L I N N E A C O O P E R

Hypertension

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.

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 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

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)

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

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

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).

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 DrugsWithout compelling

indicationsWith 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 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).

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.