Pulmonary Hypertension Research Paper

Pulmonary hypertension is a type of high blood pressure that affects the arteries in your lungs and the right side of your heart.

In one form of pulmonary hypertension, tiny arteries in your lungs, called pulmonary arterioles, and capillaries become narrowed, blocked or destroyed. This makes it harder for blood to flow through your lungs, and raises pressure within your lung's arteries. As the pressure builds, your heart's lower right chamber (right ventricle) must work harder to pump blood through your lungs, eventually causing your heart muscle to weaken and fail.Pulmonary Hypertension Research Paper

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Some forms of pulmonary hypertension are serious conditions that become progressively worse and are sometimes fatal. Although some forms of pulmonary hypertension aren't curable, treatment can help lessen symptoms and improve your quality of life.

Symptoms

The signs and symptoms of pulmonary hypertension in its early stages might not be noticeable for months or even years. As the disease progresses, symptoms become worse.

Pulmonary hypertension symptoms include:

• Shortness of breath (dyspnea), initially while exercising and eventually while at rest
• Fatigue
• Dizziness or fainting spells (syncope)
• Chest pressure or pain
• Swelling (edema) in your ankles, legs and eventually in your abdomen (ascites)
• Bluish color to your lips and skin (cyanosis)
• Racing pulse or heart palpitations

Causes

Your heart has two upper chambers (atria) and two lower chambers (ventricles). Each time blood passes through your heart, the lower right chamber (right ventricle) pumps blood to your lungs through a large blood vessel (pulmonary artery).Pulmonary Hypertension Research Paper

With pulmonary hypertension, the rise in blood pressure is caused by changes in the cells that line your pulmonary arteries. These changes can cause the walls of the arteries to become stiff and thick, and extra tissue may form. The blood vessels may also become inflamed and tight.

These changes in the pulmonary arteries can reduce or block blood flow through the blood vessels. This makes it harder for blood to flow, raising the blood pressure in the pulmonary arteries.Pulmonary Hypertension Research Paper

Pulmonary hypertension is classified into five groups, depending on the cause.

Group 1: Pulmonary arterial hypertension

• Cause unknown, known as idiopathic pulmonary arterial hypertension
• A specific gene mutation that can cause pulmonary hypertension to develop in families, also called heritable pulmonary arterial hypertension
• Certain drugs — such as certain prescription diet drugs or illegal drugs such as methamphetamines — or certain toxins
• Heart abnormalities present at birth (congenital heart disease)
• Other conditions, such as connective tissue disorders (scleroderma, lupus, others), HIV infection or chronic liver disease (cirrhosis)

Group 2: Pulmonary hypertension caused by left-sided heart disease

• Left-sided valvular heart disease, such as mitral valve or aortic valve disease
• Failure of the lower left heart chamber (left ventricle)

Group 3: Pulmonary hypertension caused by lung disease

• Chronic obstructive pulmonary disease, such as emphysema
• Lung disease such as pulmonary fibrosis, a condition that causes scarring in the tissue between the lungs' air sacs (interstitium)
• Sleep apnea and other sleep disorders
• Long-term exposure to high altitudes in people who may be at higher risk of pulmonary hypertension

Group 4: Pulmonary hypertension caused by chronic blood clots

• Chronic blood clots in the lungs (pulmonary emboli)

Group 5: Pulmonary hypertension associated with other conditions that have unclear reasons why the pulmonary hypertension occurs

• Blood disorders
• Disorders that affect several organs in the body, such as sarcoidosis
• Metabolic disorders, such as glycogen storage disease
• Tumors pressing against pulmonary arteries

Eisenmenger syndrome and pulmonary hypertension

Eisenmenger syndrome, a type of congenital heart disease, causes pulmonary hypertension. It's most commonly caused by a large hole in your heart between the two lower heart chambers (ventricles), called a ventricular septal defect.Pulmonary Hypertension Research Paper

This hole in your heart causes blood to circulate abnormally in your heart. Oxygen-carrying blood (red blood) mixes with oxygen-poor blood (blue blood). The blood then returns to your lungs instead of going to the rest of your body, increasing the pressure in the pulmonary arteries and causing pulmonary hypertension.

Risk factors

Your risk of developing pulmonary hypertension may be greater if:

• You're a young adult, as idiopathic pulmonary arterial hypertension is more common in younger adults
• You're overweight
• You have a family history of the disease
• You have one of various conditions that can increase your risk of developing pulmonary hypertension
• You use illegal drugs, such as cocaine
• You take certain appetite-suppressant medications
• You have an existing risk of developing pulmonary hypertension, such as a family history of the condition, and you live at a high altitude

Complications

Pulmonary hypertension can lead to a number of complications, including:

• Right-sided heart enlargement and heart failure (cor pulmonale). In cor pulmonale, your heart's right ventricle becomes enlarged and has to pump harder than usual to move blood through narrowed or blocked pulmonary arteries.At first, the heart tries to compensate by thickening its walls and expanding the chamber of the right ventricle to increase the amount of blood it can hold. But this thickening and enlarging works only temporarily, and eventually the right ventricle fails from the extra strain.
• Blood clots. Clots help stop bleeding after you've been injured. But sometimes clots form where they're not needed. A number of small clots or just a few large ones dislodge from these veins and travel to the lungs, leading to a form of pulmonary hypertension that can generally be reversible with time and treatment.Having pulmonary hypertension makes it more likely you'll develop clots in the small arteries in your lungs, which is dangerous if you already have narrowed or blocked blood vessels.Pulmonary Hypertension Research Paper
• Arrhythmia. Irregular heartbeats (arrhythmias) from the upper or lower chambers of the heart are complications of pulmonary hypertension. These can lead to palpitations, dizziness or fainting and can be fatal.
• Bleeding. Pulmonary hypertension can lead to bleeding into the lungs and coughing up blood (hemoptysis). This is another potentially fatal complication.

What is pulmonary hypertension?

Pulmonary hypertension (PHT) is high blood pressure in the heart-to-lung system that delivers fresh (oxygenated) blood to the heart while returning used (oxygen-depleted) blood back to the lungs.

Pulmonary versus systemic blood pressure

Unlike systemic blood pressure, which represents the force of your blood moving through the blood vessels in your body, pulmonary blood pressure reflects the pressure the heart exerts to pump blood from the heart through the arteries of the lungs. In other words, it focuses on the pressure of the blood flow in your lungs.

How blood flows through your heart and lungs

The lower right heart chamber, the right ventricle, receives oxygen-depleted blood and pumps it to your pulmonary arteries. The blood then travels to your lungs to be oxygenated, and on to the upper left heart chamber, the left atrium. From there, the oxygen-rich blood moves into the lower left chamber, the left ventricle, which pumps blood to the rest of your body through the aorta.Pulmonary Hypertension Research Paper

The numbers in pulmonary hypertension

Pulmonary blood pressure is normally a lot lower than systemic blood pressure. Normal pulmonary artery pressure is 8-20 mm Hg at rest. If the pressure in the pulmonary artery is greater than 25 mm Hg at rest or 30 mmHg during physical activity, it is abnormally high and is called pulmonary hypertension.

The long-term effects of pulmonary hypertension

Similar to how systemic high blood pressure can cause the heart to work harder to deliver blood to the body, pulmonary hypertension can occur when the arteries in the lungs narrow and thicken, slowing the flow of blood through the pulmonary arteries to the lungs. As a result, the pressure in your arteries rises as your heart works harder to try to force the blood through. Heart failure occurs when the heart becomes too weak to pump enough blood to the lungs.

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Symptoms of pulmonary hypertension

Early symptoms include:

• Shortness of breath during routine activity
• Fatigue
• Chest pain
• Racing heartbeat
• Pain in upper right side of abdomen
• Decreased appetite

Later symptoms include:

• Feeling light-headed, especially during physical activity
• Fainting
• Swelling in the ankles or legs
• Bluish lips or skin

Diagnosis and treatment

Pulmonary hypertension can develop slowly, without early signs and symptoms. When symptoms do occur, they may be attributed to asthma or other lung or heart conditions.Pulmonary Hypertension Research Paper

To diagnose pulmonary hypertension, your doctor may ask about your symptoms and risk factors, including other medical conditions and family history. Having a family member with pulmonary hypertension increases your risk of developing the disease.

Medical evaluation

Your physician may recommend tests and procedures to diagnose pulmonary hypertension and discover its cause and severity. Common diagnostic tests include an echo cardiograph, chest X-ray, electrocardiogram (EKG) and catheterization of the right heart. Discovering the underlying cause may involve a chest CT scan, chest MRI, lung function tests, polysomnogram (PSG), lung ventilation/perfusion scan and blood tests.Pulmonary Hypertension Research Paper

Once you have a diagnosis of pulmonary hypertension, exercise testing can help your doctor determine its severity. The test measures how well your heart and lungs work while you are on a treadmill or bicycle, so the doctor can rate your activity level. Exercise testing may be ongoing during your treatment in order to monitor your progress.

Types of pulmonary hypertension

The World Health Organization has established five groups of pulmonary hypertension.

Group 1 pulmonary arterial hypertension (PAH)

Group 1 PAH includes pulmonary hypertension that has no known cause; is inherited; is caused by drugs or toxins; is caused by conditions such as connective tissue disease, HIV infection, liver disease, congenital heart disease, sickle cell disease, or schistosomiasis; or is caused by conditions that affect the veins and small blood vessels of the lungs.

Group 2 pulmonary hypertension

Group 2 pulmonary hypertension is often associated with left heart disease such as mitral valve disease or long-term high blood pressure. Left heart disease is the most common cause of pulmonary hypertension.Pulmonary Hypertension Research Paper

Group 3 pulmonary hypertension

Group 3 is related to lung problems like chronic obstructive pulmonary disease (COPD) and interstitial lung disease, as well as sleep apnea and other sleep-related breathing disorders.

Group 4 pulmonary hypertension

Group 4 includes pulmonary hypertension caused by blood clots in the lungs or general clotting disorders.

Group 5 pulmonary hypertension

Group 5 includes pulmonary hypertension triggered by other disorders. Examples of such diseases or conditions are blood disorders such as polycythemia vera and essential thrombocythemia; systemic disorders such as sarcoidosis and vasculitis; metabolic disorders such as thyroid and glycogen storage disease; and other conditions such as kidney disease and tumors that press on the pulmonary arteries.

Factors that can affect pulmonary hypertension

While pulmonary hypertension has no cure, you can live an active, fulfilling life by working with your doctor to manage your symptoms. Talk to your doctor before taking over-the-counter medicine, as some can worsen symptoms of pulmonary hypertension or interfere with prescriptions — and keep a list of medicines with you. Ask whether you should get a pneumonia vaccination or flu shot. Additionally, pregnancy can pose serious risks for women with pulmonary hypertension, so be sure to discuss birth control options with your physician.Pulmonary Hypertension Research Paper

These lifestyle changes can improve your symptoms:

• Quit smoking. Your doctor can recommend programs and products to help.
• Follow a healthy diet. Eat a variety of fruits, vegetables, and whole grains, plus lean meat, poultry, fish and low-fat/fat-free milk. Your diet should be low in fat, cholesterol, sodium and sugar.
• Watch your weight. A daily record of your weight can help you be aware of rapid weight gain, which may be a sign that your pulmonary hypertension is worsening.
• Stay active. Incorporate physical activity such as walking into your lifestyle. Discuss the level of activity with your doctor. Avoid straining or lifting heavy weights. Rest when you need to.
• Avoid sitting in a hot tub or sauna, or taking long baths, which will lower your blood pressure.
• Be cautious about air travel or high-altitude locales. You may need to travel with extra oxygen.
• Get support for the anxiety and stress of living with pulmonary hypertension. Talk with your healthcare team, or ask for a referral to a counselor. A support group for people living with pulmonary hypertension can be invaluable in learning how to cope with the illness.

Pulmonary hypertension is hard to diagnose early because it's not often detected in a routine physical exam. Even when the condition is more advanced, its signs and symptoms are similar to those of other heart and lung conditions.Pulmonary Hypertension Research Paper

To diagnose your condition, your doctor may review your medical and family history, discuss your signs and symptoms, and conduct a physical examination. Doctors may order several tests to diagnose pulmonary hypertension, determine the severity of your condition and find out the cause of your condition. Tests may include:

• Echo cardiogram. Sound waves can create moving images of the beating heart. An echo cardiogram can help your doctor to check the size and functioning of the right ventricle, and the thickness of the right ventricle's wall. An echo cardiogram can also show how well your heart chambers and valves are working. Doctors may also use this to measure the pressure in your pulmonary arteries.In some cases, your doctor will recommend an exercise echo cardiogram to help determine how well your heart and lungs work under stress. In this test, you'll have an echo cardiogram before exercising on a stationary bike or treadmill and another test immediately afterward. This could be done as an oxygen consumption test, in which you may have to wear a mask that assesses the ability of your heart and lungs to deal with oxygen and carbon dioxide.Pulmonary Hypertension Research Paper

  Other exercise tests may also be done. These tests can help determine the severity and cause of your condition. They may also be done at follow-up appointments to check that your treatments are working.

• Chest X-ray. A chest X-ray can show images of your heart, lungs and chest. This test can show enlargement of the right ventricle of the heart or the pulmonary arteries, which can occur in pulmonary hypertension. This test can also be used to identify other conditions that may be causing pulmonary hypertension.
• Electrocardiogram (ECG). This noninvasive test shows your heart's electrical patterns and can detect abnormal rhythms. Doctors may also be able to see signs of right ventricle enlargement or strain.
• Right heart catheterization. After you've had an echo cardiogram, if your doctor thinks you have pulmonary hypertension, you'll likely have a right heart catheterization. This test can often help confirm that you have pulmonary hypertension and determine the severity of your condition.During the procedure, a cardiologist places a thin, flexible tube (catheter) into a vein in your neck or groin. The catheter is then threaded into your right ventricle and pulmonary artery.

  Right heart catheterization allows your doctor to directly measure the pressure in the main pulmonary arteries and right ventricle. It's also used to see what effect different medications may have on your pulmonary hypertension.

• Blood tests. Your doctor might order blood tests to check for certain substances in your blood that might show you have pulmonary hypertension or its complications. Blood tests can also test for certain conditions that may be causing your condition.Pulmonary Hypertension Research Paper

Your doctor might order additional tests to check the condition of your lungs and pulmonary arteries and to determine the cause of your condition, including:

• Computerized tomography (CT) scan. During a CT scan, you lie on a table inside a doughnut-shaped machine. CT scanning generates X-rays to produce cross-sectional images of your body. Doctors may inject a dye into your blood vessels that helps your arteries to be more visible on the CT pictures (CT angiography).Doctors may use this test to look at the heart's size and function and to check for blood clots in the lungs' arteries.
• Magnetic resonance imaging (MRI). This test may be used to check the right ventricle's function and the blood flow in the lung's arteries. In this test, you lie on a movable table that slides into the tunnel. An MRI uses a magnetic field and pulses of radio wave energy to make pictures of the body.
• Pulmonary function test. This noninvasive test measures how much air your lungs can hold, and the airflow in and out of your lungs. During the test, you'll blow into a simple instrument called a spirometer.
• Polysomnogram. This test detects your brain activity, heart rate, blood pressure, oxygen levels and other factors while you sleep. It can help diagnose a sleep disorder such as obstructive sleep apnea.
• Ventilation/perfusion (V/Q) scan. In this test, a tracer is injected into a vein in your arm. The tracer maps blood flow and air to your lungs. This test can be used to determine whether blood clots are causing symptoms of pulmonary hypertension.Pulmonary Hypertension Research Paper
• Open-lung biopsy. Rarely, a doctor might recommend an open-lung biopsy. An open-lung biopsy is a type of surgery in which a small sample of tissue is removed from your lungs under general anesthesia to check for a possible secondary cause of pulmonary hypertension.

Genetic tests

If a family member has had pulmonary hypertension, your doctor might screen you for genes that are linked with pulmonary hypertension. If you test positive, your doctor might recommend that other family members be screened for the same genetic mutation.

Pulmonary hypertension classifications

Once you've been diagnosed with pulmonary hypertension, your doctor might classify the severity of your disease into one of several classes, including:

• Class I. Although you've been diagnosed with pulmonary hypertension, you have no symptoms with normal activity.
• Class II. You don't have symptoms at rest, but you experience symptoms such as fatigue, shortness of breath or chest pain with normal activity.
• Class III. You're comfortable at rest, but have symptoms when you're physically active.
• Class IV. You have symptoms with physical activity and while at rest.Pulmonary Hypertension Research Paper

Treatment

Pulmonary hypertension can't be cured, but doctors can help you manage your condition. Treatment may help improve your symptoms and slow the progress of pulmonary hypertension.

It often takes some time to find the most appropriate treatment for pulmonary hypertension. The treatments are often complex and require extensive follow-up care. Your doctor might also need to change your treatment if it's no longer effective.

When pulmonary hypertension is caused by another condition, your doctor will treat the underlying cause whenever possible.

Medications

• Blood vessel dilators (vasodilators). Vasodilators open narrowed blood vessels. One of the most commonly prescribed vasodilators for pulmonary hypertension is epoprostenol (Flolan, Veletri). The drawback to epoprostenol is that its effects last only a few minutes.This drug is continuously injected through an intravenous (IV) catheter via a small pump that you wear in a pack on your belt or shoulder. Potential side effects of epoprostenol include jaw pain, nausea, diarrhea and leg cramps, as well as pain and infection at the IV site.

  Another form of the drug, iloprost (Ventavis), can be inhaled six to nine times a day through a nebulizer, a machine that vaporizes your medication. Because it's inhaled, it goes directly to the lungs. Side effects associated with iloprost include chest pain — often accompanied by a headache and nausea — and breathlessness.

  Treprostinil (Tyvaso, Remodulin, Orenitram), another form of the drug, can be given four times a day. It can be inhaled, taken as oral medication or administered by injection. It can cause side effects such as a headache, nausea and diarrhea.

• Endothelin receptor antagonists. These medications reverse the effect of endothelin, a substance in the walls of blood vessels that causes them to narrow. These drugs may improve your energy level and symptoms. However, these drugs shouldn't be taken if you're pregnant. Also, these drugs can damage your liver and you may need monthly liver monitoring.These medications include bosentan (Tracleer), macitentan (Opsumit), and ambrisentan (Letairis).
• Sildenafil and tadalafil. Sildenafil (Revatio, Viagra) and tadalafil (Cialis, Adcirca) are sometimes used to treat pulmonary hypertension. These drugs work by opening the blood vessels in the lungs to allow blood to flow through more easily. Side effects can include an upset stomach, headache and vision problems.Pulmonary Hypertension Research Paper
• High-dose calcium channel blockers. These drugs help relax the muscles in the walls of your blood vessels. They include medications such as amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others) and nifedipine (Procardia, others). Although calcium channel blockers can be effective, only a small number of people with pulmonary hypertension respond to them.
• Soluble guanylate cyclase (SGC) stimulator. Soluble guanylate cyclase (SGC) stimulators (Adempas) interact with nitric oxide and help relax the pulmonary arteries and lower the pressure within the arteries. These medications should not be taken if you're pregnant. They can sometimes cause dizziness or nausea.

• Anticoagulants. Your doctor is likely to prescribe the anticoagulant warfarin (Coumadin, Jantoven) to help prevent the formation of blood clots within the small pulmonary arteries. Because anticoagulants prevent normal blood coagulation, they increase your risk of bleeding complications.Take warfarin exactly as prescribed, because warfarin can cause severe side effects if taken incorrectly. If you're taking warfarin, your doctor will ask you to have periodic blood tests to check how well the drug is working. Many other drugs, herbal supplements and foods can interact with warfarin, so be sure your doctor knows all of the medications you're taking.
• Digoxin. Digoxin (Lanoxin) can help the heart beat stronger and pump more blood. It can help control the heart rate if you experience arrhythmias.
• Diuretics. Commonly known as water pills, these medications help eliminate excess fluid from your body. This reduces the amount of work your heart has to do. They may also be used to limit fluid buildup in your lungs.
• Oxygen. Your doctor might suggest that you sometimes breathe pure oxygen, a treatment known as oxygen therapy, to help treat pulmonary hypertension, especially if you live at a high altitude or have sleep apnea. Some people who have pulmonary hypertension eventually require continuous oxygen therapy.Pulmonary Hypertension Research Paper

Surgeries

• Atrial septostomy. If medications don't control your pulmonary hypertension, this open-heart surgery might be an option. In an atrial septostomy, a surgeon will create an opening between the upper left and right chambers of your heart (atria) to relieve the pressure on the right side of your heart.Atrial septostomy can have serious complications, including heart rhythm abnormalities (arrhythmias).
• Transplantation. In some cases, a lung or heart-lung transplant might be an option, especially for younger people who have idiopathic pulmonary arterial hypertension.Major risks of any type of transplantation include rejection of the transplanted organ and serious infection, and you must take immunosuppressant drugs for life to help reduce the chance of rejection.

Pulmonary hypertension (PH) is a rare, life-threatening disease characterized by high blood pressure in the lungs due to damage to the pulmonary arteries. These vessels, which are responsible for transporting blood from the heart to the lungs, become narrowed and blocked due to the disease. Therefore, the heart needs to work harder to properly pump the blood, becoming enlarged and weakened. Patients are particularly at risk of developing other conditions and suffering right heart failure.Pulmonary Hypertension Research Paper

There is currently no cure for pulmonary hypertension, but there are treatments that can help ease the symptoms, slow the progression of the disease and improve patients’ quality of life. According to the National Heart, Lung and Blood Institute (NHLB) from the National Institutes of Health (NIH), PH is treated with medicines, procedures, and other therapies, which are prescribed based on the subtype of the disease diagnosed as well as its severity.

How to Treat Pulmonary Arterial Hypertension: Group 1

The group 1 defined by the World Health Organization (WHO) includes inherited or familial PH and idiopathic PH, which means that the cause for it is unknown, as well as PH caused by determined drugs or conditions. Medication is one of the courses of treatment for group 1 pulmonary arterial hypertension. The most common drugs are meant to relax the blood vessels in the lungs and reduce excess cell growth in the blood vessels. Medication, which can be taken orally, inhaled or injected, include phosphodiesterase-5 inhibitors such as sildenafil, prostanoids, such as epoprostenol, endothelin receptor antagonists, such as bosentan and ambrisentan, and calcium channel blockers, such as diltiazem.

Physicians can prescribe one or more medications, as well as request an acute vasoreactivity test to evaluate how the pressure in the pulmonary arteries reacts to prescribed drugs. In addition, the doctor may also recommend medical and surgical procedures. During an atrial septostomy (sep-TOS-toe-me), a catheter is placed through a blood vessel of the leg into the heart’s septum, which is the wall that separates the left and right atria. A tiny balloon on the tip of the tube is then inflated, creating an opening between the atria and relieving the pressure. While the atrial septostomy is a very rare procedure, lung transplants and heart-lung transplants are more common alternatives.Pulmonary Hypertension Research Paper

How to Treat Pulmonary Hypertension: Groups 2 and 3

Group 3 pulmonary hypertension includes cases of the disease caused by left-side diseases such as mitral valve disease. In order to treat patients in this group, physicians will focus on the treatment of the underlying condition with lifestyle changes, medicines, and surgery.

Similarly, cases in the group 3 pulmonary hypertension are caused by lung conditions like chronic obstructive pulmonary disease (COPD) and interstitial lung disease, or sleep disorders like sleep apnea. In addition to treating the underlying cause of the disease, physicians may also recommend oxygen therapy, a resource administrated through soft, plastic prongs that fir into the nose at home or in a hospital, to increase the level of oxygen in the blood.

How to Treat Pulmonary Hypertension: Groups 4 and 5

Group 4 pulmonary hypertension includes cases of the disease caused by blood clots in the lungs or blood clotting disorders. To treat this, patients are often prescribed blood-thinning medicines to prevent the formation or enlargement of clots. Surgery is also an option to remove scarring in the pulmonary arteries due to old blood clots. Group 5 pulmonary hypertension includes all other conditions that cause PH, such as thyroid disease and sarcoidosis, or an object, such as a tumor pressing on the pulmonary arteries. The treatment of patients in this group is conducted by treating the underlying cause.Pulmonary Hypertension Research Paper

Treatments Used in All Types of Pulmonary Hypertension

In addition to the personalized treatments for each group, there are also numerous treatments that can be applied to all types of pulmonary hypertension. These include diuretics, or water pills, which help reduce fluid buildup in the body, such as swelling in the ankles or feet. Blood-thinning medicines are used to avoid blood clots, while digoxin improves heart beat strength, helping it pump more blood, as well as to control the heart rate in the case of abnormal heart rhythms, such as atrial fibrillation or atrial flutter.

Physicians may also recommend oxygen therapy to increase the levels of oxygen in the blood, as well as lifestyle alterations and moderated physical activity to improve patients ability to be active. Researchers worldwide are currently working to improve pulmonary hypertension treatments, and find a cure for the disease.