Hypertension

1Definition

Hypertension is persistently raised arterial blood pressure, measured correctly on two or more occasions. Most guidelines use 140/90 mmHg or more (office reading) as hypertension; the ACC/AHA uses 130/80 or more.

2Classification

• ESC 2024: non-elevated below 120/70; elevated BP 120–139/70–89; hypertension 140/90 or more.
• ISH 2020 and Indian guidelines: hypertension 140/90 or more; grade 1 140–159/90–99; grade 2 160/100 or more.
• Primary (essential): about 90% or more, no single cause. Secondary: kidney disease, hormonal causes, sleep apnoea, drugs.

3Causes and risk factors

• Age, family history, obesity (especially abdominal), high salt intake (pickles, papad, packaged snacks), low potassium intake, physical inactivity, alcohol, stress, smoking, diabetes, sleep apnoea.
• Secondary causes: chronic kidney disease, renal artery stenosis, hyperaldosteronism, thyroid disease, coarctation of the aorta, pregnancy, steroids and NSAIDs.

4Pathophysiology to impairments

• BP = cardiac output × peripheral resistance. Most hypertension comes from stiff, narrowed small arteries (raised resistance), with salt and water retention and nervous system overactivity.
• Long-term high pressure damages target organs: heart (left ventricular hypertrophy, heart failure, coronary disease), brain (stroke, dementia), kidneys, eyes (retinopathy) and arteries (PAD, aneurysm).
• Physio-relevant impairments: reduced exercise tolerance, risk during straining, drug side effects.

5Clinical features

Usually no symptoms (the "silent killer"). Sometimes headache, dizziness or nosebleeds. Very high BP can cause severe headache, blurred vision, chest pain, breathlessness or confusion (an emergency).

6Investigations

• Correct BP measurement: seated, back supported, arm at heart level, correct cuff size, rested 5 minutes, two readings; home or 24-hour readings to confirm.
• Blood and urine tests for kidney function, sugar, lipids; ECG for left ventricular hypertrophy; echo; eye examination.

7Medical management

• Lifestyle change for everyone (section 14).
• Drugs: ACE inhibitors or ARBs, calcium channel blockers, thiazide-type diuretics; beta-blockers for specific indications. Often two drugs in one tablet.
• Targets: below 130/80 for most adults (ACC/AHA 2025); ESC 2024 aims for a systolic of 120–129 if tolerated.

8Complications

Stroke, heart attack, heart failure, kidney failure, retinopathy, aortic aneurysm and dissection, PAD, vascular dementia. Good BP control lowers all of these.

9PT assessment

• BP both arms at rest (correct cuff), HR, medicines and timing, target-organ disease (heart, kidney, eyes), other risk factors.
• Activity level, diet and salt intake, alcohol, smoking, stress, sleep.
• BMI, waist; fitness (6MWT or step test) with BP before and after.
• Outcome measures: resting BP (home readings), weight and waist, 6MWT, activity minutes a week.

10PT diagnosis by ICF

Real paper (S23, 15 marks): schoolteacher, 50, chest pain and hypertension, treated conservatively

Functional diagnosis: a 50-year-old schoolteacher with hypertension and chest pain of probable cardiac origin (angina), managed with medicines, with reduced exercise tolerance and fear of exertion, limiting walking, stairs and standing to teach, and restricting her work and family roles.

• Before treating: confirm the cause of the chest pain with the doctor (ECG, troponin); resting BP below 180/110; no chest pain at rest.
• Plan: treat it like stable angina with hypertension: education on BP and angina, GTN use and warning signs; graded walking at RPE 11–13 (moderate), building to 30 minutes on most days, kept below the heart rate that brings on angina; light resistance training with breathing out on effort; relaxation and stress management; a low-salt diet rich in fruit and vegetables, and weight control; regular medicines and home BP checks. The angina sections of the IHD page give the doses and stop criteria.
• Participation: pacing at school (sitting for part of the class, planning stair use), return to full duties as symptoms settle.

Practice case (not from a paper): a 52-year-old bank clerk with stage 2 hypertension, BMI 28, sedentary, high salt intake and work stress. Impairments: raised BP, low fitness, excess weight. Activity: limited brisk walking and stair climbing. Participation: at risk of losing work through stroke or heart disease. Environment: desk job and fried canteen food (barriers); family and a nearby park (facilitators). Personal: stress, low awareness.

11Goals

• Short-term (4 weeks): correct home BP measurement; walking 30 minutes on most days; salt reduced.
• Long-term (3–6 months): BP at target; 5% or more weight loss; regular aerobic, resistance and isometric training; stress management habits.

12PT management (7 marks in S18)

• Warm-up and a longer cool-down (10 minutes) to avoid a sudden BP drop.
• Progress duration first, then intensity.
• Combine with weight loss and diet change for the best effect.

13Precautions and stop criteria

• Avoid breath-holding (Valsalva), very heavy lifting and long head-down positions.
• Isometric holds: keep breathing throughout; avoid in uncontrolled hypertension.

14Lifestyle modification

15Prognosis

Treated, well-controlled hypertension greatly reduces stroke and heart disease. Lifestyle change alone can control stage 1 hypertension in many people and reduces the number of drugs needed in others.

16Exam corner

• S23 Q3(b), 15 marks50-year-old schoolteacher admitted with chest pain and hypertension, treated conservatively. Functional diagnosis and physiotherapy management. Use this page with the angina sections of the IHD page.
• S18 Q2(a), 7 marksPhysiotherapy management of hypertension.
• Inside long cases"Known hypertensive" in CABG and MI cases (S17, S18, W18, W19, W20, S24, S26), amputation (S19) and others.

Technique cards for this topic: exercise physiology, exercise testing, cardiac rehabilitation, drugs, yoga.

Keywords to underline

140/90 stage 1 and 2 target organ damage aerobic most days isometric handgrip avoid Valsalva longer cool-down salt below 2,300 mg do not exercise above 180/110