Hypertension (HTN) is an increasing threat to global public health, a leading cause of premature death, and an important modifiable risk factor for coronary artery disease (CAD), stroke, and renal failure. The global burden of HTN is expected to increase from the current estimate of 1 billion affected individuals to 15.6 billion affected individuals by 2025.^[1] Aggressive lifestyle modifications are recommended in all subjects with HTN irrespective of age, gender, race, risk factors, or associated comorbidities. Statins for primary prevention of CAD are often needed in patients with HTN. The special issue of HTN from ""Aamchi Mumbai"" (our Mumbai) includes contribution from diverse specialties and provides insights into specific issues which a cardiologist, internist, pulmonologist, neurologist, interventional cardiologist, or pediatrician encounter. Clinicians from across the Mumbai have put forward their views on subjects varying from BP levels to therapeutic interventions. Management of HTN in specific circumstances (e.g., pregnancy, obstructive sleep apnea (OSA), resistant and secondary HTN) have been eloquently addressed.

How to cite this article: Sharma S. Special issue on hypertension from, ""Amachi Mumbai."" Hypertens 2020;6(2):38-39.

Received: 09-06-2020;

Accepted: 14-06-2020

Hypertension is a well-established modifiable risk factor for stroke. As the prevalence of hypertension is increasing over the past few decades, it is becoming increasingly important to diagnose hypertension early and adjust the treatment vigilantly. A distinct pathologic process is involved in hypertensive individuals leading to stroke. Hypertension causes alteration of blood-brain barrier by affecting endothelial and smooth muscle cells, resultant vascular remodeling, and hypertrophy which prompt atherosclerosis and lipohyalinosis in large and small vessels, respectively. Therapy in the first few hours of stroke has evolved very rapidly and thrombolysis and thrombectomy are being routinely employed. These require specific blood management which avoids complications. Poorly managed blood pressure (high as well as low) in acute and/or chronic settings leads to disastrous outcomes of stroke in terms of mortality and long-term morbidity. Different non-pharmacological and pharmacological measures are available for hypertension management in the primary and secondary prevention of stroke. Well-managed hypertension over long periods of time leads to reduction in the long-term morbidity and mortality from strokes. Various guidelines and trials are available for the management of hypertension in stroke . In this paper, we discuss the various updates of the management of hypertension in cerebral vascular diseases for prevention, recurrence, and acute and chronic management.

Key words: Hypertension, pathophysiology of hypertension, prevention, stroke, treatment

How to cite this article: Khadilkar SV, Patel R, Singh R. Considerations in the Management of Hypertension in Cerebral Vascular Diseases. Hypertens 2020;6(2):40-44.

Received: 12-05-2020;

Accepted: 27-05-2020

Prevalence of hypertension (HT) in children is increasing. Part of the reason is the rise in the population of children with obesity and part is better screening for HT though far from ideal. Neonatal and infantile HT remains relatively poorly described in terms of epidemiology, normative data, and available antihypertensive medications. The 2017 American Academy of Pediatrics guidelines on the management of HT in children have used data from children with normal body mass index thereby lowering the cutoffs for definition of HT compared to earlier. HT is now staged as elevated, Stage 1 and Stage 2, making earlier terminologies obsolete. Elevated blood pressure (BP) is important as studies show that an elevated BP as a child increases risk of developing HT as an adult as well as metabolic syndrome. Ambulatory BP monitoring in pediatrics is increasingly being used in various situations though so far there is no normative data for children <120 cm in height. Investigations into the cause of HT may be limited when the patient is over 6 years of age and is overweight or obese or has family history of HT and the physical examination is normal. The two major causes of secondary HT in pediatrics are renal/reno-vascular and endocrine. Lifestyle modification plays a major role in therapy. It includes weight reduction/control by increasing physical activity, nutritious, and low-fat diet and reducing salt intake. The first-line medications for oral therapy are angiotensin converting enzyme inhibitors, angiotensin receptor blockers, thiazide diuretics, and calcium channel blockers. Lifelong follow-up is essential for care of the pediatric patient with HT.

Key words: Blood pressure, hypertension, management, pediatrics

How to cite this article: Garekar S. Hypertension in Children. Hypertens 2020;6(2):45-51.

Received: 18-05-2020;

Accepted: 29-05-2020

Hypertension (HTN) in women has generated more focus in view of reports of increased prevalence. Women compared with men exhibit a steeper increase in blood pressure (BP) as early as in the third decade and continue in a linear time course thereafter. HTN is the most common medical disorder during pregnancy. Pre-existing HTN is defined as HTN diagnosis before pregnancy, early in pregnancy (before 20 weeks of gestation), or HTN continues after 6 weeks postpartum. Gestational hypertension (GH) is defined as HTN first diagnosis during pregnancy after 20 weeks of gestation. Antihypertensive medications should be initiated at BP ≥150/95 mmHg for patients with pre-existing HTN and >140/90 mmHg for patients with gestational HTN with or without proteinuria. BP target should be <140/90 for all hypertensive pregnant women. Women who take antihypertensive treatments other than ACE inhibitors, ARBs, thiazide or thiazide-like diuretics, and limited evidence available have not shown an increased risk of congenital malformation with such treatments. Labetalol is first-line medication during pregnancy and lactation. Antihypertensives should be restarted after delivery and tapered slowly only after days 3-6 postpartum. Most antihypertensive medicines taken while breastfeeding is safe. Women with established strong clinical risk factors for preeclampsia should be treated ideally before 16 weeks with low-dose aspirin 75-162 mg/day. Women with GH or preeclampsia have increased risks of cardiovascular disease and recurrence of preeclampsia and GH in future pregnancies.

Key words: Gestational hypertension, hypertension during pregnancy, hypertension, labetalol, preeclampsia, proteinuria

How to cite this article: Jadhav UM, Khilari VS. Hypertension in Women. Hypertens 2020;6(2):52-57.

Received: 15-05-2020;

Accepted: 28-05-2020

The cornerstone of treatment in hypertension is lifestyle management and pharmacotherapy. A remedial cause of hypertension called as secondary is present in small number of patients. Percutaneous or surgical treatment can be curative or highly effective in controlling the blood pressure in these cases. Balloon angioplasty and stent implantation provide excellent blood pressure control in coarctation of aorta and nonspecific aortoarteritis. There is considerable debate regarding stent deployment in atherosclerotic renal artery stenosis and its use should be restricted to select group. The results of percutaneous interventions are remarkable in fibromuscular dysplasia and post renal transplant graft restenosis .Surgery has a definite role in endocrine disorders like pheochromocytoma ,adrenal adenoma and cushing's disease. Renal denervation is an attractive therapy for patients with essential hypertension who are refractory to pharmacotherapy. Ongoing studies will provide real world indications for this technique.

Key words: Aortic stenting, hypertension, renal denervation, renal stenting, transcatheter interventions

How to cite this article: Sharma S. Interventional Treatment of Secondary and Essential Hypertension. Hypertens 2020; 6(2):58-63.

Received: 13-05-2020;

Accepted: 27-05-2020

The bene?ts of blood pressure (BP) lowering treatment for the prevention of cardiovascular disease are well established. However, aggressive control of BP is controversial, as it leads to a reduction in organ perfusion and function, thereby increasing overall morbidity and mortality. An elusive balance is now being sought between deleterious effects of hypotension and protective autoregulatory mechanism. Here, we perform a systematic review of data and the current status of aggressive control of BP in various clinical settings.

Key words: Aggressive blood pressure control, autoregulatory mechanisms, hypotension

How to cite this article: Sanzgiri P, Reddy KVC. Newer and Aggressive Blood Pressure Goals to Treat Hypertension 2020;6(2):64-69.

Received: 12-05-2020;

Accepted: 29-05-2020

Life style alterations and drug therapy are the main stay in the treatment of hypertension (HTN). Five classes of drugs, for example, angiotensin-converting enzyme inhibitor (ACEI), aldosterone receptor blocker (ARB), beta-blocker (BB), calcium channel blocker (CCB), and diuretics have been recommended by various guidelines and these agents are standard of care. This review focusses on certain agents which have become available or new data have emerged with the existing compound. Azilsartan, a recently approved ARB, has been shown to provide sustained and superior antihypertensive effect as compared to existing sartans. Nebivolol, a third-generation long-acting BB with vasodilatory effects, provides excellent hemodynamic and side effect profile. A number of third- and fourth-generation CCB (benidipine, azelnidipine, and cilnidipine) are available in our country. These compounds are highly vascular selective and display organ protection effects. The use of these agents can be individualized depending on the likely benefits. Spironolactone, an old drug with modest blood pressure lowering effects, has proved to be an excellent add-on fourth agent in patients with resistant HTN.

Key words: Azelnidipine, azilsartan, benidipine, hypertension treatment, nebivolol

How to cite this article: Sharma S. Newer Drug Choices in Hypertension Treatment. Hypertens 2020;6(2):70-73.

Received: 13-05-2020;

Accepted: 29-05-2020

Cardiovascular disease (CVD) accounts for significant morbidity and mortality globally. Obstructive sleep apnea (OSA) is the repeated stoppage of inspiratory airflow due to oropharyngeal obstruction during sleep. This results in lack of oxygen, disturbance to sleep, and adrenergic nervous system stimulation. Consequently, the blood pressure rises, there are tachycardia, vascular dysfunction, widespread inflammation, and resistance to insulin. All these changes are said to contribute to the development of CVD. A large volume of evidence has accumulated in favor of OSA linking it to hypertension, coronary artery disease, cardiac failure, and various cardiac arrhythmias. Increased public awareness of OSA and its early detection, prompt diagnosis, and institution of appropriate treatment, including continuous positive airway pressure, would help in adequate control of this potentially modifiable risk factor in the era of increasing CVD.

Key words: Cardiovascular disease, hypertension, obstructive sleep apnea

How to cite this article: Tampi PS. Obstructive Sleep Apnea, Hypertension, and Cardiovascular Disease. Hypertens 2020;6(2):74-78.

Received: 15-05-2020;

Accepted: 30-05-2020

Resistant hypertension (HT) is a vexing problem and accounts for approximately 10% of all cases of HT. According to European and American Heart Association/American College of Cardiology guidelines, it is defined as blood pressure (BP) above target levels despite optimal dosing of three antihypertensive medications of which one is a thiazide diuretic. The other two are most often a calcium channel blocker and an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. It is imperative to first rule out all causes of pseudoresistant HT such as inaccurate BP measurement, prominent white coat effect, poor medication compliance, and inadequate optimization of treatment. Contributing lifestyle factors and secondary causes of HT must also be looked for and corrected before labeling the patient as having resistant HT. Investigations should include basic tests to evaluate for end-organ damage and in selected cases tests to rule out the common secondary causes such as sleep disorders, primary hyperaldosteronism, chronic kidney disease, and renovascular HT. When treating such patients, the first step is to change from hydrochlorothiazide to chlorthalidone or indapamide which are more effective diuretics. If a fourth drug is to be added, the strategy of choice is to add a mineralocorticoid receptor antagonist such as spironolactone eplerenone or amiloride. Beta-blockers, alphablockers, centrally acting drugs such as clonidine, and vasodilators such as hydralazine are other medicines that can be used for very resistant cases. For patients with very stubborn HT, newer interventional modalities may be tried. Among these, the most investigated is renal (sympathetic) denervation by either ultrasound or radiofrequency ablation. Another newer target is carotid baroreceptor modulation. Although an exciting frontier in the treatment of resistant HT, their efficacy, safety, and exact role await further randomized studies.

Key words: Drug therapy mineralocorticoids, interventional treatment, pseudoresistant hypertension, resistant hypertension

How to cite this article: Pinto RJ. The Perplexing Problem of Resistant Hypertension - Evaluation and Treatment (Review). Hypertens 2020;6(2):79-86.

Received: 14-05-2020;

Accepted: 30-05-2020

Hypertension remains the strongest risk factor for development of coronary artery disease ( CAD) and often both these conditions co-exist. Genetic and environmental factors interact to determine whether an individual may develop hypertension and related CAD. Blood pressure lowering itself reduces cardiovascular disease (CVD) risk in patients with hypertension ,however a residual cardiovascular risk persists and necessitates better evaluation and treatment of these individuals. For primary prevention of CAD, the key factor is lowering of blood pressure rather than the choice of the drug, whereas for secondary prevention there is merit in choosing the appropriate agent. From a practical standpoint, an office BP of <130/80 is the target for most patients, if well tolerated (except for people above age 65 years, for whom the 2018 ESC/ESH guidelines recommend a target of <140/80). Care needs to be taken to keep DBP above 70 mm in some patients. Certain drugs should be avoided in CAD with heart failure and in CAD without HF. While statins are recommended for secondary prevention of CVD in all hypertensives, they are recommended in those at moderate to high risk for primary prevention. Aspirin is indicated in all patients for secondary prevention, but has restricted recommendation for primary prevention.

Key words: Hypertension, Coronary artery disease, blood pressure targets, primary and secondary prevention

How to cite this article: Mehta AK. Managing Hypertension in Coronary Artery Disease. Hypertens 2020;6(2):87-93.

Received: 14-05-2020;

Accepted: 26-05-2020