INTRODUCTOIN: -

Hypertension, commonly referred to as high blood pressure, constitutes a significant

health issue that presently impacts nearly 1 billion individuals globally. Recent analysis
conducted by the World Health Organization (WHO) suggests that this figure could
escalate to approximately 1.57 billion by the year 2025. (Carey et al,.2022) As of 2024,
it is estimated that one in three individuals, or 33% of the global population, will
experience hypertension. Among those diagnosed with hypertension, approximately
46% remain undiagnosed and unaware of their condition. In 1975, the number of
individuals diagnosed with hypertension stood at nearly 600 million; by 2019, this figure
rose to 1.13 billion, largely due to increasing risk factors associated with hypertension in
low- and middle-income countries. (Mills et al,.2020) In India, nearly 63% of total deaths
are attributed to noncommunicable diseases, with 27% linked to cardiovascular
diseases (CVD), affecting 45% of individuals aged 40 to 69. Elevated blood pressure is
recognized as a significant risk factor for CVDs, and uncontrolled hypertension
represents a major risk factor for cardiovascular events. Among the estimated 220
million people in India living with hypertension, only 12% have achieved blood pressure
control. (Bowles et al.,2018)

Hypertension, commonly referred to as high blood pressure, is a chronic illness

characterized by consistently high blood pressure in the arteries. Usually, high blood
pressure doesn't cause any symptoms on its own. Stroke, peripheral arterial disease,
heart failure, atrial fibrillation, dementia, vision loss, and chronic kidney disease are all
significantly increased by it. Globally, hypertension is a leading cause of premature
mortality. (Buford et al.,2016)

High blood pressure can be defined as either primary (essential) or secondary

hypertension. (Schiffrin et al., 2020) Approximately 90-95% of cases are primary, which
is defined as high blood pressure caused by nonspecific lifestyle and genetic factors.
Excess salt in the diet, excessive body weight, smoking, physical inactivity, and alcohol
consumption are all lifestyle variables that enhance risk. The other 5-10% of instances
are classified as secondary hypertension, which is defined as high blood pressure
caused by a clearly recognized cause, such as chronic kidney disease, renal artery
constriction, an endocrine problem, or the use of birth control pills. (Norlander et
al.,2018)

There are two types of blood pressure measurements: systolic (first number) and
diastolic (second number). Most persons have normal blood pressure at rest in the
range of 100-140 millimeters mercury (mmHg) systolic and 60-90 mmHg diastolic.
[7]
(Oparil et al.,2015) Most persons have high blood pressure when their resting blood
pressure is consistently at or above 130/80 or 140/90 mmHg. Different numbers apply
to youngsters. Ambulatory blood pressure monitoring over 24 hours appears to be more
accurate than office-based blood pressure measurements. (Gabb et al.,2020)

Men are somewhat more likely to have hypertension than women. (Mocumbi et
al.,2024) Men have a higher prevalence of hypertension than women under the age of
50, while men and women have the same prevalence of hypertension above the age of
50. Hypertension affects more women than males over the age of 65. (Hoeper et
al.,2017) The prevalence of hypertension increases with age. Hypertension is prevalent
in high-, middle-, and low-income countries. People with poor socioeconomic position
are more likely to experience it. Diabetics are approximately twice as likely to have
hypertension. (Hoeper et al.,2016)

Lifestyle modifications and drugs can help to control blood pressure and reduce the risk
of health issues. Weight loss, physical activity, reduced salt intake, decreased alcohol
consumption, and a balanced diet are all examples of lifestyle modifications. If lifestyle
improvements are insufficient, blood pressure medication is prescribed. In 90% of
cases, up to three drugs given at the same time help regulate blood pressure.
(Umemura et al.,2019) Medication for moderately high arterial blood pressure (defined
as >160/100 mmHg) has been linked to an increased life expectancy. The efficacy of
medication on blood pressure between 130/80 mmHg and 160/100 mmHg is less
obvious, with some studies showing improvement and others finding no benefit. High
blood pressure affects 33% of the global population. Approximately half of all people
with high blood pressure are unaware that they have it. (Wang et al., 2018)

Hypertension is rarely associated with symptoms. Half of all people with hypertension
are ignorant of their condition. Hypertension is typically detected as part of a health
check or when seeking medical attention for an unrelated issue. (Seravalle et al.,2024)
Some patients with high blood pressure experience headaches, lightheadedness,
vertigo, tinnitus (buzzing or hissing in the ears), blurred vision, or fainting spells. These
symptoms, however, may be due to accompanying worry rather than high blood
pressure. (Padmanabhan et al.,2015)

Secondary hypertension is hypertension due to an identifiable cause and may result in

certain specific additional signs and symptoms. (Kintiraki et al.,2015) Cushing's
syndrome, for example, usually causes truncal obesity, glucose intolerance, moon face,
a fat hump behind the neck and shoulders (known as a buffalo hump), and purple
abdominal stretch marks, in addition to high blood pressure. Hyperthyroidism typically
results in weight loss, increased appetite, rapid heart rate, bulging eyes, and tremor.
Renal artery stenosis can be linked with a localized abdominal bruit to the left or right of
the midline, or both. Aortic coarctation commonly causes lower extremity blood pressure
to be lower than in the arms, as well as delayed or absent femoral arterial pulses.
Pheochromocytoma can induce sudden episodes of hypertension, along with
headaches, palpitations, a pale complexion, and excessive perspiration. (Imig et
al.,2019) A hypertensive crisis is defined as severely increased blood pressure (systolic
of 180 mmHg or diastolic of 120 mmHg or higher). Hypertensive crisis is classified as
hypertensive urgency or hypertensive emergency, depending on whether or not end-
organ damage exists. (Kjeldsen at el.,2018)

In hypertensive emergencies, there is no evidence of end-organ damage caused by

high blood pressure. In these circumstances, oral medicines are used to gradually
reduce blood pressure over a 24-48-hour period. (Jiang et al 2016) A hypertensive
emergency is defined by evidence of immediate organ damage. The brain, kidney,
heart, and lungs are the most commonly damaged organs, with symptoms such as
disorientation, drowsiness, chest pain, and shortness of breath. In a hypertensive
emergency, blood pressure must be decreased quickly to prevent further organ
damage. However, there is insufficient data from randomized controlled trials to support
this method. (Griendling et al.,2021)
Hypertension occurs in about 8-10% of pregnancies. Hypertension in pregnancy is
diagnosed when two blood pressure measures taken six hours apart are greater than
140/90 mmHg. Hypertension in neonates and young infants can cause failure to thrive,
seizures, irritability, a lack of energy, and breathing difficulties. Hypertension in older
babies and children can cause headaches, unexplained irritability, exhaustion, failure to
thrive, impaired vision, nosebleeds, and facial paralysis. (Galiè et al.,2019)

Primary (also known as essential) hypertension is caused by a complex combination of

genetic and environmental variables. (Drummond et al.,2019) More than 2000 common
genetic variations with minor effects on blood pressure, as well as some rare genetic
variants with significant effects on blood pressure, have been discovered as being
associated with hypertension. There is further evidence that DNA methylation at
numerous neighboring CpG sites may link some sequence variations to blood pressure,
presumably through impacts on vascular or renal function. (Everett et al.,2015)

Blood pressure rises with age in civilizations with a Western diet and lifestyle, and the
risk of becoming hypertensive in later life is high in most of these societies. Several
environmental and behavioral factors affect blood pressure. Reducing dietary salt
intake, as well as weight loss, exercise, vegetarian diets, increasing dietary potassium
intake, and calcium supplements, all lower blood pressure. Increased alcohol
consumption is linked to greater blood pressure, although the potential implications of
other factors such as caffeine consumption and vitamin D insufficiency remain unclear.
The average blood pressure is higher in winter than in summer. (Rodriguez-Iturbe et
al.,2017) Depression is associated with hypertension and loneliness is also a risk
factor. Periodontal disease is also associated with high blood
pressure. Arsenic exposure through drinking water is associated with elevated blood
pressure. Air pollution is associated with hypertension. Whether these associations are
causal is unknown. Early life events such as low birth weight, maternal smoking, and
loss of breastfeeding may be risk factors for adult essential hypertension, but the
strength of the correlations is modest, and the mechanisms linking these exposures to
adult hypertension are unknown.(Oliveros et al.,2020)
Secondary hypertension is the result of a recognized cause. Kidney disease is the
leading secondary cause of hypertension. Endocrine diseases such as Cushing's
syndrome, hyperthyroidism, hypothyroidism, acromegaly, Conn's syndrome or
hyperaldosteronism, renal artery stenosis (due to atherosclerosis or fibromuscular
dysplasia), hyperparathyroidism, and pheochromocytoma can all induce hypertension.
Obesity, sleep apnea, pregnancy, aortic coarctation, excessive liquorice consumption,
excessive alcohol consumption, some prescription medications, herbal treatments, and
stimulants like cocaine and methamphetamine are all potential causes of secondary
hypertension. (Hoeper et al.,2016)

Most persons with established essential hypertension have increased resistance to

blood flow (total peripheral resistance), resulting in high pressure while cardiac output
remains normal. There is evidence that some younger adults with prehypertension or
'borderline hypertension' have high cardiac output, an accelerated heart rate, and
normal peripheral resistance, a condition known as hyperkinetic hypertension. (Naha et
al.,2015) As their cardiac output declines and peripheral resistance increases with age,
these people may develop the usual symptoms of established essential hypertension in
their later years. It is unclear whether this trend is typical of all people who acquire
hypertension. The increased peripheral resistance in established hypertension is
primarily due to structural narrowing of small arteries and arterioles, however a
decrease in the number or density of capillaries may also contribute. (Perumareddi et
al.,2019)

It is uncertain if vasoconstriction of arteriolar blood arteries contributes to hypertension.

Hypertension is also linked to impaired peripheral venous compliance, which can
increase venous return, cardiac preload, and, eventually, diastolic dysfunction.
Hypertensive patients with increased heart rate variability (HRV) are at risk for atrial
fibrillation. (Konukoglu et al.,2017)

systolic hypertension is explained by increased arterial stiffness, which usually

accompanies aging and may be aggravated by high blood pressure.(Hamrahian et
al.,2017)
Pulse pressure (the difference between systolic and diastolic blood pressure) is typically
elevated in elderly adults with hypertension. This can mean that systolic pressure is
excessively high while diastolic pressure is normal or low, resulting in isolated systolic
hypertension. The high pulse pressure in older adults with hypertension or isolated
Several theories have been proposed to explain the increase in peripheral resistance in
hypertension. The majority of data points to either abnormalities in the kidneys' salt and
water management (especially in the intrarenal renin-angiotensin system) or
abnormalities in the sympathetic nervous system. These pathways are not mutually
exclusive, and both are likely to play some role in the majority of cases of essential
hypertension. Endothelial dysfunction and vascular inflammation have also been
postulated as potential contributors to increased peripheral resistance and vascular
damage in hypertension. Interleukin 17 has sparked interest for its ability to increase the
production of numerous other immune system chemical signals known to be implicated
in hypertension, including tumor necrosis factor alpha, interleukin 1, interleukin 6, and
interleukin 8. (Butalia et al.,2018)

Excess sodium or insufficient potassium in the diet causes excessive intracellular

sodium, which contracts vascular smooth muscle, restricting blood flow and so raising
blood pressure. Non-modulating essential hypertension is a type of salt-sensitive
hypertension in which sodium intake has no effect on angiotensin II-induced vascular
responses in the adrenals or kidneys. They comprise 25% of the hypertensive
population. (Hassoun at el.,2021)
Hypertension is defined as persistently elevated resting blood pressure. To diagnose
hypertension, elevated blood pressure measures must be taken on at least two different
occasions. (Ott et al.,2022)

Proper blood pressure measurement technique is required to provide an accurate

diagnosis of hypertension. Improper blood pressure measurement is widespread and
can result in a blood pressure reading of up to 10 mmHg, leading to misdiagnosis and
misclassification as hypertension. (Wiysonge et al.,2017)
Once hypertension has been diagnosed, additional testing may be performed to detect
secondary hypertension, identify comorbidities such as diabetes, identify hypertension-
caused organ damage such as chronic kidney disease or heart muscle thickening, and
stratify cardiovascular disease risk. (McLaughlin et al.,2015)

Preadolescent children are more likely to develop secondary hypertension, with kidney
illness being the most common reason. Primary or essential hypertension is more
common in teenagers and adults, and it involves several risk factors, including obesity
and a family history of hypertension. (Ruopp et al.,2022) A full history and physical
examination should be performed as part of the initial assessment following
hypertension diagnosis. The World Health Organization recommends the following initial
tests: serum electrolytes, serum creatinine, lipid panel, HbA1c (fasting glucose), urine
dipstick, and electrocardiogram (ECG/EKG). Serum creatinine levels are evaluated to
determine the existence of kidney disease, which can be the cause or outcome of
hypertension. (Ruopp et al.,2022)

Uric acid is a byproduct of the metabolic breakdown of purine nucleotides and a natural
component of urine. (Mandal et al.,2015) Uric acid is a heterocyclic molecule composed
of carbon, nitrogen, oxygen, and hydrogen, having the formula C5H4N4O3. (Ndrepepa
et al.,2018) It produces urate ions and salts, including ammonium acid urate. The
enzyme xanthine oxidase (XO) catalyzes the production of uric acid from xanthine and
hypoxanthine. XO, which enzyme present in mammals, is primarily a dehydrogenase
and seldom an oxidase. (El Ridi et al.,2017)

Xanthine is made from other purines. Xanthine oxidase is a big enzyme with an active
site composed of the metal molybdenum linked to sulfur and oxygen. Uric acid is
produced in hypoxic environments (low oxygen saturation). In humans, uric acid (really
hydrogen urate ion) is the last oxidation (breakdown) result of purine metabolism and is
expelled in urine; in most other mammals, the enzyme uricase further oxidizes uric acid
to allantoin. The loss of uricase in higher primates coincides with the loss of the ability to
produce ascorbic acid, implying that urate may partially substitute for ascorbate in such
animals. Both uric acid and ascorbic acid are powerful reducing agents (electron
donors) and antioxidants. In humans, hydrogen urate ions account for more than half of
blood plasma's antioxidant capability. (Maiuolo et al.,2016)
The normal range for uric acid in human blood plasma is 3.4-7.2 mg/dL for men and 2.4-
6.1 mg/dL for women. Hyperuricemia and hypouricemia are terms used to describe uric
acid contents in blood plasma that exceed and fall below the normal range.
Hyperuricosuria and hypouricosuria are terms used to describe uric acid concentrations
in urine that are higher than or lower than usual. Uric acid levels in saliva may correlate
with blood uric acid levels.(Giordano et al.,2015)

Hyperuricemia (high uric acid levels), which causes gout, can have a variety of causes,
including nutrition. A high consumption of dietary purine, high fructose corn syrup, and
sucrose can raise uric acid levels. (Wu et al.,2016) Reduced renal excretion can cause
high serum uric acid levels. Fasting or fast weight reduction may temporarily raise uric
acid levels. Certain medications, such as thiazide diuretics, might raise blood uric acid
levels by interfering with kidney clearance. Tumor lysis syndrome is a metabolic
consequence of certain malignancies or chemotherapy that results from the release of
nucleobases and potassium into the plasma. Diabetic hyperglycemia and excessive
alcohol intake create pseudohypoxia (a disruption in the NADH/NAD+ ratio). (Wang et
al.,2020)

A survey in the United States found that 3.9% of the population had gout, while 21.4%
had hyperuricemia without symptoms. (Lanaspa et al.,2020) Excess blood uric acid
(serum urate) can cause gout, a painful disorder characterized by needle-like uric acid
crystals known as monosodium urate crystals that form in joints, capillaries, skin, and
other tissues. Gout can occur at serum uric acid levels as low as 6 mg/dL, yet a person
can have serum values as high as 9.6 mg/dL without developing gout. (Guo et al.,2016)

Purines are converted in humans into uric acid, which is then eliminated through the
urine. Consumption of excessive amounts of purine-rich foods, particularly meat and
shellfish, increases the chance of developing gout. Purine-rich meals include liver,
kidney, and sweetbreads, as well as some seafood such as anchovies, herring,
sardines, mussels, scallops, trout, haddock, mackerel, and tuna. However, moderate
consumption of purine-rich foods has not been linked to an increased risk of gout.
(Abou-Elela et al.,2017)
Hyperuricemia is linked to an increase in risk factors for cardiovascular disease. It is
also plausible that excessive uric acid levels play a role in the development of
atherosclerotic cardiovascular disease, however the evidence is inconsistent.
Hyperuricemia is linked to components of metabolic syndrome, including in children.
(De Becker et al.,2019)

Low uric acid (hypouricemia) can have a variety of causes. Low dietary zinc intake
leads to lower uric acid levels. This effect may be more pronounced in women who use
oral contraception. Sevelamer, a medicine used to prevent hyperphosphatemia in
persons with chronic kidney failure, can drastically reduce serum uric acid. (De Becker
et al.,2019)

Review of Literature: -

Hypertension, often known as high blood pressure, is a chronic medical disorder

characterized by persistently elevated arterial blood pressure. It is a major public health
concern worldwide because of its high prevalence and link to cardiovascular disease,
stroke, kidney failure, and other consequences. (Nugroho et al.,2022) According to the
World Health Organization (2021), an estimated 1.28 billion persons aged 30-79 years
have hypertension worldwide, with a sizable proportion ignorant of the illness. (Mills et
al.,2020) The classification of hypertension has changed over time. The American
College of Cardiology (ACC) and the American Heart Association (AHA) define
hypertension as a blood pressure value of 130/80 mmHg or higher. (Al-Makki et
al.,2020) It is divided into two types: primary (essential) hypertension, which accounts
for 90-95% of instances with no identified cause, and secondary hypertension, which
originates from underlying medical diseases such as renal illness, endocrine
abnormalities, or the use of certain drugs. (Campbell et al.,2022)

The literature lists several risk factors, including genetic susceptibility, age, obesity, high
sodium intake, sedentary lifestyle, alcohol consumption, and psychological stress.
Hypertension's pathophysiology is characterized by complex interactions between
genetic, environmental, and behavioral factors that result in increased vascular
resistance and cardiac output alterations. (Akbarpour et al.,2018)
Several studies have stressed the need of detecting hypertension early and managing it
effectively to avoid long-term consequences. Lifestyle adjustments, increased physical
activity, and pharmacological therapies are frequently used as treatment options,
depending on the severity and underlying causes. (Njelekela et al.,2016)

This review will look at the available literature on hypertension's epidemiology,

pathophysiology, risk factors, and management options, in order to provide a full
understanding of the condition and identify needs for future research.

Wallace Johnson et al. 2022 determined that hypertensive crises, including

hypertensive emergencies and urgencies, are common in the emergency department
and require rapid management because they can cause irreparable end-organ damage.
Normal blood pressure (BP) regulation is disrupted during acute BP increases, resulting
in end-organ damage. Multiple organs may be harmed. Patients with hypertensive
pregnancies and postoperative hypertension should be given special consideration.
Treatment should be tailored to each patient based on the type and severity of end-
organ damage, the degree of blood pressure elevation, and the unique side effects that
each medicine may have on a patient's prior comorbidities. (Johnson et al.,2022)

Begashaw Melaku Gebresillassie et al. 2020 found that while substantial public health
programs are working to decrease hypertension, the hypertensive crisis remains a
significant clinical problem. The purpose of this study was to look at the characteristics,
treatment, and outcomes of hypertensive crisis patients hospitalized to the University of
Gondar Specialized Hospital in Ethiopia. A cross-sectional analysis of patient medical
records (n = 304) was done between January 1, 2013 and December 31, 2017. The
data were analyzed using version 21 of the Statistical Package for Social Sciences. The
analysis comprised 252 patient medical records. The mean age of all patients was 54 ±
17 years. Two hundred nineteen (86.9%) individuals have a documented history of
hypertension and are taking antihypertensive medications (n = 166, 65.9%). The bulk of
cases (n = 166, 65.9%) were hypertensive emergencies. More over one-third of the
patients (n = 98, 38.9%) said their disease was caused by noncompliance with therapy.
The most prevalent signs and symptoms on admission were headache (n = 170,
67.5%), dyspnea (n = 36, 14.3%), and vomiting (n = 33, 13.1%). One-third of the 852
tests ordered (n = 298, 34.9%) produced abnormal results. Nearly two-thirds (n = 336,
59.2%) of the prescriptions recorded were for hypertensive urgency. Captopril (136,
23.9%) and hydralazine (43, 7.6%) were the most regularly given oral and intravenous
medications, respectively. Ten individuals died throughout their 55-hour hospital stay. All
hospital deaths were attributed to a hypertensive crises. Patients with no history of
previous admission and hypertensive urgency had a substantially larger median
diastolic blood pressure drop than those with a history of admission (P =.005) and
hypertensive emergency (P =.010). These findings support improved therapy and
follow-up for these patients. Most crucial, to enhance treatment compliance, health
providers should educate their patients. (Gebresillassie BM et al.,2023)

Mohamed Farah Yusuf Mohamud 2023 discovered that hypertensive crisis (HC) is a
life-threatening clinical disease in which an abrupt rise in arterial blood pressure causes
acute damage to key organs. The primary goal of our study is to identify the
epidemiological profile, clinical characteristics, and risk factors of hypertensive crisis
patients in Somalia. This was a prospective cross-sectional research of HC patients
treated at Mogadishu Somali Turkish Training and Research Hospital in Mogadishu,
Somalia, between November 2020 and April 2021. 6239 patients were screened during
the research period. The prevalence of HC was 2.1% (128/6239). Of these, 76 (59.4%)
were men. Participants' average age (SD) was 56.5 (± 16.9) years (range: 24-98).
54.7% (70/128) satisfied the criterion for hypertensive emergency, while 45.3% (58/128)
met the hypertensive urgency requirements. The majority of patients (55.5%) took a
single antihypertensive medication, with calcium channel blockers being the most
commonly used (57.8%). The most common symptoms reported upon admission were
headache and palpitation (39.1% and 25% respectively). The most commonly given
antihypertensive medicines for first therapy were intravenous furosemide (35.2%),
sublingual captopril (25.8%), intravenous nitroglycerin (23.4%), and intravenous
labetalol (20%). The most common forms or patterns of end-organ damage caused by
HE was acute heart failure (45.7%), acute pulmonary edema (29.9%), and acute renal
injury (25.7%). Infrequent medical visits, poor compliance with medications, poor
compliance with exercise, a positive family history of hypertension, and being male were
significant predictors of HC. The odds ratios (AORs) were 20.312; p< 0.000, 7.021; p<
0.008, 6.158; p< 0.017, 3.545; p< 0.032, and 2.144; p= 0.001, respectively. In Somalia,
the hypertensive crisis is widespread among clinic patients. Infrequent medical visits,
poor adherence to medications and exercise, a positive family history of hypertension,
and being male were all significant predictors of HC. (Mohamud, M. F. Y.2023)

According to Spoorthy Kulkarni et al. 2023, acute HTN care varies depending on
available resources and local competence. High-quality evidence is either unavailable
or does not conclusively support certain rates of blood pressure decrease or specific
drugs. Finally, comments were made in conjunction with the BIHS based on existing
evidence and in the absence of unanimity. The suggested set of recommendations for
acute hypertensive conditions seeks to provide evidence-based and consistent patient
care. (Kulkarni et al.,2023)

Katherine T Mills et al. (2020) determined that hypertension is the main cause of
cardiovascular illness and early death worldwide. Because of extensive usage of
antihypertensive drugs, worldwide mean blood pressure (BP) has stayed constant or
slightly dropped during the last four decades. In contrast, the prevalence of
hypertension has risen, particularly in low and middle-income countries (LMICs).
According to estimates, 31.1% of individuals (1.39 billion) globally suffered with
hypertension in 2010. Adult hypertension prevalence was higher in low- and middle-
income countries (31.5%, 1.04 billion individuals) than in high-income countries (HICs;
28.5%, 349 million). Variations in the levels of risk factors for hypertension, such as high
salt intake, low potassium intake, obesity, alcohol consumption, physical inactivity, and a
poor diet, may account for part of the geographical disparities in hypertension
prevalence. Despite rising incidence, poor levels of hypertension knowledge, treatment,
and blood pressure control exist, particularly in low- and middle-income countries, and
there are few comprehensive estimates of hypertension's economic impact. Future
research is needed to verify implementation techniques for hypertension prevention and
control, particularly in low-income populations, as well as to accurately assess the
prevalence and cost impact of hypertension globally. (Mills et al.,2020)

According to Scott K Van Why et al 2020, hypertensive crisis, particularly in children, is

an uncommon illness defined as a sudden and abrupt increase in blood pressure that
offers a risk of rapid beginning of organ damage. Symptomatic hypertension
necessitates immediate and comprehensive examination and management. Targeted
examination can reveal a specific etiology in the majority of hypertensive crises patients.
The history and physical examination will help to determine the reason and urgency of
management. This article explores the frequent and uncommon causes of severe
hypertension in infancy, childhood, and adulthood. Clinical characteristics that may
indicate a serious underlying condition associated with severe and symptomatic
hypertension are discussed. (Mills etal.,2020)

According to Leslie L Davis 2023, an abrupt increase of blood pressure (BP) greater
than 180/120 mm Hg accompanied with target organ damage constitutes a
hypertensive emergency. Patients experiencing a hypertensive emergency require
intravenous medicine and constant monitoring in the critical care unit. A sudden rise of
blood pressure above 180/120 mm Hg without evidence of target organ damage is a
hypertensive emergency. Patients with hypertensive urgency are treated with oral
medicines and are typically returned home with outpatient follow-up. Patients with either
condition require a thorough evaluation to discover the source of the acute spike in
blood pressure, as well as instruction to optimize their treatment regimen over time.
(Davis L. L.2023)

J R Banegas et al. 2022 found that hypertension (HT) is the leading cause of death
and disability worldwide. In Spain, one in every three persons is hypertensive (66% for
those over the age of 60). Despite long-term improvements in hypertension care, only
half of treated hypertensive individuals have appropriate control. This corresponds to
40,000 cardiovascular deaths per year due to H T. Modifiable determinants of lack of
blood pressure (BP) control in Spain include: a) the white coat phenomenon (accounting
for 20-50% of false lack of control) due to not using ambulatory BP monitoring (current
use, 20%) or self-BP measurement (use, 60%) for confirming HT diagnosis; b)
insufficient patient adherence to BP reducing lifestyles (e.g., only 40% of hypertensive
patients have a sodium intake < 2.4 g/day or follow weight reduction advice); and c) use
of drug (Banegas et al.,2022)

According to Jitendra Meena et al 2021, a significant number (7%) of school-age

children in India are hypertensive. The prevalence was higher in urban and overweight
children. This study demonstrates that hypertension is a public health issue in India,
highlighting the importance of implementing public health strategies to prevent
hypertension. (Meena et al.,2021)

Bishav Mohan et al. 2019 determined that there is a high prevalence of persistent
hypertension and obesity among school-aged adolescents in a northern state in India.
Adolescent hypertension was found to be positively related with obesity (high BMI).
Childhood and adolescent obesity and high blood pressure should be prevented and
detected early to reduce the risk of metabolic syndrome and cardiovascular disease in
adulthood. (Mohan et al.,2019)

According to Claudio Borghi et al 2022, uric acid is the last result of purine
metabolism, and elevated serum levels have been directly linked to the pathophysiology
and natural history of hypertension. The link between high uric acid and hypertension
has been shown in both animals and humans, and its importance is already apparent in
the pediatric and teenage population. The process underlying blood pressure elevation
in hyperuricemia patients involves both oxidative stress and intracellular urate activity,
with XOR playing a significant role. Genetic data and extensive epidemiological meta-
analyses both confirm an increase in the relative risk of hypertension. The effects of
urate-lowering medication on blood pressure control in individuals with increased serum
uric acid have been explored in a small number of trustworthy studies, with a wide
range of patient groups and study types. However, two large meta-analyses reveal that
urate-lowering medication has a considerable effect on blood pressure, supporting the
strong link between high serum urate and blood pressure. Future research should focus
on more accurately identifying patients with cardiovascular hyperuricemia by taking into
account the correct cardiovascular threshold of serum urate, the time course of uricemia
fluctuations, and the identification of reliable markers of urate overproduction, which
could significantly clarify the clinical and therapeutic implications of the interaction
between serum uric acid and hypertension. (Borghi et al.,2022)

Yuichi Saito et al. 2021 concluded that uric acid, the byproduct of purine metabolism in
humans, is not only a cause of gout but may also play a role in the development of
cardiovascular diseases such as hypertension, atrial fibrillation, chronic kidney disease,
heart failure, coronary artery disease, and cardiovascular death. Several clinical studies
have shown serum uric acid as a predictor of cardiovascular outcomes. Although the
causal association between hyperuricemia and cardiovascular disease is still debated,
there is an increasing interest in uric acid as hyperuricemia becomes more common
around the world. This review article outlines current data on the relationship between
hyperuricemia and cardiovascular disease. (Saito et al.,2021)

According to Laura G Sanchez-Lozada et al. 2020, the link between elevated serum
urate and hypertension has long been debated. Extracellular uric acid promotes uric
acid deposition in gout, kidney stones, and possibly vascular calcification. However,
Mendelian randomization studies show that serum urate is unlikely to be the cause of
hypertension, despite increasing the risk of sudden cardiac death and diabetic vascular
disease. Nonetheless, experimental evidence strongly suggests that an increase in
intracellular urate plays a critical role in the pathophysiology of primary hypertension.
Pilot clinical trials demonstrate that reducing serum urate has a positive effect in
hyperuricemia persons who are young, hypertensive, and have good kidney function.
Some data suggests that hyperuricemia activates the renin-angiotensin system (RAS),
and inhibiting the RAS may mimic the actions of xanthine oxidase inhibitors. Lowering
blood urate concentrations or decreasing intracellular urate generation through dietary
measures such as reducing sugar, fructose, and salt intake can both reduce intracellular
urate levels. We believe that these nutrients in the western diet may have a significant
influence in the development of primary hypertension. Studies are needed to further
understand the relationship between uric acid concentrations inside and outside the cell.
Furthermore, large-scale clinical trials are required to assess if extracellular and
intracellular urate lowering can improve hypertension and cardiometabolic illness.
(Sanchez-Lozada et al.,2021)
According to Masanari Kuwabara et al. (2023), several basic and epidemiological
research have found a direct association between serum uric acid levels and
hypertension, cardiovascular, renal, and metabolic illnesses. High blood pressure is one
of the most typical signs of hyperuricemia. Several small-scale interventional trials have
shown that uric acid-lowering medications reduce blood pressure significantly in
hypertensive or prehypertensive patients. These observational or interventional
research have confirmed a causal link between uric acid and hypertension. While there
is a clinical link between uric acid and high blood pressure, it is unclear if reducing uric
acid is advantageous in the prevention of cardiovascular and renal metabolic disorders.
Several prospective randomized controlled intervention trials with allopurinol and other
uric acid-lowering medicines were recently published, and the results were nearly
entirely negative, implying that the link between hyperuricemia and cardiovascular
disease is not causal. However, it is worth noting that some of these newer trials had
significant dropout rates, and a sizable proportion of subjects were not hyperuricemia.
As a result, we should proceed with caution when interpreting these studies' findings.
This review article summarizes the findings of recent clinical studies with uric acid-
lowering medicines, with an emphasis on hypertension, cardiovascular and renal
metabolic illnesses, and examines the future of uric acid therapy. (Kuwabara et al,2023)

Yong Yang et al 2021 discovered that the correlation of uric acid with mortality and
cardiovascular outcomes in hypertensive patients yielded inconsistent results. The goal
of this meta-analysis was to determine the predictive value of uric acid in hypertension
individuals. We searched the PubMed and Embase databases (until July 31, 2020) for
relevant studies that reported the association of uric acid with mortality and
cardiovascular events in hypertensive patients. The outcome measures were
cardiovascular or all-cause mortality, coronary artery disease (CAD), stroke, and major
adverse cardiovascular events (MACEs). Eleven appropriate trials including 49,800
hypertension individuals were identified. For patients with the highest uric acid level
compared to those in the reference lower group, the pooled hazard ratio (HR) for all-
cause mortality was 1.51 (95% confidence interval [CI] 1.12-2.02), 1.68 (95% CI 1.28-
2.20) for cardiovascular mortality, 1.31 (95% CI 1.10-1.55) for CAD, and 1.48 (95% CI
1.28-1.70) for MACEs. However, there was no significant link between high uric acid
levels and incident stroke in hypertension patients. According to this meta-analysis,
elevated uric acid levels are strongly related with an increased risk of cardiovascular or
all-cause mortality, CAD, and MACEs in hypertensive individuals. Hypertensive patients
with the highest uric acid levels had a lower risk of stroke, however the difference was
not statistically significant. (Yang et al.,2021)

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