text:
Hypertension | |
Classification and external resources | |
Automated arm blood pressure meter showing arterial hypertension (shown a systolic blood pressure 158 mmHg, diastolic blood pressure 99 mmHg and heart rate of 80 beats per minute)
DiseasesDB | 6330 |
MedlinePlus | 000468 |
eMedicine | med/1106 ped/1097 emerg/267 |
MeSH | D006973 |
Hypertension (HTN) or high blood pressure, sometimes called arterial hypertension, is a chronic medical condition in which the blood pressure in the arteries is elevated.[1] This requires the heart to work harder than normal to circulate blood through the blood vessels. Blood pressure is summarised by two measurements, systolic and diastolic, which depend on whether the heart muscle is contracting (systole) or relaxed between beats (diastole) and equate to a maximum and minimum pressure, respectively. Normal blood pressure at rest is within the range of 100-140mmHg systolic (top reading) and 60-90mmHg diastolic (bottom reading). High blood pressure is said to be present if it is persistently at or above 140/90 mmHg.
Hypertension is classified as either primary (essential) hypertension or secondary hypertension; about 90–95% of cases are categorized as "primary hypertension" which means high blood pressure with no obvious underlying medical cause.[2] The remaining 5–10% of cases (secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart or endocrine system.
Hypertension is a major risk factor for stroke, myocardial infarction (heart attacks), heart failure, aneurysms of the arteries (e.g. aortic aneurysm), peripheral arterial disease and is a cause of chronic kidney disease. Even moderate elevation of arterial blood pressure is associated with a shortened life expectancy. Dietary and lifestyle changes can improve blood pressure control and decrease the risk of associated health complications, although drug treatment is often necessary in people for whom lifestyle changes are not enough or not effective.
Signs and symptoms[edit]
Hypertension is rarely accompanied by any symptoms, and its identification is usually through screening, or when seeking healthcare for an unrelated problem. A proportion of people with high blood pressure report headaches (particularly at the back of the head and in the morning), as well as lightheadedness, vertigo, tinnitus (buzzing or hissing in the ears), altered vision or fainting episodes.[3] These symptoms, however, might be related to associated anxiety rather than the high blood pressure itself.[4]
On physical examination, hypertension may be suspected on the basis of the presence of hypertensive retinopathy detected by examination of the optic fundus found in the back of the eye using ophthalmoscopy.[5] Classically, the severity of the hypertensive retinopathy changes is graded from grade I–IV, although the milder types may be difficult to distinguish from each other.[5] Ophthalmoscopy findings may also give some indication as to how long a person has been hypertensive.[3]
Secondary hypertension[edit]
Some additional signs and symptoms may suggest secondary hypertension, i.e. hypertension due to an identifiable cause such as kidney diseases or endocrine diseases. For example, truncal obesity, glucose intolerance, moon faces, a "buffalo hump" and purple striae suggest Cushing's syndrome.[6] Thyroid disease and acromegaly can also cause hypertension and have characteristic symptoms and signs.[6] An abdominal bruit may be an indicator of renal artery stenosis (a narrowing of the arteries supplying the kidneys), while decreased blood pressure in the lower extremities and/or delayed or absent femoral arterial pulses may indicate aortic coarctation (a narrowing of the aorta shortly after it leaves the heart). Labile or paroxysmal hypertension accompanied by headache, palpitations, pallor, and perspiration should prompt suspicions of pheochromocytoma.[6]
Hypertensive crisis[edit]
Severely elevated blood pressure (equal to or greater than a systolic 180 or diastolic of 110 — sometimes termed malignant or accelerated hypertension) is referred to as a "hypertensive crisis", as blood pressures above these levels are known to confer a high risk of complications. People with blood pressures in this range may have no symptoms, but are more likely to report headaches (22% of cases)[7] and dizziness than the general population.[3] Other symptoms accompanying a hypertensive crisis may include visual deterioration or breathlessness due to heart failure or a general feeling of malaise due to renal failure.[6] Most people with a hypertensive crisis are known to have elevated blood pressure, but additional triggers may have led to a sudden rise.[8]
A "hypertensive emergency", previously "malignant hypertension", is diagnosed when there is evidence of direct damage to one or more organs as a result of the severely elevated blood pressure. This may include hypertensive encephalopathy, caused by brain swelling and dysfunction, and characterized by headaches and an altered level of consciousness (confusion or drowsiness). Retinal papilloedema and/or fundal hemorrhages and exudates are another sign of target organ damage. Chest pain may indicate heart muscle damage (which may progress to myocardial infarction) or sometimes aortic dissection, the tearing of the inner wall of the aorta. Breathlessness, cough, and the expectoration of blood-stained sputum are characteristic signs of pulmonary edema, the swelling of lung tissue due to left ventricular failure an inability of the left ventricle of the heart to adequately pump blood from the lungs into the arterial system.[8] Rapid deterioration of kidney function (acute kidney injury) and microangiopathic hemolytic anemia (destruction of blood cells) may also occur.[8] In these situations, rapid reduction of the blood pressure is mandated to stop ongoing organ damage.[8] In contrast there is no evidence that blood pressure needs to be lowered rapidly in hypertensive urgencies where there is no evidence of target organ damage and over aggressive reduction of blood pressure is not without risks.[6] Use of oral medications to lower the BP gradually over 24 to 48 h is advocated in hypertensive urgencies.[8]
Hypertension occurs in approximately 8–10% of pregnancies.[6] Two blood pressure measurements six hours an apart of greater than 140/90 mm Hg is considered diagnostic of hypertension in pregnancy.[9] Most women with hypertension in pregnancy have pre-existing primary hypertension, but high blood pressure in pregnancy may be the first sign of pre-eclampsia, a serious condition of the second half of pregnancy and puerperium.[6] Pre-eclampsia is characterised by increased blood pressure and the presence of protein in the urine.[6] It occurs in about 5% of pregnancies and is responsible for approximately 16% of all maternal deaths globally.[6] Pre-eclampsia also doubles the risk of perinatal mortality.[6] Usually there are no symptoms in pre-eclampsia and it is detected by routine screening. When symptoms of pre-eclampsia occur the most common are headache, visual disturbance (often "flashing lights"), vomiting, epigastric pain, and edema. Pre-eclampsia can occasionally progress to a life-threatening condition called eclampsia, which is a hypertensive emergency and has several serious complications including vision loss, cerebral edema, seizures or convulsions, renal failure, pulmonary edema, and disseminated intravascular coagulation (a blood clotting disorder).[6][10]
Failure to thrive, seizures, irritability, lack of energy, and difficulty breathing[11] can be associated with hypertension in neonates and young infants. In older infants and children, hypertension can cause headache, unexplained irritability, fatigue, failure to thrive, blurred vision, nosebleeds, and facial paralysis.[11][12]
Primary hypertension[edit]
Primary (essential) hypertension is the most common form of hypertension, accounting for 90–95% of all cases of hypertension.[2] In almost all contemporary societies, blood pressure rises with aging and the risk of becoming hypertensive in later life is considerable.[13] Hypertension results from a complex interaction of genes and environmental factors. Numerous common genetic variants with small effects on blood pressure have been identified[14] as well as some rare genetic variants with large effects on blood pressure[15] but the genetic basis of hypertension is still poorly understood. Several environmental factors influence blood pressure. Lifestyle factors that lower blood pressure include reduced dietary salt intake,[16][17] increased consumption of fruits and low fat products (Dietary Approaches to Stop Hypertension (DASH diet)), exercise,[18] weight loss[19] and reduced alcohol intake.[20] Stress appears to play a minor role[4] with specific relaxation techniques not supported by the evidence.[21][22] The possible role of other factors such as caffeine consumption,[23] and vitamin D deficiency[24] are less clear cut. Insulin resistance, which is common in obesity and is a component of syndrome X (or the metabolic syndrome), is also thought to contribute to hypertension.[25] Recent studies have also implicated events in early life (for example low birth weight, maternal smoking and lack of breast feeding) as risk factors for adult essential hypertension,[26] although the mechanisms linking these exposures to adult hypertension remain obscure.[26]
Secondary hypertension[edit]
Secondary hypertension results from an identifiable cause. Renal disease is the most common secondary cause of hypertension.[6] Hypertension can also be caused by endocrine conditions, such as Cushing's syndrome, hyperthyroidism, hypothyroidism, acromegaly, Conn's syndrome or hyperaldosteronism, hyperparathyroidism and pheochromocytoma.[6][27] Other causes of secondary hypertension include obesity, sleep apnea, pregnancy, coarctation of the aorta, excessive liquorice consumption and certain prescription medicines, herbal remedies and illegal drugs.[6][28]
In most people with established essential (primary) hypertension, increased resistance to blood flow (total peripheral resistance) accounting for the high pressure while cardiac output remains normal.[29] There is evidence that some younger people with prehypertension or 'borderline hypertension' have high cardiac output, an elevated heart rate and normal peripheral resistance, termed hyperkinetic borderline hypertension.[30] These individuals develop the typical features of established essential hypertension in later life as their cardiac output falls and peripheral resistance rises with age.[30] Whether this pattern is typical of all people who ultimately develop hypertension is disputed.[31] The increased peripheral resistance in established hypertension is mainly attributable to structural narrowing of small arteries and arterioles,[32] although a reduction in the number or density of capillaries may also contribute.[33] Hypertension is also associated with decreased peripheral venous compliance[34] which may increase venous return, increase cardiac preload and, ultimately, cause diastolic dysfunction. Whether increased active vasoconstriction plays a role in established essential hypertension is unclear.[35]
Pulse pressure (the difference between systolic and diastolic blood pressure) is frequently increased in older people with hypertension. This can mean that systolic pressure is abnormally high, but diastolic pressure may be normal or low — a condition termed isolated systolic hypertension.[36] The high pulse pressure in elderly people with hypertension or isolated systolic hypertension is explained by increased arterial stiffness, which typically accompanies aging and may be exacerbated by high blood pressure.[37]
Many mechanisms have been proposed to account for the rise in peripheral resistance in hypertension. Most evidence implicates either disturbances in renal salt and water handling (particularly abnormalities in the intrarenal renin-angiotensin system)[38] and/or abnormalities of the sympathetic nervous system.[39] These mechanisms are not mutually exclusive and it is likely that both contribute to some extent in most cases of essential hypertension. It has also been suggested that endothelial dysfunction and vascular inflammation may also contribute to increased peripheral resistance and vascular damage in hypertension.[40][41]
System | Tests |
Renal | Microscopic urinalysis, proteinuria, BUN and/or creatinine |
Endocrine | Serum sodium, potassium, calcium, TSH |
Metabolic | Fasting blood glucose, HDL, LDL, and total cholesterol, triglycerides |
Other | Hematocrit, electrocardiogram, and chest radiograph |
Sources: Harrison's principles of internal medicine[42] others[43][44][45][46][47] |
Hypertension is diagnosed on the basis of a persistent high blood pressure. Traditionally,[48] this requires three separate sphygmomanometer measurements at one monthly intervals.[49] Initial assessment of the hypertensive people should include a complete history and physical examination. With the availability of 24-hour ambulatory blood pressure monitors and home blood pressure machines, the importance of not wrongly diagnosing those who have white coat hypertension has led to a change in protocols. In the United Kingdom, current best practice is to follow up a single raised clinic reading with ambulatory measurement, or less ideally with home blood pressure monitoring over the course of 7 days.[48] Pseudohypertension in the elderly or noncompressibility artery syndrome may also require consideration. This condition is believed to be due to calcification of the arteries resulting an abnormally high blood pressure readings with a blood pressure cuff while intra arterial measurements of blood pressure are normal.[50]
Once the diagnosis of hypertension has been made, physicians will attempt to identify the underlying cause based on risk factors and other symptoms, if present. Secondary hypertension is more common in preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension.[51] Laboratory tests can also be performed to identify possible causes of secondary hypertension, and to determine whether hypertension has caused damage to the heart, eyes, and kidneys. Additional tests for diabetes and high cholesterol levels are usually performed because these conditions are additional risk factors for the development of heart disease and may require treatment.[2]
Serum creatinine is measured to assess for the presence of kidney disease, which can be either the cause or the result of hypertension. Serum creatinine alone may overestimate glomerular filtration rate and recent guidelines advocate the use of predictive equations such as the Modification of Diet in Renal Disease (MDRD) formula to estimate glomerular filtration rate (eGFR).[1] eGFR can also provides a baseline measurement of kidney function that can be used to monitor for side effects of certain antihypertensive drugs on kidney function. Additionally, testing of urine samples for protein is used as a secondary indicator of kidney disease. Electrocardiogram (EKG/ECG) testing is done to check for evidence that the heart is under strain from high blood pressure. It may also show whether there is thickening of the heart muscle (left ventricular hypertrophy) or whether the heart has experienced a prior minor disturbance such as a silent heart attack. A chest X-ray or an echocardiogram may also be performed to look for signs of heart enlargement or damage to the heart.[6]
Classification (JNC7)[1] | Systolic pressure | Diastolic pressure | ||
mmHg | kPa | mmHg | kPa | |
Normal | 90–119 | 12–15.9 | 60–79 | 8.0–10.5 |
High normal[52] or prehypertension | 120–139 | 16.0–18.5 | 80–89 | 10.7–11.9 |
Stage 1 hypertension | 140–159 | 18.7–21.2 | 90–99 | 12.0–13.2 |
Stage 2 hypertension | ≥160 | ≥21.3 | ≥100 | ≥13.3 |
Isolated systolic hypertension |
≥140 | ≥18.7 | <90 | <12.0 |
In people aged 18 years or older hypertension is defined as a systolic and/or a diastolic blood pressure measurement consistently higher than an accepted normal value (currently 139 mmHg systolic, 89 mmHg diastolic: see table —Classification (JNC7)). Lower thresholds are used (135 mmHg systolic or 85 mmHg diastolic) if measurements are derived from 24-hour ambulatory or home monitoring.[48] Recent international hypertension guidelines have also created categories below the hypertensive range to indicate a continuum of risk with higher blood pressures in the normal range. JNC7 (2003)[1] uses the term prehypertension for blood pressure in the range 120-139 mmHg systolic and/or 80-89 mmHg diastolic, while ESH-ESC Guidelines (2007)[53] and BHS IV (2004)[54] use optimal, normal and high normal categories to subdivide pressures below 140 mmHg systolic and 90 mmHg diastolic. Hypertension is also sub-classified: JNC7 distinguishes hypertension stage I, hypertension stage II, and isolated systolic hypertension. Isolated systolic hypertension refers to elevated systolic pressure with normal diastolic pressure and is common in the elderly.[1] The ESH-ESC Guidelines (2007)[53] and BHS IV (2004),[54] additionally define a third stage (stage III hypertension) for people with systolic blood pressure exceeding 179 mmHg or a diastolic pressure over 109 mmHg. Hypertension is classified as "resistant" if medications do not reduce blood pressure to normal levels.[1]
Hypertension in neonates is rare, occurring in around 0.2 to 3% of neonates, and blood pressure is not measured routinely in the healthy newborn.[12] Hypertension is more common in high risk newborns. A variety of factors, such as gestational age, postconceptional age and birth weight needs to be taken into account when deciding if a blood pressure is normal in a neonate.[12]
Hypertension occurs quite commonly in children over the age of 3 years and adolescents (2-9% depending on age, sex and ethnicity)[55] and is associated with long term risks of ill-health.[56] Blood pressure rises with age in childhood and, in children, hypertension is defined as an average systolic or diastolic blood pressure on three or more occasions equal or higher than the 95th percentile appropriate for the sex, age and height of the child. High blood pressure must be confirmed on repeated visits however before characterizing a child as having hypertension.[56] Prehypertension in children has been defined as average systolic or diastolic blood pressure that is greater than or equal to the 90th percentile, but less than the 95th percentile.[56] In adolescents, it has been proposed that hypertension and pre-hypertension are diagnosed and classified using the same criteria as in adults.[56]
The value of routine screening for hypertension in children over the age of 3 years is debated.[57] In 2004 the National High Blood Pressure Education Program recommended that children aged 3 years and older have blood pressure measurement at least once at every health care visit[56] and the National Heart, Lung, Blood Institute's and American Academy of Pediatrics made a similar recommendation.[58] However the American Academy of Family Physicians[59] support the view of the U.S. preventive Services Task Force that evidence is insufficient to determine the balance of benefits and harms of screening for hypertension in children and adolescents who do not have symptoms.[60]
Much of the disease burden of high blood pressure is experienced by people who are not labelled as hypertensive.[54] Consequently, population strategies are required to reduce the consequences of high blood pressure and reduce the need for antihypertensive drug therapy. Lifestyle changes are recommended to lower blood pressure, before starting drug therapy. The 2004 British Hypertension Society guidelines[54] proposed the following lifestyle changes consistent with those outlined by the US National High BP Education Program in 2002[61] for the primary prevention of hypertension:
- maintain normal body weight for adults (e.g. body mass index 20–25 kg/m2)
- reduce dietary sodium intake to <100 mmol/ day (<6 g of sodium chloride or <2.4 g of sodium per day)
- engage in regular aerobic physical activity such as brisk walking (≥30 min per day, most days of the week)
- limit alcohol consumption to no more than 3 units/day in men and no more than 2 units/day in women
- consume a diet rich in fruit and vegetables (e.g. at least five portions per day);
Effective lifestyle modification may lower blood pressure as much an individual antihypertensive drug. Combinations of two or more lifestyle modifications can achieve even better results.[54]
Lifestyle modifications[edit]
The first line of treatment for hypertension is identical to the recommended preventive lifestyle changes[62] and includes dietary changes,[63] physical exercise, and weight loss. These have all been shown to significantly reduce blood pressure in people with hypertension.[64] Their potential effectiveness is similar to using a single medication.[52] If hypertension is high enough to justify immediate use of medications, lifestyle changes are still recommended in conjunction with medication.
Dietary change such as a low sodium diet is beneficial. A long term (more than 4 weeks) low sodium diet in Caucasians is effective in reducing blood pressure, both in people with hypertension and in people with normal blood pressure.[65] Also, the DASH diet, a diet rich in nuts, whole grains, fish, poultry, fruits and vegetables lowers blood pressure. A major feature of the plan is limiting intake of sodium, although the diet is also rich in potassium, magnesium, calcium, as well as protein.[66] Different programs aimed to reduce psychological stress such a biofeedback, relaxation or meditation are advertised to reduce hypertension. However, overall efficacy is not greater than health education, with evidence being generally of low quality.[22][67]
Several classes of medications, collectively referred to as antihypertensive drugs, are currently available for treating hypertension. Use should take into account the person's cardiovascular risk (including risk of myocardial infarction and stroke) as well as blood pressure readings, in order to gain a more accurate picture of the person's cardiovascular profile.[68] Evidence in those with mild hypertension (SBP less than 160 mmHg and /or DBP less than 100 mmHg) and no other health problems does not support a reduction in the risk of death or rate of health complications from medication treatment.[69] Medications are not recommended for people with prehypertension or high normal blood pressure.[52]
If drug treatment is initiated the Joint National Committee on High Blood Pressure (JNC-7)[1] recommends that the physician not only monitor for response to treatment but should also assess for any side effects resulting from the medication. Reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34%, of ischaemic heart disease by 21%, and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease.[70] For most people, recommendations are to reduce blood pressure to less than or equal to somewhere between 140/90 mmHg to 160/100 mmHg.[68][71] Attempting to achieve lower levels have not been shown to improve outcomes.[71] In those with diabetes or kidney disease some recommend levels below 120/80 mmHg;[68][72] however, these are not proven.[71] If the blood pressure goal is not met, a change in treatment should be made as therapeutic inertia is a clear impediment to blood pressure control.[73]
Guidelines on the choice of agents and how best to step up treatment for various subgroups have changed over time and differ between countries. The best first line agent is disputed.[74] The Cochrane collaboration, World Health Organization and the United States guidelines supports low dose thiazide-based diuretic as first line treatment.[74][75][64] The UK guidelines emphasise calcium channel blockers (CCB) in preference for people over the age of 55 years or if of African or Caribbean family origin, with angiotensin converting enzyme inhibitors (ACE-I) used first line for younger people.[76] In Japan starting with any one of six classes of medications including: CCB, ACEI/ARB, thiazide diuretics, beta-blockers, and alpha-blockers is deemed reasonable while in Canada and Europe all of these but alpha-blockers are recommended as options.[74][52]
Drug combinations[edit]
The majority of people require more than one drug to control their hypertension. In those with a systolic blood pressure greater than 160 mmHg or a diastolic blood pressure greater than 100 mmHg the American Heart Association recommends starting both a thiazide and an ACEI, ARB or CCB.[64] An ACEI and CCB combination can be used as well.[64]
Unacceptable combinations are non-dihydropyridine calcium blockers (such as verapamil or diltiazem) and beta-blockers, dual renin–angiotensin system blockade (e.g. angiotensin converting enzyme inhibitor + angiotensin receptor blocker), renin–angiotensin system blockers and beta-blockers, beta-blockers and centrally acting agents.[77] Combinations of an ACE-inhibitor or angiotensin II–receptor antagonist, a diuretic and an NSAID (including selective COX-2 inhibitors and non-prescribed drugs such as ibuprofen) should be avoided whenever possible due to a high documented risk of acute renal failure. The combination is known colloquially as a "triple whammy" in the Australian health industry.[62] Tablets containing fixed combinations of two classes of drugs are available and while convenient for the people, may be best reserved for those who have been established on the individual components.[78]
In the elderly[edit]
Treating moderate to severe hypertension decreases death rates and cardiovascular morbidity and mortality in people aged 60 and older.[79] There are limited studies of people over 80 years old but a recent review concluded that antihypertensive treatment reduced cardiovascular deaths and disease, but did not significantly reduce total death rates.[79] The recommended BP goal is advised as <140/90 mm Hg with thiazide diuretics being the first line medication in America,[80] and in the revised UK guidelines calcium-channel blockers are advocated as first line with targets of clinic readings <150/90, or <145/85 on ambulatory or home blood pressure monitoring.[76]
Resistant hypertension[edit]
Resistant hypertension is defined as hypertension that remains above goal blood pressure in spite of concurrent use of three antihypertensive agents belonging to different antihypertensive drug classes. Guidelines for treating resistant hypertension have been published in the UK[81] and US.[82] It has been proposed that a proportion of resistant hypertension may be the result of chronic high activity of the autonomic nervous system; this concept is known as "neurogenic hypertension".[83]
Renal nerve ablation[edit]
Surgical disruption to the sympathetic nervous system was employed in the 1930s to reduce blood pressure. Although it was effective it resulted in severe side effects and by the 1970s it had been superseded by the new antihypertensive drugs.[84] More recently selective renal nerve radiofrequency ablation has been developed. This employs a catheter-based device that uses radiofrequency (RF) energy to cause thermal damage to the nerves surrounding the renal artery without affecting abdominal, pelvic, or lower-extremity sympathetic nerves. Clinical trials indicate that this method lowers blood pressure and, so far, major side effects have been relatively infrequent, although cases of renal artery dissection, femoral artery pseudoaneurysm, excessive decreases in blood pressure and heart rate are amongst the reported adverse effects.[84] It has been suggested that renal nerve ablation may have a role in the management of resistant hypertension but its long term efficacy and safety have not been evaluated.[84]
As of 2000, nearly one billion people or ~26% of the adult population of the world had hypertension.[86] It was common in both developed (333 million) and undeveloped (639 million) countries.[86] However rates vary markedly in different regions with rates as low as 3.4% (men) and 6.8% (women) in rural India and as high as 68.9% (men) and 72.5% (women) in Poland.[87] In Europe hypertension occurs in about 30-45% of people as of 2013.[52]
In 1995 it was estimated that 43 million people in the United States had hypertension or were taking antihypertensive medication, almost 24% of the adult United States population.[88] The prevalence of hypertension in the United States is increasing and reached 29% in 2004.[89][90] As of 2006 hypertension affects 76 million US adults (34% of the population) and African American adults have among the highest rates of hypertension in the world at 44%.[91] It is more common in blacks and native Americans and less in whites and Mexican Americans, rates increase with age, and is greater in the southeastern United States. Hypertension is more prevalent in men (though menopause tends to decrease this difference) and in those of low socioeconomic status.[2]
The prevalence of high blood pressure in the young is increasing.[92] Most childhood hypertension, particularly in preadolescents, is secondary to an underlying disorder. Aside from obesity, kidney disease is the most common (60–70%) cause of hypertension in children. Adolescents usually have primary or essential hypertension, which accounts for 85–95% of cases.[93]
Hypertension is the most important preventable risk factor for premature death worldwide.[94] It increases the risk of ischemic heart disease[95] strokes,[6] peripheral vascular disease,[96] and other cardiovascular diseases, including heart failure, aortic aneurysms, diffuse atherosclerosis, and pulmonary embolism.[6] Hypertension is also a risk factor for cognitive impairment and dementia, and chronic kidney disease.[6] Other complications include hypertensive retinopathy and hypertensive nephropathy.[1]
Modern understanding of the cardiovascular system began with the work of physician William Harvey (1578–1657), who described the circulation of blood in his book "De motu cordis". The English clergyman Stephen Hales made the first published measurement of blood pressure in 1733.[97][98] Descriptions of hypertension as a disease came among others from Thomas Young in 1808 and especially Richard Bright in 1836.[97] The first report of elevated blood pressure in a person without evidence of kidney disease was made by Frederick Akbar Mahomed (1849–1884).[99] However hypertension as a clinical entity came into being in 1896 with the invention of the cuff-based sphygmomanometer by Scipione Riva-Rocci in 1896.[100] This allowed the measurement of blood pressure in the clinic. In 1905, Nikolai Korotkoff improved the technique by describing the Korotkoff sounds that are heard when the artery is ausculated with a stethoscope while the sphygmomanometer cuff is deflated.[98]
Historically the treatment for what was called the "hard pulse disease" consisted in reducing the quantity of blood by blood letting or the application of leeches.[97] This was advocated by The Yellow Emperor of China, Cornelius Celsus, Galen, and Hippocrates.[97] In the 19th and 20th centuries, before effective pharmacological treatment for hypertension became possible, three treatment modalities were used, all with numerous side-effects: strict sodium restriction (for example the rice diet[97]), sympathectomy (surgical ablation of parts of the sympathetic nervous system), and pyrogen therapy (injection of substances that caused a fever, indirectly reducing blood pressure).[97][101] The first chemical for hypertension, sodium thiocyanate, was used in 1900 but had many side effects and was unpopular.[97] Several other agents were developed after the Second World War, the most popular and reasonably effective of which were tetramethylammonium chloride and its derivative hexamethonium, hydralazine and reserpine (derived from the medicinal plant Rauwolfia serpentina). A major breakthrough was achieved with the discovery of the first well-tolerated orally available agents. The first was chlorothiazide, the first thiazide diuretic and developed from the antibiotic sulfanilamide, which became available in 1958.[97][102] Subsequently beta blockers, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers and renin inhibitors were developed as antihypertensive agents.
Society and culture[edit]
The World Health Organization has identified hypertension, or high blood pressure, as the leading cause of cardiovascular mortality. The World Hypertension League (WHL), an umbrella organization of 85 national hypertension societies and leagues, recognized that more than 50% of the hypertensive population worldwide are unaware of their condition.[103] To address this problem, the WHL initiated a global awareness campaign on hypertension in 2005 and dedicated May 17 of each year as World Hypertension Day (WHD). Over the past three years, more national societies have been engaging in WHD and have been innovative in their activities to get the message to the public. In 2007, there was record participation from 47 member countries of the WHL. During the week of WHD, all these countries – in partnership with their local governments, professional societies, nongovernmental organizations and private industries – promoted hypertension awareness among the public through several media and public rallies. Using mass media such as Internet and television, the message reached more than 250 million people. As the momentum picks up year after year, the WHL is confident that almost all the estimated 1.5 billion people affected by elevated blood pressure can be reached.[104]
High blood pressure is the most common chronic medical problem prompting visits to primary health care providers in USA. The American Heart Association estimated the direct and indirect costs of high blood pressure in 2010 as $76.6 billion.[91] In the US 80% of people with hypertension are aware of their condition, 71% take some antihypertensive medication, but only 48% of people aware that they have hypertension adequately control it.[91] Adequate management of hypertension can be hampered by inadequacies in the diagnosis, treatment, and/or control of high blood pressure.[105] Health care providers face many obstacles to achieving blood pressure control, including resistance to taking multiple medications to reach blood pressure goals. People also face the challenges of adhering to medicine schedules and making lifestyle changes. Nonetheless, the achievement of blood pressure goals is possible, and most importantly, lowering blood pressure significantly reduces the risk of death due to heart disease and stroke, the development of other debilitating conditions, and the cost associated with advanced medical care.[106][107]
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Welcome to the official website for the Snowdonia Mountains and Coast region here in North Wales. Looking for a holiday, short break or day visit in Snowdonia? Here you will find all the information you need. If you can't find what you looking for get in touch on Facebook, Twitter or contact any of our Information Centres.
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There's plenty to do for all the family with events, attractions and outdoor activities all set in stunning scenery. Our website has plenty of information and ideas to help you plan your visit.
Home to the Snowdonia National Park and the biggest mountain in Wales and England, Snowdon at 3,560ft, where you can visit by foot or train. There's also a long coastline of sandy beaches, spectacular cliffs and glorious estuaries, which along the Llŷn Peninsula is a protected 'Area of Outstanding Natural Beauty'.
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Find Snowdonia accommodation including Hotels, Bed and Breakfast, Guest Houses, Inns, Snowdonia Cottages and Self Catering Units. If you need help or would like to book your accommodation, then please contact one of our Information Centres with your requirements.
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Five Industrial Heritage Attractions of Snowdonia The landscape of Snowdonia may be lush and nature-rich, but that's not to say man hasn't had a hand in shaping it. Here are five great Snowdonia attractions with an emphasis on industrial heritage.
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The ever popular property exhibition at the Wetherby Racecourse is back for 2013 on the weekend of the 17th-18th May 10am-5pm. If you are in search of a brand new home in France, take the opportunity to register for free entrance to this must-see event and gain the chance to browse from a huge variety of French properties for sale. Full details of the exhibitors attending and the seminar programme will be available soon.
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French Property Exhibitions are the largest, most informative property events in the UK and a must for any potential French home buyer; they bring together estate agents, developers, solicitors, banks and other professionals covering just about every aspect of buying your property in France. Whichever location has taken your fancy - and suits your budget - you're sure to find a suitable property.
Organised by the UK's leading French property publication, French Property News, our exhibitions will provide you with all the information you need to purchase your dream home across the Channel.
View thousands of the latest properties on the market from agents specialising exclusively in France - and gain valuable advice from the experts in moving, buying and financing.
Whether you are seeking a permanent residence, holiday home or buy-to-let or investment property, we guarantee you will walk away feeling more informed and at least one step closer to making your French property purchase a reality.
An overview of Exclusive Healthcare
Come and see Exclusive Healthcare at The French Property Exhibition this weekend!
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Win a return flight to France from Leeds Bradford Airport!
By attending the French Property Exhibition in May, you are in with the chance to win a return flight to a French destination of your choice!
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Seminar Programme 2013
Our free seminars allow you to gain all the information you need to make an informed decision on buying a property in France... All seminars will have a Q and A session at the end.
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H. Appleyard's 5 top tips for moving to France
Are you planning your relocation to France? Here are some key points to follow to ensure a stress-free move...
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UK versus France
The first true twinning between the civic authorities of a French and English town was between Harrogate and Bagnères de Luchon in 1953...
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The Titrette® is the new generation of bottletop burette from BRAND. the BrandTech Titrette Bottletop Burette has a number of innovative features and upgrades for more accurate and convenient titration.
Features of the BrandTech Titrette Bottletop Burette include:
- Class A Precision: The Titrette® bottletop burette has an innovative new measuring system which matches the Class A accuracy of glass burettes and, if needed, can offer the precision of 3 decimal places below 20mL. This is an important feature for users who need to work within the Class A error limits of glass burettes according to DIN EN ISO 385 or within volumetric tolerance per ASTM E287.
- User Serviceable: The Titrette® can be quickly and easily disassembled in a matter of minutes – for cleaning, to replace the piston/cylinder, or to replace the batteries. Maintenance is easy and convenient, without the need to send it out for repair.
- Light Protection: To protect light-sensitive media, the installed clear cylinder inspection windows can be easily replaced with the supplied clip-on amber-colored windows.
- Low Profile: All components move within the housing, reducing headroom requirements. The compact design and the light weight ensure good stability. The titrating tube can be adjusted horizontally and vertically.
Smooth, Low-Force Operation: The large handwheels provide smooth, precise control from rapid to dropwise titration. - Optional Computer Interface: The Titrette® is available with a RS232 interface for direct transfer of data to a PC.
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Sweatshirts $30.00 each Sizes S, M, and L To purchase, email Ginger Kowalchuk Other items can be found here: Merchandise
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Sustainability Case Competition
The Dorothy D. and Roy H. Park Center for Business and Sustainable Enterprise is housed in a LEED Platinum Building, where sustainability is emphasized throughout. To further highlight business and sustainability, the School of Business sponsors a Sustainability Case Competition focused on a real organization with a business and sustainability issue.
The 2013 Sustainability Case competition will focus on developing a marketing plan for the New York State Sustainability Education Working Group. The plan will focus on increasing student awareness at college campuses across New York State about sustainability, what it means and why it is important. Student teams will develop marketing plans focused on reaching college students that include strategies for analysis, planning, implementation and assessment. Three teams will win the top prizes which amount to $10,000 ($5,000 first place, $3,500 second place, $1,500 third place).
If you have a question or need some sustainability guidance, we have staff and faculty that can help. Click here.


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A half-century after the advent of the pill, the Obama administration on Monday ushered in a change in women's health care potentially as transformative: coverage of birth control as prevention, with no copays.
Services ranging from breast pumps for new mothers to counseling on domestic violence were also included in the broad expansion of women's preventive care under President Barack Obama's health care overhaul.
Since birth control is the most common drug prescribed to women, health plans should make sure it's readily available, said Health and Human Services Secretary Kathleen Sebelius. "Not doing it would be like not covering flu shots," she said.
For more on this story, see the August 4 issue of the Navarre Press or subscribe online.


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we arrived in the afternoon and were greeted very friendly and warmly. as the roomfares were abit high we asked for a discount and the lady promptly shaved off 300php from her initial offer. we liked the resort a lot! even though there was no real beach and there's a lot of stones in the water...the premises are well looked... More
- Also Known As:
- Flower Beach & Dive Resort Bohol Hotel
- Flower Beach And Dive Resort Bohol
- Flower Beach & Dive Resort Bohol Hotel Bohol Island
- Flower Beach & Dive Resort Bohol Bohol Province, Philippines
- Official Description (provided by the hotel):
- FloWer-Beach Resort is located in a quiet area of Bohol, on a beautiful sandy beach in the city of Anda, far away from the mass tourism of Panglao.We offer high quality bungalows arranged in duplex units, each equipped with private toilet and shower, private terrace with seaview, minibar. Our deluxe units additionally with aircondition, TV+DVD., warm showers.Free beachbeds and umbrellas. Restaurant with local as well as foreignkitchen, Bar, and Disco on request.Own divecenter with all equipment for rent, spacious boat, dive courses from PADI Open water Diver up to Divemaster level possible.Tours available by our Van through the island or by our boats along the coast for diving and snorkeling trips. ... more less
- Reservation Options:
- TripAdvisor is proud to partner with Booking.com, HostelBookers and Agoda so you can book your Flower Beach & Dive Resort Bohol reservations with confidence. We help millions of travelers each month to find the perfect hotel for both vacation and business trips, always with the best discounts and special offers.


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In trading equities and derivatives speculatively, one of the biggest rules repeated constantly by successful investors is to take the emotion out of the process. This might sound a bit abstract, but it's a real effect that happens – especially with those new to the game. People who open a new position tend to grow attached to it, remaining confident that their decision was right even if the market moves in the wrong direction. They end up rooting for their position instead of analyzing and adjusting to new information and market moves. Countless traders have been stop-lossed (or lost the upper limit of cash on the trade) watching their position, convinced that it will move in the way they thought it would.
Emotion is arguably the biggest roadblock to successful trading – a skill that requires complete separation from the securities or derivatives invested in. In binary options, emotion plays a slightly different role. Once a trade is opened, it usually cannot be exited before expiry. One might think that this takes care of the problem. But psychological fallacies still come into play when traders who have had success with a certain asset or entry time in the past might tend to repeat it, even if the data goes against it.
To combat the negative effects of human psychology on trading, mechanized binary options systems have been developed. Bigger financial firms use computerized systems with algorithms and models, but most retail traders define a system as a set of rules for trading. Binary options systems typically help investors screen for potentially profitable assets, find an entry position (or the proper strike price), and execute when the time is right. Systems usually use technical analysis tools to recognize these factors. A system might, for example, say that the proper time to buy a put binary option is when the chart breaks through the support line at the end of a "head and shoulders" pattern, which often indicates a downturn.
Like anything else that might give a binary options trader an advantage, systems don't typically come free. It is recommended that an investor who is considering using a system do some research and read reviews before investing any money into a particular one. Also, investors should realize that no binary options system is infallible. Speculative markets are inherently unpredictable, so it's important to keep management strategies (such as trade diversification) in place regardless of the system in use.


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Robert Griffin III's recovery from reconstructive knee surgery has been covered like no other. Presidents have spoken with him. Released statements have been parsed for hidden meaning. And eventually we'll know the exact moment when the Washington Redskins quarterback starts running again. According to Griffin's dad, that moment will arrive in the next week. The Washington Post reported Monday that Griffin is expecting to receive clearance to run on the field again over the next week. "He's been running in the pool, and some on the treadmill," Griffin Jr. said. "But they're just about ready to take it out on the field."


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Important information regarding the Programme Specification and Regulations booklet
This document contains all the regulations for a specific programme(s) and the associated regulations for individual courses that can be taken on a stand-alone basis as follows:
- The programme regulations are divided into the Programme Specification and the Detailed Regulations (which includes relevant Annexes). The Programme Specification gives the core regulatory information about the programme and is supplemented by the Detailed Regulations.
- The Regulations concerning provision for individual courses are divided in to a Summary of provision for individual courses and the Detailed regulations for the provision of individual courses (which may include relevant Annexes).
- The document also contains a Glossary which defines certain terms used within the document and a section with details about related documents and sources of information to which a student is likely to need to refer at different times in their studies.
Some regulations are General Regulations, which means that they apply for all University of London International Programmes at a given level of study. These regulations are marked with (GR) next to the paragraph number.
Students registered for any of the programmes covered by this programme specification and Detailed Regulations are required to comply with procedures, deadlines and instructions issued by the University, including the University of London Regulations. The University is not responsible for any consequences arising from a student's failure to comply with the regulations, procedures, deadlines or instructions.
See the section on related documents and sources of information.
On all matters where the regulations need to be interpreted, or are silent, the University's decision is final.
For the duration of a student's registration for a specific programme, core elements (set out in the Programme Specification) of that programme will remain unchanged unless appropriate consultation with students has taken place. However, the Programme Specification and Regulations are reviewed and published annually, and certain programme details are subject to change. Each year's programme specification and Detailed Regulations replace those of the previous year, and students must ensure that they always refer to the current year's programme specification and regulations.
Changes for registered students will be introduced as follows:
- Two years' notice will be given when a course is withdrawn, when a syllabus is substantially amended, when a prerequisite for a course is introduced, and when the assessment method for a subject is changed.
- Five years' notice will be given if the University decides to withdraw the programme.
- All other regulations may be amended without notice. If a change to the regulations is considered to have an adverse effect on students, appropriate student consultation will take place prior to introducing the change to a current student cohort. Normally major changes to a programme will only be introduced for a new cohort of students.
Examples of changes to the regulations which can be considered to have an adverse effect for registered students are significant changes to the structure of the programme, changes to the progression rules in the programme, changes to the weighting of courses and changes to pass marks or the classification of the award.
Students registered for the programmes covered by this programme specification and regulations are registered with the University of London International Academy. The Colleges of the University of London and the University of London International Academy collaborate to deliver the University of London International Programmes
All University of London International Programmes adhere to the University's agreed policies for academic programmes and awards


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Tue, Jul 10, 2012 at 3:05 AM
Nicki Minaj attended the 2012 BET Awards tonight at The Shrine Auditorium in Los Angeles, California. Nicki Minaj performed "Champion" & "Beez In The Trap" with 2 Chainz. Nicki Minaj later on in the show won "Best Female Hip-Hop Artist for the 3rd time in a row. Check out the photos below.
On Wed, Jul 11, 2012 at 2:22 PM, LilMizzAngelMinaj said:
Loved The Performance! Alwayz Killz Iht Ouht There!!!!!
On Tue, Jul 10, 2012 at 6:02 PM, Mz.Cutiie:HarajukuBarbieXx said:
This is the first television performance where she didnt rap over the track. So proud of her
You can tell she really got into it because she accidently said Motherfuckers in the last chorus. oop.
On Tue, Jul 10, 2012 at 5:56 AM, acb2796 said:
she killed it. follow me on twitter ;) @acb2796
On Tue, Jul 10, 2012 at 4:49 AM, Jade Cook said:
Claim that throne barbz!
On Tue, Jul 10, 2012 at 3:08 AM, chundoll said:
yess adorable :OO love u nickii and yall barbz n kenz MUAAH! add or write me if u like
On Tue, Jul 10, 2012 at 3:07 AM, chundoll said:
On Tue, Jul 10, 2012 at 3:06 AM, chundoll said:
On Tue, Jul 10, 2012 at 3:05 AM, chundoll said:
More events coming soon.


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IIFA Awards 2012 - full list of winners. Zoya Akhtar's Zindagi Na Milegi Dobara and Imtiaz Ali's Rockstar dominate 13th International Indian Film Academy (IIFA) awards. ZNMD a Road trip drama wins highest accolades at IIFA Awards and on the other … [Read more...]
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IIFA Awards 2012 full list of winners
June 11, 2012 by Bollywood Billi
Filed Under: Hindi Movie News Tagged With: Bollywood Oscars, full list of winners, IIFA, IIFA Awards, IIFA awards 2012, IIFAawards, Ranbir, Road trip drama, Rockstar, Vidya, Winners of 2012 IIFA Awards, Zindagi Na Milegi Dobara, ZNMD


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Where are 'Blossom' stars today?
Published On: Dec 09 2011 08:30:16 AM PST
Updated On: Apr 18 2013 11:00:00 PM PDT
With Mayim Bialik celebrating her 38th birthday on December 12, what better time to check in to see what the stars of the hit 1990s sitcom "Blossom" up to today?
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