Hypertension
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Hypertension



Essential or primary hypertension occurs for no known reason and accounts for 95% of hypertension in adults [i]. 
 



HEALTH PROMOTION & DISEASE PREVENTION
Health promotion is a very important aspect of care. It involves knowing the following about hypertension (HTN):

  • What is normal vs. abnormal blood pressure?
  • What are the sequela of uncontrolled blood pressure? 
  • Why is hypertension called the "Silent Killer"?

To answer these questions, I often refer to a comprehensive visual guide. However, the simple chart below from the National High Blood Pressure Education Program [ii], is adequate to begin with: 


Systolic [top #]
Diastolic [bottom#]
Ideal
< 120
< 80
Pre-HTN
120-139
80-90
Stage HTN
140-159
 90-99
 Stage 2 HTN
 >160
 >100
The new onset of BP higher than 180/110 or diastolic HTN with or without systolic HTN after 50 or before 30 years of age is unusual. Secondary (e.g. renal) HTN should be ruled out. Drugs that can cause secondary HTN are NSAIDS & COX II inhibitors, decongestants, oral contraceptives, steroids, cocaine, and herbs such as ephedra.

Disease prevention is the most important. Prehypertension is the points at which lifestyle, diet and exercise modifications are most effective. There is a linear progression of cardiovascular damage with consistent BPs above 120/ 80 mmHg with increased risk of stroke, renal failure, myocardial infarction etc. An increase in 20 mm Hg in systolic BP (top number); or 10 mm Hg in diastolic BP (bottom number) increases the risk for cardiovascular disease by 50%. In general the bottom number is more important. Disease prevention includes:

  • Weight Loss & Exercise 30 to 45 minutes of aerobic exercise daily

  • Limiting Alcohol Intake to < 1 standard drinks per day for men, and <0.5 for women. Three to 5 standard drinks per day increases the risk for hypertension [i]. 

  • Reducing Cholesterol and Saturated Fats. Elevated LDL is a major predictor of CVD. The goal is to decrease LDL by 30 to 40% with a target of 70 to 100 mg/dl (<100 for moderate risk, or <70 if very high risk exists). Triglycerides <150, and a total cholesterol of <200 [iii]. 

  • Adequate Daily Mineral Intake of calcium, magnesium & potassium.

  • Smoking Cessation. Smoking causes HTN by hardening blood vessels (arteriosclerosis) and the narrowing vessels (vasoconstriction).

  • Limiting Daily Sodium Intake to < 2.4 gm sodium, and <6g sodium chloride. Sodium is also in condiments, antacids, and herbs (e.g. sea salt baths) etc.  Limiting sodium intake is very important if someone is on a diuretic to control hypertension. As the drug's concentrations falls after the daily dose, a period of post-diuretic sodium retention may follow. If dietary salt intake is high then the amount of sodium loss in response to the diuretic may be partial or completely offset by post diuretic sodium retention [iv]. 

The American Public Health Association advocates a 50% reduction in the sodium content of all foods. While this would have a modest effect on individuals, the population effect on the huge number of at-risk people would significantly reduce cardiovascular morbidity and mortality [v].

  • Diabetic Teaching. Diabetics have greater than a 65% chance of dying from heart attack or stroke due to microvascular disease. BP control, along with lifestyle modifications for lipid and glycemic control are 1st line therapy for Type II Diabetes [v]. Standard of care to lower CVD risk are (1) glycemic control (target A1C  is <7.0), (2) BP management, (3) statin drug therapy, and antiplatelet therapy if certain CVD risk factors exist. The goal is a BP<140/90 mmHg. However 130/80 mmHg is ideal. 

SCREENING INTERVENTIONS
There are guidelines and screening methods that monitor and predict a persons risk for suffering from the sequelae of hypertension in the future:

  • JNC 7 Guidelines See the Seventh Report of the Joint  Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure for the diagnosis and treatment of hypertension.
  • Framingham Score is based on age, HDL, systolic BP, and smoking status. A score of 20% or greater indicates risk for a heart attack in 10 years, and the need for primary care & prevention. 
  • Metabolic Syndrome The constellation of symptoms are insulin resistance (type 2 diabetes) plus at least 2 of the following: stage 1 HTN, elevated TG, low HDL, abdominal obesity, and albuminuria. Metabolic syndrome increases the risk of cardiovascular disease.

DIAGNOSING HYPERTENSION
One's blood pressure reading  is influenced by many factors at any given time (especially anxiety vs. calm). To account for the variations and to achieve a more-or-less baseline reading, hypertension is diagnosed based on two blood pressures taken on two different occasions. Plus symptoms, namely dizziness, headache, nosebleeds, blurry vision and numbness. 

A baseline BP can even vary depending on the time of day [vi]. According to Vaughn's Summaries,  the highest BP occurs normally about midday, and the lowest at about 3-4 AM. For other people, this BP dip occurs around 6 - 9 AM, and is associated with abnormal sleep patterns, sleep apnea, heavy snoring, drug and alcohol abuse, etc. This variation in BPs can be as significant as 150/95 (stage 1 HTN)  in the morning, and 130/85 (pre-HTN) in the evening. A difference between having to take medication vs. lifestyle modification.

TREATING HYPERTENSION
Treatment guidelines comes from the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8), National Institute of Health. These guidelines outline drug regimens based on the type of HTN (primary or secondary); the stage of HTN (pre-HTN, stage I, stage II); and comorbidities such as chronic kidney disease, diabetes, heart failure, CAD risk, post MI, history of stroke. The drug regimen is adjusted if the BP goal is not met. There are many classes of drugs to choose from and it may take awhile to determine which medication(s) is right for any individual. For unknown reasons, race is a determinant of response to some medications.


INTEGRATIVE  MEDICINE TIP: Chinese medicine accounts for diurnal fluctuation in blood pressure, with something called the Horary Clock or the Circadian Rhythm of Qi flow through the organ systems. The highest blood pressure occurs at mid-day;  noon-time is indeed associated with the Heart according the Horary Clock. 
 
"There are some treatment protocols where the actual time of a treatment may be enhanced by coordinating the treatment with the flow of Qi according to the Horary Clock. [Since] this is not always practical, organs opposite each other on the Horary clock will balance each other regardless of the time treated [vii]. Hence, mid-day (or the opposite   23:00-01:00) are good times to do things to benefit cardiovascular health.

For example napping for 1 hour between 11AM to 1PM (Heart time) nourishes the spiritual Heart (the Shen). Nurturing yourself and relationships then winding down for sleep between 7PM to 11PM (Pericardium and San jiao time) strengthens and rests the Heart. Sleeping well between 11PM to 1AM (Gallbladder time) restores the Heart. Not achieving deep sleep by 1AM to 3AM (Liver time) increases the risk for "deficiency Liver Fire Flaring", which is a pattern associated with HTN in Chinese medicine. This is a critical time because the Liver is the last organ system before qi enters a new diurnal cycle. Jue Yin is the deepest level of qi & blood flow

See how to care for your cardiovascular health according to the Horary Clock. (Do not take Kyushin Pills without a prescription from an Chinese herbal prescriber because studies show one of its herbal ingredient interacts with the cardiac drug called Digoxin).


Sources
Dunphy, L.M., Winland-Brown, J.E., Porter, B. O. & Thomas, D. J. (2011). Primary care: The art and science of advanced practice nursing (3rd ed). Philadelphia, PA: F.A. Davis Company. ISBN: 978-0-8036-2255-5
Edmunds & Mayhew. (2013). Pharmacology for the primary care provider. (4th ed.) St. Louis, MO: Elsevier.
Epocrates Online. Essential Hypertension.
Jarvis, C. (2011). Physical examination and health assessment (6th ed). Philadelphia, PA: Saunders. 
Marley, J. (20140. Chinese medicine body clock. Acupuncture Services of New York City. Retrieved from http://www.acupuncture-services.com.
Mayo Clinic. Cholesterol levels: What numbers should you aim for. In Diseases and Conditions. Retrieved from www.mayoclinic.org.
National Heart, Lung and Blood Institute. The seventh report of the Joint  committee on prevention, detection, evaluation, and treatment of high  blood pressure (JNC 7).  Retrieved from www.nhlbi.nih.gov
Vaughn's Summaries (2014). Vaughn's Normal Blood Pressure Chart. Retrieved  from www.vaughns-1-pagers.com.







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