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What Are the Thresholds for Initiating Treatment for High Blood Pressure As Listed in the Current ACC/AHA Guidelines?

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Hypertension is one of the most important modifiable risk factors for cardiovascular disease (CVD), the leading cause of mortality both in China and worldwide. According to a 2000 nationally representative survey, 28.6% and 25.8% of Chinese men and women, respectively, are hypertensive

Annually, China spends more than $3 billion on hypertension treatment and $30 billion on the treatment of CVD, representing a substantial share of its national health care resources. In the next 25 years, the financial burden of hypertension will increase even further as the number of hypertensive people is projected to grow by 65% by 2025.

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Hypertension is a common and major cause of stroke and other cardiovascular disease. There are many causes of hypertension, including defined hormonal and genetic syndromes, renal disease and multifactorial racial and familial factors. It is one of the leading causes of morbidity and mortality in the world and will increase in worldwide importance as a public health problem by 2020. Blood pressure (BP) is defined as the amount of pressure exerted, when heart contract against the resistance on the arterial walls of the blood vessels. In a clinical term high BP is known as hypertension. Hypertension is defined as sustained diastolic BP greater than 90 mmHg or sustained systolic BP greater than 140 mmHg. The maximum arterial pressure during contraction of the left ventricle of the heart is called systolic BP and minimum arterial pressure during relaxation and dilation of the ventricle of the heart when the ventricles fill with blood is known as diastolic BP. Hypertension is commonly divided into two categories of primary and secondary hypertension. In primary hypertension, often called essential hypertension is characterised by chronic elevation in blood pressure that occurs without the elevation of BP pressure results from some other disorder, such as kidney disease. Essential hypertension is a heterogeneous disorder, with different patients having different causal factors that lead to high BP. Essential hypertension needs to be separated into various syndromes because the causes of high BP in most patients presently classified as having essential hypertension can be recognized. Approximately 95% of the hypertensive patients have essential hypertension. Although only about 5 to 10% of hypertension cases are thought to result from secondary causes, hypertension is so common that secondary hypertension probably will be encountered frequently by the primary care practitioner. In normal mechanism when the arterial BP raises it stretches baroceptors, (that are located in the carotid sinuses, aortic arch and large artery of neck and thorax) which send a rapid impulse to the vasomotor centre that resulting vasodilatation of arterioles and veins which contribute in reducing BP

Most of the book suggested that there is a debate regarding the pathophysiology of hypertension. A number of predisposing factors which contributes to increase the BP are obesity, insulin resistance, high alcohol intake, high salt intake, aging and perhaps sedentary lifestyle, stress, low potassium intake and low calcium intake. Furthermore, many of these factors are additive, such as obesity and alcohol intake.

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One way to improve control could be to start early and utilize combination therapy. The JNC-7 recommends initiation of therapy with combination therapy rather than a single agent if BP is more than 20/10 mm Hg above the treatment goal as in stage II hypertension. A two-drug regimen includes a diuretic appropriate for the level of renal function (Reddy KS, Katan MB

Diet, 2004). An increasing number of antihypertensive combination products are available in a number of dosing especially in India. Although combination products are convenient it is often less expensive to use individual agents and titration of doses of the two agents is easier when the two drugs are prescribed separately. Once BP control is achieved with given doses of two agents, switching to the same therapy in combination is a good option. The advantages and disadvantages of using combination products have been reviewed. Caution is advised when using combination therapy in older persons and diabetic patients, because of the increased risk of precipitous declines in BP or aggravation of orthostatic hypotension. Goal BP may be difficult to achieve in some patients with systolic hypertension, but any reduction is beneficial. Thus, in some patients, a higher systolic goal may be reasonable. In patients who require drugs, lower initial doses should be considered, especially in the presence of orthostatism or co-morbid vascular diseases. Serum creatinine concentrations often increase acutely when these drugs are used, so serum creatinine and potassium should be measured within several days of initiating treatment. An increase in creatinine is not a reason to stop the drug unless it is excessive or associated with severe hyperkalaemia. Concomitant use of potassium-sparing diuretics, potassium supplements, or nonsteroidal anti-inflammatory drugs should be avoided (Gupta R, Joshi P, 2008). A persistent increase in creatinine with treatment raises the possibility of renal artery stenosis. Most patients with kidney disease will require a diuretic as part of the treatment regimen. If the estimated glomerular filtration rate is < 30 ml/min, thiazide diuretics are usually ineffective, and loop diuretics are required.

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In summary, although the choice of first-line drug therapy may exert some effects on different long-term cardiovascular endpoints, randomized clinical trials and meta-analyses demonstrated that blood pressure reduction per se is the primary determinant in primary and secondary prevention. Hypertension is non-curable. But can reduce the consequences of disease or disease treatments can be mainly identified as pharmacological and non-pharmacological. Pharmacologically antihypertensive drugs can be used. They can be mainly classified as Diuretics, Beta blockers, ACE inhibitors, Angiotensin II receptors antagonists, Renin inhibitors, alpha blockers, Ca2+ channel blockers and others.

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Sindhwani V. Role of dietary modification with zero-oil diet in coronary artery disease patients. MSc dissertation. Delhi: Delhi University; 2004.

Reddy KS, Katan MB. Diet, nutrition and the prevention of hypertension and cardiovascular diseases. Public Health Nutr. 2004;7:167–86.

Kim S, Popkin BM. Understanding the epidemiology of overweight and obesity: a real global public health concern. Int J Epidemiol. 2006;35:60–7. discussion 81-2.

Gupta R, Deedwania PC. Obesity and the metabolic syndrome: management issues. In: Mohan V, Rao GHR, editors. Type 2 diabetes in South Asians: Epidemiology, risk factors and prevention. New Delhi: Jaypee Brothers Medical Publishers; 2006. pp. 104–37.

Gupta R, Joshi P, Mohan V, Reddy KS, Yusuf S. Epidemiology and causation of coronary heart disease and stroke in India. Heart. 2008

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