Hypertension/ja: Difference between revisions

| caption      = 自動化された腕の[[sphygmomanometer/ja|血圧計]]で[[artery/ja|動脈]]高血圧（[[systolic blood pressure/ja|収縮期血圧]]で示される。158 mmHg、[[diastolic blood pressure/ja|拡張期血圧]]は99 mmHg、[[heart rate/ja|心拍数]]は80拍/分である)

生活習慣の改善と薬物療法は血圧を下げ、健康合併症のリスクを低下させる。生活習慣の改善には、[[weight loss/ja|減量]]、[[exercise/ja|身体運動]]、[[Health effects of salt/ja|塩分摂取量]]の減少、アルコール摂取量の減少、[[healthy diet/ja|健康的な食事]]などがある。生活様式の変更が十分でない場合は、[[blood pressure medication/ja|血圧治療薬]]が使用される。最大3種類の薬を同時に服用することで、90％の人の血圧をコントロールすることができる。薬物による中等度の高動脈血圧（160/100mmHg以上と定義）の治療は、[[life expectancy/ja¥生命予後]]の改善と関連している。130/80 mmHgから160/100 mmHgの間の血圧に対する治療の効果はあまり明らかでなく、有益であるとするレビューもあれば、有益性は不明であるとするレビューもある。高血圧は、世界人口の16〜37％が罹患している。2010年には、高血圧が全死亡の17.8％（世界で940万人）の要因であったと考えられている。

二次性高血圧は、同定可能な原因による高血圧であり、特定の徴候および症状が追加されることがある。例えば、[[Cushing's syndrome/ja|クッシング症候群]]は、高血圧を引き起こすだけでなく、しばしば[[Abdominal obesity/ja|三頭筋肥満]]、[[glucose intolerance/ja|耐糖能異常]]、[[moon face/ja|ムーンフェイス]]、首や肩の後ろの脂肪のこぶ（バッファローコンプと呼ばれる）、および紫色の腹部の[[stretch marks/ja|妊娠線]]を引き起こす。[[Hyperthyroidism/ja|甲状腺機能亢進症]]は食欲亢進を伴う体重減少、[[tachycardia/ja|速い心拍数]]、[[exophthalmos/ja|眼球膨張]]、振戦を頻繁に引き起こす。[[Renal artery stenosis/ja|腎動脈狭窄症]]（RAS）は、正中線の左側または右側に限局した腹部[[拍動]]を伴う（片側性RAS）こともあれば、両方の部位に伴う（両側性RAS）こともある。[[Coarctation of the aorta/ja|大動脈瘤]]は、腕に対する下肢の血圧低下、または[[femoral artery/ja|大腿動脈脈拍]]の遅延または欠如を頻繁に引き起こす。[[Pheochromocytoma/ja|褐色細胞腫]]は、頭痛、[[palpitation/ja|動悸]]、[[Pallor/ja|青白い外観]]、および[[Diaphoresis|excessive sweating/ja|過度の発汗]]を伴う高血圧の突然のエピソードを引き起こすことがある。

[[low birth weight/ja|低出生体重児]]，[[Smoking and pregnancy/ja|母親の喫煙]]，[[breastfeeding/ja|母乳育児]]の欠如といった幼児期の出来事は，成人本態性高血圧の危険因子である可能性があるが，これらの曝露と成人高血圧を結びつける機序は依然として不明である。未治療の高血圧患者では、正常血圧の人に比べて[[hyperuricemia/ja|高血中尿酸]]の割合が高いことが判明しているが、前者が因果関係にあるのか、腎機能の低下に伴うものなのかは不明である。平均血圧は夏よりも冬の方が高いかもしれない。[[Periodontal disease/ja歯周病]]も高血圧と関連している。

高血圧における末梢抵抗の上昇を説明するために、多くのメカニズムが提唱されてきた。多くのエビデンスは、腎臓の塩分と水分の処理の障害（特に腎内[[renin–angiotensin system/ja|レニン-アンジオテンシン系]]の異常）か、[[sympathetic nervous system/ja|交感神経系]]の異常のいずれかが関与している。これらの機序は相互に排他的ではなく、本態性高血圧のほとんどの症例では両者がある程度寄与していると考えられる。また、[[endothelial dysfunction/ja|内皮機能障害]]や血管の[[inflammation/ja|炎症]]も高血圧における末梢抵抗の増加や血管障害に関与している可能性が示唆されている。[[Interleukin 17/ja|インターロイキン17]]は，[[tumor necrosis factor alpha/ja|腫瘍壊死因子α]]，[[interleukin 1/ja|インターロイキン1]]，[[interleukin 6/ja|インターロイキン6]]，[[interleukin 8/ja|インターロイキン8]]など，高血圧に関与していると考えられている他のいくつかの[[cytokine/ja|サイトカイン|免疫系の化学シグナル]]の産生を増加させる役割を担っていることで注目を集めている。

Dietary changes shown to reduce blood pressure include diets with low sodium, the [[DASH diet]] (Dietary Approaches to Stop Hypertension), which was the best against 11 other diet in an umbrella review, and plant-based diets. There is some evidence [[green tea]] consumption may help lower blood pressure, but this is insufficient for it to be recommended as a treatment. There is evidence from randomized, double-blind, placebo-controlled clinical trials that [[Hibiscus tea]] consumption significantly reduces systolic blood pressure (-4.71 mmHg, 95% CI [-7.87, -1.55]) and diastolic blood pressure (−4.08 mmHg, 95% CI [-6.48, −1.67]). [[Beetroot|Beetroot juice]] consumption also significantly lowers the blood pressure of people with high blood pressure.

Increasing [[Potassium#Nutrition|dietary potassium]] has a potential benefit for lowering the risk of hypertension. The 2015 Dietary Guidelines Advisory Committee (DGAC) stated that potassium is one of the shortfall nutrients which is under-consumed in the United States. However, people who take certain antihypertensive medications (such as ACE-inhibitors or ARBs) should not take potassium supplements or potassium-enriched salts due to the risk of high levels of potassium.

Physical exercise regimens which are shown to reduce blood pressure include [[isometric exercise|isometric resistance exercise]], [[aerobic exercise]], [[resistance exercise]], and device-guided breathing.

Stress reduction techniques such as [[biofeedback]] or [[transcendental meditation]] may be considered as an add-on to other treatments to reduce hypertension, but do not have evidence for preventing cardiovascular disease on their own. Self-monitoring and appointment reminders might support the use of other strategies to improve blood pressure control, but need further evaluation.

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===Medications===

Several classes of medications, collectively referred to as [[antihypertensive drug|antihypertensive medication]]s, are available for treating hypertension.

First-line medications for hypertension include [[Thiazide|thiazide-diuretics]], [[calcium channel blockers]], [[angiotensin converting enzyme inhibitor]]s (ACE inhibitors), and [[Angiotensin II receptor blocker|angiotensin receptor blockers]] (ARBs). These medications may be used alone or in combination (ACE inhibitors and ARBs are not recommended for use together); the latter option may serve to minimize counter-regulatory mechanisms that act to restore blood pressure values to pre-treatment levels, although the evidence for first-line combination therapy is not strong enough. Most people require more than one medication to control their hypertension. Medications for blood pressure control should be implemented by a stepped care approach when target levels are not reached. Withdrawal of such medications in the elderly can be considered by healthcare professionals,  because there is no strong evidence of an effect on mortality, [[myocardial infarction]], or [[stroke]].

Previously, [[beta-blockers]] such as [[atenolol]] were thought to have similar beneficial effects when used as first-line therapy for hypertension. However, a Cochrane review that included 13 trials found that the effects of beta-blockers are inferior to that of other antihypertensive medications in preventing cardiovascular disease.

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===Resistant hypertension===

Resistant hypertension is defined as high blood pressure that remains above a target level, in spite of being prescribed three or more antihypertensive drugs simultaneously with different [[mechanism of action|mechanisms of action]]. [[Adherence (medicine)|Failing to take prescribed medications as directed]] is an important cause of resistant hypertension. Resistant hypertension may also result from chronically high activity of the [[autonomic nervous system]], an effect known as ''neurogenic hypertension''. Electrical therapies that stimulate the [[baroreflex]] are being studied as an option for lowering blood pressure in people in this situation.

Some common secondary causes of resistant hypertension include [[obstructive sleep apnea]], [[pheochromocytoma]], [[renal artery stenosis]], [[coarctation of the aorta]], and [[primary aldosteronism]]. As many as one in five people with resistant hypertension have primary aldosteronism, which is a treatable and sometimes curable condition.

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=== Refractory hypertension ===

{{Main|Refractory hypertension}}

Refractory hypertension is characterized by uncontrolled elevated [[blood pressure]] unmitigated by five or more antihypertensive agents of different classes, including a long-acting [[thiazide-like diuretic]], a [[calcium channel blocker]], and a blocker of the [[renin-angiotensin system]]. People with refractory hypertension typically have increased sympathetic nervous system activity, and are at high risk for more severe cardiovascular diseases and all-cause mortality.

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===Non-modulating===

Non-modulating essential hypertension is a form of [[salt]]-sensitive hypertension, where [[sodium]] intake does not modulate either [[Adrenal gland|adrenal]] or [[Kidney|renal]] [[Vascular system|vascular]] responses to [[angiotensin II]]. Individuals with this subset have been termed non-modulators. They make up 25–30% of the hypertensive population.

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==Epidemiology==

[[File:Hypertension World Map Men 2014.png|thumb|upright=1.5|Rates of hypertension in adult men in 2014]]

[[File:Hypertensive heart disease world map - DALY - WHO2004.svg|thumb|upright=1.5|[[Disability-adjusted life year]] for [[hypertensive heart disease]] per 100,000&nbsp;inhabitants in 2004:

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===Adults===

{{As of|2019}}, at least 1 billion 278 million adults aged 30–79 worldwide (over 16% of [[world population]]), including 626 million women and 652 million men, were estimated to have hypertension. This is approximately 278 million up from 2014 and almost double compared to year 1990, when there were estimated 648 million adults in the same age group living with the condition worldwide.

Hypertension is ''slightly'' more frequent in men, in those of low [[socioeconomic status]], and it becomes more common with age. It is common in high, medium, and low-income countries. In 2004, rates of high blood pressure were highest in Africa (30% for both sexes), and lowest in the Americas (18% for both sexes). Rates also vary markedly within regions with country-level rates as low as 22.8% (men) and 18.4% (women) in Peru and as high as 61.6% (men) and 50.9% (women) in Paraguay. Rates in Africa were about 45% in 2016.

In Europe, hypertension occurs in about 30–45% of people {{as of|2013|lc=y}}. In 1995 it was estimated that 43 million people (24% of the population) in the United States had hypertension or were taking antihypertensive medication. By 2004 this had increased to 29% and further to 32% (76&nbsp;million US adults) by 2017. In 2017, with the change in definitions for hypertension, 46% of people in the United States are affected. African-American adults in the United States have among the highest rates of hypertension in the world at 44%. It is also more common in [[Filipino Americans]] and less common in US [[European Americans|whites]] and [[Mexican American]]s. Differences in hypertension rates are multifactorial and under study.

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===Children===

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==Prognosis==

{{Main|Complications of hypertension}}

[[File:Main complications of persistent high blood pressure.svg|thumb|upright=1.4|Diagram illustrating the main complications of persistent high blood pressure]]

Hypertension is the most important [[List of preventable causes of death|preventable risk factor for premature death]] worldwide. It increases the risk of [[ischemic heart disease]], [[strokes]], [[peripheral vascular disease]], and other cardiovascular diseases, including [[heart failure]], [[aortic aneurysm]]s, diffuse [[atherosclerosis]], [[chronic kidney disease]], [[atrial fibrillation]], [[cancer]]s, [[leukemia]] and [[pulmonary embolism]]. Hypertension is also a risk factor for [[cognitive impairment]] and [[dementia]]. Other complications include [[hypertensive retinopathy]] and [[hypertensive nephropathy]].

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==History==

{{Main|History of hypertension}}

[[File:William Harvey ( 1578-1657) Venenbild.jpg|Image of veins from Harvey's ''Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus''|left|thumb]]

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===Measurement===

Modern understanding of the cardiovascular system began with the work of physician [[William Harvey]] (1578–1657), who described the circulation of blood in his book "''De motu cordis''". The English clergyman [[Stephen Hales]] made the first published measurement of blood pressure in 1733. However, hypertension as a clinical entity came into its own with the invention of the cuff-based [[sphygmomanometer]] by [[Scipione Riva-Rocci]] in 1896. This allowed easy measurement of systolic pressure in the clinic. In 1905, [[Nikolai Korotkoff]] improved the technique by describing the [[Korotkoff sounds]] that are heard when the artery is ausculted with a stethoscope while the sphygmomanometer cuff is deflated. This permitted systolic and diastolic pressure to be measured.

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===Identification===

Descriptions of hypertension as a disease came among others from [[Thomas Young (scientist)|Thomas Young]] in 1808 and especially [[Richard Bright (physician)|Richard Bright]] in 1836. The first report of elevated blood pressure in a person without evidence of kidney disease was made by [[Frederick Akbar Mahomed]] (1849–1884).

Until the 1990s, systolic hypertension was defined as systolic blood pressure of 160 mm Hg or greater. In 1993, the WHO/ISH guidelines defined 140 mmHg as the threshold for hypertension.

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===Treatment===

Historically the treatment for what was called the "hard pulse disease" consisted in reducing the quantity of blood by [[bloodletting]] or the application of [[leech]]es. This was advocated by The [[Yellow Emperor]] of China, [[Aulus Cornelius Celsus|Cornelius Celsus]], [[Galen]], and [[Hippocrates]]. The therapeutic approach for the treatment of hard pulse disease included changes in lifestyle (staying away from anger and [[sexual intercourse]]) and dietary program for patients (avoiding the consumption of [[wine]], meat, and pastries, reducing the volume of food in a meal, maintaining a low-energy diet and the dietary usage of [[spinach]] and [[vinegar]]).

In the 19th and 20th centuries, before effective pharmacological treatment for hypertension became possible, three treatment modalities were used, all with numerous side-effects: strict sodium restriction (for example the [[rice diet]]), [[sympathectomy]] (surgical ablation of parts of the [[sympathetic nervous system]]), and pyrogen therapy (injection of substances that caused a fever, indirectly reducing blood pressure).

The first chemical for hypertension, [[sodium thiocyanate]], was used in 1900 but had many side effects and was unpopular. Several other agents were developed after the [[World War II|Second World War]], the most popular and reasonably effective of which were [[tetramethylammonium chloride]], [[hexamethonium]], [[hydralazine]], and [[reserpine]] (derived from the medicinal plant ''[[Rauvolfia serpentina]]''). None of these were well tolerated. A major breakthrough was achieved with the discovery of the first well-tolerated orally available agents. The first was [[chlorothiazide]], the first [[thiazide]] [[diuretic]] and developed from the antibiotic [[sulfanilamide]], which became available in 1958. Subsequently, [[beta blocker]]s, [[calcium channel blockers]], [[angiotensin converting enzyme]] (ACE) inhibitors, [[angiotensin receptor blockers]], and [[renin inhibitors]] were developed as antihypertensive agents.