Hypertension

• Disease of the arteries

  • Consistent elevation of systemic arterial blood pressure

• Blood pressure= systolic/diastolic

  • Systolic= force/contraction 100-120mmHg

  • Diastolic= relaxation 60-80 mmHg

    • High bp → obstruction OR greater pressure when pumping

    • Common disorder that impacts 25% of the population; leads to major risk of atherosclerosis, CHF, and renal failure

• Hypertensive bp → 130/80 or greater

• 2 types of HT: Primary/Essential HT or Secondary HT

Blood Pressures

Essential/Primary Hypertension

• MOST COMMON TYPE OF HT

• Problems lie in the blood vessels

• Genetic and environmental factors; but, don’t know where the problem lies in the gene defects; usually runs in the family

• Affects 92-95% of individuals with HT

→ Risk Factors

• Increase in age → wear & tear of heart and blood vessels in age

• Family history → cultural/lifestyle

• Race/ethnicity → African Americans at highest risk for hypertension

• Sex → males at higher risk

  • All are ESSENTIAL, cannot be changed

• High sodium intake → diet, H2O follows, increase in pressure

• Inflammation

• Obesity/weight gain

• Insulin resistance

  • The 3 go hand in hand, diabetes and hypertension are usually seen together

• Dyslipidemia → high cholesterol

• Alcohol, smoking, prolonged/current stress → all cause vasoconstriction -

→ S&S

• ASYMPTOMATIC, NO SYMPTOMS

• Non-specific fatigue

• Malaise

• The body adapts

→ Diagnostics

• CBC

• Kidney panel (BUN/creatinine)

• Lipid profile

• Urinalysis

• EKG

• ECG

• With patients, you would measure a first time, have them come in again and measure again, and then make them come in a final time for 3 measurements in order to rule out hypertension; NEVER treat upon first reading

→ Treatment

• CONSERVATIVE = reducing the risks

  • Lifestyle changes

  • Low sodium diet

  • Weight reduction

  • Exercise

  • Decrease stress

  • Patient education

• Medicines

  • Diuretics → African American community responds well to this treatment

  • ACE inhibitors

  • ARB

  • Calcium channel blockers

  • Beta blockers

→ Complications

• HYPERTENSIVE CRISIS (malignant hypertension)

  • Retinopathy

  • Elevated BP

  • Nephrosclerosis

  • CHF, atherosclerosis, angina, MI

  • CVA

• RAPIDLY PROGRESSES

• 180/>120

• Life-threatening with organ damage

• Don’t respond to medications

• If they do survive, can lead to dialysis or coma

Secondary Hypertension

• Systemic disease that raises peripheral vascular resistance or cardiac output

  • UNCOMMON

• Usually caused by something else (ex: sleep apnea, renal artery stenosis, hypothyroidism)

Coronary Artery Disease (CAD)

• Caused by atherosclerosis

  • Blockage of blood flow

• Narrowing of coronary arteries leads to myocardial ischemia → MI

Atherosclerosis

• Form of arteriosclerosis

• Presence of atheroma (plaque) in the large arteries

  • Cause of atheromas = damage

    • When atheromas break, causes an embolism/thrombus which can lead to a MI

    • Fatty streak is #1 sign of atherosclerosis and CAN be reversed

• Related to diet, exercise, and stress

Risk Factors for Atherosclerosis

• Genetic abnormalities

• Family Hx

• Age

• Males (females protected by estrogen until menopause)

• Hyperlipidemia

• Obesity

• Sedentary lifestyle

• Cigarette smoking

• Diabetes

• Inflammation

Angina Pectoris

• Local, temporary deprivation of the coronary blood supply (O2) to meet myocardial needs → chest pain

  • Blockage (thrombus/embolus)

• Occurs in different patterns

Stable/Classic Angina Pectoris

• Recurrent, intermittent brief episodes of substernal chest pain

• Pressure, heaviness, squeezing, burning or choking sensation

• Triggered by physical or emotional stress

• Lasts 1-5 minutes, relieved by rest or nitroglycerin

• No cell death or necrosis

• Physical exam is often normal in findings

Angina is a warning sign of progression of disease

→ Diagnostics

• CBC

• EKG

• Stress test (treadmill/nuclear)

• ECG

• CT scan & angiography

• Cath lab

→ Treatment

• Relieve symptoms, and slow progression of disease by reducing complications (stop smoking, treat risks)

• Nitroglycerin → decreases the demand for O2, reduces systemic resistance

• Ranolazine → anti-anginal

Acute Coronary Syndromes

• Unstable angina = 1 foot into the heart attack door

  • REVERSIBLE MI

• Myocardial infarction (MI) → acute process that is sudden and extended obstruction of the myocardial blood supply which causes myocardial cell death

Unstable Angina Pectoris

• Reversible myocardial ischemia without necrosis

• Angina at rest

  • More frequent/severe and prolonged

    • Changed from usual pattern of angina

      • Longer in duration

      • Lower in threshold

  • DOES NOT RESPOND TO NITRO

    • Only relieved with time

    • Requires aggressive treatment

Myocardial Infarction (MI)

• Heart attack

• Atherosclerosis most common cause

  • Thrombus from atheroma may obstruct artery; size and location determines damage

• The irreversible death (necrosis) of heart muscle secondary to prolonged lack of O2 supply (ischemia)

  • Occurs when coronary artery is totally obstructed → necrosis

→ S&S

• Severe chest pains

  • Intense lasting for 30-60 minutes

• Radiating pain to neck, shoulder, jaw, and LEFT arm

• Levine sign → clenched fist over the heart (seen mainly in women)

• Epigastric → belly pain, not life threatening but MI can mask as belly pain

• Nausea & vomiting from pain as a sympathetic response

• Diaphoresis

• Dyspnea → SOB

• Fatigue & malaise

→ Diagnostics

• TROPONIN LEVELS

  • CK-MB isoenzymes if troponin test not an option

• CBC

• Comprehensive metabolic panel

• Lipid profile

• 12 Lead EKG

  • ST segment depression, T wave inversion or ==ST segment elevation ==

• ECG

• CT/MRI (waste of time & $$)

• Angiography

→ Treatment

• Oxygen therapy to reduce cardiac demand

• Aspirin

• Nitroglycerin → vasodilator

• Morphine → relieves pain, lowers stress, vasodilates blood vessels which increases blood flow

• ACE inhibitors

• Beta blockers

• Calcium channel blockers

• Thrombolytic agents

• Tissue plasminogen activator (once cleared for use)

• Statins

• Angioplasty & stents (only when troponin levels are not lowering)

• Coronary artery bypass surgery

• External counter pulsation (ECP)

→ Complications

• Sudden death

• Cardiogenic shock

• CHF

• Rupture of necrotic heart tissues/cardiac tamponade (increases mortality or CVA risk)

• Thromboembolism causing a CVA w/LVMI

Prinzmetal Angina

• Vasospasms

• Angina occurs at rest during sleep, and occurs in clusters

• Does not develop during treadmill tests

• No evidence of cardiac diseases or atherosclerotic heart disease

• Occurs in younger people

• More often seen in females than males

→ Pathophysiology

• Reduced nitric oxide availability

• Imbalance of sympathetic and parasympathetic systems

• Increased alpha-adrenergic receptors activity

→ Treatment

• Nitroglycerin (acute attacks)

• Calcium channel blockers (maintenance)

Heart Failure

• Inability of the heart to pump enough blood to meet the body’s needs → inadequate perfusion of tissues

  • Less filling of the heart (diastole)

  • Insufficient stroke volume (systole)

• Can be left or right sided heart failure

Functional

• Systolic dysfunction: inability to generate adequate cardiac output to perfuse tissues; EF <40%

• Diastolic dysfunction: decreased compliance of left ventricle, abnormal relaxation

• High output (other diseases cause heart to fail)

• Both pumps fail = biventricular failure

→ LEFT SIDED HF

Left sided HF = Lungs

• CONGESTIVE HEART FAILURE (CHF)

• Most common type of HF

• Low cardiac output

• Dyspnea (pulmonary congestion/edema)

• “Left HF is a disease with symptoms”

→ S&S

• Restlessness

• Confusion

• Orthopnea

• Tachycardia

• Exertional dyspnea

• Fatigue

• Cyanosis

• Tachypnea

• Blood-tinged sputum

• Cough/crackles/wheezes

• Paroxysmal nocturnal dyspnea

→ RIGHT SIDED HF

Right sided HF = Rest of the body

• Most common cause is LEFT SIDED HF

• Inability of the right ventricle to provide adequate blood flow at a normal venous pressure

• “Right HF is a disease with signs”

→ S&S

• Pedal edema

• Fatigue

• “Pitting” edemas

• Ascites

• Enlarged liver & spleen

• Increased venous pressure

• May be secondary to chronic pulmonary problems

• Distended jugular

• Weight gain

• Anorexia/complaints of GI distress

• Dependent edema

→ High-Output HF

• Normal heart function, something caused an increased demand, the heart can’t keep up

• Inability of the heart to supply the body with nutrients, despite adequate blood volume and normal/elevated myocardial contractility

• Causes include: severe anemia, hyperthyroidism, septicemia, and beriberi (B12 deficiency)

Shock

• Cardiovascular system fails to perfuse tissues adequately

• Manifestations often include feeling weak, cold, hot, nauseated, dizzy, confused, afraid, thirsty, SOB, hypotension, tachycardia, increased respiratory rate

Hypovolemic = acute trauma

• Loss of blood or plasma

  • Blood vessels ⬇️

  • Blood pressure ⬇️

  • Heart workload ⬆️

• Caused by hemorrhage, burns, dehydration, peritonitis, pancreatitis

Cardiogenic = heart at fault

• Decreased pumping capability of the heart

• Caused by MI of left ventricle, cardiac arrhythmia, pulmonary embolus

Vasogenic = nervous system at fault

• Vasodilation owing to loss of sympathetic and vasomotor tone

• Caused by pain and fear, spinal cord injury, hypoglycemia (insulin shock)

Anaphylatic = immune response

• Systemic vasodilation and increased permeability owing to severe allergic reaction

• Caused by insect stings, drugs, nuts, and shellfish

Septic/Endotoxic = immune but by gram-negative organisms

• Vasodilation owing to severe infection, often gram negative bacteria

• Caused by virulent microorganisms or multiple infections