Hypertension&Coronary Artery Disease 176 Lecture Notes Week 7 Day 2

Secondary Hypertension

• Something else is causing it (e.g., renal failure, adrenal gland diseases, aortic stenosis).
• Narrowing of the aorta (aortic stenosis) increases afterload, making the heart work harder.
• Head trauma and pregnancy can also cause hypertension.

Pathophysiology of Hypertension

• Blood pressure must be high enough to perfuse the body but low enough to avoid stressing the vascular system.
• Blood pressure consists of systolic and diastolic numbers.

Systolic Pressure

• Pressure on the vessels when the heart is contracting or squeezing blood out.

Diastolic Pressure

• Pressure on the vessels when the heart is filling with blood (resting).
• Systolic should always be higher than diastolic.
• Hypertension is an elevated level of either systolic or diastolic blood pressure.

Hypertension Values

• Defined as systolic above 120 and diastolic above 80.
• Normal: 120/80.
• Prehypertension: 120-129/80-89.
• Stage 1 Hypertension: 140-159/90-99.
• Stage 2 Hypertension: >160/>100.
• Hypertensive Crisis: >180/>120 (medical emergency).

Risk Factors of Hypertension

Non-Modifiable

• Genetic predisposition (family history).

Modifiable

• Smoking, high salt intake, anxiety, high stress levels, obesity, diabetes, and other chronic illnesses.

Signs and Symptoms of Hypertension

• Often called the "silent killer" because there may not be obvious signs and symptoms.
• Main indicator: elevated blood pressure reading.
• Severe hypertension symptoms: dizziness, blurred vision, severe headache, and nausea.
• These can indicate a hypertensive crisis leading to stroke, aneurysm, or heart attack.

Hypertension Treatment

Antihypertensive Medications

• Bring blood pressure down.
• Classes: ACE inhibitors/ARBs, beta blockers, calcium channel blockers, digoxin, and diuretics (easy as ABCD).
• Missing doses can lead to rebound hypertension (unsafe spike in blood pressure).

Lifestyle Changes

• Decrease salt intake (heart-healthy diet), increase exercise, stop smoking, and manage stress levels.

Hypertensive Crisis Management

• Emergency requiring immediate intervention.
• Systolic >180 or diastolic >120 puts major stress on vessels.
• Symptoms: blurred vision, dizziness, nausea, pounding headache.
• Treatment: IV antihypertensives for quick and effective blood pressure reduction.

Nursing Considerations

Blood Pressure Measurement

• Manual blood pressure is best; machines can be inaccurate.
• Place the cuff over the brachial artery.

Hypertensive Crisis Specifics

• Severe headache, blurred vision, nausea, vomiting, confusion, diastolic pressure >130.
• Gradually bring down blood pressure to avoid causing a stroke.
• Example: reduce from 220/110 to 160/90-100 initially.
• Frequent vital signs, administer meds, and implement seizure precautions.

Malignant Hypertension

• Can occur after anesthesia; screen for family history of problems after surgery.

Standard Hypertension

• Typically has no symptoms ("silent killer").
• Possible symptoms: headache, nosebleeds, dizziness.
• Monitor BUN, creatinine, and liver enzymes to assess for organ damage over time.
• Screening is important for at-risk individuals.

Complications of Hypertension

• Eyes: blindness or hemorrhages.
• Brain: Transient Ischemic Attacks (TIAs) - mini strokes (warning sign for stroke).
• Kidneys: Renal failure.
• Heart: Aneurysms (monitor or surgically repair depending on size and stability).

Blood Pressure Targets by Age

• In 2017, it was determined that for patients 60 or older, a systolic blood pressure up to 150 is acceptable.
• Vessels and heart are stiffer with age, affecting elasticity.
• However, control blood pressure if above 150.

Treatment Strategies

• Gradually reduce peripheral vascular resistance.
• Avoid rapidly lowering blood pressure to normal levels.

NCLEX vs. Real-World Practice

• NCLEX: Lifestyle changes first, then medication.
• Real world: Often start with antihypertensive drugs and lifestyle changes simultaneously.

Antihypertensive Medications

• Reduce workload of the heart.
• Easy as ABCD: ACE inhibitors/ARBs, Beta blockers, Calcium channel blockers, Digoxin and Diuretics.

ACE Inhibitors

• Stands for Angiotensin Converting Enzyme Inhibitors.
• Inhibit the enzyme that converts angiotensin I to angiotensin II.
• Angiotensin II constricts vessels, so inhibiting its formation keeps vessels dilated.
• Also prevents secretion of aldosterone, reducing water and sodium retention.
• Medication names end in "-pril" (e.g., enalapril, lisinopril, captopril).
• Side effects: ACE (Angioedema, Cough, Elevated potassium levels).
• Angioedema and elevated potassium are dangerous.

ARBs

• Angiotensin II Receptor Blockers.
• Block angiotensin II receptors, preventing vessel constriction.
• Medication names end in "-sartan" (e.g., candesartan, losartan, olmesartan, valsartan).
• Fewer side effects than ACE inhibitors (less likely to cause cough or angioedema).

Beta Blockers

• Block beta one receptors, needed for the sympathetic nervous system.
• Sympathetic nervous system increases heart rate, blood pressure, and respiratory rate (fight or flight).
• Beta blockers relax the system, lowering heart rate and blood pressure.
• Medication names end in "-olol" (e.g., metoprolol, atenolol, propranolol, carvedilol).
• Always assess pulse and blood pressure before administering.
• Side effects (the B's): Bradycardia and heart blocks, Breathing problems (bronchospasms, avoid in asthma), Bad for heart failure patients (in acute settings), Blood sugar masking (hypoglycemia), Blood pressure lowered (hypotension).
• Hold if heart rate <60 and blood pressure is too low.

Calcium Channel Blockers

• Lower heart rate and blood pressure by blocking calcium movement.
• Calcium causes stronger heart contractions, so blocking it relaxes the heart.
• Decreases heart workload, increases oxygen supply, and relaxes vessels.
• Medication names: Very Nice Drugs (Verapamil, Nifedipine, Diltiazem).

Nursing Considerations for Antihypertensives

• Monitor for hypotension and orthostatic hypotension (drop in blood pressure with position change).
• Educate patients to change positions slowly and dangle feet before standing.
• Monitor electrolyte levels (mainly potassium and sodium).
• Assess for angioedema (swelling below the skin, especially near eyes, face, and mouth).
• Educate patients not to stop taking medication suddenly (rebound hypertension).
• Medication should be tapered off slowly under medical supervision.

Coronary Artery Disease (CAD)

• Narrowing of vessels that perfuse the heart itself.
• Heart gets blood supply during diastole.
• Atherosclerosis is the primary cause.

Pathophysiology

• Cholesterol deposits (plaques) narrow arteries, decreasing blood flow to the heart.

Risk Factors

• Age, gender (men at greater risk, women post-menopause), existing health conditions (high blood pressure, high cholesterol, diabetes, overweight), lifestyle (physical inactivity, stress, unhealthy diet, smoking), family history.

Signs and Symptoms

• Chest pain (angina), shortness of breath, fatigue, heart attack.
• Heart attack symptoms: crushing substernal chest pain, pain in shoulders or arms, shortness of breath, sweating.

Diagnosis

• Medical history, physical exam, blood work, electrocardiogram (ECG), echocardiogram, stress tests, cardiac catheterization and angiogram, cardiac CT scan.

Treatment

• Lifestyle changes (healthier foods, exercise, weight loss, stress reduction, quitting smoking).
• Medications (aspirin, cholesterol-modifying medications, beta blockers).
• Medical procedures (angioplasty, coronary artery bypass graft).

Specific Artery

• Left anterior descending (LAD) artery feeds the ventricular septum.

Angina Pectoris

• Pain in the chest.

Chronic Stable Angina

• Predictable (exertional).
• Caused by stable plaques narrowing the lumen.
• Relieved by rest or nitroglycerin.
• Nitroglycerin dosing: one tablet every five minutes times three doses.
• Check blood pressure between doses.
• Ask about erectile dysfunction drug use (vasodilators) in the last 24 hours (can cause significant drop in blood pressure).

Unstable Angina

• Acute coronary syndrome.
• Plaque rupture with clot formation.
• Unpredictable; nitro may not help.

Prismetal (Variant) Angina

• Arterial spasm.
• May mimic an MI; arteries appear clean in the cath lab.
• Treated with drugs.

Collateral Circulation

• New vessels that go around blockages (detour).
• Develops over time with slow vessel narrowing or exercise.

Cardiac Testing

• EKGs/ECGs (electrocardiograms).
• Exercise stress test.
• Holter monitoring (telemetry at home to identify arrythmias or chest pain).
• Coronary angiography (cath lab).

CAD Treatment

• Cardiac diet (low sodium, low fat, low cholesterol).
• Nitrates (nitroglycerin, isosorbide) - vasodilators.
• Beta blockers - vasodilate, slow heart rate.
• Calcium channel blockers - vasodilation.
• Cath lab procedures.

Percutaneous Coronary Intervention (PCI)

• Angioplasty (balloon).
• Stents (support vessel wall after angioplasty).

Post-Cath Care

• Access site: radial, brachial, or femoral artery.
• Watch for post-procedural bleeding.
• If groin access, patient must lie flat for six hours (can tilt slightly).
• Assess perfusion below the access site (fingers or foot).

Unstable Angina Treatment

• Medical management if high risk for surgery.
• Aggressive treatment like heart attack.

Myocardial Infarction (MI)

• Heart muscle is dying from lack of oxygen.

Pathophysiology

• Coronary arteries become blocked, leading to oxygen deprivation.
• Plaque buildup narrows vessels or ruptures, blocking arteries.

Risk Factors

• History of coronary artery disease, high cholesterol, high blood pressure, family history, stressors, smoking.

Signs and Symptoms

• Crushing chest pain (elephant sitting on chest), left arm pain, shortness of breath, sweating (diaphoresis), pallor, nausea/vomiting.
• Women may have atypical symptoms (fatigue, shoulder discomfort, heartburn).

Diagnosis

• EKG rhythm strip - STEMI vs NSTEMI.

STEMI

• ST elevation myocardial infarction.
• Total occlusion of a main coronary blood vessel. STEMI think "serious".

NSTEMI

• Non ST elevation myocardial infarction.

• Blood flow is being restricted, not stopped.

• Partial occlusion.

• ST elevation indicates total blockage.

• ST depression and T wave inversion indicate injury.

Diagnostic Tools

*EKG and Troponin level tests.

Treatment

• MONA (Morphine, Oxygen, Nitroglycerin, Aspirin).

Morphine

• Takes workload off the heart and relieves pain.

Oxygen

• Heart deprived of oxygen.

Nitroglycerin

• Vasodilator (opens vessels).

Aspirin

• Prevents platelets from sticking together.

Treatment Considerations

• Thrombolytics (clot busters)
• end in "-plase" and ACE.
• Cardiac catheterization (cath lab).
• Percutaneous coronary intervention (angioplasty).
• Coronary artery bypass graft (CABG)/ Open heart surgery.

Medications Used

• Thrombolytics, Heparin IV, Nitroglycerin, Beta Blockers, Calcium Channel Blockers.

Patient Presentation

• Classic chest pain: crushing, squeezing, band around chest.
• Left chest radiating to left arm and/or left jaw (classic male).
• Women may have shoulder or back pain.
• Sense of impending doom, diaphoretic, nauseated.

EKG

• ST elevation (STEMI) - blockage.
• ST depression (NSTEMI) - ischemia.

Troponin

• Gold standard for heart damage.
• Starts to elevate 1-3 hours after damage.

Medical treatment

• To preserve function

MONA Mnemonic

M (Morphine)

• Helps with pain, is a vasodilator, and helps with air hunger.

O (Oxygen)

• If saturation is below 90%.

N (Nitroglycerin)

• Vasodilator and to open up vessels

A (Aspirin)

• Make platelets less sticky. 325 mg

CABG

• Creates artificial collateral. Harvests the greater saphenous vein out of the patient.'s leg and puts it into the heart.