High Blood Pressure (Hypertension) — Causes, Risks and Treatment in Hyderabad

Diagnosis and monitoring

• Blood pressure should be measured in both arms at the first assessment — a difference of more than 10 mmHg between arms suggests subclavian or aortic disease
• Home blood pressure monitoring is recommended for all patients — more accurate than isolated clinic readings
• 24-hour ambulatory blood pressure monitoring (ABPM) is the gold standard — detects white coat hypertension and non-dipping pattern (failure of BP to fall during sleep, associated with higher cardiovascular risk)
• Organ damage assessment: ECG and echocardiogram (left ventricular hypertrophy), urine albumin-creatinine ratio (kidney involvement), fundoscopy (retinal changes)
• Secondary cause screening: renal function, urine analysis, electrolytes, thyroid function, renal artery duplex ultrasound when clinical features suggest

Treatment

Lifestyle modification — first and always

• Salt reduction: below 5 grams per day (approximately 1 teaspoon). The DASH diet — rich in fruits, vegetables, whole grains, and low-fat dairy — is specifically proven to lower blood pressure by 8–14 mmHg
• Weight loss: every 1 kg of weight loss reduces systolic blood pressure by approximately 1 mmHg
• Regular aerobic exercise: 150 minutes per week of moderate-intensity activity reduces systolic BP by 4–8 mmHg
• Alcohol reduction: below 14 units per week in men, below 8 units in women
• Smoking cessation: does not directly lower blood pressure but dramatically reduces overall cardiovascular risk
• Stress management: chronic psychological stress sustains sympathetic activation and blood pressure elevation

Antihypertensive medications

Most patients with stage 2 hypertension need medication in addition to lifestyle changes. The four main first-line classes — each with specific indications and preferences:

• ACE inhibitors / ARBs (e.g. ramipril, telmisartan) — preferred in patients with diabetes, CKD, or heart failure. Protect kidney function.
• Calcium channel blockers (e.g. amlodipine) — effective in all groups. Preferred in elderly and South Asian patients. Excellent for isolated systolic hypertension.
• Thiazide / thiazide-like diuretics (e.g. chlorthalidone, indapamide) — first-line for uncomplicated hypertension. Reduce fluid volume and vascular resistance.
• Beta-blockers (e.g. bisoprolol, atenolol) — preferred in patients with coronary artery disease, heart failure, or atrial fibrillation. Not first-line for uncomplicated hypertension.

Most patients with stage 2 hypertension require 2 to 3 medications to reach target. Starting with a low-dose combination rather than maximising one drug before adding another achieves targets faster with fewer side effects.

Resistant hypertension

Blood pressure that remains above target despite three medications at optimal doses (including a diuretic) is called resistant hypertension. This requires specialist evaluation to: exclude white coat effect with ABPM, identify secondary causes (particularly primary aldosteronism and renal artery stenosis), optimise medication selection, and consider additional agents such as spironolactone, doxazosin, or renal denervation.

Frequently asked questions

Does hypertension cause symptoms?
Usually not — which is why it is called the silent killer. Most patients with hypertension feel completely normal until a complication occurs. Severe hypertension can cause headaches (particularly in the morning), visual disturbances, nosebleeds, or shortness of breath — but these are not reliable indicators of blood pressure level. The only way to know is to measure it.

Once I start blood pressure medication, do I have to take it forever?
For most patients with essential hypertension, yes — blood pressure returns to its previous level when medication is stopped. However, significant and sustained lifestyle changes (major weight loss, strict salt restriction, regular exercise) can allow dose reduction in some patients. Always discuss any change in medication with Dr. Bhishma Chowdary before stopping or reducing.

What is the best time to take blood pressure medication?
For most patients, morning dosing is standard. However, for patients with a non-dipping pattern on ABPM (blood pressure that doesn't fall at night), taking at least one antihypertensive at bedtime — particularly an ARB — has been shown in studies to reduce cardiovascular events. This should be discussed with your cardiologist.

My blood pressure is controlled on medication — do I still need follow-up?
Yes. Blood pressure targets should be confirmed at regular intervals. Medications need adjustment as weight changes, kidney function evolves, and other conditions develop. Organ damage monitoring — echocardiogram, renal function, urine albumin — should be repeated every 1 to 2 years in treated hypertensives.

Can renal artery blockage cause high blood pressure?
Yes. Renal artery stenosis — narrowing of the arteries supplying the kidneys — is an important and treatable cause of secondary hypertension. It should be suspected in patients with difficult-to-control blood pressure, sudden worsening of previously stable hypertension, young patients, or patients whose kidney function worsens on ACE inhibitors or ARBs. Dr. Bhishma Chowdary performs renal angioplasty and stenting for this condition at AIG Hospitals.