aorta or kidney arteries, or endocrine disorders such as excess aldosterone, cortisol, or catecholamines. Persistent hypertension is a major risk factor for hypertensive heart disease, coronary artery disease, stroke, aortic aneurysm, peripheral artery disease, and chronic kidney disease.

<span class="mw-page-title-main">Heart failure with preserved ejection fraction</span> Medical condition

Heart failure with preserved ejection fraction (HFpEF) is a form of heart failure in which the ejection fraction – the percentage of the volume of blood ejected from the left ventricle with each heartbeat divided by the volume of blood when the left ventricle is maximally filled – is normal, defined as greater than 50%; this may be measured by echocardiography or cardiac catheterization. Approximately half of people with heart failure have preserved ejection fraction, while the other half have a reduction in ejection fraction, called heart failure with reduced ejection fraction (HFrEF).

<span class="mw-page-title-main">Hypertension and the brain</span>

Hypertension is a condition characterized by an elevated blood pressure in which the long term consequences include cardiovascular disease, kidney disease, adrenal gland tumors, vision impairment, memory loss, metabolic syndrome, stroke and dementia. It affects nearly 1 in 2 Americans and remains as a contributing cause of death in the United States. There are many genetic and environmental factors involved with the development of hypertension including genetics, diet, and stress.

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