Shinikizo la juu la damu

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Rukia: urambazaji, tafuta
Hypertension
Classification and external resources
Automated arm blood pressure meter showing arterial hypertension (shown a systolic blood pressure 158 mmHg, diastolic blood pressure 99 mmHg and heart rate of 80 beats per minute).
ICD-10 I10.,I11.,I12.,
I13.,I15.
ICD-9 401
OMIM 145500
DiseasesDB 6330
MedlinePlus 000468
eMedicine med/1106 ped/1097 emerg/267
MeSH D006973

Shinikizo la juu la damu (HTN) au presha ya juu ya damu, pia huitwa shinikizo la mishipa ya damu, ni sugu hali ya ugonjwa ambapo nguvu ya msukumo wa damu katika mishipa inaongezeka. Ongezeko hilo husababisha moyo kufanya kazi kupita kiasi ili uzungushe damu katika mishipa ya damu. Kuna vipimo viwili vya shinikizo la damu, yaani systolic na diastolic, shinikizo au presha ya systolic ni kipimo cha damu ambacho kinapima nguvu ya msukumo wa damu katika mishipa ya damu wakati moyo unadunda. Shinikizo au presha ya diastole inapima nguvu ya msukumo wa damu katika mishipa ya damu wakati moyo umepumetulia au kati ya mapigo ya moyo (diastole). Kipimo cha kawaida cha shinikizo la damu ni 100–140 milimita za mekyuri (mmHg) systolic (kipimo cha juu) na 60–90  milimita za mekyuri (mmHg) diastolic (kipimo cha chini). Shinikizo la juu la damu hutokea kama kipimo kikiwa zaidi ya 140/90 mmHg kwa muda mrefu.

Kuna aina mbili ya shinikizo la juu la damu shinikizo la juu la damu la asili na shinikizo la damu linalosababishwa na magonjwa mengine. Kadiri ya asilimia 90–95% ya watu wanaathirika na "shinikizo la juu la damu la asili", yaani wana ugonjwa huu bila kuwa na chanzo cha kisayansi kinachofahamika.[1] Magonjwa mengine ya mafigo, mishipa, moyo, mfumo wa homoni huathiri asilimia 5–10% iliyobaki ya watu wenye shinikizo la damu (shinikizo la damu linalosababishwa na magonjwa mengine).

Shinikizo la juu la damu ndio sababu kubwa kihatarishi ya upoozaji, mshtuko wa moyo (mashambulizi ya moyo), moyo kushindwa kufanya kazi, kutuna kwa ukuta wa mishipa (k.m., kutuna kwa ukuta wa aota au mkole), chujio la mshipa wa kupeleka damu kwenye moyo au peripheral arterial disease, na inasababishwa na ugonjwa sugu wa figo. Hata ongezeko la wastani la shinikizo la damu husababisha upunguzaji wa matarajio ya muda wa kuishi. Ili kuthibitisha shinikizo la damu, lishe bora na mabadiliko katika mtindo wa kuishi lazima yazingatiwe pamoja na kupunguza matatizo yanayoathiri afya. Hata hivyo, matumizi ya dawa ni muhimu kwa watu ambao mabadiliko ya mtindo wa maisha hautoshelezi kupunguza shinikizo la juu la damu. kutuna kwa ukuta wa ateri mitihili ya puto kutokana na udhaifu wa sehemu hiyo

Uainishaji la shinikizo la damu[hariri | hariri chanzo]

Classification (JNC7)[2] Systolic pressure Diastolic pressure
mmHg kPa mmHg kPa
Kawaida 90–119 12–15.9 60–79 8.0–10.5
Dalili ya shinikizo la juu la damu 120–139 16.0–18.5 80–89 10.7–11.9
Aina ya 1 shinikizo la juu la damu - kali 140–159 18.7–21.2 90–99 12.0–13.2
Aina ya 2 shinikizo la juu la damu - kali kiasi ≥160 ≥21.3 ≥100 ≥13.3
Isolated systolic
shinikizo la juu la damu - kali sana
≥140 ≥18.7 <90 <12.0

Watu wazima[hariri | hariri chanzo]

Kwa watu wenye umri wa miaka 18 au zaidi, shinikizo la juu la damu linaweza kuwa systolic na/au diastolic kama kipimo hicho ni zaidi kuliko kipimo cha kawaida kinachokubalika ambacho ni (139 mmHg systolic, 89 mmHg diastolic: tazama table — Uainishaji (JNC7)). Kama vipimo vinapatikana baada ya kutumia chombo kinachopima presha kwa masaa 24 (24-hour ambulatory) au kufanya maangalizi nyumbani, vipimo vya chini vinatumiwa (135 mmHg systolic or 85 mmHg diastolic).[3] Pia miongozo ya kimataifa ya hivi karibuni imegawanya shinikizo la damu katika vikundi mbali mbali vyenye vipimo chini ya kipimo cha shinikizo la juu la damu ili kuthibitisha hatari iliyopo ya shinikizo la juu la damu. JNC7 (2003)[2] anatumia neno dalili ya kuwa na shinikizo la juu la kwa presha ya damu iliyo kati ya 120 na 139 mmHg systolic na/au 80–89 mmHg diastolic, wakati Miongozo ya ESH-ESC (2007)[4] and BHS IV (2004)[5] inatenganisha katika vikundi vya hali inayofaa, vya kawaida, na vya kawaida kiasi kutofautisha presha zilizopo chini ya 140 mmHg systolic na 90 mmHg diastolic. Shinikizo la juu la damu pia imegawanywa katika vikundi vifuatavyo: JNC7 inatofautisha shinikizo la juu la damu aina ya I, shinikizo la juu la damu aina ya II, na shinikizo la juu la damu hatua kali sana. Shinikizo la juu la damu ambayo ni kali sana (Isolated systolic hypertension) ni presha ya juu sana inayoambatana na presha ya kawaida ya diastolic, hali hii huwatokea sana wazee.[2] The ESH-ESC Guidelines (2007)[4] and BHS IV (2004),[5] inatambua aina ya tatu (aina ya III) ya shinikizo la juu la damu kwa watu ambao wana presha ya juu ya systolic inayozaidi 179 mmHg au presha ya diastolic inayozidi 109 mmHg. Shinikizo la juu la damu liko katika kundi la "sugu" kama madawa hayapunguzi shinikizo la damu hadi vipimo vya kawaida.[2]

Watoto waliozaliwa karibuni na watoto wachanga[hariri | hariri chanzo]

Si kawaida kwa watoto waliozaliwa karibuni kuwa na shinikizo la juu la damu na ni asilimia 0.2 hadi 3% ya watoto wachanga ambao wanapata. Shinikizo la damu haipimwi mara kwa mara kama watoto ni wadogo na wana afya nzuri. [6] Shinikizo la damu huwapata watoto ambao wako katika hatari kubwa. Kuna masuala tofauti ya kuangalia, kama vile kipindi cha ujazito, umri baada ya utungaji mimba, na uzito wakati wa kuzaliwa kabla ya kuamua kama kipimo cha shinikizo la damu ni cha kawaida kwa mtoto mchanga.[6]

Watoto na Vijana[hariri | hariri chanzo]

Ni kawaida kwa watoto na vijana kupata shinikizo la damu (asilimia 2–9% hutegemea na umri, jinsia, na asili)[7] and is associated with long-term risks of ill-health.[8] Hivi sasa kuna pendekezo la kuwapima damu watoto wenye zaidi ya miaka mitatu na kuangalia kama wana shinikizo la juu la damu kila wanapoenda kupimwa afya yao. Kabla ya kuthibitisha kama mtoto ana shinikizo la juu la damu mtoto lazima apimwe mara kadhaa.[8] Shinikizo la damu huongezeka utotoni kufuatana na umri , wa watoto, shinikizo la damu linatambulika kama ni systolic ya kawaida au diastolic baada ya kupimwa zaidi ya mara tatu au zaidi ya asilimia 95 ambayo ni kawaida kufuatana na jinsia, umri na urefu wa mtoto. Dalili ya shinikizo la juu la damu (Prehypertension) kwa watoto linatambulika kama shinikizo au presha ya kawaida ya systolic au shinikizo au presha ya diastolic kama ni zaidi au sawa na asilimia 90, lakini ni chini ya asilimia 95.[8]Kwa vijana, inapendekezwa kwamba shinikizo la juu la damu na dalili ya shinikizo la juu la damu zichunguzwe na kuainisha kwa kutumia vigezo vya watu wazima.[8]

Ishara na Dalili[hariri | hariri chanzo]

Mara nyingi watu wenye shinikizo la damu hawana dalili yoyote, na huwa inagundulika baada ya kufanya uchunguzi kwa kawaida kupitia screening, au wakati maangalizi ya afya yanafanywa kwa sababu nyingine. Watu wengine wenye shinikizo la damu huwa wanapata maumivu ya kichwa (haswa nyuma ya kichwa na asubuhi), pamoja na kuchanganyikiwa, kizunguzungu, sikio kelele (mvumo au mazomeo masikioni), kutoweza kuona vizuri au matukio ya kuzirai.[9]

Baada ya uchunguzi wa mwili, kunakuwa na wasiwasi wa shinikizo la juu la damu kama kuna upanuzi wa mishipa ya damu ya retina baada ya kufanya uchunguzi wa optic fundus iliyopo nyuma ya jicho kwa kutumia chombo cha kufanyia uchunguzi yaani ophthalmoscopy.[10] Classically, ukali wa mabadiliko ya shinikizo la damu ya retina linagawanya kwenye vikundi kuanzia I hadi IV, ingawa inaweza kuwa vigumu kuzitofautisha aina kali kiasi.[10] Chombo cha kufanyia uchunguzi wa macho kinaweza kuonyesha muda ambao mtu amekuwa na shinikizo la juu la damu=Fisher2005/>

Shinikizo la juu la damu litokanalo na magonjwa mengine[hariri | hariri chanzo]

Dalili zingine zinaweza kusababishwa na magonjwa mengine, yani shinikizo la damu linaloletwa na sababu zingine zinazojulikana kama vile magonjwa ya figo au mabadiliko ya mfumo wa homoni. Kwa mfano, unene wa kifua na tumbo, uthibiti mbaya wa sukari, moon facies au mkusanyiko wa mafuta usoni, mkusanyiko wa mafuta mgongoni ("buffalo hump") na purple striae au alama za unene huonyesha dalili ya ugonjwa wa homoni wa Cushing's syndrome.[11] Ugonjwa unaoathiri kikoromeo na acromegaly yaani mwili hutengeneza homoni ya kukuza umbo pia huweza kuleta shinikizo la juu la damu na dalili zake za kawaida huonekana.[11] Wembamba wa mishipa ya tumbo au abdominal bruit inaweza kuwa ni ishara ya renal artery stenosis au kuziba kwa mishipa ya damu ipelekayo damu kwenye figo. Shinikizo la chini la damu katika miguu au mapigo ya mshipa wa mguu yanayochelewa au ukosefu wa mapigo mapigo ya mshipa wa mguu inaweza kuwa ni dalili ya aortic coarctation (kupungua kwa upana wa mshipa mkuu utoao damu kwenye moyo kwenda mwilini). Shinikizo la damu ambalo linalotofautiana sana na kuumwa kwa kichwa, mpapatiko wa moyo, kubadilika rangi ya ngozi, na utoaji jasho ni lazima kuwe na wasiwasi wa pheochromocytoma yaani saratani ya tezi iliyo juu ya figo.[11]

Hali ya hatari ya shinikizo la juu la damu[hariri | hariri chanzo]

Shinikizo la damu lililo juu kupita kiasi (sawa au zaidi ya 180 au diastolic ya 110, wakati mwingine huitwa shinikizo la damu linaloweza kuleta kifo au linaloharakisha kifo) inatambulika kama "hali ya hatari ya shinikizo la juu la damu." Shinikizo la damu vinavyozidi vipimo hivi vinaonyesha hali kubwa ya hatari ya ugonjwa huu. Watu wenye viwango hivi vya shinikizo la damu wanaweza wasiwe na dalili zozote, ila wanaweza kulalamika kuumwa kwa kichwa (asilimia 22% ya wagonjwa)[12] na kuwa na kizunguzungu kuliko watu wa kawaida.[9] Dalili zingine za hali ya hatari ya shinikizo la damu ni kutoona vizuri au kutopumua vizuri kwa sababu moyo haufanyi kazi vizuri au kutojisikia vizuri uchovu kwa sababu mafigo yanashindwa kufanya kazi.[11] Watu wengi wenye hali ya hatari ya shinikizo la damu wanatambulika kuwa na msukumo mkubwa wa damu, lakini vichocheo vingine vinaweza kuongezea msukumo.[13]

"Shinikizo la damu la ghafla", zamani ilikuwa inajulikana kama "shinikizo la damu inayodhuru", hutokea ikiwa kuna ithibati ya madhara yanayotokea katika ogani za mwili kwa sababu ya shinikizo la juu la damu. Madhara haya yanaweza kuwa hypertensive encephalopathy au shinikizo kichwani, inasababishwa na uvimbe wa ubongo na kutofanya kazi vizuri, na husababisha kichwa kuumwa na kupoteza fahamu (kuchanganyikiwa au kusinzia). Retinal papilloedema and fundal kuvuja damu kutokana na mpasuko wa mishipa midogo ya macho na kutoa usaha au maji ni dalili nyingine ya madhara ya ogani. Maumivu ya kifua yanaweza kuwa ni dalili ya uharibifu wa misuli ya moyo (ambayo baadaye yanaleta upungufu wa damu kati ya misuli ya moyo) au wakati mwingine ukuta wa ndani wa aorta huchanika na damu, kuchanika kwa ukuta wa mshipa mkuu uitwao aota/mkole. Kukosa pumzi, kukohoa, na kukohoa makohozi yenye damu ni dalili ya pulmonary edema au mapafu kujaa maji. Hali hii inaleta uvimbe wa seli za mapafu unaosababishwa na udhaifu wa upande wa kushoto wa moyo, na uwezo mdogo wa upande wa kushoto wa moyo kusukuma damu kutoka kwenye mapafu hadi mishipa ya damu.[13] Figo kupoteza uwezo wake wa kufanya kazi upesi (figo kushindwa kufanya kazi kwa ghafla) na microangiopathic hemolytic anemia au upungufu wa damu (uharibifu wa seli za damu) unaweza kutokea.[13] Katika hali hizi, shinikizo la chini la damu ni muhimu ili kupunguza madhara ya ogani.[13] Kwa upande mwingine, hakuna ushahidi unaonyesha kuwa shinikizo la damu linatakiwa kupunguzwa kwa kasi wakati wa matatizo ya dharura ya shinikizo la juu la damu iwapo kuna ogani iliyoathirika. Upunguzaji wa ghafla wa shinikizo la damu unaweza kuwa ni hatari.[11] Matumizi ya dawa ya kushusha shinikizo la damu hatua kwa hatua zaidi ya masaa 24 hadi 48 yanapendekezwa wakati wa dharura inayotokana na shinikizo la juu la damu.[13]

Ujaauzito[hariri | hariri chanzo]

Shinikizo juu la damu hutokea takribin 8-10% za ujaa uzito. Wanawake karibu wote wenye shinikizo juu la damu wakiwa na mimba walikwishaumwa na shinikizio la damu la kawaida. Hali hiyo ikitokea katika ujaa uzito ni dalili ya kwanza ya kifafa cha mimba kabla hakijashikika kabisa. Maradhi hayo hutokea katika muda wa pili wa ujaa uzito na majuma machache baada ya kujifungua. Uaguzi wa maradhi hayo ni pamoja na shinikizo la damu kuongezeka na dalili za protini ndani ya mkojo. Maradhi hayo hutokea takribin 5% ya ujaa uzito yakisababisha takribin 16% ya vifo vya wenye ujaa uzito. Hatari ya kifo cha mtoto inaongezeka maradufu kutokana na maradhi hayo dunia nzima. Kwa kawaida hakuna dalili maalum za kifafa cha mimba kabla hakijashikika kabisa hugunduliwa na uchujaji wa kawaida. Zinapotokea dalili za maradhi hayo hizo ndizo ni kuumwa kichwani, taabu za kuona vizuri (mwanga wa kumulika ghafla) kutapika, maumivu ya epigastriumu na kuvimba. Kifafaa cha mimba kabla hakijashikika kabisa wakati mwingine inaweza kuletea hali inayotisha maisha inayoitwa kifafa cha mimba. Kifafa cha mimba kinaleta hali ya dharura ya shinikizo la damu inayotatiza sana. Matatizo hayo ni pamoja na upofu, kuvimba kwa ubongo, utendaji wa kiklonasi ulio katika hali ya kukazika au kuvutika na kutia kifafa, kuharibika kwa mafigo, edema ya mapafu, disseminated intravascular coagulation (kutoganda vizuri kwa damu). Shinikizo juu ya damu ikiathiri uja uzito: Dawa Ukunga na Elimuuzazi:[14]

WATOTO WACHANGA na WANA[hariri | hariri chanzo]

Kushindwa kustawi, kutiliwa kifafa, usumbufu, uchovu/kukosa nguvu, hali inayorudiarudia ya kudhikisha kwa mapofu kushindwa kuhema vizuri Shinikizo Juu la Damu: [15] can be associated with hypertension in neonates and young infants. Kuhusu watoto wachanga ambao wameshahitimu umri zaidi pamoja na wana, shinikizo la juu la damu linaweza kuumiza kichwa, usumbufu usioelezeka, uchovu (uchovu wa kiganga), kushindwa kustawi, macho kutiliwa kiwi, kutokwa na damu puani, hatimaye kiharusi uso kupoozwa baadaye. [16]

KUZIDI KWA UKALI WA SHINIKIZO LA JUU LA DAMU[hariri | hariri chanzo]

ATHARI[hariri | hariri chanzo]

{Athari kuu za Shinikizo la Juu la Damu} thumb|Diagram illustrating the main complications of persistent high blood pressure. Shinikizo la juu la damu linachangia vifo vya watoto wachanga zaidi kuliko athari zingine nalo linaweza kupatiwa kinga.[17] It increases the risk of ischemic heart disease[18] strokes,[11] peripheral vascular disease,[19] and other cardiovascular diseases, including heart failure, aortic aneurysms, diffuse atherosclerosis, and pulmonary embolism.[11] Hypertension is also a risk factor for cognitive impairment, dementia, and chronic kidney disease.[11] Other complications include:

ATHARI[hariri | hariri chanzo]

SHINIKIZO JUU LA DAMU LA KIMSINGI[hariri | hariri chanzo]

Shinikizo la juu la damu la kimsingi ni aina inayojulikana zaidi ikiwa chanzo cha 90-95% za miathirika ya shinikizo la juu la damu[1] Takribin jamii zote za kisasa shinikizo la damu linapanda juu katika nyakati za kuzeeka.[21] Shinikizo la juu la damu linatokana katika ushirikiano wa viini-urithi na athari za mazingira. Viini-urithi vingi vya kawaida vikiwa na athari ndogo juu ya shinikizo la damu vimeshatambulika[22] as well as some rare genes with large effects on blood pressure[23] lakini shinikizo juu la damu linalotokana na viini-athari halijaeleweka vizuri hadi leo hii,[24] increased consumption of fruits and low-fat products (Dietary Approaches to Stop Hypertension (DASH diet)). Exercise,[25] weight loss[26] and reduced alcohol intake also help lower blood pressure.[27] The possible role of other factors such as stress,[25] caffeine consumption,[28] and vitamin D deficiency[29] are less clear cut. Insulin resistance, which is common in obesity and is a component of syndrome X (or the metabolic syndrome), is also thought to contribute to hypertension.[30] Utafiti wa hivi karibuni umedhulumu matukio ya maisha ya watoto wachanga kwa mfano, [uzito mdogo wa mtoto mchanga], tabia ya uvutaji sigara ya akina mama, na [kutowanyonyesha watoto] kama athari za hatari zinazoumiza watu wazima na shinikizo la damu la kimsingi.[31] However, mechanisms linking these exposures to adult hypertension remain obscure.[31]

SHINIKIZO LA JUU LA DAMU LA HATUA YA PILI[hariri | hariri chanzo]

Shinikizo la juu la damu la hatua ya pili linatokana na chanzo kinachojulikana. Maradhi ya mafigo ni chanzo kinachozidi cha shinikizo la juu la damu hatua ya pili.[11] Chanzo kingine cha shinikizo la juu la damu ni hali tofauti za tezi zenye kunyesa ndani kwa ndani kama kwa mfano Cushing's syndrome, hyperthyroidism, hypothyroidism, acromegaly, Conn's syndrome or hyperaldosteronism, hyperparathyroidism, and pheochromocytoma.[11][32] Vyanzo vingine vya shinikizo la juu la damu hatua ya pili ni pamoja na [unene], [kushindwa kupumua kunakoleta usingizi wa mang’amung’amu], [kuwa na mimba], [kufinyika kwa aota], ulaji zaidi wa [urukususu] na dawa fulani zilizo halali zikiwa na zile zote zisizo halali pamoja na dawa za kienyeji.[11][33]

Pathophysiology[hariri | hariri chanzo]

A diagram explaining factors affecting arterial pressure

Watu karibu wote wakiumia shinikizo la juu la damu la kimsingi linalowekwa imara, kinzi inayoongezeka kwa utiririko wa damu (kinzi kabisa ukingoni) inasababisha shinikizo la hali ya juu wakati utiririko wa damu kutoka moyoni unaendelea kama kawaida.[34] Uthibitisho upo kubainisha vijana wengine wanaoumia shinikizo la juu la damu ambalo halijashikana kabisa wana utiririko wa damu kutoka moyoni wa kiwango cha juu, pigo linalozidi kawaida la moyo na kinzi ya kawaida ukingoni. This condition is called hyperkinetic borderline hypertension.[35] These individuals develop typical features of established essential hypertension in later life as their cardiac output falls and peripheral resistance rises with age.[35] Whether this pattern is typical of all people who ultimately develop hypertension is disputed.[36] Increased peripheral resistance in established hypertension is mainly attributable to structural narrowing of small arteries and arterioles.[37] Reduction in number or density of capillaries may also contribute to peripheral resistance.[38] Shinikizo juu la damu pia linahusika na ukosefu wa ujikunjaji wa mishipa iliyoko ukingoni,[39] which may increase return of blood to the heart, increase cardiac preload, and ultimately cause diastolic dysfunction. Ikiwa kuongezeka kwa finyo linaloendelea la mishipa ya damu huchangia shinikizo la juu la damu la kimsingi linalowekwa imara hakujathibitishwa.[40]

Pulse pressure (difference between systolic and diastolic blood pressure) is frequently increased in older people with hypertension. This situation can involve systolic pressure that is abnormally high, but diastolic pressure may be normal or low. This condition is called isolated systolic hypertension.[41] High pulse pressure in elderly people with hypertension or isolated systolic hypertension is explained by increased arterial stiffness, which typically accompanies aging and may be exacerbated by high blood pressure.[42] Many mechanisms have been proposed to account for rise in resistance seen within arterial system in hypertension. Most evidence implicates one or both of these causes:

These mechanisms are not mutually exclusive and it is likely that both contribute to some extent in most cases of essential hypertension. Limedokezwa kuwa kutofanya vizuri kwa kuta za ndani za mishipa ya damu pamoja na inflamesheni ya mishipa huenda inachangia kinzi inayoongezeka ukingoni pamoja na kuharibika kwa mishipa[45][46]

Utambuzi[hariri | hariri chanzo]

Mfano vipimo kutumbukiza katika shinikizo la damu
Mfumo Majaribio
mfumo mkojo ya figo Urinalysis Microscopic urinalysis, proteinuria, serum bun blood urea nitrogen BUN (damu urea nitrojeni) na /au creatinine
Endokrini mfumo Endokrini Serum sodiamu, potasiamu, calcium, TSH (thyroid-stimulating hormone) .
Umetaboli kufunga damu glucose, cholesterol jumla, HDL na LDL cholesterol, triglycerides
Wengine Hematocrit, electrocardiogram, na radiograph kifua
Vyanzo: Harrison's ya kanuni ya dawa za ndani[47] others[48][49][50][51][52]

Shinikizo la damu ni kupatikana wakati mgonjwa ana vinavyoendelea shinikizo la damu. Kijadi,[3] utambuzi unahitaji vipimo vitatu vya sphygmomanometer tofauti kwa vipindi vya mwezi mmoja.[53] Ya awali ya ukaguzi ya wagonjwa la damu ni pamoja na historia na uchunguzi wa kimwili history na physical examination. Pamoja na Upatikanaji wa saa 24 ambulatory wachunguzi wa shinikizo la damu mashine ya damu nyumbani shinikizo, muhimu wa kuepuka utambuzi sahihi ya wagonjwa na shinikizo la damu kanzu nyeupe imesababisha mabadiliko katika itifaki. Katika Uingereza, sasa ni bora kufuatilia moja alimfufua kliniki ya kusoma na kipimo ambulatory. Kufuatilia pia inaweza kufanyika, lakini chini ya walau, na nyumbani ufuatiliaji shinikizo la damu katika kipindi cha siku saba.[3]

Mara baada ya uchunguzi wa shinikizo la damu yamepatikana, madaktari kujaribu kubaini sababu ya msingi juu ya hatari na dalili nyingine, kama sasa. shinikizo la damu sekondari ni ya kawaida zaidi kwa watoto karibisha kijani na kesi nyingi husababiswa na ugonjwa wa figo renal disease. Msingi au shinikizo la damu ni muhimu zaidi ya kawaida katika Vijana na ina hatari nyingi, ikiwa ni pamoja na hatima na historia ya familia ya shinikizo la damu.[54] Vipimo vya maabara pia kuwa walifanya kubainisha sababu ya uwezekano wa shinikizo la damu ya sekondari, na kuamua kama shinikizo la damu unaosababisha uharibifu wa moyo, macho, na mafigo. Vipimo vya ziada kama ajali ya ugonjwa wa kisukari na Viwango vya juu vya cholesterol ni kutumbukiza kwa sababu hizi ni hali ya hatari kwa ajili ya maendeleo ya ugonjwa wa moyo na kuhitaji matibabu.[1]

Creatinine Serum ni kipimo cha kupima kwa uwepo wa ugonjwa wa figo, ambao unaweza kuwa ama sababu au matokeo ya shinikizo la damu. Serum creatinine peke inaweza kuza thamani kiwango ya glomerular filtration. Miongozo ya hivi karibuni kutetea matumizi ya mamlinganyo uingizaji kama vile Muundo wa mpangilio wa chakula katika formula figo Magonjwa (MDRD) na makisio ya kiwango cha glomerular filtration (eGFR). [55] eGFR pia yanaweza kutoa kipimo msingi ya kazi ya figo ambayo yanaweza kutumika kwa ajili ya kufuatilia madhara ya dawa kadhaa antihypertensive juu ya kazi ya figo. Upimaji wa sampuli za mkojo kwa ajili ya protini kutumika kama kiashiria cha sekondari ya ugonjwa wa figo. Electrocardiogram (EKG/ECG) ni kufanyika kwa kuangalia kwa ushahidi kwamba moyo upo katika matatizo kutokana na shinikizo la damu. Inaweza pia kuonyesha kugandamana kwa misuli ya moyo (kushoto ventrikali hypertrophy) au kama moyo una uzoefu kabla madogo ya usumbufu kama vile mashambulizi ya kimya moyo. Kifua X-ray au echocardiogram pia inaweza kufanywa kwa kuangalia kwa ishara ya moyo utvidgningen au uharibifu wa moyo. [11]

Kinga[hariri | hariri chanzo]

Idadi ya watu ambao wanashinikiza la juu la damu ni kubwa japo hawatambui.[56] Hutua ya kushughulikia idadi ya watu wote wanaotakiwa kupunguza madhara ya shinikizo la damu na kupunguza haja ya tiba ya antihypertensive dawa za kulevya. Mabadiliko ya maisha Ilipendekeza kuwa shinikizo la damu liwe chini, kabla ya kuanza dawa za tiba. 2004 Uingereza shinikizo la damu Society la miongozo[56] mapendekezo ya mabadiliko ya maisha yafuatayo sambamba na miongozo ilivyoainishwa na Marekani ya taifa ya mipango ya High BP elimu ya mwaka 2002[57] kwa ajili ya kuzuia msingi wa shinikizo la damu ni kama ifuatavyo:

  • Kudumisha kawaida uzito wa mwili (kwa mfano. mwili molekuli index 20–25 kg/m2).
  • Kupunguza malazi sodium ujali kwa mmol <100  mmol/ siku (<6 g ya kloridi sodium au<2.4 g ya sodium kwa siku).
  • Kushiriki katika shughuli za mara kwa mara aerobic kimwili kama vile kutembea upesi (≥30 min kwa siku, wengi siku za juma).
  • Punguza pombe kwa vitengo visivyozidi 3 units/ kwa siku kwa wanaume na vitengo visivyozidi 2 units/ kwa siku kwa wanawake.
  • Hutumia lishe lenye matunda na mbonga (kwa mfano, angalau tano sehemu kwa siku).

Mabadiliko mwafaka ya mtindo wa maisha yanaweza kupunguza shinikizo la damu kama ilivyo kwa dawa ya mtu binafsi ya antihypertensive na kupata matokeo bora zaidi. [56]

Udhibiti[hariri | hariri chanzo]

Mabadiliko katika mtindo wa maisha[hariri | hariri chanzo]

Aina ya kwanza ya matibabu ya shinikizo la damu ni inafanana na mabadiliko ya mtindo wa maisha yaliyopendekezwa,[58] na ni pamoja na mabadiliko ya malazi[59] physical exercise, and weight loss. Mazoezi ya viungo, na kupunguza uzito. Mabadiliko haya yote yameonekana kupunguza kwa kiasi kikubwa shinikizo la damu[60] kama shinikizo la damu ni ya juu kiasi cha kuhalalisha matumizi ya haraka ya dawa, mabadiliko ya maisha bado yanapendekezwa..

Mipango mbalimbali iliyoundwa na kupunguza dhiki ya kisaikolojia biofeedback, ulegezaji, au kutafakari hutangazwa ili kupunguza shinikizo la damu. Hata hivyo, tafiti za kisayansi , kwa ujumlahazina usaidi wala ufanisi wao, kwa sababu masomo kwa ujumla ya ubora wa chini.[61][62][63]

Malazi na mabadiliko kama vile chakula cha chini sodiamu ni faida. Muda mrefu ( zaidi ya wiki 4) chini -sodiamu chakula katika Caucasian, race Caucasians ni bora katika kupunguza shinikizo la damu, kwa watu na shinikizo la damu na kwa watu wenye shinikizo la damu ya kawaida .[64] pia , chakula DASH diet, lishe lenye karanga, nafaka, samaki, kuku, matunda, na mboga, ambayo husaidia kukuza moyo na Taifa , Mpafu, na damu Taasisi, punguza shinikizo la damu. Kipengele kikubwa cha mpango wa sodiamu, ingawa mlo pia ni tajiri potassiamu, magnesiamu , calcium, na protini.[65]

Dawa[hariri | hariri chanzo]

Madarasa kadhaa ya dawa, pamoja inajulikana kama antihypertensive madawa ya kulevya s, sasa zipo kwa ajili ya kutibu shinikizo la damu. Mtu hatari wa moyo na mishipa ( ikiwa ni pamoja na hatari ya infarction myocardial na kiharusi) na masomo ya shinikizo la damu ni kuchukuliwa wakati maagizo madawa ya kulevya.[66] Ikiwa matibabu ya madawa ya kulevya ni ikianzishwa,Moyo ya taifa,Mapafu,na damu Taasisi ya saba ya pamoja ya kamati ya taifa ya juu ya shinizo la damu (JNC-7)[55] Inapendezeka kwamba kufuatilia daktari kwa ajili ya Kukabiliana na matibabu kwa ajili ya kutathmini na athari yoyote mbaya kutokana na dawa. Kupunguza shinikizo la damu na 5 mmHg inaweza kupunguza hatari ya kiharusi kwa 34% na hatari ya ungonjwa wa moyo ischemic kwa 21%. Shinikizo la damu kupunguza pia husaidia kupunguza uwezekano wa shida ya akili, moyo kushindwa , na vifo kutokana na ugonjwa wa moyo na mishipa .[67] Lengo la matibabu ya lazima ya kupunguza shinikizo la damu na chini ya 140/90 mmHg kwa ajili ya watu wengi, na chini kwa kale wenye ugonjwa wa kisukari au ugonjwa wa figo. Baadhi ya wataalamu wa afya kupendekeza kuweka Viwango vya chini 120/80 mmHg.[66][68] Kama lengo shinikizo la damu si alikutana,matibabu zaidi inahitajika.[69]

Miongozo juu ya uchaguzi wa dawa na jinsi ya kuamua bora kwa ajili ya matibabu subgroups mbalimbali vilivyobadilika na tofauti kati ya nchi. Wataalamu wala kukubaliana kuhusu dawa bora.[70] The Kushirikiana Cochrane , Shirila la Afya ya Duniani, na Umoja wa Mataifa kusaidi miomgozo ya chini -dozi thiazide-makao diuretic kama matibabu ina penda zaidi ya awali.[71][70] Uingereza Miongozo kusisitiza calcium channel blockers (CCB) kwa ajili ya watu zaidi ya umri wa miaka 55 au ya Afrika au Caribbean asili ya familia. Miongozo kupendekeza angiotensin-kuwabadili enzyme kivizas (ACEI)s kama matibabu ina penda zaidi ya awali kwa ajili ya watu wadogo.[72] katika Japan, kwa kunzia na mtu yeyote wa Madarasa sita ya dawa ikiwa ni pamoja na : CCB, ACEI/ARB, thiazide diuretics, beta blockers, na blockers alpha ni aliona nafuu. Katika Canada, yote ya dawa hizi isopokuwa alpha blockers- ni Ilipendekeza kama inawezekana chaguzi ya kwanza. [70]

Madawa ya mchanganyiko[hariri | hariri chanzo]

Watu wengi wanahitaji zaidi ya moja ya madawa ya kudhibiti shinikizo la damu zao. JNC7[55] and ESH-ESC guidelines[4] Wakili kuanza matibabu ya madawa ya mbili wakati shinikizo la damu ni zaidi ya 20  mmHg hapo juu systolic au zaidi ya 10  mmHg juu ya malengo ya diastolic. Michanganyiko ya ku penda zaidi ni rennin-angiotensin na Kalsium channel blockers, au inhibitors renin–angiotensin na diuretics.[73] Michanganyiko kukubalika ni pamoja na yafuatayo:

  • Calcium channel blockers na diuretics
  • Beta blockers na diuretics
  • Dihydropyridine calcium channel blockers na beta blockers
  • Dihydropyridine calcium channel blockers na ama verapamil or diltiazem

Michanganyiko haikubaliki ni kama ifuatavyo:

  • Yasiyo ya calcium blockers (kama vile verapamil au diltiazem) na beta blockers
  • Dual renin–angiotensin mfumo blockade (Kwa mfano, angiotensin kuwabadili enzyme kiviza + angiotensin receptor blocker)
  • Renin–angiotensin mfumo blockers na beta blockers
  • Beta blockers na madawa ya anti-adrenergic. [73]

Kuepuka michanganyiko ya kiviza ACE inhibitor au angiotensin II adui receptor antagonist, a diuretic, na NSAID ( Ikiwa pamoja na kuchangua COX-2 inhibitors na madawa ya kulevya nonprescribed kama vile ibuprofen) kila inapowezekana kutokana na hatari kubwa ya kushindwa kwa figo papo hapo. Mchanganyiko inajulikana simo kama “whammy triple” katika maandiko ya Australia ya Afya. [58] Vidonge vyenye mchanganyiko za kudumu wa Madarasa mawili ya dawa za kutosha. Wakati wao ni rahisi, wao ni bora akiba kwa ajili ya watu ambao ni amara katika vipengele mtu binafsi. [74]

Wazee[hariri | hariri chanzo]

Kutibu wastani kwa presha kali itapungua vifo na athari upande wa moyo na mishipa katika watu wenye umri wa miaka 60 na kuendelea.[75] Katika watu zaidi ya miaka 80 na umri wa tiba haionekani kwa kiasi kikubwa kupunguza vifo vya jumla lakini kupunguza hatari ya ungonjwa wa moyo.[75] Ilipendekeza shinikizo la damu lengo ni chini ya 140/90 mm Hg na thiazide diuretics ya kuwa dawa yaku penda zaidi katika Amerika.[76] Katika mwongozo mpya Uingereza, Kalsiamu-channel blockers ya matibabu ina penda zaidi na masomo kliniki lengo la chini ya 150/90 mmHg, au chini ya 145/85 mmHg juu ya ufuatiliaji ambulatory au nyumbani shinikizo la damu.[72]

Sugu shinikizo la damu[hariri | hariri chanzo]

Shinikizo la damu sugu ni shinikizo la damu kwamba bado hapo juu lengo shinikizo la damu licha ya matumizi ya mawakala wa tatu antihypertensive mali ya madaraja mbalimbali ya madawa ya kulevya antihypertensive wote mara moja. Miongozo kwa ajili ya kutibu shinikizo la damu sugu yamechapishwa katika Uingereza[77] and the US.[78]

Uwezekano[hariri | hariri chanzo]

Kama wa 2000, karibu watu bilioni moja au takriban 26% ya idadi ya watu wazima wa dunia alikuwa na shinikizo la damu .[79] Ilikuwa ni kawaida katika nchi zote mbili maendeleo (333 million) na siostawishwa (639 million).[79] Hata hivyo,Viwango kutofautiana kikubwa katika mikoa mbalimbali kwa Viwango vya chini kama 3.4% ( wanaume) na 6.8% ( wanamke) Katika maeneo ya vijijini India na kama 68.9% ( wanaume) na 72.5% (wanamke) katika Poland.[80]

Mwaka 1995 ilikadiriwa kuwa milioni 43 watu katika Muungano wa nchi za Amerika alikuwa na shinikizo la damu au walikuwa kutumika dawa antihypertensive. Takwimu hii inawakilisha karibu 24% ya idadi ya watu wazima Marekani. [81] Viwango vya shinikizo la damu nchini Marekani walikuwa kuongezeka na kufikia 29% mwaka 2004.[82][83] Kama ilivyo mwaka 2006 shinikizo la damu huathiri watu wazima Marekani 76 million US adults (34% ya idadi ya watu) na Afrika ya watu wazima Marekani kuwa miongoni mwa Viwango yva juu zaidi ya shinikizo la damu katika dunia kwa 44%.[84] Ni zaidi ya kawaida katika Wamerikani uliotekea na chini ya kawaida katika wazungu na Mexican Marekanis. Viwango vya kuongezeka kwa umri, ma ni mkubwa katika kusini mashariki mwa Marekani. Shinikizo la damu ni ya kawaida zaidi ndani ya watu kulinganisha na wanawake ( ingawa wanakuwa wamemaliza kuelekea kupunguza tofauti hii ) na kwa wale wa hali ya chini kiuchumi .[1]

Watoto[hariri | hariri chanzo]

Viwango ya shinikizo la damu kwa watoto inaongezeka. [85] Zaidi utoto shinikizo la damu, hasa katika preadolescents, ni sekondari ya ungonjwa wa msingi. Mbali na fetma, figo ugomjwa ni sababu ya kawaida (60–70%) ya shiniko la damu kwa watoto. Vijana kawaida kuwa na msingi au muhimu shinikizo la damu, ambayo akaunti kwa ajili ya 85–95% ya kesi. [86]


Historia[hariri | hariri chanzo]

Image of veins from Harvey's Exercitatio anatomica de motu cordis et sanguinis in animalibus (“An Anatomical Exercise on the Motion of the Heart and Blood in Living Beings”)

Uelewa ya kisasa ya mfumo wa moyo ulianza na kazi ya mtabibu William Harvey (1578-1657). Harvey alielezea mzunguko wa damu katika kitabu chake De Otu ordis ("On Motion of the Heart and Blood"). Padiri wa Uingereza Stephen Hales alifanya kipimo cha kwanza cha kuchapishwa cha kipimo cha shinikizo la damu katika mwaka 1733 .[87][88] Maelezo ya shinikizo la damu kama ugonjwa ulitoka, miongoni mwa wengine, Thomas Young katika mwaka 1808 na Richard Bright katika mwaka 1836 .[87] Ripoti ya kwanza ya muiniko wa shinikizo la damu katika mtu bila ushahidi wa ugonjwa wa figo ilitolewa na Frederick Akbar Mahomed (1849-1884).[89] Hata hivyo, shinikizo la damu kama chombo cha kliniki ilikuja kuwa katika mwaka 1896 na uvumbuzi wa cuff [sphygmomanometer []] na Scipione Riva-Rocci mwaka 1896.[90] Uvumbuzi huu uliruhusu shinikizo la damu kupimwa katika zahanati. Katika mwaka 1905, Nikolai Korotkoff aliboresha mbinu kwa kueleza Korotkoff sounds ambazo zilisikiwa wakati ateri ilikuwa auscultated na stetoskopu wakati sphygmomanometer cuff ilikuwa imwetolewa upepo[88]

Kihistoria matibabu ya kiitwacho "ugonjwa mgumu wa pigo la moyo" ilihusisha kupunguza kiasi cha damu na blood letting au kupaka leeches.[87] Yellow Emperor wa Uchina, Cornelius Celsus, Galen, na Hippocrates walitetea kuruhusu damu.[87] Katika karne za 19 na 20, kabla ya matibabu ya ufanisi ya pharmacological ya shinikizo la damu ilikuwa inawezekana, taratibu tatu za matibabu zilitumika, zote zikiwa na athari mbalimbali. Namna hizi ni pamoja na taratibu kali za kizuizi cha sodiamu, (kwa mfano, lishe la mchele [87]), sympathectomy (upasuaji wa kukausha sehemu za sympathetic nervous system), na tiba ya pyrogen (kudungwa dutu ambazo zilisababisha homa, pasipo moja kwa moja kupunguza shinikizo la damu).[87][91] Kemikali ya kwanza ya shinikizo la damu, sodium thiocyanate, ilitumika mwaka 1900 lakini ilikuwa na madhara mengi na haikupendwa.[87] Mawakala wengine kadhaa waliundwa baada ya Second World War. Maarufu zaidi na fanisi kiasi ilikuwa tetramethylammonium hidrojeni na isio na uasili yake hexamethonium, hydralazine, na reserpine (inayotokana na mmea wa dawa Rauwolfia serpentina). Uvumbuzi kubwa ilikuwa ya mafanikio na ugunduzi wa mawakala wa mdomo wa kwanza nzuri wanapatikana wanayovumiliwa. Ya kwanza ilikuwa chlorothiazide, ya kwanza thiazide diuretic, ambayo iliundwa na kiua vijasumu sulfanilamide na kupatikana mwaka 1958.[87][92] Iliongeza takamwili ya chumvi wakati inazuia mkusanyiko wa maji. randomized controlled trial ambayo ilifadhiliwa na Veterans Administration ikilinganishwa na hydrochlorothiazide pamoja na reserpine pamoja na hydralazine dhidi ya placebo. Utafiti huo ulisimamishwa mapema kwa sababu wale walio katika kundi la shinikizo la juu la damu ambao walikuwa wanapata tiba walipatwa na matatizo mengi zaidi ya wagonjwa waliotibiwa na ilionekana ni vibaya kumnyima matibabu kutoka kwao. Utafiti uliendelea kwa watu wenye shinikizo la damu ya chini na kuonyesha kwamba matibabu, hata katika watu walio na shinikizo la damu kiasi, kupunguza hatari ya kufa moyo na mishipa kwa zaidi ya nusu. [93] Mwaka 1975, Lasker Special Public Health Award ilitolewa kwa timu ambayo iliunda chlorothiazide. [91] Matokeo ya tafiti hizi ilisababisha kampeni za afya za umma ili kuongeza uelewa wa umma wa shinikizo la damu na ilikuza kipimo na matibabu ya shinikizo la damu. Hatua hizi huonekana zilichangia angalau kwa sehemu kwa kupungua kwa asilimia 50 katika ugonjwa wa kiharusi na ischemic heart kati ya 1972 na 1994.[91]

Jamii na utamaduni[hariri | hariri chanzo]

Awareness[hariri | hariri chanzo]

Grafu inaonyesha, kiwango cha ufahamu, matibabu na udhibiti wa shinikizo la damu ikilinganishwa na kati ya utafiti nne ya NHANES[82]

The World Health Organization imebainisha shinikizo la damu, au shinikizo la damu, kama chanzo kubwa cha cardiovascular mortality. The World Hypertension League (WHL), shirika mwamvuli la jamii 85 ya taifa ya shinikizo la damu na ligi, ilitambua kuwa zaidi ya asilimia 50 ya watu walio na shinikizo la damu duniani hawajui hali yao.[94] Ili kukabiliana na tatizo hili, WHL imeanzisha kampeni ya kimataifa juu ya shinikizo la damu mwaka 2005 na kutunikia mwezi Mei tarehe 17 kila mwaka kama World Hypertension Day (WHD). Zaidi ya miaka mitatu iliyopita, vyama zaidi vya kitaifa vimekuwa vikishiriki katika WHD na wamekuwa wabunifu katika shughuli zao za kupata ujumbe kwa umma. Mwaka 2007, kulikuwa na rekodi ya ushiriki kutoka nchi ya wanachama 47 ya WHL. Wakati wa wiki ya WHD, nchi hizi zote zilishirikiana na serikali za mitaa, jamii za kitaaluma, mashirika yasiyo ya kiserikali, na viwanda binafsi kukuza ufahamu wa shinikizo la damu kupitia kampeni kadhaa media na umma. Ukitumia mass media kama vile Internet na television, ujumbe umewafikia zaidi ya watu milioni 250. Vile kasi inaongezeka mwaka baada yaa mwaka, WHL ina matumaini kuwa karibu watu wote wanaokadiriwa kufikia bilioni 1.5 ambao wameathirika na muinuko wa shinikizo la damu wanaweza kufikiwa.[95]

Uchumi[hariri | hariri chanzo]

Shinikizo la damu ni shida sugu ya kawaida ya matibabu inayochochea ziara kwa watoa huduma msingi wa afya nchini Marekani. Shirika la Moyo Marekani limekadiria gharama za moja kwa moja na zisizo za moja kwa moja ya shinikizo la damu katika dola bilioni 76.6 katika mwaka 2010.[84] Nchini Marekani, asilimia 80 ya watu walio na shinikizo la damu wanafahamu hali zao na asilimia 71 wanachukua baadhi ya dawa za dhidi ya shinikizo la damu. Hata hivyo, asilimia 48 tu ya watu ambao wanafahamu wana shinikizo la damu wanadhibiti ipasavyo hali hiyo.[84] Inadequacies in diagnosis, treatment, or control of high blood pressure can compromise the management of hypertension.[96] Health care providers wanakabiliwa na shida nyingi ya kudhibiti shinikizo la damu, ikiwa ni pamoja na upinzani kwa kutumia dawa mbalimbali ili kufikia malengo ya shinikizo la damu. Watu pia wanakabiliwa na changamoto ya kufuata ratiba ya dawa na kufanya mabadiliko ya maisha. Hata hivyo, kufikia malengo ya shinikizo la damu inawezekana. Kupunguza shinikizo la damu inapunguza gharama kwa kiasi kikubwa ambayo inahusishwa na huduma ya matibabu ya juu.[97][98]

Uelewa[hariri | hariri chanzo]

Graph showing, prevalence of awareness, treatment and control of hypertension compared between the four studies of NHANES[82]

The World Health Organization imebainisha shinikizo la damu, au shinikizo la damu, kama chanzo kubwa cha cardiovascular mortality. The World Hypertension League (WHL), shirika mwamvuli la jamii 85 ya shinikizo la damu ya kitaifa na ligi, ilitambua kuwa zaidi ya asilimia 50 ya watu walio na shinikizo la damu duniani hawajui hali zao. [94] Ili kukabiliana na tatizo hili, WHL imeanzisha kampeni za kimataifa za shinikizo la damu mwaka 2005 na dedicated mwezi Mei tarehe 17 kila mwaka kama World Hypertension Day (WHD). Zaidi ya miaka mitatu iliyopita, zaidi ya vyama vya kitaifa vimekuwa vikishiriki katika WHD na wamekuwa wabunifu katika shughuli zao za kupeleka ujumbe kwa umma. Mwaka 2007, kulikuwa na rekodi ya ushiriki kutoka nchi wanachama 47 za WHL. Wakati wa wiki ya WHD, nchi hizi zote zilishirikiana na serikali za mitaa, jamii za kitaaluma, mashirika yasiyo ya kiserikali, na viwanda binafsi kukuza ufahamu wa shinikizo la damu kupitia kampeni kadhaa media na umma. Ukitumia mass media kama vile Internet na television, ujumbe umewafikia zaidi ya watu milioni 250. Vile kasi inaongezeka mwaka baada yaa mwaka, WHL ina matumaini kuwa karibu watu wote wanaokadiriwa kufikia bilioni 1.5 ambao wameathirika na muinuko wa shinikizo la damu wanaweza kufikiwa.[95]

Marejeo[hariri | hariri chanzo]

  1. 1.0 1.1 1.2 1.3 Carretero OA, Oparil S (January 2000). "Essential hypertension. Part I: Definition and etiology". Circulation 101 (3): 329–35. doi:10.1161/01.CIR.101.3.329. PMID 10645931. http://circ.ahajournals.org/content/101/3/329.long. 
  2. 2.0 2.1 2.2 2.3 Chobanian AV, Bakris GL, Black HR, et al. (December 2003). "Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure". Hypertension 42 (6): 1206–52. doi:10.1161/01.HYP.0000107251.49515.c2. PMID 14656957. http://hyper.ahajournals.org/content/42/6/1206.long. 
  3. 3.0 3.1 3.2 National Clinical Guidance Centre (August 2011). "7 Diagnosis of Hypertension, 7.5 Link from evidence to recommendations", Hypertension (NICE CG 127). National Institute for Health and Clinical Excellence, 102. Retrieved on 2011-12-22. 
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