Hypertension Hypertension, also known as high blood pressure, is a common cardiovascular disease. The continuous elevation of arterial blood pressure in patients can lead to damage to the heart, blood vessels, and other organs. Hypertension is a significant risk factor for developing heart disease, stroke, and other serious complications. Prevention and treatment of hypertension involve lifestyle modifications, medication therapy, and regular monitoring of blood pressure levels.

The pressure of flowing blood against the walls of the blood vessels remains consistently higher than normal.

In China, approximately one out of every three adults suffers from hypertension.

Hypertension is a controllable but lifelong disease.

The condition is primarily managed through improving lifestyle and medication.

Hypertension, also known as high blood pressure, is a condition where the pressure of the blood against the walls of the blood vessels remains consistently higher than normal during blood flow. Hypertension is often referred to as the "silent killer," as most patients may develop the condition without any symptoms, and prolonged high pressure against the blood vessel walls can lead to serious diseases such as coronary heart disease and stroke.

The latest data from the Chinese Hypertension Survey shows that from 2012 to 2015, the prevalence of hypertension among adults in China was 27.9%. This means that approximately one out of every three adults suffers from hypertension, and the overall trend of prevalence is gradually increasing. The latest survey also found that the prevalence in rural areas has surpassed that of urban areas for the first time; the prevalence of hypertension is higher among Tibetan, Manchu, and Mongolian ethnic groups compared to the Han ethnic group; and there is an increasing trend in the prevalence of hypertension from southern to northern regions.

People with a family history of hypertension;

Individuals prone to emotional agitation, as increased levels of adrenaline due to excitation of the sympathetic nervous system can lead to elevated blood pressure;

Individuals with a preference for high-salt diets;

Individuals who consume alcohol excessively;

People experiencing high work or life-related stress.

Causes of Hypertension

The causes of hypertension are a challenging issue constantly being explored by scientists worldwide, and for most hypertensive patients, the causes remain unclear. Previously, this type of hypertension was referred to as "primary hypertension," but this term is now a thing of the past, and it is currently referred to simply as hypertension.

Among patients presenting with hypertension, 5% experience elevated blood pressure due to certain specific diseases or causes, termed secondary hypertension. This type of hypertension can be cured or improved by treating the underlying diseases or causes that lead to elevated blood pressure.

The causes of hypertension include unclear origins, with a focus on risk factors such as genetic predisposition, age, and unhealthy lifestyle. Approximately 70-80% of hypertension cases are related to an unhealthy lifestyle. As risk factors for hypertension accumulate, the risk of developing the condition increases.

Causes of Secondary Hypertension

For young and middle-aged individuals with moderate to severe hypertension who show poor responses to combined drug therapy, consideration should be given to whether secondary hypertension is present, which may be caused by the following diseases leading to elevated blood pressure:

- Kidney diseases: such as glomerulonephritis, chronic pyelonephritis, etc.

- Endocrine diseases: such as menopausal syndrome, pheochromocytoma, etc.

- Cardiovascular lesions: such as aortic valve insufficiency, aortic stenosis, etc.

- Cerebrovascular lesions: such as brain tumors, head trauma, etc.

- Sleep apnea syndrome;

- Other reasons include pregnancy-induced hypertension, polycythemia, medications, etc.

Hypertension is a "lifestyle disease," and many daily behavioral habits serve as risk factors for its occurrence.

High sodium and low potassium diet

A high sodium and low potassium diet is a significant risk factor for the development of hypertension in the Chinese population. The World Health Organization (WHO) recommends a daily salt intake of 5 grams for the general population, while the average daily salt intake in China ranges from 8 to 15 grams. The WHO recommends a daily potassium intake of 3.51 grams per person, while the average daily potassium intake in China is only 1.89 grams.

Overweight and obesity

Overweight and obesity are important risk factors for the development of hypertension, especially central obesity. The risk of developing hypertension in individuals who are overweight or obese is 1.16 to 1.28 times higher than that of individuals with normal weight.

Excessive alcohol consumption

The prevalence of hypertension increases with the amount of alcohol consumed, and approximately 5-10% of hypertensive patients are affected by excessive alcohol consumption. Excessive alcohol consumption includes hazardous drinking (single alcohol intake: 41-60 g for men, 21-40 g for women) and harmful drinking (single alcohol intake: over 60 g for men, over 40 g for women).

Long-term mental stress

When individuals are in states of tension, anger, fear, suppression, anxiety, or irritability, the sympathetic nervous system is activated, leading to an increase in blood pressure. Studies have shown that individuals under mental stress have a risk of developing hypertension that is about 1.5 times higher than that of the normal population.

Lack of physical activity

Urban residents in China, especially those in their middle and younger years, generally have insufficient physical activity, which is a risk factor for hypertension.

Other factors

Other risk factors include age, family history of hypertension, concomitant diabetes, abnormal blood lipids, etc. In recent years, air pollution has also received attention, with some studies indicating a possible association between certain pollutants in the atmosphere and the development of hypertension.

Typical symptoms of hypertension include: headache, fatigue or restlessness, arrhythmia, palpitations, and tinnitus. If the patient has reached a hypertensive crisis (≥180/120 mmHg), they may experience stroke, blurred vision, loss of consciousness, memory loss, myocardial infarction, renal impairment, aortic dissection, angina, pulmonary edema, and eclampsia.

Different subtypes of hypertension have their own specific symptoms:

Pregnancy-induced hypertension, characterized by proteinuria, edema, and in severe cases, seizures, coma, or even death.

Hypertension in infants and young children may manifest as irritability, excessive excitement, high-pitched crying at night, and delayed growth and development.

Hypertension during menopause may present with symptoms such as lumbar and knee weakness, and limb edema.

Hypertension caused by specific triggers may have specific symptoms, for example, cervical hypertension may present with shoulder and neck pain, and numbness and discomfort in the upper limbs; renal hypertension may present with pain in the lumbar or flank.

When combined with other symptoms, the clinical manifestations of hypertension become more complex. There are many common comorbidities of hypertension, each with its related symptoms:

Accompanying left ventricular hypertrophy;

Accompanying coronary heart disease/myocardial infarction;

Accompanying heart failure;

Combined with diabetes;

Combined with hyperlipidemia;

Combined with renal disease;

Accompanying gout or hyperuricemia;

Combined with asthma/chronic bronchitis/pulmonary edema;

Accompanying peptic ulcer disease;

Accompanying cerebrovascular disease, including cerebral hemorrhage, transient ischemic attacks.

If a hypertensive patient's blood pressure is not controlled for a long time, it may lead to various other complications:

Aortic dissection, often manifested as sudden severe chest pain;

Abnormalities in the eye's blood vessels, gradually leading to blurred vision;

Decline in memory and comprehension;

Dementia.

Other potentially related accompanying symptoms include retinal hemorrhage, facial flushing, and dizziness.

Examinations related to hypertension include a comprehensive assessment involving medical history, physical examination, laboratory tests, genetic analysis, blood pressure measurement, and assessment of target organ damage.

Medical history:

Inquiring about family history, course of the condition, symptoms, past medical history, clues to secondary hypertension, lifestyle, and psychosocial factors.

Physical examination:

Measuring blood pressure, pulse rate, body mass index (BMI), waist circumference, hip circumference, observing for signs of Cushing's syndrome, neurofibromatosis, thyroid function, or lower limb edema, auscultation of the carotid, aorta, abdominal, and femoral arteries for murmurs; palpation of the thyroid, comprehensive cardiopulmonary examination, examination for renal enlargement (polycystic kidneys) or masses in the abdomen, and examination of arterial pulses and neurological signs in the limbs.

Laboratory tests:

Basic tests include blood biochemistry, complete blood count, electrocardiogram, and urinalysis; additional tests may include echocardiography, high-sensitivity C-reactive protein, fundus examination, and sleep apnea monitoring.

Blood pressure measurement:

The participant should rest quietly for at least 5 minutes before measurement. Blood pressure should be measured in a seated position with the arm at heart level. It is recommended to use a validated upper arm electronic sphygmomanometer. Initially, blood pressure should be measured in both arms, and the higher reading should be used for subsequent measurements.

Medications for hypertension:

Due to significant individual differences, there is no absolute "best," "fastest," or "most effective" medication. Apart from commonly used over-the-counter drugs, the most suitable medication should be chosen in consultation with a physician, considering individual circumstances.

The "Chinese Hypertension Clinical Practice Guidelines" released in 2022 state the following criteria for initiating antihypertensive medication:

- Systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg: immediate initiation of antihypertensive medication recommended.

- Systolic blood pressure 130-139 mmHg and/or diastolic blood pressure 80-89 mmHg with clinical complications: initiation of antihypertensive medication recommended.

- Systolic blood pressure 130-139 mmHg and/or diastolic blood pressure 80-89 mmHg with target organ damage (TOD) or >3 cardiovascular risk factors: initiation of antihypertensive medication is permissible.

Basic principles of antihypertensive medication include the following:

- Initiate treatment with a small effective dose and gradually increase to an adequate dose as needed. Any of the five major classes of antihypertensive drugs can be used as initial therapy.

- Preferentially use long-acting antihypertensive drugs to effectively control blood pressure over 24 hours.

- Patients with inadequate response to monotherapy should undergo combination therapy, either with free combinations or by using a single compound preparation.

- Select antihypertensive drugs based on the individual's condition.

- Antihypertensive medication should be taken lifelong, considering cost-effectiveness.

Common antihypertensive medications include calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), diuretics, and beta-blockers. The guidelines recommend that these five classes of drugs can all be used as initial therapy, and the choice of drug will be tailored to specific patient populations and comorbidities for individualized treatment. The prioritization of long-acting antihypertensive drugs aims to effectively control blood pressure over 24 hours and prevent cardiovascular and cerebrovascular complications.

Calcium channel blockers (CCBs):

Can be used alone or in combination with other four classes of drugs, particularly suitable for elderly hypertensive patients, isolated systolic hypertension, stable angina, coronary artery or carotid atherosclerosis, and peripheral vascular disease patients.

Common adverse reactions include tachycardia, facial flushing, ankle edema, and gingival hyperplasia. Dihydropyridine CCBs have no absolute contraindications, but should be used with caution in patients with tachycardia and heart failure.

Angiotensin-converting enzyme inhibitors (ACEIs):

Have a clear antihypertensive effect with no adverse effects on glucose and lipid metabolism. Limiting salt intake or adding diuretics can enhance the antihypertensive effect of ACEIs, particularly suitable for patients with chronic heart failure, post-myocardial infarction heart failure, atrial fibrillation prevention, diabetic nephropathy, non-diabetic nephropathy, metabolic syndrome, proteinuria, or microalbuminuria.

The most common adverse reaction is dry cough, which is more common in the early stages of treatment. Patients with mild symptoms can persist with the medication, while those who cannot tolerate it can switch to ARBs. Other adverse reactions include hypotension, rash, occasional angioedema, and taste disturbances. Long-term use may lead to elevated blood potassium levels, requiring regular monitoring of potassium and creatinine levels. Contraindications include bilateral renal artery stenosis, hyperkalemia, and pregnancy in women.

Angiotensin receptor blockers (ARBs):

Can reduce the incidence of cardiovascular events in patients with a history of cardiovascular disease (coronary heart disease, stroke, peripheral arterial disease) and the risk of cardiovascular events in hypertensive patients. ARBs are particularly suitable for patients with left ventricular hypertrophy, heart failure, diabetic nephropathy, coronary heart disease, metabolic syndrome, microalbuminuria, or proteinuria, and patients who cannot tolerate ACEIs. ARBs can also prevent atrial fibrillation.

Adverse reactions are rare, with occasional cases of diarrhea. Long-term use can raise blood potassium levels, requiring monitoring of potassium and creatinine levels. Contraindications include bilateral renal artery stenosis, pregnant women, and hyperkalemia.

Diuretics:

Particularly suitable for elderly hypertensive patients, isolated systolic hypertension, or patients with heart failure, and are also one of the basic drugs for refractory hypertension.

Adverse reactions are closely related to dosage, so low doses are usually used. Thiazide diuretics can cause hypokalemia, and long-term users should monitor blood potassium levels and supplement potassium as needed. They are contraindicated in patients with gout and those with significant renal insufficiency.

Beta-blockers:

Particularly suitable for hypertensive patients with rapid arrhythmias, coronary heart disease, chronic heart failure, increased sympathetic nervous system activity, and hyperdynamic state. Common adverse reactions include fatigue, cold extremities, restlessness, and gastrointestinal discomfort, and they may also affect glucose and lipid metabolism. Contraindications include moderate to severe atrioventricular block, asthma patients, and caution is advised in patients with chronic obstructive pulmonary disease, athletes, peripheral vascular disease, or impaired glucose tolerance.

Beta-blockers are not the first choice for patients with abnormal glucose and lipid metabolism, but if necessary, highly selective beta-blockers can be used with caution. Abrupt discontinuation of long-term use can lead to rebound symptoms, such as worsening of existing symptoms or new manifestations, most commonly blood pressure rebound with headache, anxiety, etc., known as withdrawal syndrome.

Among the various complications of hypertension, the incidence of hypertension accompanied by coronary heart disease is as high as 83%, and most hypertensive patients also have varying degrees of renal impairment. For these two types of patients, the blood pressure control target is below 130/80 mmHg.

Hypertension is also a major cause of cerebral hemorrhage; at the same time, during the process of lowering blood pressure, attention should be paid to the fact that too rapid a decrease in blood pressure may lead to insufficient cerebral perfusion, which can in turn induce cerebral infarction.

Lifestyle intervention, especially nutritional and exercise interventions, play an important role in the prevention and treatment of hypertension.

Nutritional guidance:

Healthy diet: adhere to a predominantly plant-based diet, with a moderate amount of animal-based foods, ensuring dietary variety and appropriate proportions of the three major nutrients.

Control energy intake: maintain a healthy weight, with daily dietary energy intake reaching or maintaining a healthy weight being appropriate, while paying attention to maintaining muscle mass.

Limit sodium intake: gradually reduce daily salt intake to below 5g per person.

Ensure intake of fresh vegetables and fruits. Daily vegetable intake should not be less than 500g, and fruit intake should be 200g to 350g.

Reduce intake of saturated fatty acids and cholesterol.

Limit alcohol consumption or abstain from alcohol.

Patients with hypertension combined with multiple diseases can adopt corresponding dietary guidance principles.

Dietary taboos: reduce sodium salt intake, gradually reducing daily salt intake to <5g (from: 2022 Chinese Clinical Practice Guidelines for Hypertension). In daily life, a "salt control spoon" can be used to measure. It should be noted that in daily life, other high-sodium condiments (such as monosodium glutamate, soy sauce, etc.), pickled products, snacks, etc., should also be controlled.

Prevention of hypertension is very important for people with a family history of hypertension or high-risk factors, and preventive measures mainly involve maintaining a healthy lifestyle.

Exercise can improve blood pressure levels. For non-hypertensive individuals and patients with stable blood pressure controlled at the target level, it is recommended to exercise at least 5 days a week, including walking, jogging, cycling, or swimming, for at least 150 minutes of moderate aerobic exercise and 75 minutes of vigorous exercise each week. High-risk patients need to undergo professional assessment before exercising.

Pay attention to reducing stress or avoiding it. Developing stress management strategies can help control blood pressure.

Quit smoking. Smoking increases blood pressure, and quitting can reduce the risk of hypertension, heart disease, and other metabolic diseases.

Healthy eating. Avoid excessive consumption of alcohol, drugs, as well as unhealthy diets high in salt, sugar, and fat.