How to treat hypertension?

[Mubarrah]

Hypertension, commonly known as “high blood pressure” is a medical condition in which the blood pressure is raised to the level where it can’t flush through the body organs and tissues.
Hypertension is the most commonly occurring disease in the Cardiovascular system. Hypertension can be treated by low salt intake, lowering cholesterol level, healthy lifestyle, and the use of medications.

What are risk factors associated with persistent hypertension?

Although many hypertensive patients are asymptomatic, however, chronic hypertension can lead to complicated cardiac issues including heart failure and cardiac stroke, which are the most common causes of death worldwide.
There are increased risks of chronic kidney disease kidney and brain damage as a result of persistently elevated blood pressure.

These complications and deaths associated with hypertension can be prevented if it is diagnosed in the early stages and treated properly.

What are the stages of hypertension?

Classification of hypertension on the basis of blood pressure.

Category	Systolic B.P (mmHg)	Diastolic B.P (mmHg)
Normal	<120	<80
Prehypertension	120-139	80-89
Hypertension	≥ 140	≥90
Hypertension stage 1	140-159	90-99
Hypertension stage 2	≥160	≥100

What is the main cause of hypertension?

The causes of high blood pressure depend upon the type of Hypertension. Sometimes a Doctor is not able to find the exact cause of high blood pressure and attributes it towards genetic reasons or some other conditions.
However, some common causes are:

• Hepatic disease i.e. Cirrhosis
• High salt intake
• Pulmonary fibrosis or bronchitis
• High cholesterol diet
• ■■■
• Cardiac defect by birth
• High blood sugar
• Excessive alcohol intake

Summary
Hypertension, also known as high blood pressure is a disease in which blood pressure is increased above the threshold and can lead to cardiac diseases. The main causes of hypertension are high salt intake, pulmonary diseases, high cholesterol levels, etc.

What are the types of hypertension?

Depending upon the etiology, there are following types of hypertension along with their signs and symptoms:

1. Primary OR Essential Hypertension

In 90% of individuals, the actual cause of this Hypertension is not known. It is diagnosed by continuously high blood pressure after three or four hospital visits. There are no specific symptoms associated with this type of hypertension.
Some patients represent the following signs:

• Frequently occurring headaches,
• Feeling of tiredness
• Dizziness
• Sometimes, blood from the nose

2. Secondary Hypertension

There is some specific cause behind this type of hypertension, for example, any defect in arteries supplying blood to organs.
There may be the following causes of secondary hypertension:

• Adrenal problem (i.e. tumor)
• Abnormality in thyroid glands
• Imbalancing of hormone
• High salt intake
• Alcohol consumption

3. Malignant Hypertension

In this type of hypertension, there is an abrupt and extreme rise in a patient’s blood pressure (about 180/120). It is the same as a hypertensive emergency and should be considered and managed like an emergency.

4. Resistant Hypertension

Resistant Hypertension is the type of hypertension in which blood pressure remains elevated no matter what therapy is given. It is mostly present in individuals, suffering from some other ailments, such as obesity, diabetes, renal problems, or in people with poor compliance with therapy.

What is Pulmonary Hypertension?

It is a serious kind of hypertension in which pulmonary arteries are either blocked or narrowed. As a result of blockage or narrowing of arteries, blood flow becomes difficult, forcing the heart to pump blood with excessive force.
This pressure on the heart depicts itself as hypertension. Due to excessive work pressure on the heart, cardiac muscles start to be weakened which may cause heart failure.
However, it can be treated effectively with medicines, after it gets diagnosed.

Summary
Various types of hypertension include essential hypertension, secondary hypertension, malignant hypertension, resistant hypertension, and another important type is pulmonary hypertension.

What is a hypertensive crisis or hypertensive emergency?

Same as malignant hypertension discussed earlier, hypertensive crises result from severely high blood pressure (180/120) that may lead to stroke, damage of blood vessels, or ■■■■■ failure. It can result from chronic hypertension.
The following factors can cause a hypertensive crisis:

• Missing the doses of blood pressure medicine
• Ruptured aorta
• Heart failure
• Eclampsia
  Hypertensive crisis can further be divided into two categories:

1. Urgent hypertensive crisis
2. Emergency hypertensive crisis

In urgent hypertensive crisis, there is an extreme rise in B.P, however, no evidence of ■■■■■ damage.
While, in an emergency hypertensive crisis, there is associated damage to the organs as a result of extremely high B.P. your blood pressure is extremely high and has caused damage to your organs and can be life-threatening.

Signs and symptoms of emergency hypertensive crisis are:

• Unbearable pain in the chest
• Severe headache
• Nausea and vomiting
• Convulsions

How hypertension can be diagnosed?

Hypertension can be diagnosed by repeatedly measuring the patient’s blood pressure. If it is constantly elevated, the patient may have hypertension. But diagnosis is not accompanied by the actual cause behind elevated blood pressure.

What is the compensatory mechanism to control blood pressure?

Blood pressure is kept in the normal range to adequately perfuse in the tissues with no damage to the vascular system including the endothelium

B.P = cardiac output (C.O) and peripheral resistance

C.O and P.R are controlled by two natural mechanisms

A. Baroreceptors

Baroreflexes act by affecting the sympathetic nervous system for normal regulation of blood pressure. When there is a lowering in blood pressure, the baroreceptors send some impulses to CV centers located in the spinal cord.
As a result of these impulses, the sympathetic system is stimulated to increase the output causing vasoconstriction. This vasoconstriction then results in increased cardiac output and blood pressure becomes normal.

B. Renin angiotensin-aldosterone system (RAAS)

This system acts by controlling the blood volume by kidneys. Baroreceptors are also situated in the kidney, hence if there is a lowering in blood pressure, renin is released by the kidneys.
Along with the baroreceptors mechanism, renin can also be released by fewer sodium levels in the body or increased excretion from the body.

Renin acts by converting angiotensinogen to angiotensin I, which is further changed into angiotensin II by a converting enzyme. Angiotensin II is vasoconstricting and acts on both arteries and veins to raise the blood pressure. It also stimulates aldosterone secretion, which causes increased Na reabsorption along with water molecules and hence increases blood volume.

How to control high blood pressure?

Hypertension can lead to several other cardiac diseases, hence it requires immediate and proper treatment along with the modification of lifestyle to lower the high blood pressure. The following categories of drugs can be used in the treatment of hypertension:

1. Diuretics

Diuretics act by increasing the excretion of sodium and water from the body. As a result of excretion, blood volume is decreased and hence blood pressure is also reduced.
The following drugs are included in this category:

• Thiazide diuretics (e.g. Hydrochlorothiazide)
• Loop diuretics (e.g. Furosemide)
• Potassium sparing diuretics (e.g. Spironolactone)

2. Sympatholytic agents

These agents act by opposing the effects of the sympathetic nervous system to lower the high blood pressure.

• Examples of these agents include beta blockers

• (e.g. Propranolol, nadolol)

3. Direct vasodilators

Vasodilators act by dilating the arteries by relaxation of smooth muscles forming walls of arteries.
They include:

• Hydralazine
• Minoxidil

4. Angiotensin-converting enzyme inhibitors

ACEIs are preferred as first-line treatment in hypertensive patients with various comorbidities or history of cardiac stroke, cardiac failure, infarction, or renal ailment.
They act by reducing peripheral resistance in blood vessels without affecting the output, heart rate, or contraction. One of the most common side effects associated with ACEIs is a persistent dry cough.

Some examples are:

• Captopril
• Enalapril
• Lisinopril

5. Angiotensin receptor blockers

They are used as alternatives to ACEIs and show their effects by blocking the angiotensin receptor hence hindering the binding of angiotensin.
They include:

• Losartan
• Valsartan
• Telmisartan etc.

6. Renin-inhibitors

Renin acts as a vasoconstrictor and causes a rise in blood pressure. A renin inhibiting agent will act in by inhibiting the vasoconstrictive action of renin thus normalizing the blood pressure.

Aliskiren, by selectively inhibiting renin, decreases the blood pressure just as ARBs, ACEIs, or diuretics do.

7. Calcium channel blockers

Depending upon the site of action, they can be classified as:

• Diphenylalkylamines (Verapamil)

  Act on smooth muscles of the heart and vessels.

• Benzothiazepines (Diltiazem)

  Acts in the same way as dihydropyridines but exhibits a favorable profile.

• Dihydropyridines (Nifedipine, Amlodipine)

  They preferably act on calcium channels of vessels as compared to channels in the heart.

8. Other options

• Alpha receptor blockers (Labetalol)
• Centrally acting drugs (Clonidine, methyldopa)
• Direct vasodilators (Hydralazine)

Summary
Treatment options for hypertension include beta-blockers, diuretics, direct vasodilators, ACEIs, ARBs, renin inhibitors, calcium channel blockers, and alpha-blockers.

What practices can be adopted for improvement in hypertension?

The following habits can be adopted for betterment of condition:

• Healthy lifestyle
• Regular exercise
• Better sleep
• Healthy diet with low salt and sugar
• Food with low fat to avoid cholesterol
• Avoid alcohol
• Avoid caffeine-containing drinks

Frequently asked questions

1. Can hypertension be completely cured?

Hypertension is a kind of ailment, which can’t be reversed once happens. It can only be managed and controlled with healthy lifestyles and medications. So, if a person is suffering from high blood pressure, he should avoid alcoholic beverages, caffeine drinks, cholesterol, or salt rich diet, or others recommended by the physician.

2. What are the warning signs of hypertension?

Hypertension should not be taken as a normal phenomenon if there are the following signs:

• Persistent and severe headache
• Mental confusion
• Nosebleed
• Increased lethargy

3. Can depression be a cause of hypertension?

According to the studies, mostly the patients suffering from hypertension also have depression and anxiety issues. Depression can directly affect the blood pressure and the patients with depression are more vulnerable to stroke, heart failure, or ischemic heart disease.

4. Does caffeine raise blood pressure?

The answer is yes, caffeine is a kind of drink that causes an abrupt rise in blood pressure. However, the underlying cause is yet unclear.
According to some studies, caffeine causes a rise in blood pressure by blocking a vasodilator hormone or by stimulating adrenaline release that raises blood pressure.

Conclusion:

Hypertension (high blood pressure) is a disease caused primarily due to depression, unhealthy lifestyle, excessive salt and sugar intake, consumption of food rich in cholesterol. It can’t be reversed but managed by healthy lifestyles and medication recommended by health care professionals.

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[Rida.Tahir9]

What is hypertension?

Hypertension, which is also known as elevated or high blood pressure, occurs without any obvious symptoms for a long period of time. However, it increases the risk of high blood pressure, heart attacks, kidney issues, etc.

Causes of hypertension:

There are several causes of hypertension, some of them are:

• It can occur due to genetic factors, like if someone blood-related to you have high blood pressure, chances are you would get it too.
• It can occur due to intake of diet which contains high amount of sodium, or fats.
• It also occurs due to fatigue, and lack of any physical activity.
• Alcohol and smoking also can contribute to high blood pressure.
• Stress is a huge reason for something to get hypertension.

Symptoms of hypertension:

There are various symptoms of hypertension, some of them are:

• It causes severe headaches.
• It also causes nosebleeds.
• It also causes a very bad chest pain.
• It also blurs the visions.
• It also causes by low physical productivity.
• In severe cases, blood also is seen in urine.
• Difficulty in breathing is also seen in this case.

Cure of hypertension:

The cure for hypertension is to take Diuretics, which is also known as water pills. This medicines help reduce the quantity of sodium in your body and controls the blood pressure. Other preventative measures include:

• Losing extra weight that may cause clogged arteries and high blood pressure.
• End smoking, drinking, and other unhealthy habits.
• Seek therapy to cope with your stress.
• Eat healthy and in limited quantities.

[samia_naeem]

High blood pressure is a common condition in individuals in which the long-term force of the blood against artery walls is high enough that it may eventually cause health problems, such as heart disease.
Blood pressure is determined both by the amount of blood that heart pumps and the amount of resistance to blood flow in the arteries. The more blood the heart pumps and the narrower arteries, the higher the blood pressure.

A person can have high blood pressure (hypertension) for years without any symptoms. Even without symptoms, damage to blood vessels and the heart continues and can be detected. Uncontrolled high blood pressure increases risk of serious health problems, including heart attack and stroke.

Causes of Hypertension

The cause of hypertension is often not known. In many cases, it is the result of an underlying condition. Stress can increase the risk of high blood pressure. Doctors call high blood pressure that is not due to another condition or disease primary or essential hypertension. If an underlying condition is the cause of increasing blood pressure, doctors call this secondary hypertension.

Primary hypertension can result from multiple factors, such as:

• hormone activity in people who manage blood volume and pressure using medication
• blood plasma volume
• environmental factors, such as stress and lack of exercise

Secondary hypertension has specific causes and is a complication of another health problem.

Chronic kidney disease is a common cause of high blood pressure, as the kidneys no longer filter out fluid. This excess fluid leads to hypertension.

Conditions that can lead to hypertension include:

• pheochromocytoma, a rare cancer of an adrenal gland
• diabetes, due to kidney problems and nerve damage
• kidney disease
• hyperparathyroidism, which affects calcium and phosphorous levels
• Cushing syndrome that corticosteroid drugs can cause
• sleep apnea
• congenital adrenal hyperplasia, a disorder of the cortisol-secreting adrenal glands
• hyperthyroidism, or an overactive thyroid gland
• pregnancy
• obesity

Risk factors

There are a number of factors that increase the risk of hypertension.

• Age: Hypertension is more common in people who are more than 60 years of age. Blood pressure can increase slowly and steadily with age as the arteries stiffen and narrow due to plaque buildup.
• Ethnicity: Some ethnic groups are more prone to hypertension than others. African Americans have a higher risk than other ethnic groups, for example. Size and weight: Being overweight or obese is a primary risk factor.
• Alcohol and tobacco use: Regularly consuming large quantities of alcohol or tobacco can increase blood pressure.
• Sex: According to a 2018 review, males have a higher risk of developing hypertension than females. However, this is only until after women reach menopause.
• Existing health conditions: Cardiovascular disease, diabetes, chronic kidney disease, and high cholesterol levels can lead to hypertension, especially as people age.

Other risk factors include:

• sedentary lifestyle
• salt rich, high fat diet
• low potassium intake

Poorly managed stress and a family history of high blood pressure can also contribute to the risk of developing hypertension.

How blood pressure and circulatory system works?

In order to survive and function properly, the tissues and organs of a body need the oxygenated blood that circulatory system carries throughout the body. When the heart beats, it creates pressure that pushes blood through a network of tube-shaped blood vessels, which include arteries, veins and capillaries. This pressure, blood pressure, is the result of two forces: The first force is systolic pressure which occurs as blood pumps out of the heart and into the arteries that are part of the circulatory system. The second force is diastolic pressure which is created as the heart rests between heart beats.

When does the damage starts in the arteries and heart?

The primary way that high blood pressure causes harm in the body is by increasing the workload of the heart and blood vessels and making them work ■■■■■■ and less efficiently.

With the time, the force and friction of high blood pressure damages the delicate tissues inside the arteries. In turn, LDL (bad) cholesterol forms plaque along tiny tears in the artery walls, signifying the start of atherosclerosis.

The more the plaque and damage increases, the narrower the insides of the arteries become, raising blood pressure and starting a vicious circle that further harm arteries, heart and the rest of the body. This can ultimately lead to other conditions ranging from arrhythmia to heart attack and stroke.

Stages of Hypertension

Doctors classify blood pressure into four main categories:
1. normal
2. prehypertension (mild)
3. stage 1 (moderate)
4. stage 2 (severe).

Treatment of these stages of hypertension depend on which category blood pressure consistently falls in when readings are taken. The stages are based on the Joint National Committee 7 report done by the National Heart, Lung and Blood Institute, which is a part of the National Institutes of Health.

Here are the current stages and their recommended treatments:

• Normal. In normal stage, systolic pressure should be less than 120 mm Hg and diastolic pressure should be less than 80 mm Hg.

Recommended Treatment
No treatment is necessary, but people should monitor their blood pressure to be sure that it remains within the normal range.

• Prehypertension: In prehypertension stage systolic pressure between 120 and 139 mm Hg or a diastolic pressure between 80 and 89 mm Hg. It is before someone crosses the threshold for the definition of hypertension but is at risk for developing hypertension.

Recommended Treatment

Researchers said that they don’t have evidence that using medications at this range is useful for preventing heart disease and stroke. However, because people in this group have some risk of moving on to developing heart disease, doctors recommend lifestyle measures to try to prevent the onset of hypertension. Lifestyle measures include exercise, managing body weight into a normal range, eating a diet high in fruits and vegetables, and choosing low-fat dairy products.

• Stage 1: Systolic pressure between 140 and 159 mm Hg or diastolic pressure between 90 and 99 mm Hg.

Recommended Treatment

Management includes the same lifestyle measures as with prehypertension and the use of one of a number of drugs that are known to not only reduce blood pressure but also to reduce the risk of heart disease and stroke. Classes of drugs include: thiazide diuretics, ACE inhibitors, angiotensin receptor blockers, beta blockers, and calcium channel blockers. people may have to try different drugs until they find the one that has the best results for them.

• Stage 2: In this stage systolic pressure 160 mm Hg or higher or diastolic pressure 100 mm Hg or higher.

Recommended Treatment

In addition to lifestyle changes, for many patients, it is recommended that a two-drug therapy chosen from among the five classes of hypertensive agents be used to get their blood pressure down.
If the systolic and diastolic pressures fall into different stages, the stage with the higher number is the one that counts. For example, if a person has a systolic pressure of 150 mm Hg but diastolic pressure is only 85 mm Hg, he will be classified as stage 1 hypertension, not prehypertension. And if a person is over age 50, it is the diastolic number that best predicts risk of cardiovascular disease.

If these stages left untreated, high blood pressure can lead to coronary heart disease, which can mean a heart attack or stroke. People should have their blood pressure checked regularly, and follow their doctor’s advice for keeping it under control.

How Blood Pressure is Measured?

Blood pressure is measured with an instrument called a sphygmomanometer, through which the user listens for the sound of the force of blood in the patient’s arteries when the heart beats (systolic pressure). Measured in millimeters of mercury (mm Hg), systolic pressure is the top number in your blood pressure reading. The second, or bottom number, is the pressure in the arteries of the heart at rest, the diastolic pressure. Generally, an adult are considered to have high blood pressure if systolic pressure reading is greater than or equal to 140 mm Hg or if diastolic pressure is greater than or equal to 90 mm Hg. But for every 20 mm Hg systolic pressure raises above 115, and for every 10 mm Hg diastolic pressure rises over 75, risk of cardiovascular disease doubles, so lower pressures are generally better.

The AHA 2017 guidelines have defined the following ranges of blood pressure:

	Systolic (mmHg)	Diastolic (mmHg)
Normal blood pressure	Less than 120	Less than 80
Elevated	Between 120 and 129	Less than 80
Stage 1 hypertension	Between 130 and 139	Between 80 and 89
Stage 2 hypertension	At least 140	At least 90
Hypertensive crisis	Over 180	Over 120

If the reading indicates a hypertensive crisis, wait 3 or 4 minutes and then repeat the test.

If the reading is the same or higher, this indicates that you need a medical emergency.

The person should seek immediate help at the nearest hospital.

Symptoms of Hypertension

A person with hypertension may not notice any symptoms, and so people often call it the “silent killer.” Without detection, hypertension can damage the heart, blood vessels, and other organs, such as the kidneys.

It is important to check blood pressure regularly.

In rare and severe cases, high blood pressure causes sweating, anxiety, sleeping problems, and blushing. However, most people with hypertension will experience no symptoms at all.

If high blood pressure becomes a hypertensive crisis, a person may experience headache and nosebleeds.

Complications

If someone has a long term hypertension, it can cause complication through atherosclerosis where plaque develops on the walls of blood vessels, causing them to narrow.

This narrowing of walls of blood vessels makes hypertension worse, as the heart must pump ■■■■■■ to circulate the blood.

Hypertension-related atherosclerosis may lead to:

• kidney failure
• heart failure and heart attacks
• amputation
• aneurysm, or abnormal bulge in the wall of an artery that can burst
• stroke
• hypertensive retinopathies in the eye, which can lead to blindness

Regular blood pressure monitoring can help people avoid these more severe complications.

Management and treatment of hypertension

Adjustments of lifestyle are the standard, first-line treatment for hypertension. Some of the recommendations are here:

Regular physical exercise

• Current guidelines recommend that all people, including those with hypertension, should engage in at least 150 minutes of moderate intensity, aerobic exercise every week, or 75 minutes a week of high intensity exercise.

• People should exercise on at least 5 days of the week.

• Examples of suitable activities are walking, jogging, cycling, or swimming.

Reduction of Stress

• People should avoid or learn to manage stress. It can help a person control blood pressure.

• Meditation, warm baths, yoga and simply going on long walks are relaxation techniques that can help them relieve stress.

• People should avoid consuming alcohol, recreational drugs, tobacco, and junk food to cope with stress, as these can contribute to elevated blood pressure and the complications of hypertension.

• Smoking can increase blood pressure. Avoiding or quitting smoking reduces the risk of hypertension, serious heart conditions, and other health issues.

. Medication for Hypertension

People can use medications to treat hypertension. Doctors will often recommend a low dose at first. Antihypertensive medications will usually only have minor side effects.

Eventually, people with hypertension will need to combine two or more drugs to manage their blood pressure.

Medications for hypertension include:

• angiotensin-converting enzyme (ACE) inhibitors
• diuretics, including thiazides, chlorthalidone, and indapamide
• beta-blockers and alpha-blockers
• calcium-channel blockers
• angiotensin receptor blockers
• central agonists
• peripheral adrenergic inhibitor
• vasodilators

The choice of medication depends on the person and any underlying medical conditions they may experience.

Diet

People can prevent themselves from high blood pressure by following a heart-healthy diet.

• By reducing salt intake

People’s average salt intake is between 9 grams (g) and 12 g per day in most countries around the world.

The World Health Organization (WHO) recommend reducing intake to under 5 g a day to help decrease the risk of hypertension and related health problems.

Lowering salt intake can benefit people both with and without hypertension.

• By moderating alcohol consumption

Moderate to excessive alcohol consumption can increase blood pressure.

The American Heart Association (AHA) recommend a maximum of two alcoholic drinks a day for men, and one for women.

A healthcare provider can help people reduce consumption if they find it difficult to moderate their alcohol intake.

• By eating more fruit and vegetables and less fat

People who have high blood pressure or people at high risk of developing high blood pressure should eat as little saturated and total fat as possible.

Instead, experts recommend the following:

• nontropical vegetable oils, for example, olive oil
• whole grain, high fiber foods
• low fat dairy products
• beans, pulses, and nuts
• fish rich in omega-3 twice a week
• a variety of fruit and vegetables
• skinless poultry and fish

It is important to avoid trans fats, hydrogenated vegetable oils, and animal fats, as well as large portion sizes.

Some fats, such as those in oily fish and olive oil, have protective effects on the heart. However, these are still fats. While they are typically healthful, people with a risk of hypertension should still include them in their total fat intake.

• By managing body weight

Excess body weight can contribute to hypertension. A fall in blood pressure usually follows weight loss, as the heart does not have to work so hard to pump blood around the body.

A balanced diet with a calorie intake that matches the individual’s size, sex, and activity level will help.

Frequently Asked Questions

• What are the warning signs of hypertension?

Symptoms of Severe High Blood Pressure:

If the blood pressure is extremely high, there may be certain symptoms to look out for, including: Severe headaches, Nosebleed, Fatigue or confusion.

• What is the main cause of hypertension?

Common factors that can be a cause of high blood pressure include:

• A diet high in salt, fat, and/or cholesterol.

• Chronic conditions such as kidney and hormone problems, diabetes , and high cholesterol.

• Family history, especially if parents or other close relatives have high blood pressure.

• What should we eat when BP is high?

Eating a diet that is rich in whole grains, fruits, vegetables and low-fat dairy products and skimps on saturated fat and cholesterol can lower blood pressure by up to 11 mm Hg if a person has high blood pressure. This eating plan is known as the Dietary Approaches to Stop Hypertension (DASH) diet.

• Does lemon lower BP?

Lemon is one of the best remedies for hypertension. It is known to make the blood vessels soft and flexible, lowering blood pressure level. Lemon contains high amounts of Vitamin C, which acts as an anti-oxidant, removing free radicals from the body.

• Is cucumber good for high blood pressure?

Cucumber is a good source of potassium and is a diuretic. A diuretic is any substance that promotes increased production of urine. Diuretics help reduce sodium and also maintain fluid balance in the body, which is essential to maintain stable blood pressure levels.

Conclusion

Hypertension is a very important disorder in aged people and is associated with higher risk of cardiovascular morbidity and mortality. The fact of reducing blood pressure values decreases the risk for cardiac death as well as neurological, metabolic, and musculoskeletal system sequelae in aged people. Therefore, the aim of the antihypertensive treatment must be to reduce cardiovascular risks and to maintain an adequate quality of life and good functional capacity in these patients.
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