Practical Handbook for Hypertension Two

Chapter 4: Medicinal treatment for hypertension

The world’s statistic data has confirmed that half of the hypertensive patients did not receive any treatments, and only half of the patients who underwent the treatments attained the effective control on their blood pressure. In China, the hypertension control rates are less than 5%. Such a low control is a direct result of the high morbidity and high mortality, mainly because of the inconsistent condition between hypertension and its related symptoms. Some people may look healthy and normal, nevertheless, their blood pressure may have risen to a dangerous level, and their internal organs may have damaged badly.

Besides restricting on diet, weight, tobacco, alcohol, and doing an appropriate exercise, hypertensive patients need medication to control their blood pressure. The drugs treatment must be in accordance to the conditions and symptoms.

High blood pressure is a slow process, and hypertension treatment needs to emphasize on the stable basis, but not to be too hasty, therefore, slower treatment is always better than the quick one. Anti-hypertension drugs usually take a very long time, and sometimes patients will be lifelong medication. Ideal anti-hypertensive drug should be effective in reducing blood pressure, and the intake is once a day with fewer side effects, so that it will not indulge other cardiovascular risk factors. The drug treatment must aim at reducing blood pressure, to strengthen the heart, brain, kidney and other organs of protection.

Type of antihypertensive drugs

In modern treatment nowadays, antihypertensive drugs can group in six categories, namely, diuretics, β-blockers, calcium antagonists, angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor antagonist II (ARB) and α receptor blocker.

Commonly used antihypertensive drugs

Inhibitors: reserpine, clonidine hydrochloride, ACEI such as captopril, enalapril
Central nervous system and sympathetic: Hydrochlorothiazide, cyclopentyl A thiazides, chlorine-thiadiazole such as furosemide
Adrenergic receptor: β-blockers such as propranolol, Atenolol, the US Metoprolol; α Blockers: benzene Benzylamine
Calcium antagonists: nifedipine
Vasodilators: hydralazine, prazosin
Postganglionic sympathetic ganglion and inhibitors: guanethidine
85 – serotonin receptor antagonist: ketanserin

Characteristics of some major antihypertensive drugs

ACEI (angiotensin converting enzyme inhibitor) and the ARB (angiotensin receptor antagonist Ⅱ) are drugs that are good to protect the organ.

ACEI is mild in nature, and may long-term reduce the blood pressure and protect the organs. Their representative drug called benazepril (Lotensin), has dual-channel discharge properties, which is widely used in the treatment of hypertension. As it has a strong affinity of renal tissue, it is a good drug to protect the kidney. A recent research reports indicate that ACEI can also significantly improve the prognosis of heart failure patients.

ARB is a recently developed hypertension drugs and it is a 1990s milestone for a cardiovascular drug. Latest research has proved its safety, effective and protection for the brain and kidney. Its representative drug called valsartan, can improve the common sexual dysfunction among the hypertensive patients.

The medicinal principles for hypertension

Modern treatment of hypertension medicines consist of 6 main categories, namely, diuretics, β-blockers, calcium antagonists, angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor antagonist Ⅱ(ARB) and α-adrenergic receptor blockers. Existing clinical trial results support the following types of antihypertensive drug combinations:

• Diuretics and β-blockers.
• Diuretics and ACEI or ARB.
• Calcium antagonist (dihydropyridine) and β-blockers.
• Calcium antagonist and ACEI or ARB.
• Calcium antagonists and diuretics.
• Α receptor blockers and β-blockers.

If necessary, other combinations have to include in the treatment consisting of the central role of medicine, such as α2 receptor agonist, effects of-receptor modulators, as well as the use of ACEI and ARB in the treatment.

There are two kinds of combined medication: the first is to take the prescribed medicine according to the dose ratio and adjustment of drugs base upon the variety and dosage of clinical needs. The second is fix ratio compound, which helps improve the compliance of the patients. Antihypertensive drug mechanisms and the type of the application of antihypertensive drugs, for example through diuretics to reduce the cycle of the content of sodium and water may help lowering blood pressure and blood volume. This treatment is commonly applicable to mild to moderate hypertensive patients, particularly for the elderly and for hypertensive patients with heart failure. The use of Hydrochlorothiazide, indapamide and β-blockers block β receptors, weakened myocardial contractility in order to reduce cardiac output, decrease myocardial oxygen consumption, inhibit renin secretion, slow down the heart rate and lower blood pressure and thereby significantly reducing the risk of stroke and coronary heart disease. The usage of these drugs are common in the treatment of coronary heart disease, angina pectoris, myocardial infarction as way to prevent the recurrence of accidents and sudden deaths, rapid arrhythmia, congestive heart failure and pregnancy-induced hypertension.

Propranolol, atenolol, metoprolol, Bisoprolol, carvedilol calcium antagonist (CCB) are some of the drugs used to inhibit calcium from passing through the cardiac and vascular muscle cells, lead the muscle relaxation and reduce resistance around the cells. This is particularly applicable to elderly hypertension, isolated systolic hypertension, hyperlipidemia, obese hypertension or electrolyte imbalance with heart, brain, kidney and vascular complications of hypertension particularly in pregnancy-related hypertension.

On the light, medium, severe hypertension, elderly hypertension, congestive heart failure, left ventricular dysfunction, non-diabetic nephropathy (a type of diabetic nephropathy) and proteinuria are applicable to the patients.

Things to bear in mind for a long-term use of antihypertensive drugs

Use small dose of medicine to obtain its effect in order to minimize its adverse reactions. If the results are dissatisfied, the patients may increase the dose gradually to obtain better effect. Large doses of medication may cause a significant rise in blood pressure. Arterial blood pressure is essential for the body’s blood flows through the tissues and organs. A sudden rise in blood pressure may significantly reduce the supply of blood to heart, brain, liver, kidney and other important organs that may finally end up with hypoxia dysfunction and other adverse consequences.

In order to prevent the organ damage effectively, the patients should constantly be in medication within 24 hours to maintain their blood pressure within the normal range. Do not simply change the drugs. When there are bad effects or side effects of the medication, the patients should swift to other varieties of drugs with the advice of the doctor.

Avoid stop using anti-hypertension drug as it may cause blood pressure and a series of anti-jumping reaction, known as clinical Antihypertensive withdrawal syndrome. A sudden rise of blood pressure may cause dizziness, headache, weakness, sweating and a series of symptoms. Certain patients may also experience cramps due to cardiovascular blood pressure, myocardial infarction or cerebral vascular accidents and life-threatening symptoms. This is because our body is already accustomed to the drugs and hence a sudden stop of medication contributes to the anti-jumping phenomenon. The patient should reduce the medication gradually together with the non-medication treatments to ensure their health safety. Never stop medication as this is dangerous for hypertensive patients.

Avoid taking medication before sleep as it may induce the occurrences of cerebral vascular disease. Traditionally, the daily dosage is three times a day. However, some patients prefer to take medication during bedtime, as they think the blood pressure will drop after medication and thus they can sleep comfortably. They never know that bedtime medication may lead to high concentration of plasma after 2 hours, and at the same time the body experiences extremely low blood pressure. The combination of these two factors may cause a substantially low blood pressure, thereby inducing cerebral thrombosis, the rise of the occurrences of cerebral vascular, as well as imposition of heart pain and myocardial infarction.

Each antihypertensive drug has its unique characteristic and thus the drug should use with care and in accordance to the condition of hypertension to reduce complicated symptoms, delay the progress of the disease and to prevent the occurrence of cerebrovascular, congestive heart failure, renal failure and other complications.

Application of antihypertensive drug treatment of hypertension needs long-term medication. Therefore, its selection should base upon availability, suitability, less side effects, easy to use such as hydrochlorothiazide and reserpine as a basic of hypertensive drugs. Patients can then choose other antihypertensive drugs based upon the conditions of their hypertension.

Clinical experimental tests have showed the advantage of the combination of several antihypertensive drugs. The combination drugs enhance the effectiveness of synergies, offset side effects of a single dose of the drug, and blood pressure drops more constantly and stable.

Phase I patients need not to take multiple drugs as their symptoms are not obvious, and normally general treatment (including tranquilizers) will do. If necessary, patients can take small amount of mild hypertensive drugs such as diuretics and Rauvolfia. Nevertheless, for phase II patients, they should take two or more antihypertensive drugs. For example, they can select the combination of reserpine, hydralazine and diuretics or re-elect enzyme inhibitors, inhibitor sympathetic postganglionic nerve ganglion block such as adrenergic receptor blockers. Phase III patients require antihypertensive effect of drugs include post-inhibitor sympathetic ganglion blockers such as clonidine hydrochloride to reward from the treatment.

A glimpse of some common antihypertensive drugs in term of their mechanisms, applications, types and adverse effects

Diuretics

Mechanism: reduce cycle in sodium and water content by stimulating kidneys excrete more sodium in urine (diuresis), which reduces pressure on the walls of the arteries and thereby lowering blood pressure

Application: commonly used in the treatment of mild to moderate hypertension, especially for the elderly, patients with congestive heart failure, polycystic ovary syndrome, kidney disorders, diabetes insipidus, female hirsutism

Type: Hydrochlorothiazide and mmetolazone (thiazide diuretics), furosemide and bumetanide (loop diuretics), spironolactone and eplerenone (potassium-sparing diuretics)

Adverse effect: increased urination, dizziness, impotence, dehydration, muscle cramps and weakness, coma, paralysis, hypotension, seizure

B-blockers

Mechanism: Block β receptors, weakened myocardial contractility, decrease the force of contraction of the heart; reduce cardiac output and myocardial oxygen consumption, inhibiting renin secretion, slow down the heart rate and lower blood pressure, thereby significantly reducing the risk of stroke and coronary heart disease.

Application: commonly used in the treatment of coronary heart disease, angina pectoris, myocardial infarction to prevent the recurrence of accidents and sudden deaths, rapid arrhythmia, congestive heart failure and pregnancy-induced hypertension.

Type: Propranolol, nadolol and pindolo (non-selective), atenolol, metoprolol and Bisoprolol (selective)

Adverse effect: mild chronic fatigue, sedation, nightmares, increased airway resistance, bradycardia and particularly propranolol could mask insulin-induced hypoglycemia

Calcium antagonist or Calcium Channel Blockers (CCB)

Mechanism: smooth muscle relaxation, reduce resistance around the adjacent cells, function as anti-angina and reduce the workload of the heart by inhibiting calcium ions through cardiac and vascular smooth muscle cells from signaling the blood vessels to constrict or tighten.

Application: commonly used in the treatment of elderly hypertension, isolated systolic hypertension, hyperlipidemia, obesity hypertension or electrolyte imbalance, hypertensive patients with heart, brain, kidney and vascular complications and pregnancy-related hypertension.

Type: Long-acting calcium antagonist amlodipine (Norvasc), calcium antagonists release nifedipine (Adalat GITS), lacidipine and sustained-release felodipine (Plendil), diltiazem, verapamil

Adverse effect: headache, nausea, heartburn, dizziness, edema, constipation and bradycardia (slow heart rate of under 60 beats per minute)

Angiotensin-converting enzyme inhibitor (ACEI)

Mechanism: slow the body’s production of a hormone that constricts blood vessels, lower arteriolar resistance and increase venous capacitance, lower renovascular resistance, lead to increased natriuresis (excretion of sodium in the urine), inhibit the production of a substance (angiotensin II that causes blood vessels to tighten), which results in lowering the resistance of the blood vessel to the flow of blood from the heart

Application: commonly used in the treatment of light, moderate and severe hypertension, elderly hypertension, congestive heart failure, left ventricular dysfunction, non-diabetic nephropathy (a type of diabetic nephropathy) and proteinuria

Type: Captopril (capoten), enalapril, benazepril, fosinopril, lisinopril, Quinapril Benazepril

Adverse effect: cough, rash, loss of taste, insomnia, diarrhea, stomach upset, abdominal cramps, pain or distention, and joint pain.

Angiotensin receptor II blocker (ARB)

Mechanism: has similar effect as ACEI but they inhibit the action of angiotensin II from entering angiotensin II receptors in the body instead of preventing the production of angiotensin II

Application: commonly used in the treatment of mild to moderate hypertension, type 2 diabetic nephropathy, proteinuria, diabetic microalbuminuria, left ventricular hypertrophy, ACEI-induced cough.

Type: Losartan, valsartan, telmisartan

Adverse effect: headache, dizziness, back and leg pain, nasal congestion, decreased amount of urine passed, diarrhea, and drop in white blood cells.

α receptor blocker or alpha-adrenergic blocking agents or alpha-blockers

Mechanism: reduce α1-adrenergic activity of the blood vessels, vascular resistance, relax certain muscles, help small blood vessels remain open, keep the hormone norepinephrine (noradrenaline) from stimulating the muscles in the walls of smaller arteries and veins, and thus causing vessels to remain open and relaxed.

Application: commonly used in the treatment of benign prostatic hyperplasia (BPH), high blood pressure, symptoms of non inflammatory chronic pelvic pain syndrome (a type of prostatitis), sugar or abnormal lipid metabolism

Type: doxazosin, prazosin, phenoxybenzamine, phentolamine, tamsulosin, alfuzosin, terazosin

Adverse effect: hypotension (low blood pressure), baroreflex response interruption, dizziness, lightheadedness, fainting when rising from a lying or sitting posture (known as orthostatic hypotension or postural hypotension), weakness, pounding heartbeat, decrease in LDL-cholesterol, headache, nausea

Chapter 5: Factors that trigger hypertension

Gender and age

Women before menopause has relatively low proportion of hypertension than men, but after menopause, there is no prevalence rate between both genders and in some circumstances, the rate of women in hypertensions may even be higher than that of men.

Unhealthy living habits

A large number of surveys showed that dietary intake is closely associated with the occurrences of stroke, hypertension and other related complications. Too much sodium, high alcohol consumption, excess fat intake in a daily diet contributes to higher blood pressure. Another study revealed that people who prefer to stay up late might have high possibility to have suffered from hypertension or stroke.

Heavy workload pressure

The rapid progress of social civilization has created competitive societies who are at high risk of working under pressure and stress. The additional pressure, undoubtedly, has led to a series of changes in human’s body. This situation leads to the increase of catecholamine secretion, which causes the vascular contraction. The vascular contraction will then worsen human’s health by increasing the blood pressure as well as burdening the heart with additional workload.

Character

Character includes personality and emotional changes matched perfectly with blood pressure. Any changes in those characters in the human’s body will lead to many subtle changes. For instance, when one gets angry, moody, impatience, the body will secrete hormone that leads to vasoconstriction (narrowing or constriction of blood vessels.) When blood vessels constrict, the flow of blood is restricted or slowed. In a long run, vasoconstriction may lead to high blood pressure.

Genetic

Many clinical data confirmed that genetic factor is one of the culprits of the causes of hypertension. If both parents are suffering from hypertension, the incidence of hypertension in their children may up to 46%, but if either of them is suffering from hypertension, the incidence of hypertension incurred in their children can be in the range of 26% to 28%. On the other hand, the incidence of hypertension in children is only 3% if parents have normal blood pressures.

Overweight or obese

Body weight has a high correlation with the blood pressure. Many clinical data from foreign sources show that people with the condition of overweight and obesity have 2 to 3 times higher risk of suffering from hypertension than that of people with ideal and standard body weight.

Smoking

Smoking can accelerate the formation of atherosclerosis besides giving rise to higher blood pressure. According to both sources from Japan and Korea, people who finished smoking two cigarettes, will have their bodies loaded with the secretion of epinephrine and norepinephrine after 10 minutes finished smoking. The secretion of these hormones may accelerate the heartbeats as well as higher systolic and diastolic blood pressure. Smokers are more susceptible to malignant hypertension. The nicotine in the tobacco inhibits the effects of antihypertensive drugs.

Drinking alcohol

Excessive alcohol consumption will definitely give rise to systolic and diastolic blood pressure, besides leading to a stroke risk. Japan experts recommend male not to drink more than 30mg of alcohol, while female should not exceed 20mg within a day.

Notes:

Epinephrine is a natural hormone, secreted from the adrenal glands as part of the sympathetic nervous system in mammals. In the situation of high stress, the secretion of epinephrine or adrenaline is helpful to cope with the stress; physiologically, it allows the individual to increase its heart rate, which in turn, increases the rate of glycogenalysis (the conversion of glycogen to glucose), creating more energy and allowing the individual to run faster, jump higher and to perform better.

Norepinephrine or noradrenaline, secreted by the adrenal medulla and the nerve endings of the sympathetic nervous system to cause vasoconstriction and increases in heart rate, blood pressure, and the sugar level of the blood.

Chapter 6: Questions and Answers

What is the relationship between age and hypertension?

In human’s life, the blood pressure does not remain static but keep on changing and fluctuating. Under the normal physiological circumstances, the blood pressure changes according to the age, gender and other unprecedented factors. When we age, the blood pressure increases gradually, the increase of systolic is always more significant than diastolic blood pressure. This is because when we age, vascular proliferation of collagen fibers gradually replacing the smooth and elastic fibers, leading to the decrease of vascular wall’s elasticity. Generally, there is a great extent of increased blood pressure in men than women. However, after menopause, the differences between both genders become relatively small.

Which careers are at high risks of hypertension?

The incidence of hypertension links closely to a job. The job that requires high degree of concentration causes long-term mental tension, and long-term exposure to environmental noise can lead to hypertension too. The career as a driver or an accountant is among the category jobs that are vulnerable to hypertension. Reliable sources confirmed that the external factors for spirit stimulation include long-term or repeated times of obvious mental stress, anxiety, irritability, and other emotional changes in the cerebral cortex that causes imbalance of excitement inhibition, resulting in the release of peripheral sympathetic catecholamine increase (mainly norepinephrine and epinephrine). In this case, the small artery contracts and thus increasing peripheral vascular resistance and finally causing blood pressure. Therefore, hypertensive patients should emphasis on the proper adjustment of physiological and psychological aspects. About 60% of the patients with hypertension have their blood pressure reduced more than 10% after two weeks proper rest from their intensive working environment.

Are there any relationships between hypertension and genetic factor?

Epidemiological and experimental data has revealed genetic factor of hypertension’s kidneys (tubular) is abnormal in sodium absorption that the body hardly assimilates the excessive salt consumption. When the volume of sodium increases with excessive water, it results in increasing blood volume and causes hypertension. The increase of sodium and water may result in vascular muscle swelling and thinned lumen. This in turns causes small blood vessels which may block the blood flowing. According to the World Health Organization definition, 40 percent of human health and longevity is rely on genetic factor and objective conditions, which 15 percent genetic and 10 per cent for social factors, and 8% for medical conditions, and 7% for the climatic conditions, and 60% by establishing their own way of life and psychological behavior. Although the hypertension may cause by genetic factor, with an appropriate diet, regular physical exercise, weight control, smoking, alcohol limitation, psychological balance, prevention and control of hypertension is entirely possible.

In what extend do patients have to control their blood pressure?

Once diagnosed hypertension, you should control the blood pressure within the normal range. Young, light and mild patients should control their blood pressure below 135/85 mmHg, while the elderly patients should keep maintain at 140/90 mmHg. Patients with systolic blood pressure should keep their blood pressure below 140 mmHg in systolic blood pressure.

Research shows that each reduced by 5 mmHg diastolic blood pressure significantly reduce the mortality rate of 32 %, 44 % reduction of stroke, diabetes complications (including amputation) by 24 %, micro vascular complications (including retinal hemorrhage) was reduced by 37%. Experts found that the most hypotension (low blood pressure) group of cardiovascular events significantly reduced the incidence of renal dysfunction but in the speed of the slowest, thus the best blood pressure control targets should set to 130/80 mmHg.

Hypertension treatment is a life-long process, even if blood pressure is control in an ideal range; the antihypertensive treatment should proceed over the time, in order to prevent those potentially dangerous complications from happening.

Do you need treatment for non-symptoms hypertension?

Hypertension is not like a cold, sneezing, nasal obstruction, sore throat that will remind you of their existence. Some people may even have an appalling blood pressure without their knowledge of getting hypertension. Hypertension is a “silent killer” that people cannot feel its arrival, which gives pressure to our heart, brain, kidneys, eyes and other important organs quietly. People who take hypertension for granted by taking excessive alcohol, mood fluctuation, seasonal transformation induced factors may give burden to the heart, brain, kidney and other vital organs of the system to experiencing a collapse.　The tragic outcome waiting for the patients is either myocardial infarction or cerebral hemorrhage　or may even end up with uremia.

The best hypertension prevention is to protect our heart, brain and kidney. Similarly, the ultimate aim of hypertension treatment is to reduce blood vessels, heart, brain, kidney and other organs from the incidence of complications and mortality. A great deal of information has also proven that the higher the systolic or diastolic blood pressure may cause the disability of cardiovascular system that may lead to greater risk of mortality. Therefore, early treatment and protection are necessary to protect organ damage even though you experience non-symptoms hypertension.

Why Women in the amenorrhea have high risk of hypertension?

Women before amenorrhea have a relatively low incidence of hypertension as compared to men, and the rate of hypertension is less than men about one third. This is because the female hormones, namely, estrogen and progesterone, have effects in decreasing the contraction of atherosclerosis vascular as well as promoting the role of sodium excretion. Therefore, these two hormones have good effects of lowering blood pressure. However, menopausal women have less secretion of these hormones but an increased secretion of pituitary hormones. This series of changes destroys the coherence role of autonomic nervous system (sympathetic and parasympathetic), which losses its ability to control the blood pressure. These reasons explain why women in their amenorrhea have unstable blood pressure leading to the occurrence of hypertension.

How to prevent menopause related hypertension?

Patients who are suffering from hyperlipidemia should strictly control their diet. They should switch from the consumption of high fat and high cholesterol diet to low cholesterol, low fat diet by eating plenty of organic leafy vegetables, soybean products and foods rich in cellulose to reduce cholesterol absorption in the intestines. Restriction on animal fats, meats, eggs will be a great reward for the patients. Fat promotes cholesterol absorption and the synthesis effect that enables the aggregation of RBC and at the same time increases the blood viscosity and the formation of thrombosis. Gradually, the blood flows slowly causing the decline in myocardial oxygen, which eventually leads to coronary sclerosis. Patients with coronary heart disease should also restrict the intake of sugar.

Overweight is the major culprit for hypertension. They should put on weight gradually and systematically but not in a hurry. Patients who undergo weight control should ensure that adequate supplementary protein is about 1 to 1.5g of protein per day for each 1kg of body weight. The lack of protein may cause the wear out of organs, malnutrition and decreased immune system. They should eat low fat, low-sugar products. While putting on weight, the patient should eat more vegetables rather than eating cakes, chocolates, candies and such.

The patients should enhance their bodies by doing some outdoor activities such as walking, tai chi and qi gong. When someone is doing physical movements, it helps energy consumptions that are useful to bring down the blood’s lipid. For the prevention and treatment of hyperlipidemia, particularly deals with those who use a lot of brain should walk or job for approximately 30 minutes a day and this will help to gradually burn out the fat in the body.

Avoid excessive tension is also useful to maintain normal nervous level. Over excitement will increase blood cholesterol, while emotional disorders and excessive tension can cause hyperlipidemia and atherosclerosis.

Long-term liquor drinkers have a relatively low concentration in the blood lipoprotein that can be easily indulged and aroused hyperlipidemia. Small amount of wine does no harm to health, but smoking has confirmed as one of the factors that indulged coronary heart disease. Therefore, the patients should put in afford to quit smoking and liquor.

How does hypertensive patient avoid uremia?

Approximately 15% of hypertension will develop into uremia (illness accompanying kidney failure). The control of blood pressure is important as it may affect the progress and treatment of uremia. Therefore, patients with hypertension should monitor their blood pressure to prevent uremia based upon the criteria below:

1. Control blood pressure within the desired level
2. Monitor closely the renal function to prevent renal blockage and damage
3. Monitor the early symptoms of uremia such as weakness, skin itching, loss of appetite, nausea, vomiting and other gastrointestinal symptoms. Other symptoms include bloodless and yellowish facial appearance, pale and colorless tongue; pale eyelid appearance may reflect the abnormal of renal function. When this situation happens, patients should get their kidneys checked.
4. Select mild antihypertensive drugs that have no renal toxicity but protect the kidneys. Many Japan and China resources have showed that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers and β-blockers in blood pressure may protect the kidney.
5. Take reasonable and appropriate diet in order to secure renal sufficiency. If renal is found insufficiency, patients should insist on low protein diet by cutting down animal and plant protein to maintain the function ability of kidneys.
6. Rest well but avoid over exhaustion

Chapter 7: Final Remarks

I dare not say this is an informative handbook, and I would like to beg your pardon for any incomplete parts of this handbook that I have not covered in details.

Every minute and even every second, many patients that are close to you or you may not know them, are striving hard with pain at the hospital, at home, or at any corners of the world. As long as their hearts are still beating, they muster their strength and courage to fight with the death.

I am seeing more and more patients who are in pain, stress, annoyance, frustrated and upset due to the illnesses. If you have ever encountered these problems and need to share your ideas, stories and experiences, I am always here to listen. I hope I can be a big tree to provide you a shade, meaning that you may benefit from my knowledge, experiences and opinions.

Dear patients, do not afraid and scared as the illnesses are not as scary as you thought, if you recognize the symptoms and have appropriate knowledge on how to deal with them. As long as you are still breathing, it is a blessing for you to continue the journey no matter what pattern of your life is. Bear in mind that the medication alone would not completely cure your health problem without your initiative to shift to healthy eating and healthy lifestyle. My last advice to you is “Make a change, your life will be different!”

This is a handbook for you, my parents, friends, relatives, and hypertensive patients. If you learn just one thing from it that will improve the way you live and feel, this handbook will be well worth of efforts, time and energy.