Hypertension

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  • Lungs, edema, keep journal of BP or regular readings, peripheral pulses
  • Proper method
    Method: sitting in chair, not exam table, with feet on floor, arm supported at heart level
    Postural check in standing too.
    After 5 minutes of rest, no smoking/caffiene for 30 min prior,
    Cuff encircle 80 % of arm
    Consider ambulatory Bp for “white coat” night pressure changes, episodic HTN, hypotensive symptoms from htn meds
  • Secondary if take away cause, high bp will go away.
    Target organ disease happens in white coat and end organ damage happens in 15-30%
  • 4th pheo
  • Listen to lungs, EF, s/s of stroke, look in eye
    Think about what htn uncontrolled for years might lead to. Review all systems
  • Lifestyle modification for those with mild htn and no cardiovascular complications.. Alone for 3-6 months
    Dietary approaches to stop hypertension
  • Goal bp 140/90, CKD 130/80
    Stage 1 140/90
    Compelling indicators HF, post mi, high CHD risk, DM, CKD, stroke prevention
    Consider hospitalization if pt comes in in htn crisis
    If > 200mmhg or dbp >120, may need hospitalization, more aggressive therapy.
  • Diuretic potentiate effects of other drugs
  • IV BB, labetolol
  • At walmart
  • Np/md make plans based on what they think is important with out consideration to the patients wishes or goals or point of view. Patient’s goals cannot be ignored. Important to have a good client-practitioner relationship.
    Consider SE (sexual dysfunction), want to try natural way of dec bp instead of meds.
  • Prevalence = total #/cases in population at a given time.
    Control rates are htn undercontrol
  • Hypertension

    1. 1. L I N N E A C O O P E R Hypertension
    2. 2. Patient Information Joseph Hill, 53 y/o black male  Recent BP readings of 210/122, 180/110, 192/108, 200/114, 182/106.  PMH  Excellent health, no physical exam since age 30 where he had elevated BP.  No meds/allergies  Family hx: unknown  Social: gardener, smokes 1-2 cigars/day, little ETOH, married with 3 grown children.
    3. 3. 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
    4. 4. 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
    5. 5. Additional history  Question about stresses in life, weight control, physical activities, and dietary intake of sodium, caffeine, and cholesterol.  BMI? 30.4  Secondary causes of HTN  ETOH, psychogenic, arteriosclerosis, adrenal disorder, thyroid disorders, amphetamines/street drugs, NSAID long-term use, renal disease, acute stress,  EKG  Chest xray  Complete neuro exam
    6. 6. 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
    7. 7. 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) Category Systolic(mmHg) Diastolic(mmHg) Normal <120 and <80 Prehypertension 120-139 or 80-89 Stage 1 HTN 140-159 or 90-99 Stage 2 HTN >160 or >100
    8. 8. 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).
    9. 9. 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  ETOH, psychogenic, arteriosclerosis, adrenal disorder, thyroid disorders, amphetamines/street drugs, NSAID long-term use, renal disease, oral contraceptives (DeMartinis, J., Uphold, C., & Graham, M., 2003).
    10. 10. 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
    11. 11. 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
    12. 12. 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).
    13. 13. 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
    14. 14. 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)
    15. 15. 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).
    16. 16. 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.
    17. 17. 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
    18. 18. 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
    19. 19. 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).
    20. 20. Prevalence in United States  National Health and Nutrition Examination Survey  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).
    21. 21. Reference  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.

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