HYPERTENSION, RISK FACTORS AND TREATMENT

Anggi L. Wicaksana, MSc

Department of Medical Surgical Nursing,

School of Nursing, Faculty of Medicine Universitas Gadjah Mada

Gd. Ismangoen 2F Jl. Farmako, Sekip Utara Fakultas Kedokteran UGM

Correspondence: anggi.l.wicaksana@ugm.ac.id


a. Definition

The normal blood pressure is needed in order to maintain vital function of organs in human body. The normal adult blood pressure is defined if systolic blood pressure (SBP) is 120 mmHg and diastolic blood pressure (DBP) is 80 mmHg. A condition, when the blood vessels have persistently raised pressure more than definition of normal blood pressure, is known as hypertension. Based on the Join Committee 8, hypertension is defined as raised blood pressure where systolic blood pressure equal or above 140 mmHg and/or diastolic blood pressure equal or above 90 mmHg (P. A. James et al., 2014; Rahajeng & Tuminah, 2009; WHO, 2016). The higher pressure of blood vessel, the harder heart has to work in pumping blood and supply perfusion need of organs. High blood pressure needs more concern, however, the ignorance of high blood pressure can increase cardiovascular risk, a life-threatening complication. As consequence, improper management of hypertension can lead some complications such as stroke, heart failure, kidney failure, blindness, rupture of blood vessel and cognitive impairment (WHO, 2016).

There are many electronic, mercury and aneroid devices to read and measure blood pressure. WHO recommends using the affordable and reliable electronic devices that have choice to select manual reading. Electronic devise is gold standard to measure blood pressure, however, in some location it could not be applied because of limited resources. Using mercury and aneroid as manual reading of blood pressure are still acceptable. When the physician would like to diagnosed hypertension, the consecutive measurement should be conducted which records the result for several days. Ideally, the blood pressure is measured twice a day in morning and evening. Two parallel measurements should be taken, at least a minute apart and with person seated. As recommended, the measurements in the first day are discharged and the average value of all the remaining measurements is taken to confirm a diagnosis of hypertension. Whenever the average finding of blood pressure is 140 mmHg or above for SBP and/or 90 mmHg for DBP, the diagnosis of hypertension is declared (WHO, 2016).

 

b. Risk Factors of Hypertension

Hypertension, like other chronic diseases, has no clear etiology but have risk factors that can propose the incidence. The main risk factors of hypertension had been released by WHO consist of three risk factors: behavioral risk factors, socioeconomic factors and metabolic factors. Each of the risk factors combines to lead and accelerate the occurrence of hypertension. Most of patients with hypertension have multi risk factors because of unhealthy life style and some of them have other complications that provoke hypertension (Rahajeng & Tuminah, 2009; WHO, 2016). Behavioral risk factors become the most common issues because most of patients with hypertension have these risk factors. The specific behavioral risk factors triggered hypertension is alcohol consumption, smoking, physical inactivity and lack of exercise, poor stress management and unhealthy diet. Unhealthy diet that could induce hypertension is eating high sodium (salty), high fat (cholesterol) and less consume fruits and vegetables. These behavioral risk factors mostly happen collectively then propose hypertension or even extreme blood pressure. Each kind of these factors can lead declining heart function and peripheral blood vessel resistant, which in turn could result in raised blood pressure. Next, socioeconomic that can be risk factors of hypertension are low income, low education, rapid urbanization and globalization and aging. Low income and low education could contribute and develop hypertension by ignorance and low awareness of management. Low income also could be social pressure then increases stress level that in turn encourages raised blood pressure. Rapid urbanization and globalization have impact to hypertension as result of unhealthy environment that stimulates behavioral risk factors. Almost the socioeconomic factors will contribute and develop to behavioral risk and eventually induce the manifestation of hypertension. Metabolic factors, the third factors contribute to hypertension, involve obesity, diabetes and high blood lipid (cholesterol). These kind of metabolic factors related to pathological mechanism that can impact cardiovascular and blood vessels (WHO, 2016).

Study on risk factors of hypertension in Indonesia showed the unhealthy life and demographic factors had significant influence toward the incidence of hypertension. The findings indicated being older person (aged more than 45 year-old), male, illiteracy, unemployed/farmer/fisherman and limited access to health care provider are the risk factor of hypertension for socio-demographic factors. In addition, for behavioral risk factors that have significant finding related to hypertension consist of smoking habit, alcohol and caffeine consumption (Rahajeng & Tuminah, 2009; Setiati & Sutrisna, 2005). Surprisingly, consumption of vegetable, sweetie foods, salty foods, fatty foods and inadequate physical activity didn’t have significant finding and only had slightly differences. Based on the physical condition and history of disease, obesity, having stress, cardiac diseases and diabetes became the risk factor of hypertension (Rahajeng & Tuminah, 2009). Other studies focus on hypertension in elderly revealed that independent variables as determinant factor influencing SBP were BMI, fat mass, abdominal circumstance, total cholesterol, arginine, carbohydrate, energy, fiber, protein and potassium intake (Kamso et al., 2007). All findings of risk factors on hypertension have linear direction with whole risk factors from WHO. Since the risk factor of hypertension in Indonesia was the real problem happen, it should become priority in dealing and overcoming hypertension problem in Indonesia.

 

c. Treatment of Hypertension

Treatment of hypertension includes comprehensive approach because hypertension is chronic disease. It has been known while treating hypertension; the main focus is involving patients and let them independent in dealing with their high blood pressure. To improve patient’s involvement in hypertension treatment, the update management had been released. The current management of hypertension suggests to closed-monitoring blood pressure (BP) and conduct healthy lifestyle (P. A. James et al., 2014; WHO, 2016). The experts had been published target BP recommendation and specify regarding the patient’s age based on strong evidence. It is recommended that the goal BP for general population aged 60-year or more is systolic blood pressure (SBP) < 150 mmHg and diastolic blood pressure (DBP) < 90 mmHg. For general population aged 18 – 59-year and patients with diabetes or chronic kidney diseases (CKD), the goal SBP is < 140 mmHg and DBP is <90 mmHg. This cut point of goal BP (SBP and DBP) becomes decision for physician to start giving antihypertensive drug (P. A. James et al., 2014). Moreover, integrated program through implementation in primary healthcare has encouraged by WHO in preventing and controlling raised blood pressure. As proposed by WHO, the six crucial elements should be initiated to address hypertension consist of integrated primary health care, cost effective of implementing program, basic diagnostic and medicine, risk factor reduction, workplace-based program and monitoring of progress (WHO, 2016). In detail, management of hypertension will be specified as pharmacological and non-pharmacological approaches.

Pharmacological approach emphasizes on drug using while non-pharmacological approach highlights risk factors reduction that mostly as behavioral changes. The evidence has strongly endorsed effective antihypertensive drugs include angiotensin converter enzyme (ACE) inhibitor, angiotensin receptor blockers, b-blockers, calcium channel blockers and thiazide type diuretics which is applied using acceptable dosage (P. A. James et al., 2014; WHO, 2016; WHO & ISH, 2003).

Non-pharmacological approach on hypertension treatment proposes behavioral change into healthy lifestyle. Like other cardiovascular diseases, patients with hypertension need encouragement to change their habit into healthy life style and implement self-management. Several behavioral changes suggested for patients with hypertension are regular exercise, smoking cessation, limiting alcohol use, stress management, healthy diet, and salt/sodium restriction. Those kinds of behavioral changes have been proved as effective strategy to promote quality of life and reduce BP gradually. Recommended regular exercise involves any types of physical activity for at least 30 minutes a day in five days a week. Smoking and alcohol cessation are also advised in managing hypertension because smoking and alcohol have direct impact to heart and blood vessel. Effective stress management can minimize the complication of hypertension. It is well known that stress can induce raised blood pressure thus appropriate stress management will help control BP. Healthy diet for patients with hypertension focus on reducing saturated and fat consumption and take five serving fruit and vegetables a day (WHO, 2005, 2016; WHO & ISH, 2003; WHO & UNAIDS, 2007). Surprisingly, low sodium consumption has proved effective method in controlling hypertension on community. Even it is not easy to have sodium restriction, however if it is well implemented, the BP could significantly decrease and inhibit the progression of complication (Cornélio et al., 2009; Sacks et al., 2001; WHO, 2016; WHO & ISH, 2003). Furthermore, every patient should be encouraged to conduct closed-monitoring of BP, blood sugar, cholesterol; regular checkup and routinely control to the cardiac clinic or hospital (WHO, 2016). These activities are kind of self-management on hypertension that involves patients in managing their disease independently. To make it happen, the awareness and adherence of self-management should be built up gradually. Health workers have a role to facilitate and reinforce patients till they have independence (WHO & ISH, 2003).

 

References

1.   Cornélio, M. E., Gallani, M. C. B. J., Godin, G., Rodrigues, R. C. M., Mendes, R. D. R., & Nadruz Junior, W. (2009). Development and reliability of an instrument to measure psychosocial determinants of salt consumption among hypertensive patients. Revista Latino-americana de Enfermagem, 17(5), 701-707.

2.      James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., . . . Ogedegbe, O. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Jama, 311(5), 507-520.

3.   Kamso, S., Rumawas, J. S., & Lukito, W. (2007). Determinants of blood pressure among Indonesian elderly individuals who are of normal and over-weight: A cross sectional study in an urban population. Asia Pacific Journal of Clinical Nutrition, 16(3), 546-553.

4.   Rahajeng, E., & Tuminah, S. (2009). Prevalensi hipertensi dan determinannya di Indonesia, Majalah Kedokteran Indonesia, 25(12), 580-587.

5.      Sacks, F. M., Svetkey, L. P., Vollmer, W. M., Appel, L. J., Bray, G. A., Harsha, D., . . . Simons-Morton, D. G. (2001). Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. New England Journal of Medicine, 344(1), 3-10.

6.    Setiati, S., & Sutrisna, B. (2005). Prevalence of hypertension without anti-hypertensive medications and its association with social demographic characteristics among 40 years and above adult population in Indonesia. Acta Medica Indonesia, 37(1), 20-25.

7.      WHO. (2016). A global brief on hypertension: Silent killer, global public health crisis. Geneva: World Health Organization.

8.  WHO, & ISH. (2003). 2003 World Health Organization (WHO)/International Society of Hypertension (ISH) statement on management of hypertension. Journal of Hypertension, 21(11), 1983-1992.

9.   WHO, & UNAIDS. (2007). Prevention of cardiovascular disease. Geneva: World Health Organization.