A Complete Guide to the Management of Hypertension
This is an article on hypertension. It explains the basics, such as the definition, diagnosis and both natural and pharmaceutical treatment options, as well as complications and risks. The article has been written and checked by a doctor and comprises the most recent information about this condition. Hypertension is explained in an easy to understand language.
What is hypertension?
To understand what hypertension, high blood pressure, arterial hypertension or other related terms mean, you need to have some basic information first. The blood that flows in our blood vessels exerts certain degree of pressure against the walls of those vessels, just like water flowing in a pipe.
The amount of pressure that blood exerts on the walls of blood vessels is known as arterial pressure.
Now the definition of hypertension should be quite easy for you to understand. Hypertension or high blood pressure is nothing but the rise in the values of arterial pressure. Or hypertension is a disorder in which the pressure of blood in the arteries increases.
You might have heard or read that the normal values of blood pressure are 120/80. But what do 120 and 80 signify?
Blood pressure is divided into two important constituents: the higher or systolic pressure and the lower or diastolic pressure. When the heart beats, it pumps blood forcefully into the blood vessels. This is when the blood pressure rises and is recorded as the higher or systolic value.
But when the heart relaxes or is not beating, it is the intrinsic quality of vessels that prevent the blood pressure from falling down to absolute zero and you end up noting the lower or diastolic value of blood pressure. Normally the systolic pressure is 120mmHg and the diastolic pressure is 80mmHg.
The increase in blood pressure can affect either systolic values of blood pressure or it can alter diastolic values of blood pressure. If the value of systolic blood pressure is raised, it is called systolic hypertension. But if the value of diastolic pressure increases, it is called diastolic hypertension.
It is very unusual to find isolated cases of systolic and diastolic hypertension. When we talk of hypertension, we mean increase in both systolic and diastolic blood pressure.
The epidemic of high blood pressure is on the rise, thanks to the western style of eating and living. Lack of exercise and eating a diet rich in saturated fat are the basic harbingers of high blood pressure and related complications.
According the American Center of Disease Control and Prevention, hypertension is the 4th leading cause of death in the United States. Moreover, at least 30% of adults in America are suffering from hypertension, according to the 2013 surveys.
Hypertension was once thought to be a disease of old but new forms of hypertension are sprouting and it has left no age untouched. The global burden of this disease is rising faster than ever. Therefore it’s necessary that you know the causes, complications and ways to get rid of this awful ailment.
What are the causes of hypertension?
Depending on the causes, hypertension can be divided into two main types:
- primary hypertension
- secondary hypertension.
Let’s see how these two types differ from each other.
Most of the times the exact cause of hypertension can’t be determined with complete certainty. And that happens in at least 90-95% cases. Such type of hypertension is labeled as primary or essential hypertension. Although the exact cause of essential or primary hypertension can’t be determined but still we can speculate what might have trigged this rise in blood pressure.
Researchers believe that it is the complex interaction of genes and environmental factors that can trigger primary hypertension. The genetic basis i.e. the genes involved in the development of hypertension are still very poorly understood.
However, epidemiological studies have pointed towards a bunch of environmental factors that might play certain role in the pathogenesis of hypertension.
Such environmental factors include:
- Increased intake of salt
- Eating a diet poor in vegetables and fruits
- Regular consumption of diet rich in fat and cholesterol like junk foods
- Sedentary lifestyle and lack of appropriate physical activities
- Gain of weight is also considered a risk factor for the development of hypertension
- Excessive smoking is an important risk factor
- Alcohol intake is also attributed to the increase in blood pressure
- Increased consumption of caffeinated drinks like coffee and sodas has also been found to have link with the pathogenesis of hypertension
- Deficiency of certain nutrients like vitamin D deficiency may also play some role.
- Sometimes essential hypertension is a component of complex metabolic disorders like syndrome X, which is associated with symptoms like weight gain, insulin resistance and hypertension.
- If hypertension sprouts in children then it might be related to low weight at the time of birth, maternal smoking before birth and inadequate breast feeding by the mother or bottle feeding in the very early stages of life.
There are very few incidences when the exact cause of hypertension can be determined with absolute certainty. Such type of hypertension is called secondary hypertension. It happens in only 5-10% cases. Some important causes of secondary hypertension include:
- Metabolic or endocrine disorders are the most important cause of secondary hypertension. Such disorders include:
- Cushing syndrome, characterized by increase in the level of corticosteroids.
- Hypothyroidism, which occurs due to the decrease in the level of thyroid hormone.
- Hyperthyroidism, which is due to the increase in the level of thyroid hormone.
- Acromegaly is an endocrine disorder characterized by excessive increase in growth hormones.
- Hyperaldosteronsim involves increase in the level of aldosteron, a hormone meant for fluid retention and regulation of body fluids and blood pressure.
- Hyperparathyroidism, which is involved in the regulation of parathyroid hormone level.
- Pheocrhomocytoma is a tumor of adrenal gland in which the secretion of steroid hormones becomes sky high.
- Secondary hypertension may be the result of certain congenital causes. For example an increased pressure in the upper extremities of the body is seen in coarctation of aorta.
- Sometimes hypertension may be the side effect of some normal body process. For example, hypertension is one of the most important complications of pregnancy and is called pregnancy induced hypertension.
- Sleep apneas with or without obesity is an important cause. Similarly obesity with or without sleep apnea can lead to the development of hypertension.
- Eating certain types of foods like liquorices has also been linked with the increase in blood pressure.
- Sometimes increase in blood pressure is the side effect of the consumption of certain drugs or herbs.
What are the signs and symptoms of hypertension?
The signs and symptoms of hypertension vary greatly depending on its type, underlying cause in specific conditions. Some of the signs and symptoms of hypertension are discussed under different headings here:
Symptoms of primary hypertension
Most of the time primary hypertension is without any obvious sign or symptom. In most cases it is an accidental finding that doctors may detect while trying to find the cause of some other disease.
For example a doctor may appreciate abnormally elevated blood pressure is an old man when he comes to the doctor with the complaints of never ending headaches. There are no clear cut symptoms on the basis of which primary hypertension can be determined but still the patients come to their physicians with a number of general and non-specific symptoms.
Some of the symptoms that sufferers of primary hypertension complain are:
- Persistent headache that doesn’t seem to go away even with the use of over the counter pain killers.
- Hearing a buzzing or hissing sound in the ears, when there is no such sound. This is called tinnitus.
- Loss of orientation of time, place and person. Such feeling can be rendered as lightheadedness or a sudden attack of vertigo. The person may even faint some time.
These are the symptoms with which a person suffering from essential hypertension may suffer but it is very important to note here that these symptoms shouldn’t be explicitly associated with hypertension as these symptoms are also seen in a number of other conditions like generalized anxiety.
Signs and symptoms of secondary hypertension
Secondary hypertension, as mentioned before, is associated with some underlying condition or the disease. So basically in such cases the symptoms of that disorder can make a physician suspicious that the patient might have hypertension, too.
For example if a patient comes to the doctor with glucose intolerance, purple stretch marks on the belly and moon shaped face then these symptoms are diagnostic for Cushing’s syndrome.
If the patient is diagnosed with Cushing’s syndrome, he certainly will have associated hypertension.
Similarly if a patient comes to the doctor with difference in pressure in the upper and lower extremities of the body and the femoral pulse is very weak to palpate then this is certainly a case of coarctation of aorta. This is where secondary hypertension will also be present.
Signs and symptoms of hypertension in pregnancy
Pregnant females make an important high risk group that has very high tendency to develop hypertension. In fact at least 8-10% of pregnant ladies develop hypertension. This increase in blood pressure can be only be related to pregnancy or can represent an already existing hypertension that is complicated by pregnancy.
The symptoms of pregnancy induced hypertension are more or less the same as ordinary hypertension like headache, vertigo, malaise, pain in the abdomen and edema in the legs.
What makes pregnancy induced hypertension so important is its ability to progress into a life threatening complications called eclampsia. It is a hypertensive crisis during pregnancy that can lead to loss of vision, convulsions, failure of kidneys, fluid accumulation in the kidney, accumulation of fluid in the brain and clotting disorders like disseminated intravascular coagulation.
Signs and symptoms of hypertension in children
If hypertension is found in some children then it is most likely that is associated with some underlying congenital abnormality like coarctation of aorta. It is very important to diagnose hypertension in children in early stages because failure to do some can lead to the development of serious complications in the children.
The symptoms of hypertension in children include:
- Failure to grow properly and inability to achieve growth bench marks.
- The child presents with lack of energy and parents usually say that he is unable to play like other children.
- Involvement of lungs is an important finding and the child usually present with. Shortness of breath and difficulty in breathing are also very important symptoms.
- The child is irritable and cries a lot.
- In serious conditions the child may even present with seizures.
- Nose bleeds are also common in such children.
- The child is unable to see properly and doesn’t perform well at school and in other activities.
What are the complications of hypertension?
Hypertension is sometimes referred to as a silent killer because of two main reasons. First, it doesn’t develop any specific symptoms like other diseases. Second, hypertension, itself, is an important risk factor for the development of countless other health complications.
So in most the cases before it even become recognizable, it has already progressed to the stage where it has started to determent other body organs and systems. Virtually there is no system of human body that remains untouched by the harmful effects of hypertension. It’s because blood is supplied to all organs.
However, the major complications of hypertension include:
Complications pertaining to heart
There is a very long list of complications pertaining to heart that may surface after long standing hypertension. Some of the major complications include:
- Ventricular hypertrophy, especially hypertrophy of left ventricle.
- Inability of the ventricles to relax and fill in properly (diastolic dysfunction).
- Obstruction of coronary blood vessels that supply the heart.
- The supply of blood to the heart decreases due to coronary obstruction and it ultimately results is congestive heart failure.
- The electrical system of the heart also gets disturbed and the result is abnormal cardiac rhythm.
Complications pertaining to the brain
Second in the list are the complications pertaining to the brain. These complications are particularly important because if left untreated, these complications are almost always life threatening. The most important complications include:
- Infarction in the brain.
- Cerebral hemorrhage.
- Subarachnoid hemorrhage.
- Shrinkage of the brain matrix due to the stenosis of vessels supplying to the brain.
- All these effects can lead to poor cognition, memory and decision making capacity.
Complications pertaining to the eyes
Eyes are perhaps the very first organ that gets affected by increase in the blood pressure. Retinal changes are among the very first changes that can be appreciated in patients with hypertension.
Following are some changes that can be seen in eyes in patients with hypertension:
- The vessels supplying the retina get disrupted.
- The destruction of blood vessels leads to the necrosis of eye tissues like smooth muscles and endothelium.
- There is swelling of optic disc.
- The optic nerve may also get damaged.
- There is significant loss of vision as hypertension progresses.
Complications pertaining to the kidneys
Kidneys are very important body organs that filter most of the harmful chemical and wastes. Kidneys are extensively damaged by increase in blood pressure.
Following are some of the changes that are seen in kidneys associated with hypertension:
- The blood pressure increase results in extensive damage to the kidney architecture.
- The damage to the kidney architecture leads to macroalbuminiuria or microalbuminiuria.
- The level of wastes in the body starts to increase.
How to diagnose hypertension?
According to the National Institute of Clinical Excellence, a person would be labeled as a case of hypertension if his blood pressure is found to be elevated in three separate sphygmomanometer measurements at the one monthly interval.
Three steps are particularly important while making a diagnosis of hypertension.
- First step is proper history of the patient. If the patient presents with complaints of persistent headache, vertigo and tinnitus then one differential diagnosis that should come to a clinician’s mind is hypertension.
- Second important step is physical examination. And among the general physical steps examination of blood pressure is the most important part.
- Once the doctor has confirmed through history and examination, the doctor will try to find the underlying cause of hypertension. If he couldn’t find some apparent cause then he would label it has primary hypertension. Otherwise if the rise in blood pressure is associated with some other condition then he would label it as a case secondary hypertension. For that the doctor may also ask for some lab tests like cholesterol levels because cholesterol level in the blood is an important risk factor for the development of hypertension.
One thing that is important to note here is that secondary hypertension is very common among pre-adolescent children. Contrary to that primary hypertension is more common in adults. The table below can be used to find the grades of hypertension:
How to treat hypertension?
Before we can start mentioning the treatment options for hypertension, it is important for you to know that there is nothing that can completely cure hypertension.
Hypertension is not like a headache that you can cure by eating some pills. However, there are some ways through which it can be managed and blood pressure can be kept within normal range.
Another important question that needs answer here is that why is it important to cure hypertension in first place? The answer to this question is quite simple.
Hypertension may not produce any significant side effects on the body on its own but it can trigger a number of life threatening complications in almost all organs of the human body.
Luckily, there are a number of ways through which hypertension can be managed. All these ways to manage hypertension are mentioned in detail one by one:
Drugs for hypertension
There is a long list of medicines that can be used for the management of hypertension. These medicines include:
- Diuretics. Diuretics (like carbonic anhydrase inhibitors) make one of the first line drugs that can be used for the treatment of hypertension. These drugs are also called water pills because they help in the excretion of surplus water from the body. This decrease in the blood volume then exerts little pressure on the walls of blood vessels and thus blood pressure is mitigated.
- Angiotensin converting enzyme (ACE) inhibitors. Angiotensin is a potent enzyme secreted by the kidneys, which results in narrowing of the blood vessels and elevation of blood pressure. These drugs put a stop to the production of this enzyme and subsequent rise in blood pressure due to the narrowing of arteries.
- Angiotensin receptor blockers. The main target of these drugs is angiotensin receptor through which angiotensin acts. By interfering with the action of angiotensin, these drugs help decrease blood pressure.
- Beta blocker. These are the kind of drugs that decrease the beating of heart and open up your blood vessels. Both these effects result in significant reduction in blood pressure.
- Calcium channel blockers. Calcium plays a very important role in the regulation of blood pressure in two ways. First, it is very important for your heart because heart muscles because heart muscles need calcium for contraction. Second, calcium in the walls of blood vessels result in the contraction of the walls of the blood vessels and this causes a rise in blood pressure. Calcium channel blockers hinder both these processes and this ultimately results in a reduction in blood pressure.
- Renin blockers. Renin is a preliminary form of angiotensin and it converts, by a series of chemical reactions to form angiotensin. Therefore these drugs lower blood pressure by interfering with the synthesis of angiotensin.
Herbal remedies for hypertension
If you’re looking for some natural way to cure hypertension in a cost effective and safe manner then herbal remedies are just the thing you need. Here is a compilation of herbal remedies that you can try for hypertension.
- Stevia - the herb stevia is a sweetener. It holds a substance known as stevioside that is said to be 100 to 300 times sweeter than sugar, yet gives no calories. Stevia is generally utilized as a part of Japanese soda pops, biting gum and treats. However it hasn't gotten very prominent in the west. A 2000 study was conducted in the Division of Cardiovascular Medicine, Taipei Medical College and was partnered by Taipei Wan Fang Hospital, Taiwan. That study included 106 individuals with moderate hypertension and effects of stevioside on those individuals were tests. It was found that stevioside given at a measurement of 250mg, three times every day, lessened circulatory strain by around 10 percent. Comparable results were found in a later study in 2003 from the Bureau of Medicine, Taipei Medical University, Taiwan. This two-year, two fold visually impaired, placebo-controlled investigation of 174 individuals with gentle hypertension utilized two fold the dosage and discovered decrease in circulatory strain of around six to seven percent.
- Garlic - several studies have indicated blood pressure lowering effects of garlic. Both raw and fried garlic can help keep hypertension under control and can help cut back cholesterol levels. Garlic helps calm down blood vessels by stimulating the assembling of hydrogen sulphide and nitric oxide. Garlic is one in all the foremost commonly used herbs in our store cupboards and is usually cited as a good choice for heart-conscious people. Garlic encourages a brisk and healthy circulation and helps widen blood vessels. Garlic has been reported to lower hypertension as well as cholesterol and stop blood clots from forming. Garlic makes your blood vessels relax. A 2007 study from the University of Alabama, Birmingham, discovered that contemporary garlic, similar to two cloves, caused blood vessels to relax up to 72% more powerfully than a placebo. You can take garlic as a supplement if you don’t just like the distinctive smell or the taste. Eat 1-2 cloves of slightly crushed garlic daily. You should be able to crush them along with your hands. Crushing garlic cloves creates sulphide, a compound that promotes smart blood flow, removes gas and decrease the pressure on the heart. If you don’t like to eat raw garlic or if you feel burning sensation, then take it along a cup of milk. You can even combine 5-6 drops of garlic juice in four teaspoons of water and take it twice every day.
- Achillea Wilhelmsii - this plant is filled with sesquiterpene lactones and flavonoids, substances that are shown to be effective in lowering blood pressure. It widely exists in Iran but is not so common in the U.S. A 2000 study from the Isfahan University of Medical Sciences, Iran found that 60 women and men with gentle average blood pressure who were treated with this herb experiment considerably faced lower hypertension after 2-6 months on the trial.
- Onion - Quercetin is such a substance found in onions that's an associated flavonol (an antioxidant). This antioxidant could be really helpful for lowering the chance of heart disease and stroke. The Journal of Nutrition proved in a study that individuals who used onions had a small decrease in blood pressures over those that got a placebo. Try to eat one medium-sized, raw onion every day. You also can combine half teaspoon each of onion juice and honey and take it twice daily for 1-2 weeks.
- Green Coffee Bean Extract - What about the beans in your coffee can? Studies have shown that coffee berry extract have a very strong link with the reduction in blood pressure. A 2006 study from the Health Care product Laboratories, Kao Corporation, Tokyo found that the chlorogenic acids in water-soluble green coffee bean extract decreased hypertension (high blood pressure) spontaneously in hypertensive humans and rats. The findings were also reported in a 2006 study from same laboratory, which checked out the blood pressure effects on 117 male volunteers with nominal high blood pressure. Results were similar and showed reduction in blood pressure. The results of regular, ordinary coffee on blood pressure are enormously uncertain. Coffee speeds up your metabolism and increases your heart rate. However normal coffee is not typically believed to possess a positive result on your heart therefore drinking too much ordinary coffee isn’t the way to solve your high blood pressure issues.
- Hawthorn - the herb hawthorn improves circulation and facilitates the heart. Also it causes the relaxation of blood vessels and rescues them from any harm. All this helps in the normalization of the blood pressure. A 2006 study from the University of Reading, England investigated the consequences of hawthorn for high blood pressure in patients with hypertension associated with type II diabetes who were taking suggested drugs. Patients who took 1200 mg of hawthorn extract everyday over 16 weeks showed bigger fluctuation (mostly decrease) in pressure than the control group. Hawthorn extract comes in capsule form and is usually thought to be safe to consume over a number of months.
- Olives - olives are considered one of the most demanding heartiest diets in the world. According to studies of Dr. L Aldo Ferrara, Olive Oil could be helpful in reduce blood pressure. It had been found that the polyphenols in olive Oil could decrease amount of hypertension medicines required by the patients.
- Hibiscus - an extract from the hibiscus flower has got a vital role in ancient eastern remedies and could have identical benefits for our heart as tea and red wine. The flower is alleged to contain antioxidants. Hibiscus is usually created into a bitter-tasting tea. A 1999 study from the Beheshti University of Medical Sciences & Health Services, Iran found sour tea (Hibiscus sabdariffa) to lower high blood pressure.
- Cinnamon - cinnamon has been useful for both blood sugar and heart disease in paitents with diabetes. In a recent study performed at the centre for Health Sciences situated in the state of Ohio, 22 people got either placebo or a cinnamon. Those people who took the cinnamon had a 13%-23% increase in their antioxidant levels , had lower blood sugars and reduced blood pressure.
- Other Herbs - there are varieties of different herbs and foods that can be beneficial in lowering blood pressure. These herbs include asparagus, lime blossom, coleus forskohlii, hibiscus, saffron, mistletoe, rauwolfia, maitake and mushrooms. You can take advantage for your entire body by taking advantage of the antioxidants and anti-inflammatory effects of these herbs and spices. Another extra advantage of herbs is that they have a lower caloric content and you can simply use them in cooking and making a meal for your blood pressure treatment. Herbal recourses may be a tasty addition to foods like soup, casseroles, meat, fish and vegetables. They can even be baked into cakes and breads. Herbal recourses are economical and easier to keep and use than prescription medications. It’s very necessary that superior quality herbs are used and you should consult with a proper physician before using these herbs for medical purposes.
Home remedies for hypertension
If you’re still now satisfied with our inventory of remedies for hypertension and still looking for some easy to use remedies then this section is for you. You can try a bunch of home remedies to beat hypertension in a convenient way. All you need to do is look your pantry and refrigerator for the right ingredients.
Some of the most popular home remedies for hypertension are as follows:
- Lemons - lemons facilitate in keeping blood vessels soft and flexible. Lemon accomplishes this by removing any rigidity in the blood vessels. This is how consuming lemons help reduce high blood pressure. Additionally, you can help lower your probability of heart failure by using lemon juice on daily basis, as lemon juice is very rich in Vitamin B content. You just have to drink warm water added with a half lemon juice every morning with an empty stomach. For best results, don't add sugar or salt in it.
- Watermelon Seeds - watermelon seeds contain a compound known as cucurbocitrin, a compound that help widens the blood vessels. Meanwhile, it also helps improve functions of kidney. This successively reduces blood pressure levels and also helps plenty with arthritis. Also, a 2010 Florida State pilot study proved that watermelon facilitates decrease in blood pressure due to its vasodilatory effect. Grind same quantities of poppy seeds (khus khus) dried and watermelon seeds. Take one teaspoon of this mixture in morning with empty stomach and once more in the the evening. Alternatively, add 2 teaspoons of gently crushed, dried watermelon seeds to at least one cup of poached water. Steep it for about an hour and then strain it. Take 4 tablespoons of this water at equal span of time throughout the day.
- Banana - this useful fruit is packed with potassium, thus it widens blood vessels and is an excellent snack for you if you’re a hypertensive patient. Add a banana to your breakfast (my banana-raspberry oatmeal makes an excellent morning meal) or for a night treat, slice a banana into many half-inch wheels, put them into a little plastic bag, and freeze. Frozen Bananas can play a vital role in balancing blood pressure.
- Celery - the high level of the 3-N-butylphthalide and phytochemical that exist in celery can greatly help control your hypertension. Phthalates facilitate in relaxing the muscles in and around blood vessel walls, thereby making extra space and permitting the blood to flow in easily. At the same time, it will help decrease the strain hormones that constrict blood vessels and contribute to the increase in blood pressure. Try to eat one stalk of celery beside a glass of water every day. If you like, you'll be able to munch on celery throughout the day.
- Coconut Water - people with hypertension should keep their bodies well hydrated. For this you should make a habit to drink at least 8-10 glasses of daily. Coconut water is especially useful for lowering blood pressure. A 2005 study in the American Medical Journal found that coconut water, being highly rich in magnesium; potassium and vitamin C, facilitates to decrease heart beat and blood pressure. Moreover coconut oil can also be used in cooking for this purpose.
- Cayenne Pepper - those of you who have high blood pressure, you can have the benefit of the uptake of cayenne pepper. It helps sleek blood flow by preventing platelets from clumping along and accumulating within the blood. You can add a pinch of this pepper to a bowl of soup or some cayenne pepper to fruit or vegetable dish.
- Honey - honey will decreases pressure from the heart and not only this it also has a calming effect on blood vessels. Therefore eating honey on regular basis will be useful in reducing high blood vessels. Eat 2 teaspoons of honey on an empty stomach every morning. You may also combine one teaspoon ginger juice and honey along two teaspoons of Cumin seeds power. It must be eaten twice a day. Another effective remedy is to combine honey with basil juice in equal quantity and have it on an empty stomach daily.
- Fenugreek seeds - Fenugreek seeds are a good ingredient for lowering high blood pressure. This property is attributable to their high potassium and dietary fiber content. Boil 1-2 teaspoons of fenugreek seeds in water for concerning two minutes, so strain it. Place the seeds in a blender and blend it into a paste. Eat this paste twice daily, once in the morning on an empty stomach and once in the evening. Follow this remedy for 2 to 3 months to note a big improvement in your blood pressure level. In addition to the victimization of these natural remedies as a part of treatment for high blood pressure, it's essential to follow your doctor’s medical and dietary recommendation and opt for regular checkups.
There are some lifestyle changes that can help patients with hypertension.
- Exercise daily for at least 30 minutes. It has proven to decrease blood pressure.
- Quit smoking
- Decrease the intake of alcohol
- Try relaxing exercises and yoga to get rid of tension and anxiety
- Try to remain as happy as possible
- Spend more time with family
- Lose some weight
- Limit the intake of high fat food
- Decrease the intake of salt
- Increase the intake of higher fiber food such as vegetables and fruits
- Drink fruit and vegetable juices instead of colas and soft drinks.
|Written by:||Michal Vilímovský (EN)|
|Education:||Medical student, 3rd Faculty of Medicine, Charles University, Prague, Czech Republic|
|Published:||July 27, 2014 10:32 PM|
|Last updated:||August 2, 2015 5:25 AM|
|Next scheduled update:||August 2, 2017 5:25 AM|