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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 [1]. In the Eastern Mediterranean Region, the prevalence of hypertension averages 26% and it affects approximately 125 million individuals [2]. Of greater concern is that cardiovascular complications of high blood pressure are on the increase, including the incidence of stroke, end-stage renal disease and heart failure.

Recent data suggest that individuals who are normotensive at age 55 years have a 90% lifetime risk for developing hypertension. The relationship between blood pressure and risk of cerebrovascular disease events is continuous, consistent and independent of other risk factors. The higher the blood pressure, the greater the chance of myocardial infarction, heart failure, stroke and kidney disease for individuals aged 40–70 years, each increment of 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood pressure doubles the risk of cardiovascular disease. These alarming data support a need for greater emphasis on public awareness of the problem of high blood pressure and for an aggressive approach to antihypertensive treatment.

Over the past three decades there has been unprecedented production of scientific information in the form of longitudinal and cross-sectional studies and trials intended to reduce variations in treatment patterns and to assist standard-setting groups. There has been a proliferation of published guidelines proposed by various scientific bodies throughout the world. This has happened because the science base that has been derived from clinical trials is sufficiently broad that different conclusions have been drawn from the results. Differences between published guidelines often reflect the choices and ranking of various forms of evidence used in supporting the benefits of therapy versus the cost to individual patients and to the general population. Guideline differences may also reflect both cultural attitudes regarding approaches to medical care and limits of available resources.

Hypertension is defined as systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg. Hypertension is divided into two stages.

• Stage 1 includes patients with systolic blood pressure 140–159 mmHg or diastolic blood pressure 90–99 mmHg.

• Stage 2 includes patients with systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥100 mmHg.

Isolated systolic hypertension is defined as systolic blood pressure ≥140 mmHg and diastolic blood pressure <90 mmHg. Accelerated hypertension is characterized by markedly elevated blood pressure (diastolic blood pressure usually >120 mmHg) associated with retinal haemorrhage and exudates (grade 3 Kimmelstiel-Wilson retinopathy). If untreated, it commonly progresses to malignant hypertension, which is characterized by papilloedema (grade 4 Kimmelstiel-Wilson retinopathy). Both accelerated and malignant hypertensions are associated with widespread degenerative changes in the walls of resistance vessels including hypertensive encephalopathy, haematuria and renal dysfunction. A more elaborate classification of blood pressure is provided by the European Society of Hypertension and the European Society of Cardiology

The diagnosis of hypertension in adults is made when the average of two or more diastolic blood pressure measurements on at least two subsequent visits is ≥90 mmHg, or when the average of multiple systolic blood pressure readings on two or more subsequent visits is ≥140 mmHg. Patients should be clearly informed that a single elevated reading does not constitute a diagnosis of hypertension but is a sign that further observation is required.

The presence of cardiovascular risk factors, particularly diabetes mellitus, target organ damage and associated cardiovascular and renal disease, substantially increases the risk of hypertension. The level of risk is used to determine the threshold and type of therapeutic intervention. Box 1 indicates the most common risk factors, target organ damage and associated clinical conditions that are used to stratify risk

Causes of hypertension

The various causes of hypertension are listed in Box 2. Primary (essential or idiopathic) hypertension is systemic hypertension of unknown cause that results from dysregulation of normal homeostatic control mechanisms of blood pressure in the absence of detectable known secondary causes. Over 95% of all cases of hypertension are in this category. Secondary hypertension is systemic hypertension due to an underlying disorder. It accounts for <5% of cases of hypertension

Uncomplicated hypertension is usually asymptomatic and many of the symptoms often attributed to hypertension such as headache, tinnitus, dizziness and fainting are probably psychogenic in origin. They may reflect hyperventilation, induced by anxiety over the diagnosis of a lifelong disease that threatens well-being and survival.

Hypertension if not properly managed or treated often leads to the following

Cardiac damage

Vascular damage

Renal damage

Brain damage

However recent data indicate that, surprisingly, a person’s general sense of well-being often improves during initiation of medical treatment of hypertension. These new data suggest that hypertension may not be as asymptomatic as was previously assumed. Even if not totally asymptomatic, hypertension can go unrecognized for years because overt symptoms and signs generally coincide with the onset of target organ damage. Therefore, proper technique of blood pressure measurement is the cornerstone of hypertension detection.

Treatment of hypertension can be achieved with the help of the following

Lifestyle modifications

Cessation of smoking

Weight reduction and physical exercise

Reduction of salt intake and other dietary changes

Cessation of alcohol consumption

Tailoring drug therapy to the pathophysiology of the patient’s hypertension