Hypertension is an important risk factor for the development of cardiovascular morbidity and mortality. In 2002, 10.9% of all deaths in the developed countries were attributable to hypertension, making it the second major risk factor of overall death just below tobacco use (12.2%) but over high cholesterol (7.6%), alcohol use (9.2%) and obesity (7.4%). In addition, about half of all cardiovascular disease (mortality and morbidity combined) is attributable to high blood pressure. High blood pressure in early stages causes no symptoms, so it is easy to ignore. However, if left untreated it can damage vital organs over the years and eventually it can lead to serious complications. Fortunately, it is widely considered as one of the most preventable causes because of the availability of effective antihypertensive drugs. Many pharmacological agents are available for treatment; however, the choice depends on the patients‟ age, diagnosis, co-morbidities, appropriate strength-dosage scheme and patients‟ tolerability. Hypertension can affect all ages despite gender and ethnicity. This review gives a general overview about the management of hypertension.
Hypertension is an important risk factor for the development of cardiovascular morbidity and mortality. In 2002, 10.9% of all deaths in the developed countries were attributable to hypertension, making it the second major risk factor of overall death just below tobacco use (12.2%) but over high cholesterol (7.6%), alcohol use (9.2%) and obesity (7.4%). In addition, about half of all cardiovascular disease (mortality and morbidity combined) is attributable to high blood pressure. Fortunately, it is widely considered as one of the most preventable causes because of the availability of effective antihypertensive drugs . Arterial hypertension or high blood pressure is a chronic medical condition which is characterized by elevated blood pressure in the arteries and is an important risk factor for future development of cardiovascular disease.
Arterial hypertension belongs to asymptomatic diseases because it usually does not cause symptoms for years until a vital organ is damaged . Hypertension is reported to be the fourth contributor to premature mortality in developed countries and the seventh in developing countries. Almost 12.8% (7.5 million) of the total deaths and around 3.7% of the total DALYS (disability adjusted life years) are due to raised blood pressure (BP) [3,4]. Recent epidemiological data suggest both an increase in the prevalence (urban: 25% and rural: 10-15%) and poor levels of control of hypertension in India [4,5].
Hypertension is a major health problem throughout the world because of its high prevalence and its association with increased risk of cardiovascular disease. Advances in the diagnosis and treatment of hypertension have played a major role in recent dramatic declines in coronary heart disease and stroke mortality in industrialized countries . However, in many of these countries, the control rates for high blood pressure have actually slowed in the last few years. It is estimated that by 2010, 1.2 billion people will be suffering hypertension worldwide. Elevated BP is an established risk factor for cardiovascular disease. The relationship between BP level and cardiovascular risk is continuous, therefore the distinction between normotension and hypertension is arbitrary [7,8].
Appropriate management of hypertension reduces the risk for cardiovascular disease, renal disease, cerebrovascular disease, and death [9-12]. However, determining the most appropriate BP targets, particularly for adults aged 60 years or older, has been controversial. Debate about the goal for systolic BP (SBP) among adults treated for hypertension has intensified, especially in light of recent recommendations .
Blood pressure is represented by two values. The higher value called systolic is the highest pressure in the arteries when the heart contracts (systole). The lower value is the lowest pressure in the arteries when the heart relaxes between beats (diastole).Arterial hypertension for adults, who don’t suffer from any other kind of diseases, is defined by an elevation of
blood pressure to 140 / 90 mm Hg or to higher values [14,15].
On the table below there is a classification of arterial blood
pressure according to European Society of Hypertension (ESH)
 (Table 1 & Figure 1).
All patients should be managed with non-pharmacologic
interventions/therapeutic lifestyle modifications to lower BP.
Patients with pre-hypertension should be followed up yearly to
detect and treat HPT as early as possible. Decisions regarding
pharmacological treatment should be based on the individual
patient’s global cardiovascular risk. In subjects with MEDIUM
RISK or HIGHER, the threshold for commencing HPT treatment
should be lower. Therapeutic lifestyle changes should be
recommended for all individuals with HPT and pre-HPT. It may
be the only treatment necessary in Stage 1 HPT. A high degree
of motivation is also needed to sustain the benefits of nonpharmacological
treatment. It is also important to remember
that lifestyle modification requires a concerted effort and
reinforcement on behalf of the practitioner. Lifestyle modification
works better with concurrent behavioral intervention than just
passive advice. This non-pharmacological management includes
weight reduction, sodium restriction, avoidance of alcohol
intake, regular physical exercise, healthy eating and cessation of
Weight-reducing diets in overweight hypertensive persons
can result in modest weight loss in the range of 3-9% of body
weight  and are associated with blood pressure reduction
of about 3-6 mmHg. It is advisable for overweight hypertensive
patients to lose at least 5% of their weight.
High salt intake is associated with significantly increased
risk of stroke and total cardiovascular disease . Evidence
from published systematic review and meta analyses showed
that restricting sodium intake in people with elevated blood
pressure in the short term leads to reductions in blood pressure
of up to 10.5 mmHg systolic and 2 mmHg diastolic [20-22]. An
intake of <100 mmol of sodium or 6g of sodium chloride a day
is recommended (equivalent to <1¼ teaspoonfuls of salt or 3
teaspoonfuls of monosodium glutamate) [23-26].
Alcohol consumption elevates BP acutely. For those who
consume alcohol, intake should be restricted to no more than
21 units for men and 14 units for women per week (1 unit is
equivalent to one half-pint of beer or 100 ml of wine or 20 ml of
“proof whisky”). Meta analyses have shown that, interventions
to reduce alcohol consumption caused a small but significant
reduction (3.3/2 mmHg) in both systolic and diastolic blood
respectively . Hypertensives who are heavy drinkers are also
more likely to have hypertension resistant to drug treatment. The
only way to reduce these patients’ BP effectively is by reducing
or stopping their alcohol intake .
Aerobic exercise is more effective than resistance training
(e.g., weight lifting) . Exercise like walking-jogging can result
in a reduction of 13/18 mmHg in SBP/DBP . More recent
evidence showed that resistant exercise is effective in lowering
blood pressure among normotensives and pre-hypertensives
but not among hypertensives . However isometric resistant
exercise can reduce BP by 10.4/6.7 mmHg as shown by a recent
meta-analysis . General advice on cardiovascular health
would be for modest exercise, such as brisk walking for a total of
at least 150 mins per week [33,34].
A diet rich in fruits, vegetables and low-fat dairy products
with reduced saturated and total fat can substantially lower BP (11/6 mmHg in hypertensive patients and 4/2 mmHg in patients
with high normal BP). 55 (Level I) More recently, diet high in
L-Arginine has been shown to be able to reduce BP by 5.4/2.3
Relaxation interventions were shown to be associated with
statistically significant reductions in systolic and diastolic blood
pressure of about 3 mmHg . However, another systematic
review of studies on the effect of stress reduction on blood
pressure found small and non-significant effect on blood
pressure . It is not recommended for routine provision in
These include micronutrient alterations, caffeine reduction
and dietary supplementation with fish oil, potassium, calcium,
magnesium and fibre. However, the evidence for its beneficial
effect is limited [37-40]. In summary while weight reducing
diet, regular exercise, alcohol and salt restriction have been
consistently shown to be beneficial in reducing BP in patients,
the evidence thus far has not been consistent for relaxation
therapies and supplementations with calcium, magnesium or
potassium  (Table 2).
It has been proved by way of a large number of RCTs that by
lowering the blood pressure values in hypertensive subjects the
subsequent complications of HT can be reduced. Though some
trials depict superiority of one class of antihypertensive drug
over other types, meta-analyses from trials of larger sample size
have failed to show clinically significant differences between
drug classes and hence the beneficial effects of BP lowering are
largely independent of the drugs employed [43,44]. Lifestyle
modifications can be very effective but in real life patients usually
need a combination of them with pharmacological therapy.
Very often they need more than one type of anti-hypertensive
medication or combination of more in order to achieve their
blood pressure target goal.
Combination of lifestyle modifications and pharmacological
medication may allow reduction of drugs doses, better
therapeutic control, more effective treatment and prevention of
other cardiovascular risks factors [2,16,45].
f) Direct inhibitors of renin (Aliskiren-New in therapy,
lack of experience) (Table 3).
For better pharmacological treatment outcomes, drugs
should be chosen on the basis of efficacy, safety, convenience to
the patient and cost. For assessment of efficacy evidence from
large scale clinical trials should be used. Moreover, recognition of
adverse effects is another important factor because is associated
with patient adherence and effectiveness of treatment. In
addition, the use of regimens (FDC) that is more convenient to
the patient like once-daily regimens and also cost of treatment
are other important factors because could help to improve the
patient compliance  (Table 4).
In conclusion arterial hypertension is an important risk
factor for cardiovascular diseases and also contributes to
increased morbidity and mortality. Hypertension’ is indeed a
major public health problem accounting for drastic downward
shifts in the economic progress of a country. That too in a country
like India, the impact of this dreadful disease on the healthcare
system as a whole is humongous. Figures portray that about Rs.
43 billion of the annual income among the adult working class
in our country is spent for the management of HT. Suboptimal
control of BP is the most common attributable risk for death
worldwide. HT goals can be achieved and maintained only
by a team-based approach with aid from all health personnel
like general physicians, medical specialists, trained nurses,
dieticians and pharmacists. Moreover, studies have shown the
significance of multi-disciplinary approach in the management
of HT. Emphasis should also be on strict lifestyle modifications
which act as the cornerstone for prevention and treatment of HT
Many pharmacological agents are available for treatment;
however, the choice depends on the patients‟ age, diagnosis, comorbidities,
appropriate strength-dosage scheme and patients‟
tolerability. Hypertension can affect all ages despite gender
and ethnicity. Lifestyle modifications, including weight loss,
reduction of dietary sodium intake, aerobic physical activity
of at least 30 minutes a day at least three times a week, and a
reduction in alcohol consumption, are a relatively cost-effective
way to reduce high blood pressure. There is wide variability
in the cost of antihypertensive medications; newer and more
expensive agents have not been shown to be significantly safer
or more effective than many older, well-established medications
that are available in generic form. Fixed combinations of
antihypertensive medications offer less dosing flexibility and
are often substantially more expensive than prescribing the
component medications independently. It is our goal to not just
decrease the risk of CV diseases brought about by elevated BPs
but to prolong their lives as well.