The document discusses hypertension including its definition, classification, risk factors, symptoms, complications, diagnosis, and management. It provides details on lifestyle modifications and drug therapies used to treat hypertension as well as the management of hypertensive crises. The document is intended to serve as an educational reference for healthcare providers on the topic of hypertension.

1. HTN
Dr. Ram Sharan Mehta
Medical-Surgical Nursing Department
Dr. RS Mehta, MSND, BPKIHS 1

2. Definition
• Hypertension is a systolic blood pressure
greater than 140 mm Hg and a diastolic
pressure greater than 90 mm Hg over a
sustained period, based on the average of
two or more blood pressure
measurements taken in two or more
contacts with the health care provider after
an initial screening.
Dr. RS Mehta, MSND, BPKIHS 2

3. Dr. RS Mehta, MSND, BPKIHS 3

4. New Facts
For persons over age 50, SBP is a more important than DBP as
CVD risk factor.
Starting at 115/75 mmHg, CVD risk doubles with each
increment of
20/10 mmHg throughout the BP range.
Persons who are normotensive at age 55 have a 90% lifetime
risk for developing HTN.
Those with SBP 120–139 mmHg or DBP 80–89 mmHg should
be considered prehypertensive who require health-promoting
lifestyle modifications Dr. RS Mehta, MSND, BPKIHS
to prevent CVD. 4

5. International Health Survey: Harrison
Prevalence of hypertension is 22% in Canada, of
which 16% is controlled; 26.3% in Egypt, of which
8% is controlled; and 13.6% in China, of which 3%
is controlled. Hypertension is a worldwide
epidemic; in many countries, 50% of the
population older than 60 years has hypertension.
Overall, approximately 20% of the world's adults
are estimated to have hypertension. The 20%
prevalence is for hypertension defined as blood
pressure in excess of 140/90 mm Hg. The
prevalence dramatically increases in patients
older than 60 years.RS Mehta, MSND, BPKIHS
Dr. 5

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8. Classification of HIN
1. Systolic HTN / Diastolic HTN
- Systolic BP > 140/ Diastolic BP > 90
2. Primary [essential] HTN/Secondary HTN
- Majority idiopathic cause/cause known
3. White coat HTN: Normotensive otherwise
4. Malignant HTN: DBP > 120 mg, Retinal
hemorrhage, papilledema, ARF, Rapid
vascular deterioration
Dr. RS Mehta, MSND, BPKIHS 8

9. Classification of HTN according to
Type
Cause/etiology Degree of severity
• borderline/liable
•White coat
Systolic /Diastolic Primary/secondary •Benign
•Malignant
•accelerated
Dr. RS Mehta, MSND, BPKIHS 9

10. Benefits of Lowering BP
Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%
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12. Use of holter
Dr. RS Mehta, MSND, BPKIHS 12

13. Source:RS Mehta, MSND, BPKIHS
Dr. Bruner, May be western countries 13

14. Aetiology of Hypertension
• Primary – 90-95% of cases: essential or idiopathic
• Secondary – about 5% of cases
– Renal or renovascular disease
– Endocrine disease
• Cusings syndrome
• Acromegaly
• hypothyroidism
– Coarctation of the aorta
– Iatrogenic
• Hormonal / oral contraceptive
• NSAIDs
Dr. RS Mehta, MSND, BPKIHS 14

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16. Risk Factors
• Modifiable: weight/obesity, stress,
diet-cholesterole/ coffee/ salt,
alcohol, smoking, sedentary job,
Diabetes, Durgs-OCP.
• Non-Modifiable: Hereditary, sex,
age, race.
Dr. RS Mehta, MSND, BPKIHS 16

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18. CVD Risk Factors
Hypertension (Major Risk Factor)
Cigarette smoking
Obesity* (BMI >30 kg/m2)
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 CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome. Mehta, MSND, BPKIHS
Dr. RS 18

19. Dr. RS Mehta, MSND, BPKIHS 19

20. Pathophysiology
• Primary HTN: the actual pathogenesis of
HTN remain unknown. Failure to maintain
Normal blood pressure.
Elderly:
atherosclerosis, loss of connective
tissue elasticity, decrease in relaxation
of vascular smooth muscle, which
reduce ability of vessels to distend and
recoil.
Dr. RS Mehta, MSND, BPKIHS 20

21. Pathophysiology
Four control systems plays a major
role in maintaining BP. They are:
• arterial baroreceptor system
• regulation of body fluid volume
• renin angiotensin system
• vascular autoregulation.
Dr. RS Mehta, MSND, BPKIHS 21

22. C/F: General
• Early stage of HTN is asymptomatic
• Morning occipital headache
• Fatigue
• Dizziness
• Palpitation
• Flushing
• Blurred vision gradually blindness occur
• epistaxis
Dr. RS Mehta, MSND, BPKIHS 22

23. C/F
• Mild to moderate: asymptomatic except
intermittent risk of BP
• Moderate to severe: headache with
dizziness, flushing, fatigue, vertigo,
palpitations.
• Severe: Morning-throbbing subocipital
headache, blurred vision, epistaxis,
hematuria, papilledema
Dr. RS Mehta, MSND, BPKIHS 23

24. • Malignant HTN: retinopathy,
papilledema
• HTN encephalopathy is manifested
by: restlessness, blurred vision,
dizziness, headache, N/V.
• Renal insufficiency manifested by:
proteinuria, hematuria, hemolytic
anemia, LVF, Pulmonary edema.
Dr. RS Mehta, MSND, BPKIHS 24

25. Hypertensive crisis
• It includes hypertensive urgencies and
emergencies:
1. Hypertensive urgencies: DBP> 120-130, with
optic disc edema, end organ complication etc)
2. Hypertensive emergencies:
a. Accelerated HTN: SBP>210, DBP>130, with
headache, blurred vision, focal neurological
symptom and pailloedema.
b. Malignant HNT: SBP>210, DBP>140 (130), with
headache, blurred vision, papilloedema, arterial
fibrisis, renal failre etc.
Dr. RS Mehta, MSND, BPKIHS 25

26. Dx
• BP: 2 separate visit, at least 2 weeks apart
• CxR/ECG: LVH, Cardiomegaly, arrythmias
• Blood chemistry: BUN (>20 mg %),
Creatinin (>1.5%)
• CBC, lipid profile, sugar profile
• Urine analysis
• Special examination: IVP, Fundoscopy
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27. Hypertensive Retinopathy
Grade I Grade II
• Narrowing of arterioles • Hemorrhages
Dr. RS Mehta, MSND, BPKIHS 27

28. Hypertensive Retinopathy
Grade III Grade IV
• Extensive hemorrhages • Exaggerated changes of
• Retinal exudates grade III
• Cotton wool patchesRS Mehta, MSND,Disk edema (not
Dr.
•
BPKIHS 28
papilledema)

29. Hypertension: Reason to Treat
• Reduce incidence of stroke: 35-40%
• Reduce incidence of MI: 20-25%
• Reduce incidence of Heart failure: 50%
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32. Management of HTN
A. Non-pharmacological
1.Salt restriction
2.Relief of stress
3.Weight reduction
4.Avoid alcohol and cigarette
5.Dietary fat modification
6. Exercises
7.Caffeine restriction
8.Relaxation technique BPKIHS
Dr. RS Mehta, MSND, 32

33. B. Drug therapy
a. Beta-blockers
b. Calcium channel blockers
c. ACE (angiotensin converting enzyme) inhibitors
d. Angiotensin II receptors blockers
e. Diuretics
Stepped care approach/
Step down therapy/
Combination therapy
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35. • Beta-blockers: Atenolol 50-100 mg od/bd
Contraindications: COPD, Br. Asthma,
CCF, Heart block
• Calcium channel channel blockers:
Nifedipine 10-20 mg 8 hrly if diastolic BP
more than 110 mm of Hg, may use S/L 5-
10 mg cap but not practice now a days.
S/E: Palpitation, headache, flushing, pedal
edema.
Dr. RS Mehta, MSND, BPKIHS 35

36. ACE inhibitors:
a. Catopril 25-50 mg tds
b. Enalpril 5-20 mg OD
c. Lisnopril 5-20 mg OD
S/E: Sudden hypotension, neutropenia,
albunninuria
Note:
ACE inhibitor are more preferred when HTN
is associated with heart failure, IHD, DM and
renal disease with protenurea.
Dr. RS Mehta, MSND, BPKIHS 36

37. Angiotensin II receptor blockers
1. Losartan 20-100 mg/day
2. Valsartan 80mg/day
3. Candesartan 8-16mg/day
S/E: angioedema, allergic reaction, rashes
Dr. RS Mehta, MSND, BPKIHS 37

38. Management of hypertensive crisis
Parenteral IV agents:
1. Sodium nitropruside
2. Nitroglycerine
3. Esmolol
4. etc
Dr. RS Mehta, MSND, BPKIHS 38

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41. Hypertensive crises
• Abnormal elevated blood
pressure: 20% of emergency
department patients
• Hypertensive crisis: 1%
Dr. RS Mehta, MSND, BPKIHS 41

42. •History
• Duration of hypertension
• Duration of current symptoms
• Other medical problems
–CNS manifestations
–Cardiovascular manifestations
–Renal manifestations
–Medications
Dr. RS Mehta, MSND, BPKIHS 42

43. • Neurologic symptoms
–Headache (85%)
–New-onset blurred vision (60%)
–Weight loss (75%)
–Nausea and vomiting
–Weakness and fatigue (30%)
–Change in mental status
Dr. RS Mehta, MSND, BPKIHS 43

44. • Imaging studies
–Chest x-ray
• Signs of CHF, pulmonary edema, or
coarctation of aorta
–Head CT scan
• Abnormal neurologic exam
intracranial bleeding, edema, or
infarction
Dr. RS Mehta, MSND, BPKIHS 44

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48. Hypertension and Diabetes
• Hypertension co-exists with type II in about
40% at age 45 rising to 60% at age 75.
• 70% of type II patients die from cardio-
vascular disease.
• At least 60% of patients will require 2 or 3
antihypertensive agents to achieve tight
control.
Dr. RS Mehta, MSND, BPKIHS 48

49. Follow-up
• For patients with BP stabilised by
management, follow up should normally be
three monthly (interval should not exceed 6
months), at which the following should be
assessed by a trained nurse/Doctor:
* Measurement of BP and weight
* Reinforcement of non-pharmacological advice
* General health and drug side-effects
* Test urine for proteinuria (annually)
Dr. RS Mehta, MSND, BPKIHS 49

50. Thank-You
Dr. RS Mehta, MSND, BPKIHS 50