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he is certified as a hypertension specialist by the american society of hypertension and is a fellow of the society. elevated blood pressure is one among multiple responses to endothelial dysfunction and vascular smooth muscle dysfunction, both of which precede the development of hypertension by decades. as to the question “which occurs first, the vascular disease or the hypertension?” most people now believe that the micro-vascular disease and the endothelial dysfunction occur first, dr. houston said, with the blood pressure as a marker. considering genetics and epigenetics, dr. houston noted that most of the single-nucleotide polymorphisms (snps) related to hypertension and cardiovascular disease are associated with oxidative stress, inflammation, and immune dysfunction.