Hypertension, commonly known as the 'silent killer,' affects approximately 30% of adults globally and contributes to over 7 million deaths annually. It is characterized by persistently elevated blood pressure (≥140/90 mmHg) and has various causes, classifications, and treatment strategies, including lifestyle modifications and medications. The management of hypertension aims to reduce cardiovascular risks and prevent complications such as heart disease, stroke, and kidney failure.

2. Hypertension
“Silent killer” (Hoel & Howard, 1997)

3. M. Daniel
HTN
Significance
Definition
Classification
Risk factors
Manifestation
Treatment
Nursing care
Complications

4. Problem Magnitude
Hypertension( HTN) is the most common public health problem in the world
(30% adults)
 Ethiopia 20- 30%
Worldwide prevalence estimates for HTN may be as much as 1 billion.
>7 million deaths per year may be attributable to hypertension.
“Silent killer”

5. Definition
Hypertension: is defined as persistently elevated, systolic and/or diastolic blood
pressure of 140/90 mmHg or more in subjects aged 18 years and above.
The definition also applies to those individuals who are already taking
antihypertensive medications even if their current blood pressure is less than
140/90mmHg
Systolic blood pressure (SBP) is the pressure exerted when the heart
contracts and diastolic blood pressure (DBP) is the pressure exerted when
the heart muscle relaxes

6. Cont…
Average of two or more properly measured, seated BP readings each time.
On two or more separate office visits.
Systolic BP is more important CV risk factor after age 50.
Diastolic BP is more important before age 50.

7. Pathophysiology

8. Factors Influencing BP
PVR
 Is the force opposing the movement of blood
 Primarily affects diastolic BP (DBP)
CO
 Stroke volume & heart rate
 Primarily affects the systolic BP (SBP)
BP = CO x SVR

9. R/Ship of factors in the control of BP
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10. Accurate Blood Pressure Measurement
The BP apparatus should be regularly inspected and validated.
Blood pressure can be measured either by a conventional sphygmomanometer,
using a stethoscope, or by an automated electronic device.
Well trained and regularly retrained professional.
Patient properly prepared and positioned and seated quietly for at least 5 minutes
in a chair.
The auscultatory method should be used.
Noxious avoided (Caffeine, exercise, and smoking) should be avoided for at least
30 minutes before BP measurement.
Cuff size- appropriate

11. How to measure blood pressure
Effective treatment algorithms for hypertension are dependent on accurate blood
pressure measurement.
The following advice should be followed for measuring blood pressure:
Use the appropriate cuff size, noting the lines on the cuff to ensure that it is
positioned correctly on the arm. (If the arm circumference is >32 cm, use large
cuff.)
On initial evaluation it is preferable to measure blood pressure on both arms and
use the arm with the higher reading thereafter
The patient should be sitting with back supported, legs uncrossed, empty bladder,
relaxed for 5 minutes and not talking.
It is preferable to take at least two readings at each occasion of measurement and
to use the second reading.

12. Diagnosing Hypertension
The diagnosis of hypertension should be confirmed at an additional patient visit,
usually 1 to 4 weeks after the first measurement depending on the measured
values and other circumstances.
In general, hypertension is diagnosed if, on two visits, on different days:

13. Classification
www.nhlbi.nih.gov

14. Prehypertension
SBP 120 -139mmHg and/or DBP 80 - 89 mmHg.
Pre-HTN is not a disease category rather a designation for individuals at high risk
of developing HTN.
Individuals who are prehypertensive are not candidates for drug therapy but
should be firmly and unambiguously advised to practice lifestyle modification
Pre-HTN with diabetes/kidney disease, drug therapy is indicated if a trial of
lifestyle modification fails to reduce their BP to 130/80 mmHg or less.

15. Hypertensive Crises
Hypertensive Urgencies: No progressive target-organ dysfunction(Accelerated
Hypertension)
Hypertensive Emergencies: Progressive end-organ dysfunction(Malignant
Hypertension)

16. Hypertensive Urgencies
Severely elevated BP in the upper range of stage II HTN.
Without progressive end-organ dysfunction.
E.g., Highly elevated BP without severe headache, shortness of
breath or chest pain.
Usually due to under-controlled HTN.

17. Hypertensive Emergencies
Severely elevated BP (>180/120mmHg).
With progressive target organ dysfunction.
Require emergent lowering of BP.
Examples: Severely elevated BP with:
 Hypertensive encephalopathy
 Acute left ventricular failure with pulmonary edema
 Acute MI or unstable angina pectoris
 Dissecting aortic aneurysm

18. Types of HTN
 Primary HTN:
Essential HTN.
accounts for 90%-95% cases of HTN.
unknown etiology.
 Secondary HTN:
less common cause of HTN
( 5%-10%).
Potential cause –identifiable.

19. Risk Primary HTN
Age
Sex
Family history
Race
Smoking
Sedentary lifestyle
Obesity :BMI
Diet
Stress
Diabetes mellitus
 Raised Cholesterol
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20. Causes of Secondary HTN
Common
Intrinsic renal disease
Renovascular disease
Endocrine
Coarctation of Aorta
Pheochromocytoma

21. Target Organs
CVS (Heart and Blood Vessels)
The kidneys
Nervous system
The Eyes

22. Renin-angiotensin-aldosterone mechanism
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23. Effects On CVS
Ventricular hypertrophy, dysfunction and failure.
Arrhithymias
Coronary artery disease, Acute MI
Arterial aneurysm, dissection, and rupture.

24. Effects on The Kidneys
Glomerular sclerosis leading to impaired kidney function and finally end stage
kidney disease.
Ischemic kidney disease especially when renal artery stenosis is the cause of
HTN.

25. Nervous System
Stroke, intracerebral and subaracnoid hemorrhage.
Cerebral atrophy and dementia.

26. The Eyes
Retinopathy, retinal hemorrhages and impaired vision.
Vitreous hemorrhage, retinal detachment
Neuropathy of the nerves leading to extraoccular muscle
paralysis and dysfunction

27. Clinical manifestations of hypertensions
General
 Usually asymptomatic
Slow progressive rise in BP
With severity symptoms involves systems
Headache
Fatigability
Dizziness
Palpitation
Blurring of vision
Epistaxis
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28. Systemic effects of HPN
Arteries/vascular effect
Worsens atheroma
Narrowed lumen
Blurring of vision
Epistaxis
Aneurysm
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29. HTN
Endothelial
injury
Increased
afterload
LV hypertrophy
Atheroscler
osis
Increased myocardial
demand and decreased diastolic
coronary flow
Vascular lumen
narrowing and
occlusion
Worsening of
HTN
CHD M ischemia
Figure : Pathophysiological link between hypertension and CHD.

30. Systemic effects cont.
Kidneys
Arterial changes cause chronic glomerular ischemia with
subsequent glomerulosclerosis, tubular atrophy and scarring
which destroys individual nephrons one by one
Nocturia
Increased BUN & serum creatinine
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31. Systemic effects cont.
Heart
Left ventricular hypertrophy
Congestive cardiac failure
Ischemic heart disease
Angina pectoris
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32. Systemic effects cont.
Brain
Cerebral infarction; micro-infarcts (lacunae)
Cerebral hemorrhage
Dizziness
Weakness
Faintness (sudden fall)
TIA
CVA/stroke
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33. Systemic effects cont.
Aorta
Atheroma and aneurysms
Dissecting aneurysms
Eyes
Arterial changes, retinal exudates, hemorrhages
Progression: long course but eventually serious side effects
Papilloedema
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34. Systemic effects cont.
Death may be due to:
Cardiac failure
MI
Stroke
Renal failure
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35. Diagnostic tests
History and Physical Examination
BP measurement
Ophthalmologic examination
 Laboratory Ix
Urinalysis for blood, proteins, glucose, Urine catecholamine
Renal panel for electrolytes, urea and creatinine , BUN
Fasting Lipids and Glucose
ECG
Vascular ultrasonography
Echocardiography
Chest X-ray
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36. Patient evaluation
Assess lifestyle and identify other CV risk factors or concomitant disorders that
may affect prognosis and guide treatment
To identify causes of high BP- secondary HTN
To assess the presence or absence of target organ damage and CVD

37. Lifestyle and CV Risk factors
Cigarette smoking
Obesity
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimated GFR <60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men under age 55 or women
under age 65)

38. Target Organ Damage
Heart
 Left ventricular hypertrophy
 Angina or prior myocardial infarction
 Prior coronary revascularization
 Heart failure
Brain; Stroke or transient ischemic attack
Chronic kidney disease
PVD
Retinopathy

39. Goals of Treatment
Goal of management
To reduce overall CV risk factors and control BP to target level by
possible means. < 140/90 mm Hg; <130/80 if diabetic or renal d/s.
 The primary focus should be on attaining the SBP goal.
 To reduce CV and renal morbidity and mortality
 Rx benefits
Reductions in stroke incidence, averaging 35–40 percent
Reductions in MI, averaging 20–25 percent
Reductions in HF, averaging >50 percent.

40. Management of HTN
Non drug intervention (Patient Education and Lifestyle Modification
Pharmacological Treatment
Follow up
Hypertension treatment is indicated for adults diagnosed with hypertension, as
defined above (SBP ≥140 mmHg and/or DBP ≥90 mmHg).
Patients with SBP ≥180 mmHg or DBP ≥110 mmHg may be indicated for
immediate treatment based on one assessment
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41. Lifestyle modification
Modification Recommendation Approximate
SBP reduction
(range)
Body Wt reduction Maintain normal body wt BMI (18.5-24.9 kg/M2 5-20mmHg
Adoption of DASH
eating plan
Consume diet rich in fruits, veg, and low fat dairy products
with a reduced content of saturated and total fat
8-14 mmHg
Dietary Na+
reduction
Reduce daily sodium intake to less than 2.4 gm (<5-6gm
NACL)
2-8mmHg
Physical activity Engage in regular aerobic physical exercise such as brisk
walking (at least 30 minutes per day for most of days of
weeks
4-9mmHg
Moderation of
alcohol
Limit consumption to no more than 2 drinks eg 24 Oz beer,
10 Oz wine, ) per day men and no more than one drink
women.
2-4mmHg

42. Drugs Available for Treatment of Hypertension
Diuretics
ACE inhibitors/ARBs
Calcium channel blockers (CCBs)
Alpha-blockers
Central acting agents
Vasodilators
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43. Cont’…
Choice of antihypertensive drug for Primary Health Care in Ethiopia: Who should receive
hypertension drug treatment and when?
Indicated for adults diagnosed with hypertension, as defined above (SBP ≥140 mmHg and/or
DBP ≥90 mmHg) who couldn’t achieve target blood pressure with three months of life style
modification.
For grade 2 hypertension (SBP 160-179 and/or DBP 100-109mmHg)
Confirm diagnosis within one week and Start antihypertensive treatment with CCB.
Immediate treatment is Indicated for adults diagnosed with hypertension at initial presentation
in those with :
End-organ damage
High CVD risk (Lab based WHO cardiovascular risk >20% or non-Lab based WHO
cardiovascular risk >10%
Hypertensive Crises (SBP ≥180 mmHg or DBP ≥110 mmHg)

44. Initial Monotherapy In Uncomplicated Hypertension:
Long-acting dihydropyridine calcium channel blocker such as amlodipine as first
line drug for the treatment of uncomplicated essential hypertension:- Amlodipine
5 mg daily, escalate to 10 mg if BP is uncontrolled.
Thiazide diuretics such as hydrochlorothiazide to be used as add on when target
BP not achieved on long-acting dihydropyridine calcium channel blocker such as
amlodipine:- Hydrochlorothiazide 25 mg Po daily
If a third agent is needed, the alternative class of medication is ACE inhibitors:-
Lisinopril 5 mg daily, escalate dose to 40 mg Po daily if BP is uncontrolled or
Enalapril 5 mg Po BID, escalate to 20 mg Po BID if BP is uncontrolled
Pregnant women and women of childbearing age not on effective contraception
CCBs should be used.

45. Hypertensive Emergencies Requiring Immediate BP
Lowering
First Line Treatment:- Labetalol 20-40mg IV every 10min to 300mg (2mg/min
infusion)
Alternative :- Hydralazine 5-20mg IV repeat after 20min

46. Nursing Management
Assessment
 Comprehensive nursing assessment focusing CVD and systemic manifestations
 Including history of
Angina/MI Stroke: Complications of HTN, Angina may improve with b-blokers
Asthma, COPD: Preclude the use of b-blockers
Claudication: May be aggravated by b-blockers
Gout: May be aggravated by diuretics
Family history of HTN: Important risk factor
Family history of premature death: May have been due to HTN
Cigarette smoker: Aggravate HTN, independently a risk factor for CAD and stroke
High alcohol: A cause of HTN
High salt intake: Advice low salt intake; dietary likes and dislikes
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47. Nursing diagnosis
Risk for decreased CO related to Increased vascular resistance, vasoconstriction,
Myocardial ischemia, or Ventricular hypertrophy/ rigidity
Activity intolerance related
Pain
Knowledge deficit
Risk non compliance with therapeutic regiment related to side effects of
prescribed drugs

48. Nursing intervention
 Improving cardiac output
 Improving activity tolerance
 Alleviating pain
 Patient education
 Compliance to therapeutic regimens
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49. Potential complications of hypertension
Hypertensive Heart Disease
 CAD
 Left ventricular hypertrophy
 Heart failure
Cerebrovascular Disease
 Stroke
 PVD
 Nephrosclerosis
 Retinal Damage
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50. Thank you!!!!!!!