Hypertension: have we missed something?

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If you were wearing red on February 5th, chances are that you already know February is American Heart Month. For its part, the slogan this year for the Centers for Disease Control and Prevention is "Make blood pressure control your goal." The aim is to prevent a million heart attacks and strokes in the US by 2017.

Reducing hypertension is one of the goals of 2016 American Heart Month.

High blood pressure (BP), or hypertension, affects some 70 million Americans, quadrupling the chance of a person dying from a stroke and tripling the chance of dying from heart disease.
Physicians prescribe medications to lower BP but with limited effect. Some people do not see the benefit, some may suffer unwanted side effects and others may hear stories about adverse effects that cause them to discontinue treatment, as previously reported by Medical News Today.
For many, it may be that the treatment is not targeting the underlying cause.
Hypertension that results from a medical condition, such as obstructive sleep apnea, adrenal gland tumors or thyroid problems, is called secondary hypertension. This type of high BP can result from medications such as hormone treatments and painkillers, recreational drugs and even herbal remedies. Secondary hypertension usually starts suddenly and causes higher blood pressure than primary hypertension.
Over 90% of people with high blood pressure have primary hypertension. It progresses gradually over the years, increases with age and is affected by hereditary factors. Lifestyle factors, such as too much salt, lack of exercise, obesity or heavy alcohol consumption can cause primary hypertension.
While advice and treatment for high BP mainly focuses on lifestyle factors or dysfunction of the cardiovascular system, some researchers are looking elsewhere. This spotlight will touch on some new approaches to hypertension.

A question of neurology

According to the American Academy of Neurological and Orthopedic Surgeons (AANOS), hypertension "is not only a problem of the heart, kidneys or blood vessels but also of the central nervous system."

Fast facts about hypertension

• 29% of Americans have high BP
• Only 52% have their condition under control
• High BP caused the deaths of 360,000 Americans in 2013.

Prof. Julian Paton and colleagues, from Bristol University in the UK, are among researchers studying the relationship between high BP and the brain, and particularly the nerves in the brainstem.
To understand the role of the nervous system in blood flow, we will start by looking at the autonomic and sympathetic nervous systems.
Some of our actions, we control; we choose to raise our hands or close our eyes.
But we cannot normally choose to breathe or to stop our heart from beating. It is the autonomic nervous system that controls involuntary actions such as cardiovascular system function. The autonomic nervous system includes the sympathetic nervous system.
When we are stressed, the sympathetic nervous system, sometimes called "fight or flight," steps in. The adrenal glands produce more of the neurotransmitters epinephrine (adrenaline) and norepinephrine (noradrenaline), and extra blood is pumped to the muscles, which delivers additional nutrients and oxygen until the crisis is over.
Prof. Paton explained to MNT:

"The nervous system is connected via nerves to the heart and every blood vessel in your body. Via these nerves, it can increase heart rate and narrow blood vessel diameter. Both cause blood pressure to go up."

"Neurogenic hypertension is related to excessive and abnormally high sympathetic activity," he added.
The additional activity is normally temporary. If it continues, it can become a problem.
Researchers have previously associated stress with long-term hypertension. MNT recently reported that teenagers who are easily stressed are more at risk of hypertension later in life.
In 2014, Mancia and co-researchers, from the University of Milan in Italy, found abnormally high amounts of norepinephrine and epinephrine in people with normal blood pressure but whose families had a history of hypertension. These "sympathetic bursts" have also been seen in patients with high BP.
Mancia's team concluded that high BP can result from a dysfunction in the autonomic nervous system. They propose that a "central sympathetic overdrive" is responsible for hypertension in some people, depending on their genetic background or blood pressure phenotype.

The 'selfish brain hypothesis' of hypertension

The kidneys are key to the cardiovascular system because they regulate the balance of salts and fluid, which has a direct effect on BP.

Resistance in the brainstem may lead to hypertension.

If the kidneys lack blood, they can call on the brain for provisions. The brain supplies the kidneys, but this will cause an imbalance, because the brain will be short of blood. Hypertension will occur.
The term "selfish brain" was coined by Prof. Achim Peters of Lübeck University in Germany, a specialist in obesity.
The hypothesis perceives the brain as having "a special hierarchical position" in the body. If there is a bottleneck, so that the brain cannot get enough energy, says Prof. Peters, it will call the energy back to itself.
Research has shown that many patients with hypertension have narrow blood vessels at the base of the brain and low blood flow, also called high resistance.
Some scientists are now speculating that low blood flow in the brainstem may cause systemic hypertension in order to boost blood flow to the brain.
Prof. Paton explained to MNT:

"A question we are addressing is that brain blood flow determines blood pressure levels; said differently, if brain blood flow is low then hypertension may develop through activation of the sympathetic nervous system. Why? Well, high blood pressure will help to push more blood into the brain. This is the so-called selfish brain hypothesis of hypertension."

If blood flow to the brain decreases, the brain will send out instructions to the body to constrict blood vessels, boosting the blood supply to the brain but resulting in high BP.
In hypertension, the sympathetic nerve signals to the blood vessels makes them stiff, their walls become thicker and resistance increases; if this happens in arteries to the head, it makes it harder for blood to reach the brain. Prof. Paton's team is seeking to better understand what causes this to happen.
The question is: does reduced blood flow to the brain cause hypertension, as is generally believed, or does hypertension decrease the brain's blood supply?