HTN Objectives

Describe the physiology (normal functions) associated with blood pressure regulation

• Renin-angiotensin-aldosterone system (RAAS)

  1. Kidneys release renin in response to low BP or decreased Na levels

  2. Renin acts on angiotensinogen (protein produced in liver/ precursor to angiotensin I/substrate for the enzyme renin) to form angiotensin I which is then converted to angiotensin II (hormone that raises BP through vasoconstriction, increasing thirst, and stimulating the release of aldosterone (a hormone that regulates BP and salt balance in the body by increasing sodium and water reabsorption in the kidneys, while increasing potassium excretion)

Etiology of HTN

• Essential hypertension is high BP without an identifiable cause resulting from a complex interplay of genetic and environmental factors.

Define essential/primary hypertension

• Essential/primary hypertension is high BP without an identifiable cause resulting from a complex interplay of genetic and environmental factors.

Identify comorbid disease states that can cause hypertension

• Chronic Kidney Disease (CKD)

• Thyroid disease

• Sleep apnea

• Obesity

• Diabetes

• Heart Failure/Heart Disease

Identify the common clinical presentation of hypertension (1c)

• No symptoms at all; “silent killer”

• Hypertensive crisis (when BP spikes to dangerous level (180/120 mm or higher) – symptoms include severe headache, nosebleeds, blurred vision, chest pain

Describe how hypertension is diagnosed (1)

• Blood pressure measurements – average of 2 or more readings on 2 or more different occasions

• Additional tests may be required: blood tests, urine test, ECG

Classify blood pressure values as normal, elevated, stage 1, or stage 2 (1a, 1e)

• Hypotension:  <90 and <60

• Normal:  <120 and <80

• Elevated:  120-129 and <80

• Stage 1:  130-139 or 80-89

• Stage 2:  ³ 140 or ³ 90

• a definite cause for the elevated BP is not known; accounts for 90-95% of cases

• Primary

hypertension that is caused by another medical condition (sleep apnea, medications, CKD

Secondary

elevated BP occurs outside of a medical environment (LVMI, smokers, drinkers, diabetics, hypertensive patients)

masked

elevated BP only occurs in a medical environment

white coat HTN

List the blood pressure goal for adult patients with hypertension (1e)

• Less than 130/80 mm Hg

Describe the long-term complications of hypertension (1f)

• CKD, heart attack, stroke, heart failure, retinopathy

Describe how weight management and diet (nonpharmacological strategies) impact the pathophysiology of hypertension (1d)

1. Weight management: obesity and HTN – excess weight is linked to SNS overactivity, insulin resistance and activation of RAAS promoting Na retention and cause vasoconstriction thereby increase blood volume and peripheral resistance

2. Dietary changes: sodium reduction – high Na leads to volume expansion by causing the kidneys to retain more water and salt. This resets the “pressure natriuresis (Na excretion)” curve than balances BP and Na excretion; consuming less salt shifts the curve back to normal allowing the kidneys to excrete more Na and water reducing blood volume and BP.

   1. DASH diet: rich in potassium (promotes Na excretion), magnesium, and calcium

• Describe how physical activity, alcohol/tobacco, and stress (nonpharmacological strategies) impact the pathophysiology of hypertension (1d)

1. Physical Activity: strengthens the heart (pumps more blood with less effort), improves vascular function, normalizes the nervous system (reduces SNS activity contributing to lower BP)

2. Alcohol and tobacco cessation: both stimulate the SNS leading to release of epinephrine/norepinephrine leading to vasoconstriction and increase in HR and BP

3. Stress reduction – chronic stress activates the SNS leading to continuous release of stress hormones like cortisol and adrenaline – these hormones increase HR and promote vasoconstriction

What are certain antihypertensives drugs considered first line?

• First line drugs have been shown to reduce morbidity (suffering from a disease) and mortality (death); they reduce CV events

What therapy for someone with greater than or equal to 130/80 mmHg with CVD, CKD, or DM?

initiate therapy

What therapy for some greater than or equal to 140/90 mm Hg?

initiate therapy

What therapy for someone at no or low risk?

focus on lifestyle changes for 3-6 months before considering medication, unless patient is elderly

Efficacy monitoring for HTN?

1. monitor for BP reduction

2. prevention of morbidity/mortality

What three classes of HTN mediations cause bradycardia?

1) beta blockers

2) non-DHP CCB

3) centrally acting alpha 2 agonist

a widely used method to estimate the glomerular filtration rate (GFR) which is a key measure of overall kidney function.

creatinine clearance

What eGFR indicates kidney issues?

> 30%

Identify hypotension based on blood pressure thresholds?

less than 90/60 mm Hg

symptoms of hypotension?

• Dizziness/lightheadedness, weakness/fatigue, blurred vision, headache, N/V, confusion

Define the term person-centered communication. (85)

1. Prioritizes the individual’s dignity, experiences, and preferences often using person-first language and active listening to foster trust and shared understanding.

   1. Empathic responses

   2. Tailored communication

   3. Empowering the person to have control over their situation

Explain the importance of person-centered communication. (85)

1. Improved outcomes, increased trust, enhanced dignity, effective information sharing

Describe the Righting Reflex

1. Righting reflex is a natural human tendency to want to fix or solve problems for others.

2. Righting reflex undermines the patient’s sense of autonomy and ownership, make the patient feel judged, prevents patient from developing own goals