1.

Case

A 47 year old man presents to your office for dollow up visit. He was
seen 3 weeks ago for an upper respiratory infection and noted
incidentally to have a blood pressure of 164/98 mmHg. He vaguely
remembered being told in the past that his blood pressure was
“borderline”. He feels fine, no complaints, and his review system is
enterely negative. He does not smoke cigarrates, drinks a couple of
beers on the weekends, and does not exercise regulary. He has a
sedentary job. His father died of stroke at the age of 69 years. His
mother is alive and in good health at the age of 72 years. He has two
siblings and is not aware of any chronic medical issues they have. In
the office today, his blood pressure is 156/96 mmHg in his left arm and
152/98 mmHg in the right arm. He is afebrile his pulse is 78 bpm,
respiratory rate 14 breaths per minute, he is 70 inc tall, and weights
210 lb. A general physical examination is normal.

2. Key words
 Blood pressure
 Sedentary job and life
 Body weights and heights

3. Theory / Definition
Hypertension is a state of systolic blood pressure of more than 140
mmHg and diastolic pressure of more than 90 mmHg. Blood pressure
is measured with a properly calibrated spygmomanometer (80% of the
size of the cuff covering the arm) after the patient is resting
comfortably, sitting on his back straight or supine for at least 5 minutes
to 30 minutes after smoking or drinking coffee.1 Hypertension with no
known cause is defined as essential hypertension. Some authors
prefer the term primary hypertension to distinguish it from other
hypertension which is secondary to known causes. According to The
Seventh Report of The Joint National Committee on Prevention,
Detection, Evaluation and Treatment of High Blood Pressure (JNC VII)
the classification of blood pressure in adults is divided into optima,
normal, high normal, grade 1,2,3 hypertension.
 i. EPIDEMIOLOGY
Hypertension is an increase in blood pressure that gives symptoms
that continue for a target organ, such as a stroke for the brain,
coronary heart disease for heart blood vessels and for the heart
muscle. This disease has become a major problem in public health in
Indonesia and in several countries in the world 3. Increasing the
elderly population, the number of patients with hypertension is likely to
increase 2. It is estimated that about 80% increase in cases of
hypertension, especially in countries developed in 2025 from a
number of 639 million cases in 2000, estimated to be 1.15 billion
cases in 2025. This prediction is based on the current number of
people with hypertension and the current population growth.

ii. ETIOLOGY
Cause of essential hypertension is not known with certainty. Primary
hypertension is not caused by a single and special factor.
Hypertension is caused by various interrelated factors. Secondary
hypertension is caused by known primary factors such as kidney
damage, certain drug disorders, acute stress, vascular damage and
others. The most common cause in patients with malignant
hypertension is hypertension that is not treated. The relative risk of
hypertension depends on the amount and severity of modifiable and
non-modifiable risk factors.

iii. RISK FACTORS

Factors that cannot be modified include genetic, age, sex and ethnic
factors. While the factors that can be modified include stress, obesity
and nutrition. 2
a. Genetic factors
The existence of genetic factors in certain families will cause the family
to have a risk of suffering from hypertension. This is related to the
increase in intracellular sodium levels and the low ratio between
potassium to sodium. Individuals with hypertensive parents have twice
the risk of developing hypertension than people who do not have
families with a history of hypertension. In addition, 70-80% of cases
are obtained essential hypertension with a family history of
hypertension

b. Age
The incidence of hypertension increases with age. Patients aged over
60 years, 50 - 60% have blood pressure greater than or equal to
140/90 mmHg. This is the effect of degeneration that occurs in people
who are older. Hypertension is a multifactorial disease that arises
caused of the interaction of various factors. With increasing age, blood
pressure will also increase. After the age of 45 years, the artery walls
will experience thickening due to the accumulation of collagen in the
muscle layer, so that the blood vessels will gradually narrow and
become stiff. Systolic blood pressure increases because the flexibility
of large blood vessels decreases with age until the seventh decade
while diastolic blood pressure rises until the fifth and sixth decades
and then settles or tends to decrease. Increased age will cause some
physiological changes, in the elderly there is an increase in peripheral
resistance and sympathetic activity. The regulation of blood pressure,
namely reflex baroreceptors in old age, has reduced sensitivity, while
the role of the kidneys has also been reduced where renal blood flow
and glomerular filtration rates have decreased.

c. Gender
The prevalence of hypertension in men is the same as women. But
women are protected from cardiovascular disease before
menopause.8 Women who have not yet experienced menopause are
protected by the hormone estrogen which plays a role in increasing
levels of High Density Lipoprotein (HDL). High levels of HDL
cholesterol are protective factors in preventing the process of
atherosclerosis. The protective effect of estrogen is thought to be an
explanation of a woman's immunity at premenopausal age. In
premenopausal women begin to lose little by little the hormone
estrogen which has been protecting blood vessels from damage. This
process continues where the estrogen hormone changes in quantity
according to the woman's natural age, which generally begins to occur
in women aged 45-55 years.

d. Ethnicity
Hypertension is more common in black people than in white people.
Until now, the exact cause is unknown. But in black people found
lower renin levels and greater sensitivity to vasopressin.

e. .Obesity
Body weight is a determinant factor in blood pressure in most ethnic
groups at all ages. According to the National Institutes for Health USA
(NIH, 1998), the prevalence of high blood pressure in people with a
Body Mass Index (BMI)> 30 (obesity) is 38% for men and 32% for
women, compared with a prevalence of 18% for men and 17 % for
women who have a BMI <25 (normal nutritional status according to
international standards). According to Hall (1994) physiological
changes can explain the relationship between being overweight and
blood pressure, namely the occurrence of insulin resistance and
hyperinsulinemia, activation of the sympathetic nerves and the renin-
angiotensin system, and physical changes in the kidneys. Increased
energy consumption also increases plasma insulin, where natriuretic
potential causes sodium reabsorption and increased blood pressure
continuously.

f. Salt intake in the diet

The world health agency, the World Health Organization (WHO)
recommends patterns of salt consumption that can reduce the risk of
hypertension. The recommended sodium level is no more than 100
mmol (about 2.4 grams of sodium or 6 grams of salt) per day.
Excessive sodium consumption causes the concentration of sodium in
the extracellular fluid to increase. To normalize intracellular fluid drawn
out, so that the volume of extracellular fluid increases. The increase in
the volume of extracellular fluid causes an increase in blood volume,
thus affecting hypertension. 10 Because it is recommended to reduce
consumption of sodium / sodium. The main sources of sodium /
sodium are sodium chloride (table salt), flavoring monosodium
glutamate (MSG), and sodium carbonate. The recommended
consumption of table salt (containing iodine) is no more than 6 grams
per day, equivalent to one teaspoon. In fact, excessive consumption is
 due to the cooking culture of our society which is generally wasteful
using salt and MSG.

g. Smoke
Smoking causes elevated blood pressure. Heavy smoking can be
associated with an increased incidence of malignant hypertension and
the risk of renal artery stenosis with ateriosclerosis.3 In a prospective
cohort study by Dr. Thomas S Bowman of Brigmans and Women's
Hospital, Massachusetts on 28,236 subjects with no history of
hypertension, 51% of subjects did not smoke, 36% were novice
smokers, 5% subjects smoked 1-14 cigarettes per day and 8% of
subjects smoked more than 15 sticks per day. Subjects continue to be
studied and within a median of 9.8 years. The conclusion in this study
is the highest incidence of hypertension in the group of subjects with
smoking habits of more than 15 cigarettes per day.

h. Personality type
Statistically, type A behavior patterns have been shown to be related to
hypertension prevalence. Type A behavior patterns are behavior
patterns that are in accordance with Rosenman's type A behavioral
pattern criteria determined by observing and filling in Rosenman's self
rating questionnaire. Regarding how the mechanism of type A
behavior patterns causes hypertension, many studies relate to its
ambitious, competitive nature, work that is never tired, always being
chased by time and always feeling dissatisfied. These properties will
release catecholamines which can cause the prevalence of elevated
serum cholesterol levels, which will facilitate atherosclerosis. Stress
will increase peripheral vascular resistance and cardiac output so that
it will stimulate sympathetic nerve activity. The stress can be related to
work, social class, economy, and personal characteristics

iv. CLASSIFICATION
Blood pressure was classified based on measurements averaging
twice at each visit.
iv. COMPLICATIONS
Hypertension is a major risk factor for heart disease, congestive
heart failure, stroke, vision problems and kidney disease. High blood
pressure generally increases the risk of these complications.
Untreated hypertension will affect all organ systems and ultimately
shorten life expectancy by 10-20 years. 19 Mortality in hypertensive
patients is faster if the disease is not controlled and has caused
complications to several vital organs. The most common cause of
death is heart disease with or without stroke and kidney failure.
Complications that occur in mild and moderate hypertension affecting
the eyes, kidneys, heart and brain. In the eye in the form of retinal
bleeding, visual disturbances to blindness. Heart failure is a disorder
that is often found in severe hypertension in addition to coronary and
myocardial abnormalities. In the brain bleeding often occurs due to
the outbreak of microaneurisms that can result in death. Other
disorders that can occur are thromboembolic processes and transient
ischemic attack (TIA). Kidney failure is often found as a complication
of long-standing hypertension and in an acute process such as
malignant hypertension.
The risk of cardiovascular disease in hypertensive patients is
determined not only by high blood pressure but also the absence or
damage to target organs and other risk factors such as smoking,
dyslipidemia and diabetes mellitus. 21 Systolic blood pressure
exceeding 140 mmHg in individuals over 50 years old, is an
important cardiovascular risk factor. Also starting from blood
pressure 115/75 mmHg, an increase every 20/10 mmHg increases
the risk of cardiovascular disease twice.
v. PROGNOSIS
Hypertension can be controlled properly with appropriate treatment.
Therapy with a combination of lifestyle changes and antihypertensive
medications can usually maintain blood pressure at levels that will
not cause damage to the heart or other organs. The key to avoiding
serious complications from hypertension is to detect and treat before
damage occurs

4. Analysis
 Clinical Appproach
Hypertension is a state of systolic blood pressure of more
than 140 mmHg and diastolic pressure of more than 90
mmHg

 Objective
 A man 47 years old man have blood pressure is
156/96 mmHg in his left arm and 152/98 mmHg in the
right arm.
 He is 70 inc tall, and weights 210 lb. A general
physical examination is normal.
 He has a sedentary job.
 His father died of stroke at the age of 69 years. His
mother is alive and in good health at the age of 72
years.
 He does not smoke cigarrates, drinks a couple of
beers on the weekends, and does not exercise
regulary.

 Patophysiology
The mechanism of hypertension is through the formation of
angiotensin II from angiotensin I by angiotensin I converting
enzyme (ACE). ACE plays an important physiological role in
regulating blood pressure. Blood contains angiotensinogen
which is produced in the liver. Furthermore, by the hormone,
renin (produced by the kidneys) will be converted into
angiotensin I. By ACE in the lungs, angiotensin I is converted to
angiotensin II. Angiotensin II has a key role in raising blood
pressure through two main actions.5 The first action is to
increase the secretion of antidiuretic hormone (ADH) and thirst.
ADH is produced in the hypothalamus (pituitary gland) and
 works on the kidneys to regulate osmolality and urine volume.
With increasing ADH, very little urine is excreted outside the
body (antidiuresis), so it becomes concentrated and high in
osmolality. To thin it, the volume of extracellular fluid will be
increased by drawing fluid from the intracellular part. As a result,
blood volume increases which will eventually increase blood
pressure
The second action is to stimulate aldosterone secretion from
the adrenal cortex. Aldosterone is a steroid hormone that has an
important role in the kidneys. To regulate extracellular fluid
volume, aldosterone will reduce the excretion of NaCl (salt) by
re-absorbing it from the kidney tubules. Increasing the
concentration of NaCl will be diluted back by increasing the
volume of extracellular fluid which in turn will increase blood
volume and pressure.

The pathogenesis of essential hypertension is multifactorial and

very complex. These factors alter the function of blood pressure to
adequate tissue perfusion including hormone mediators, vascular
activity, blood circulation volume, vascular caliber, blood viscosity,
cardiac output, vascular elasticity and neural stimulation. The
pathogenesis of essential hypertension can be triggered by several
factors including genetic factors, salt intake in the diet, stress levels
can interact to cause symptoms of hypertension. The journey of
essential hypertension develops from hypertension which
sometimes appears to be persistent hypertension. After a long
asymptomatic period, persistent hypertension develops into
hypertension with complications, where damage to target organs in
the aorta and small arteries, heart, kidneys, retina and central
nervous system.
Hypertension progression starts from prehypertension in
patients aged 10-30 years (with increased cardiac output) then
becomes hypertension early in patients aged 20-40 years (where
peripheral resistance increases) then becomes hypertension at 30-
50 years of age and eventually becomes hypertensive with
complications at the age of 40-60 years.

 Diagnosis
Before making diagnosis of hypertension, repeated
measurements are required for at least three different occasions for
four to six weeks. Measurements at home can use an appropriate
sphygmomanometer thus increasing the number of measurements
for analysis.

 Clinical Symptoms
Symptoms of the disease that usually occurs both in people with
hypertension, and in someone with normal blood pressure
hypertension, namely headache, dizziness, anxiety, palpitations,
nasal bleeding, difficulty sleeping, shortness of breath, irritability,
ringing in the ears, ringing feels heavy , pounding and urinating
frequently at night. Symptoms due to hypertension complications
that have been encountered include disorders; vision, nerves,
heart, kidney function and cerebral disorders (brain) resulting in
seizures and bleeding of the blood vessels of the brain resulting in
paralysis, disturbance of consciousness to coma.

 Physical Examinations
  Laboratory

 Education
a) Blood Pressure Targets
According to the Joint National Commission (JNC) 7, the
recommended blood pressure target that must be achieved is
<140/90 mmHg and the blood pressure target for patients with
chronic kidney disease and diabetes is ≤ 130/80 mmHg. The
American Heart Association (AHA) recommends achieving blood
pressure targets, which are 140/90 mmHg, 130/80 mmHg for
patients with chronic kidney disease, chronic arterial disease or
equivalent chronic artery disease, and ≤ 120/80 mmHg for patients
with failure heart. Meanwhile, according to the National Kidney
Foundation (NKF), the target blood pressure that must be achieved
is 130/80 mmHg for patients with chronic kidney disease and
diabetes, and <125/75 mmHg for patients with> 1 g proteinuria.
Figure: drug treatment strategy to reach blood pressure target
 b) Lifestyle Modifications
Implementing a lifestyle that positively influences blood pressure
has implications both for the prevention and treatment of
hypertension. Lifestyle modification of health promotion is
recommended for individuals with pre-hypertension and as an
adjunct to drug therapy in hypertensive individuals. This
intervention is for the overall risk of heart disease. Although the
impact of lifestyle interventions on blood pressure will be more
visible in people with hypertension, in short-term trials, weight loss
and reduction in dietary NaCl have also been shown to prevent the
development of hypertension. In patients with hypertension, even if
the intervention does not result in a decrease in blood pressure
sufficient to avoid drug therapy, the amount of medication or dose
needed to control blood pressure can be reduced. Effective diet
modification to reduce blood pressure is to reduce body weight,
reduce NaCl intake, increase potassium intake, reduce alcohol
consumption, and overall healthy diet.
Preventing and overcoming obesity is very important to reduce
blood pressure and risk of cardiovascular disease. An average
decrease in blood pressure of 6.3 / 3.1 mmHg was observed after
weight loss of 9.2 kg. Exercise regularly for 30 minutes such as
walking, 6-7 per day a week, can reduce blood pressure. There is
individual variability in terms of blood pressure sensitivity to NaCl,
and this variability may have a genetic basis. Based on the results
of a meta-analysis, lowering blood pressure by limiting daily intake
to 4.4-7.4 g NaCl (75-125 meq) causes a decrease in blood
pressure of 3.7-4.9 / 0.9-2.9 mmHg in hypertension and a lower
decrease in people normal blood. Alcohol consumption in people
who consume three or more drinks per day (a standard drink
containing ~ 14 g of ethanol) is associated with high blood
pressure, and a decrease in alcohol consumption is associated with
a decrease in blood pressure. Similarly, DASH (Dietary Approaches
to Stop Hypertension) includes a diet rich in fruits, vegetables, and
low-fat foods effective in lowering blood pressure.

 Medical Treatment

The types of antihypertensive drugs for pharmacological therapy of

hypertension recommended by JNC 7 are:
 Diuretics, especially Thiazide (Thiaz) or Aldosterone
Antagonist types
 Beta Blocker (BB)
 Calcium Chanel Blocker or Calcium antagonist (CCB)
 Angiotensin Converting Enzym Inhibitor (ACEI)
 Angiotensin II Receptor Blocker or Areceptor antagonist /
blocker (ARB)

For most hypertensive patients, therapy is begun gradually, and

blood pressure targets are reached progressively within a few
weeks. It is recommended to use antihypertensive drugs with a
long service life or that provide efficacy 24 hours by giving once
a day. The choice whether to start therapy with one type of
antihypertensive drug or in combination depends on the initial
blood pressure and the presence or absence of complications. If
therapy is started with one drug and in a low dose, and then the
blood pressure has not reached the target, then the next step is
to increase the dose of the drug, or move to another
antihypertensive with a low dose. Side effects can generally be
avoided by using low doses, both single and combination. Most
patients need a combination of antihypertensive drugs to reach
their blood pressure targets, but combination therapy can
increase treatment costs and reduce patient compliance
because the number of drugs that need to be taken increases.

The combination of drugs that have been proven effective and

can be tolerated by patients are:
5. Conclusion
A 47 years old man thant came for physical test diagnosed by
grade 1 hypertensi, obese level 1. He has risk factors include sex,
age, family history, obesity and life style. Management for this
patient not only pharmacological agents but nonpharmacological
agents tho.