Patient Information Joseph Hill, 53 y/o black male
Recent BP readings of 210/122, 180/110, 192/108, 200/114, 182/106.
Excellent health, no physical exam since age 30 where he had elevated BP.
Family hx: unknown Social: gardener, smokes 1-2 cigars/day, little ETOH, married with 3 grown children.
Review of Systems General: considers himself “healthy”. From the South and primarily eats fried foods. HEENT: Occasional occipital HA late in day , worse in evening. No visual disturbance, tinnitus, or vertigo. Heart: no CP or tightness Lungs: no dyspnea or cough
Physical Exam General: moderately obese VS: HR 72, RR 16, Temp 98.4, wt 224#, 6’0”, BP 204/116 RA, 204/144 LA lying 200/116 sitting, 194/118 standing. HEENT: fundi have arteriole narrowing and AV nicking, hemorrhage and exudates. Heart: no murmurs or rubs, S1 and S2 normal and S4 heard at the apex and L lateral position. Neck: no JVD or bruits
Additional history Question about stresses in life, weight control, physical activities, and dietary intake of sodium, caffeine, and cholesterol. BMI? 30.4
Pathogenesis Force against the walls of the BV. Systolic is pressure in arteries as heart contracts Diastolic is pressure when heart relaxes (Breen, 2008). Variable involving the volume of blood and degree of dilation or constriction Regulation of body fluid volume, salt intake R-A-A system Vascular autoregulation, SNS Obesity, genetics
Hypertension Def: persistent elevation of SBP > 140mmHg and DBP > 90mmHg, or taking HTN medication. Using proper method Classification (DeMartinis, J., Uphold, C., & Graham, M., 2003). Based on ave. of 2+ readings after initial visit, obtained over at least 2 visits over a period of 1-several weeks. If different categories, use higher category (Agency for healthcare Research and Quality, 2006)
Types of hypertension Essential HTN (90-95%), no identifiable cause Secondary HTN: identifiable cause. Pheochromocytoma, renal artery stenosis, Cushings(DeMartinis, J., Uphold, C., & Graham, M., 2003). Factors that can increase BP: Obesity, psychogenic stress, high fat and sodium intake, oral contraceptives, ETOH, insulin resistance, low birth weight, neurovascular abnormalities, “white coat” (Breen, 2008).
Differential diagnosis Real HTN vs those who appear to be hypertensive due to incorrect measures. Clinical manifestations Central obesity, hirsutism, purple striae, ecchymosis Widening pulse pressure, acute anterior chest and back pain, feeling of doom Wt loss, nervousness, exophthalmia, tremors Paroxysmal c/o headache, perspiration, palpitations, dizziness
Diagnostic testing Before beginning therapy UA, CBC, fasting dexi, CMP, Creatinine, fasting lipid panel, EKG, Hct Plus whatever you are ruling out TSH, urine VMA, triglycerides/cholesterol, BUN/Cr, drug screen
Target Organ Disease Precipitates many diseases CHD, Left ventricular hypertrophy, HF, TIA, stroke, dementia, PVD, retinopathy (Breen, 2008). May not appear until 10-20 years after disease
Plan/Management Maintain arterial pressure <140 SBP and <90 DBP DASH diet Lifestyle modification Maintain normal body weight (BMI 18.5-24.9) Reduce dietary sodium Limit ETOH one drink/day, smoking cessation Regular aerobic physical exercise most days of the week for 30 min, weight reduction. Adequate intake of K+ (>3500mg) Diet rich in fruits and vegies, low-fat dairy, and decreased fat (DeMartinis, J., Uphold, C., & Graham, M., 2003). (Agency for Healthcare Research and Quality, 2006; US Department of Health and Human Services, National Institute of Health, 2003).
Screening Family history of CHD Smoking status, diet, ETOH, physical activity Blood pressure, BMI, waist circumference, pulse (afib). Fasting lipoprotein profile Fasting glucose Update regularly At each routine visit At each routine visit, at least every two years At least every 5 years If risk factor for hyperlipidemia or diabetes, every two years (Bickley, 2009) Risk Factor Frequency Screen every 2 years for <130/80, more frequent for higher
Algorithm for treatment of HTN Lifestyle modification Not at goal BP Initial Drugs Without compelling indications With compelling indications Stage 1: Thiazide type diuretics for most. May consider ACEI, ARB, BB, CCB, combo Stage 2: Two drug combo (thiazide diuretic and ACEI or ARB or BB or CCB) Drugs for compelling indications. Other antiHTN drugs as needed. Not at goal BP Inc dose or add drugs until BP met. Consult with MD/specialist. (Burke, M. & Laramine, J. 2004; US Department of Health and Human Services, National Institute of Health, 2003)
Compelling indications DM Heart Failure Heart failure with symptomatic vent dysfunction CKD Post-MI Stable angina ACS Recurrent stroke prevention African Americans Elderly Thiazide diuretic, ACE I, ARD, B-blocker, CCB ACE I, B-blocker ACE I, B-blocker, ARB, aldosterone blocker along with diuretic ACE I or ARB ACE I, B-blocker, aldosterone blocker B-blocker B-blocker, ACE I ACE I and thiazide diuretic Diuretics and CCB have best effect Thiazides or b-blocker + thiazide(DeMartinis, J., Uphold, C., & Graham, M., 2003).
Controlling BP If still uncontrolled after 2 weeks-2 months Increase dose of initial drug Switch drugs if no response/SE If not taking diuretic, they should start. Add another drug to regimen or use combination drug.
Hypertensive Emergencies Urgency when desirable to reduce BP in hours, no significant TOD, may have HA or vision disturbance. Emergency prevent or limit TOD (hemorrhage, encephalopathy, papilledema, unstable angina, MI, HF, pulmonary edema, aneurysm, preeclampsia) BP >200/120 with s/s Parenteral
Medication Side effects HCTZ $4 Lisinopril $4 Metoprolol $4 Valsartan $78.84 Diltiazem $4 Inc cholesterol and glucose levels, decrease K, Na, Mg, inc uric acid, Ca. hyponatremia. Cough. Rarely angioedema, hyperkalemia, rash, loss of taste, leukopenia Bronchospasm, bradycardia, HF, mask hypoglycemia, impaired circulation, insomnia, fatigue, decreased exercise tolerance, Angioedema, hyperkalemia (avoid salt substitutes), confusion, decreased urine production ,irregular heart beat (CP), difficulty breathing. Confusion, mental depression, feeling faint, lightheaded, redness or loosening of skin, slow or irregular heart beat, swelling of feet/ankles, unusual bleeding. Drug treatment
Newest trends, Ethical considerations Trends Increased focus on SBP and pulse pressure Multiple drug therapy for faster control Diuretics included Even slight elevations increase risk of CV disease. Strict adherence to numbers. Ethics Medication regimen and patient satisfaction/ participation emphasized. Consider SE, pt goals. (DeMartinis, J., Uphold, C., & Graham, M., 2003).
Prevalence in United States National Health and Nutrition ExaminationSurvey 1988-1994 and 1999-2004 Prevalence rate increased 24.4% to 28.9%, largest inc in non-Hispanic women. Attributed to increase in BMI Treatment rates increased: 53.1% to 61.4% Control rates increased: 26.1%-35.1% (Cutler et al, 2008).
Agency for Healthcare Quality and Research. (2006). Screening for high blood pressure. In The guide to clinical preventive services (pp. 67-70). Rockville, MD: Lippincott, Williams, & Wilkins.
Bickley, L.(2009). The cardiovascular system. In Bickley, L and Szilagyi, P (Eds.), Bates’ pocket guide to physical examination and history taking, 6th ed. Philedelphia: Lippincott, Williams, & Wilkins.
Breen, J. (2008). An introduction to causes, detection and management of hypertension. Nursing standard. 23(14): 42-46.
Burke, M. & Laramine, J. (2004) Cardiovascular system. In Burke, M. & Laramine, J. (Eds.) Primary care of the older adult: A multidisciplinary approach, 2nd Ed. (pp. 254-304). Philedelphia, PA: Mosby, Inc.
Cutler, J., Sorlie, P., Wolz, M., Thom, T., Fields, L., Roccella, E. (2008). Trends in Hypertension Prevalence, Awareness, Treatment, and Control Rates in United States Adults Between 1988–1994 and 1999–2004. Hypertension. 52: 818
DeMartinis, J., Uphold, C., & Graham, M. (2003). Cardiovascular problems. In Uphold, C. & Graham, M. (Eds.), Clinical guidelines in family practice 4th ed. (pp 453-532) . Gainsville, Fl: Barmarrae books. US Department of Health and Human Services, National Institute of Health. (2003). Reference card from the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Retrieved on March 11, 2009 from http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf.