Hypertension Specialist

• Introduction – Certified Hypertension Specialist in Montgomery County, Maryland
• Importance of Normal Blood Pressure (Physiology of Blood Pressure)
• Classification and Prevalence of Hypertension
• Types of Hypertension
  • Primary (Essential) Hypertension
  • Secondary Hypertension
  • White Coat Hypertension
  • Isolated Systolic Hypertension
  • Malignant Hypertension
  • Resistant hypertension 
• Symptoms of Hypertension
• Complications of Uncontrolled Hypertension
  • Cardiovascular Diseases
  • Stroke
  • Kidney Damage
  • Etc
• Lifestyle Change, the Main Therapy for Hypertension:
• Medical Therapy
  • Thiazide Diuretics 
  • Angiotensin-Converting Enzyme Inhibitors
  • Angiotensin II Receptor Blockers
  • Etc
• Interventional Procedures:
  • Renal Denervation
  • Electrical Stimulation of the Carotid sinus
• Monitoring Patients with Hypertension
• Summary

Introduction – Certified Hypertension Specialist in Montgomery County, Maryland

As a Certified Hypertension Specialist (CHS) based in Montgomery County, Maryland, my role revolves around offering compassionate guidance and comprehensive care to individuals dealing with high blood pressure in our local community. I am dedicated to improving the management of hypertension, a condition that has a significant impact on cardiovascular health.

Importance of Normal Blood Pressure (Physiology of Blood Pressure)

Blood pressure (BP) is the force of blood against artery walls as the heart pumps. Its role is vital for distributing oxygen, nutrients, and hormones to tissues, enabling waste removal, and maintaining internal balance. Proper blood pressure supports lung oxygen exchange, kidney function, and blood vessel health. It’s regulated by the nervous system, hormones, and local factors.

Unlike high blood pressure, which can harm arteries and contribute to conditions such as cardiovascular and chronic kidney disease, normal blood pressure ensures tissue perfusion, substance transport, homeostasis, and organ function. This emphasizes its critical physiological importance in maintaining bodily well-being.

Classification and Prevalence of Hypertension

Hypertension is a global health concern due to its high prevalence and strong association with cardiovascular diseases, strokes, and various complications. Globally, an alarming 1.1 billion people, constituting 26% of adults, grapple with hypertension. In the USA, the problem is equally substantial, with 48% of adults affected by high blood pressure.

Blood pressure is classified based on following readings:

• Normal: Systolic < 120 mmHg and Diastolic < 80 mmHg
• Elevated: Systolic 120-129 mmHg and Diastolic < 80 mmHg
• Hypertension Stage 1: Systolic 130-139 mmHg or Diastolic 80-89 mmHg
• Hypertension Stage 2: Systolic ≥ 140 mmHg or Diastolic ≥ 90 mmHg

The above classification aids a hypertension specialist to make accurate diagnoses and treatment decisions.

Types of Hypertension

Hypertension has been classified by various types. For example, primary hypertension, often tied to lifestyle, is the most prevalent. Secondary hypertension results from underlying medical issues like kidney disease. White coat hypertension is seen in clinical settings. Isolated systolic hypertension primarily affects older individuals. Malignant hypertension is a severe form needing urgent care. Resistant hypertension, uncontrolled by medications, adds another layer of complexity. Below, we’ll delve into further details of these hypertension types.

1. Primary (Essential) Hypertension

This is the most common type of hypertension, accounting for about 90-95% of cases. Primary hypertension develops gradually over time and is typically influenced by a combination of genetic, lifestyle, and environmental factors. It tends to have no identifiable underlying cause and is often related to risk factors such as age, family history, obesity, sedentary lifestyle, high sodium intake, and stress.

2. Secondary Hypertension

This type of hypertension is caused by an underlying medical condition or certain medications. Secondary hypertension accounts for about 5-10% of cases. It can result from kidney disease, hormonal disorders (such as primary aldosteronism or Cushing’s syndrome), obstructive sleep apnea, thyroid problems, certain medications (like birth control pills or decongestants), adrenal gland tumors, and more. Unlike primary hypertension, secondary hypertension tends to appear suddenly and can often be cured if the underlying cause is treated. Below is a breakdown of some common causes of secondary hypertension.

• Kidney Diseases: Conditions that affect the kidneys can disrupt the body’s ability to regulate blood pressure. Examples include chronic kidney disease, polycystic kidney disease, and renal artery stenosis (narrowing of the arteries that supply blood to the kidneys).

• Obstructive Sleep Apnea: A sleep disorder characterized by repeated interruptions in breathing during sleep. It can lead to increased sympathetic nervous system activity and elevated blood pressure.

• Medications: Certain medications, such as birth control pills, decongestants, nonsteroidal anti-inflammatory drugs (NSAIDs), and some antidepressants, can raise blood pressure in some individuals.

• Pregnancy-Induced Hypertension: Conditions like preeclampsia and gestational hypertension can lead to high blood pressure during pregnancy.

Managing secondary hypertension involves identifying and treating the underlying cause. It’s crucial to work closely with healthcare professionals to diagnose the specific reason for elevated blood pressure and develop an appropriate treatment plan.

3. White Coat Hypertension

White coat syndrome, also known as white coat hypertension, refers to a phenomenon where individuals experience elevated blood pressure in clinical settings, such as doctor’s offices, due to anxiety or stress related to medical visits. Despite having normal blood pressure in their everyday lives, the presence of medical professionals in a clinical environment can lead to temporary spikes. It’s important to distinguish this from real chronic hypertension for accurate diagnosis and treatment.

4. Isolated Systolic Hypertension

Isolated systolic hypertension is a condition characterized by elevated systolic blood pressure (the top number in a blood pressure reading) while the diastolic pressure (the bottom number) remains within a normal range. Typically, this occurs in older individuals as arteries stiffen with age, causing the heart to pump blood against higher resistance. Isolated systolic hypertension is associated with an increased risk of heart disease, stroke, and other cardiovascular complications, necessitating careful monitoring and management.

5. Malignant Hypertension

Malignant hypertension is a severe and life-threatening form of high blood pressure. It arises suddenly and escalates rapidly, causing a dangerous spike in blood pressure levels. This condition can damage organs such as the heart, brain, and kidneys, leading to stroke, heart attack, kidney failure, or vision problems. Immediate medical attention is crucial to prevent severe complications or even death.

6. Resistant hypertension

Resistant hypertension refers to a challenging condition in which blood pressure remains persistently high despite the use of multiple medications. It’s diagnosed when a person’s blood pressure remains above the target levels (often defined as 130/80 mmHg) despite adherence to a regimen of at least three different blood pressure-lowering medications, including a diuretic. 

Resistant hypertension is concerning because it significantly increases the risk of cardiovascular events, stroke, and organ damage. Common underlying factors include lifestyle issues, secondary causes of hypertension, medication non-adherence, and the complex interplay of various physiological mechanisms. Managing resistant hypertension requires a comprehensive approach, including medication optimization, addressing contributing factors, lifestyle modifications, and close medical supervision to mitigate risks and improve overall cardiovascular health.

Symptoms of Hypertension

Hypertension, often called the “silent killer,” usually lacks noticeable symptoms in its early stages. Regular blood pressure checks are vital for detection. Severe or extremely high blood pressure levels can cause symptoms like headaches, vision changes, chest pain, shortness of breath, dizziness, or fatigue. However, these signs are not specific to hypertension and can overlap with other conditions. Regular monitoring is crucial for accurate diagnosis. If severe symptoms like chest pain or sudden vision changes occur, immediate medical attention is necessary, as they might signal a hypertensive crisis requiring urgent intervention.

Complications of Uncontrolled Hypertension

Hypertension can result in organ damage by subjecting blood vessels to excessive stress throughout the body. This sustained pressure initiates a series of structural and functional changes that may negatively impact vital organs. Some of the potential outcomes of uncontrolled hypertension include:

• Cardiovascular Diseases: Hypertension is a significant risk factor for heart diseases such as coronary artery disease, heart attack (myocardial infarction), and heart failure. The elevated pressure strains the heart, causing it to work harder and potentially leading to the thickening of the heart muscle (left ventricular hypertrophy) and decreased pumping efficiency.

• Stroke: Uncontrolled hypertension can damage blood vessels in the brain, increasing the risk of stroke. If a blood vessel bursts (hemorrhagic stroke) or if there’s a blockage in a blood vessel supplying the brain (ischemic stroke), it can result in brain damage, paralysis, or even death.

• Kidney Damage: Chronic high blood pressure can damage the blood vessels in the kidneys, impairing their ability to filter waste and excess fluids from the body. This can lead to kidney disease (nephropathy) and eventually progress to kidney failure, requiring dialysis or a kidney transplant.

• Eye Problems: Hypertension can damage blood vessels in the eyes, leading to retinopathy. This condition can cause vision problems and, in severe cases, even result in blindness.

• Aneurysms: Elevated blood pressure can weaken blood vessel walls, leading to the formation of aneurysms—bulges in blood vessels. If an aneurysm ruptures, it can result in life-threatening internal bleeding.

• Peripheral Artery Disease (PAD): Hypertension contributes to the development of atherosclerosis, a condition in which arteries become narrowed and hardened due to plaque buildup. This can lead to reduced blood flow to the limbs, causing pain and increasing the risk of infections and tissue damage.

• Cognitive Decline: Uncontrolled hypertension may increase the risk of cognitive decline and dementia, possibly due to its impact on blood vessels in the brain.

• Metabolic Syndrome: Hypertension is often associated with other risk factors such as obesity, high cholesterol, and insulin resistance. These collectively contribute to metabolic syndrome, increasing the risk of diabetes and heart disease.

• Sexual Dysfunction: High blood pressure can affect blood flow to the genital area, leading to sexual dysfunction in both men and women.

• Complications During Pregnancy: Uncontrolled hypertension during pregnancy (gestational hypertension or preeclampsia) can endanger the health of both the mother and the developing fetus.

It’s essential to manage hypertension through lifestyle changes, medication, and regular medical check-ups to prevent or mitigate these complications. Early detection and proper management can significantly reduce the risk of serious health issues associated with uncontrolled hypertension.

Lifestyle Change, the Main Therapy for Hypertension:

Lifestyle modifications serve as the cornerstone of hypertension control, with the central focus on adopting the DASH diet, rich in fruits, vegetables, lean proteins, and low-fat dairy, while simultaneously curbing sodium intake. 

Attaining and maintaining a healthy weight through a balanced diet and regular physical activity, encompassing at least 150 minutes of weekly aerobic exercise like brisk walking or cycling, remains pivotal. 

Limiting daily salt intake to approximately 2,300 mg or less and practicing moderate alcohol consumption (up to one drink daily for women and two for men) are important components. Cessation of smoking is advised due to its contribution to elevated blood pressure and cardiovascular risks.

These comprehensive lifestyle changes are instrumental in effectively managing blood pressure and mitigating associated complications.

Medical Therapy

The decision to start medications for hypertension depends on factors like the individual’s blood pressure levels, overall health, risk factors, and the presence of related health conditions. Typically, medical therapy is initiated when blood pressure reaches the hypertension Stage 1 level or higher, particularly if the person has other risk factors such as diabetes, kidney disease, or a history of heart disease. Here are some key medications commonly employed for treating high blood pressure:

• Thiazide Diuretics (e.g., hydrochlorothiazide): Thiazide diuretics are commonly prescribed as first-line treatments. They help the kidneys eliminate excess sodium and water, decreasing blood volume and thus lowering blood pressure. They can also improve blood vessel function over time. Thiazides are especially effective for patients with mild to moderate hypertension and are often part of combination therapies.

• Angiotensin-Converting Enzyme (ACE) Inhibitors (e.g., lisinopril): ACE inhibitors block the conversion of angiotensin I to angiotensin II, a hormone that narrows blood vessels and raises blood pressure. By inhibiting this conversion, ACE inhibitors lead to blood vessel relaxation, reduced blood volume, and lower blood pressure. They are especially beneficial for patients with heart failure, diabetes, and kidney disease.

• Angiotensin II Receptor Blockers (ARBs) (e.g., losartan): ARBs work by blocking the binding of angiotensin II to its receptors, preventing blood vessels from constricting. This results in blood vessel relaxation and reduced blood pressure. ARBs are often prescribed when ACE inhibitors cause side effects.

• Renin Inhibitors (e.g., aliskiren): Renin inhibitors target the renin-angiotensin system at its earliest step. By inhibiting renin, they reduce the production of angiotensin II, resulting in blood vessel relaxation and lowered blood pressure. Renin inhibitors are less commonly used than ACE inhibitors and ARBs, and may be reserved for certain patients.

• Calcium Channel Blockers (e.g., amlodipine): Calcium channel blockers prevent calcium from entering muscle cells in blood vessel walls and the heart. This relaxes blood vessels, decreases heart rate, and reduces the force of heart contractions. Some calcium channel blockers like diltiazem and verapamil are particularly effective for patients with high heart rates or angina (chest pain).

• Beta-Blockers (e.g., metoprolol): Beta-blockers lower blood pressure by blocking the effects of adrenaline on the heart and blood vessels. They reduce heart rate, cardiac output, and the heart’s workload, which collectively lower blood pressure. Beta-blockers are often prescribed to patients with heart conditions or migraines.

• Diuretics (Loop Diuretics, e.g., furosemide): Loop diuretics are potent diuretics that work on the ascending loop of Henle in the kidneys. They remove excess fluid from the body, decrease blood volume, and subsequently lower blood pressure. Loop diuretics are often used for patients with more severe hypertension or heart failure.

• Alpha-Blockers (e.g., doxazosin): Alpha-blockers block certain nerve impulses, leading to relaxation of blood vessel walls. This dilation of blood vessels reduces resistance to blood flow and subsequently lowers blood pressure. Alpha-blockers are often prescribed for patients with both hypertension and an enlarged prostate.

• Alpha-Beta Blockers (e.g., carvedilol): Alpha-beta blockers combine the effects of both alpha and beta blockade. They reduce heart rate and cardiac output while also relaxing blood vessels. They are often used for patients with both high blood pressure and certain heart conditions.

• Direct Vasodilators (e.g., hydralazine): Direct vasodilators work by directly relaxing and dilating arterial blood vessels, thus reducing resistance to blood flow and lowering blood pressure. They are often used as add-on therapies when other medications are insufficient.

• Aldosterone Synthase Inhibitors (e.g., Baxdrostat): Aldosterone synthase inhibitors represent a novel class of medications currently undergoing clinical trials for treating resistant hypertension. These drugs function by inhibiting the production of the aldosterone synthase enzyme, which is responsible for excessive salt and fluid retention, a leading cause of hypertension. Based on recent research, FDA approval of Baxdrostat for this purpose is expected in the near future.

It’s essential to emphasize that the choice of medications mentioned above depends on factors like the patient’s overall health, medical history, and potential side effects. Hypertension specialists meticulously select medications or combinations tailored to individual needs.

Interventional Procedures: 

In cases of severely challenging-to-treat hypertension, as mentioned earlier (see resistant hypertension), procedures like renal denervation and carotid sinus stimulation may be viable options. These interventions involve using radiofrequency energy to disrupt nerve activity around the kidneys and electrical stimulation of the carotid sinus, both aimed at lowering blood pressure. Below is an extended discussion on each procedure.

• Renal Denervation: It requires insertion of a catheter with an electrode tip into the renal arteries that supply blood to the kidneys. Radiofrequency or ultrasound energy is then used to ablate (destroy) the sympathetic nerves located in the renal artery wall. These nerves play a role in regulating blood pressure. By disrupting their activity, renal denervation aims to lower blood pressure. 

• Electrical Stimulation of the Carotid Sinus: It involves applying controlled electrical impulses to the carotid sinus, a small structure located in the carotid artery in the neck. This procedure is designed to improve the activity of the carotid sinus baroreceptors, which are responsible for regulating blood pressure. By stimulating these baroreceptors, it is possible to lower blood pressure levels in patients when other treatments have been ineffective. 

However, it’s necessary to note that the above interventional techniques are still under research and development or practiced only in specialized academic centers.

Monitoring Patients with Hypertension

Hypertension monitoring involves regular assessments to track blood pressure levels, treatment efficacy, and preventing complications. Blood pressure measurements, often taken using a sphygmomanometer or automated device, provide vital information. Ambulatory blood pressure monitoring (ABPM) supplies a comprehensive view over 24 hours, aiming to avoid white coat syndrome in clinic settings. 

Patients can use home blood pressure monitors, which offer a broader and more realistic perspective over time. An ideal home blood pressure goal is <130/80 mmHg. Overall, regular follow-up appointments ensure effective long-term management, optimizing blood pressure control, preventing complications, and tailoring care to individual needs. 

Summary

As a Certified Hypertension Specialist in Montgomery County, Maryland, I offer personalized guidance for managing high blood pressure within my community. My approach is centered on tailored strategies to reduce risks of heart diseases, strokes, and kidney concerns among others. I provide ongoing education and follow ups to ensure consistent hypertension control and prevention of complications.

Dr. Tashko