Medsurg HTN

Prevalence and Incidence of HTN

½ adults in US meet HTN guidelines (MANY untreated)

BP inc = inc risk for MI, stress, vision loss, etc

Prevalence and Incidence of HTN: Black Persons

• highest prevalence

• most likely to have resistant HTN

• develop at younger age (women more often than men)

• more likely to have nocturnal non-dipping

• aggressive HTN and more organ damage

• most likely to have angioedema and cough from ace inhibitors

Prevalence and Incidence of HTN: Hispanic Persons

less likely to receive treatment

low rates of BP control and levels of awareness (of HTN and HTN tx)

Prevalence and Incidence of HTN: Men

higher prevalence <64

Prevalence and Incidence of HTN: Women

preeclampsia can be early signs of CVD risk

more difficult to control ages 70-79

after 64 HTN more common for women (menopause related)

HTN Diagnosis Criteria

need two or more readings accurately performed in both arms on two separate occasions (same locations both times) in order to consider proper diagnosis

normal: <120 systolic and <80 diastolic

elevated (preHTN): 120-129 systolic and <80 diastolic

HTN Stage 1: 130-139 systolic OR 80-89 diastolic

• treat w/ lifestyle modifications and one first line drug (ACE, ARB, Thiazide, CCB)

HTN Stage 2: >/=140 systolic OR >/=90 diastolic

• treat w/ two first line drugs of different classes and lifestyle modifications

Primary HTN

90% of HTNs

essential or idiopathic

no identifiable cause

many contributing factors (obesity, stress, smoking, alcohol, tobacco, high cholesterol, ethnicity, diabetes, overproduction of sodium retaining hormones, or inc sodium intake)

hallmark: persistently inc SVR

Secondary HTN

sudden acute onset

specific cause that can often be identified/corrected

ex: bladder retention (neuro), cirrhosis, pregnancy induced HTN, congenital narrowing of aorta, drug related (estrogen replacement/birth control), cocaine, endocrine problems (cushings syndrome), renal disease, sleep apnea

Symptoms of HTN

“silent killer”

asymptomatic until sever and target organ disease occurs

secondary symptoms: fatigue, dizziness, palpitations, angina, and dyspnea

• due to the effects on blood vessels in various organs/tissues or inc workload on heart

HTN crisis: nose bleeds, severe headaches, and dyspnea

Common Complications of HTN: Eye

arteriovenous nicking

narrowing of retinal arterioles

hemorrhages or exudates

papilledema

Common Complications of HTN: Brain

stroke (TIA)

Common Complications of HTN: Kidney

microalbuminuria

proteinuria

serum creatinine >/= 1.5 mg/dL

Common Complications of HTN: Heart

CAD

heart failure

left ventricular hypertrophy

Common Complications of HTN: Abdominal

aneurysm

aortic dissection

Common Complications of HTN: Peripheral Vascular

intermittent claudication

caint/absent peripheral pulses

Diagnosis

Fasting blood glucose

Routine urinalysis

BMP w/ GFR, calcium, and magnesium (determines renal involvement)

CBC

Serum lipid profile (total lipids, triglycerides, HDL, LDL) - info on CAD

Serum uric acid (baseline levels may rise during diuretic therapy)

12 lead EKG

TTE

Lifestyle Modifications for HTN

weight loss (1 kg weight loss can result in 1 pt dec in BP)

nutrition and diet

• DASH diet (lowers BP & LDLs):

  • eat: vegetables, fruits, whole grains, fat free/low-fat dairy, fish, poultry, beans, nuts & seeds, vegetable oil

  • limit: fatty meats, full-fat dairy, sugar sweetened beverages, sweets, sodium intake

NA reduction (salty six)

• pizza, lunch meats, bread, soup, sandwiches, poultry

Moderate ETOH use/cut down on tobacco products

Physical activity

• 150 moderate/75 vigorous per wk

• muscle strengthening 2x per wk

other risk factors: social determinants of health (SODH) and psychological

Orthostatic BP measurements

supine for 3 min (baseline reading of BP and HR) → repeat BP and HR sitting → repeat standing → repeat after standing 3 min

normal: dec of <10 SBP, slight inc DBP and HR

positive: dec >20 SBP, dec >10 DBP and/or inc HR >20

Gerontologic considerations for HTN

age related physical changes:

• loss of elasticity in large arteries from atherosclerosis

• inc collagen content and stiffness of myocardium

• inc PVR

• dec adrenergic receptor sensitivity

• blunting of baroreceptor reflexes

• dec renal function

• dec renin response to NA and H@O depletion

Medications:

• dec absorption d/t dec blood flow to gut

• prolonged excretion/metabolism

• inc risk for orthostatic HTN (baroreceptor reflex)

• BP drops most likely (1 hr) after meals

Resistant HTN

“failure to reach goal BP with rull doses of 3-drug therapy including diuretic”

Pseudoresistant

• improper BP measurement (BP cuff size)

• inadequate drug doses

• inappropriate drug therapy

• poor adherence

• white coat syndrome

Volume Overload

• drug induced, corticosteroids, NSAIDs, oral contraceptives

• cyclosporine and tacrolimus (prograf)

• erthropoietin, excess salt intake

• sympathomimetics (decongestants, diet pills)

• herbal supplements (ma huang, bitter orange), illegal drugs, licorice

• inadequate diuretic therapy

• volume retention from kidney disease

Associated conditions

• excess ETOH

• increasing obesity

• OSA

Hypertensive Crisis

systolic >180 and/or DIastolic >120

hypertensive emergency

• need to rule other things out first

• includes evidence of target organ damage

• likely require hospitalization (w/out treatment further bad side effects could happen)

hypertensive urgency: may not require hospitalization, more common, no end organ damage, more controllable/treatable, can be associated w/ chronic stable complications (angina, HF, etc)

S/S Hypertensive Crisis

Hypertensive encephalopathy (result of inc cerebral capillary permeability)

• severe HA, N/V, seizures, confusion, and coma

chest pain

confusion

dyspnea

renal symptoms

vision changes

aortic dissection (severe abd/chest pain)

cardiac decomposition

absent pulses eventually after bleeding into abd cavity

Treatment for Hypertensive Crisis

medication and BP goal determined by specific HTN emergency (cause)

BP decrease gradually over 24 hrs (rapid dec = stroke, MI, etc)

• MAP reduced app. 10-20% in 1st hr (target <180/<120)

• MAP reduced app 5-15% of next 23 hrs (target <160/<110)

Major exceptions:

• acute phase of ischemic stroke

• acute aortic dissection

• intracerebral hemorrhage

after 8-24 hrs of BP control, oral meds, and IV therapy titrated and d/c’d