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HYPERTENSIONDr Rajesh T Eapen
ATLAS Hospital
Muscat
History of
Hypertension
History of
Hypertension
• Historical records as far back as 2600 B.C. hold mention
of “hard pulse disease”
• First treatme...
Lithograph showing the
leeching of a patient, date
unknown.
National Library of Medicine,
Bethesda, Maryland
Measurement of HTN
• No way to measure prior to 1700s
• Physicians could estimate by feeling pulse
Measurement
of HTN
• 1733 – Reverend Stephen Hales measured the intra-
arterial BP of a horse
• 1905 – N.C. Korotkoff reported on the method of
auscultation of brachial artery, the method which is widely
used today
•...
Factors Influencing
Blood Pressure
Blood Pressure = Cardiac Output x
Systemic Vascular
Resistance
Factors Influencing BP
• HR
• SNS/PNS
• Vasoconstriction/vasodilation
• Fluid volume
– Renin-angiotensin
– Aldosterone
– A...
Hypertension
Definition
• Hypertension is sustained elevation of BP
– Systolic blood pressure  140 mm Hg
– Diastolic bloo...
Classification
(JNC7)
Systolic pressure Diastolic pressure
mmHg mmHg
Normal 90–119 60–79
High normal or
prehypertension
12...
Accurate BP measurement
• Who checks your patients BP?
– You or Staff
• IF Staff – Do they know what to listen for or do t...
Hypertension
• For persons over age 50, SBP is more
important than DBP as a CVD risk factor
• Starting at 115/75 mmHg, CVD...
Classification of Hypertension
• Primary (Essential) Hypertension
- Elevated BP with unknown cause
- 90% to 95% of all cas...
Classification of Hypertension
• Primary Hypertension
- Contributing factors:
•  SNS activity
• Diabetes mellitus
•  Sod...
Classification of Hypertension
• Secondary Hypertension
- Contributing factors:
• Coarctation of aorta
• Renal disease
• E...
Risk Factors for Primary
Hypertension
• Age (> 55 for men; > 65 for women)
• Alcohol
• Cigarette smoking
• Diabetes mellit...
Risk Factors for Primary
Hypertension
• Family history
• Obesity (BMI > 30)
• Ethnicity (African Americans)
• Sedentary li...
Hypertension
Clinical Manifestations
• Frequently asymptomatic until severe
and target organ disease has occurred
– Fatigu...
How to Prevent HTN
Lifestyle modifications prevent
HTN and include:
 Maintaining a Healthy Weight
 Reduce Salt/Sodium In...
Hypertension: Complications
• Complications are
primarily related to
development of
atherosclerosis
(“hardening of
arterie...
Hypertension
Complications
The common complications are
target organ diseases occurring in the
Heart
Brain
Kidney
Eyes
Hypertension
Complications
Hypertensive Heart Disease
• Coronary artery disease
• Left ventricular hypertrophy
• Heart fa...
Hypertension
Complications
 Cerebrovascular Disease
• Stroke
 Peripheral Vascular Disease
 Nephrosclerosis
 Retinal Da...
Left Ventricular Hypertrophy
TO SUMMARISE
Hypertension
Diagnosis
• Diagnosis requires several elevated
readings over several weeks (unless >
180/110)
• BP measureme...
Hypertension
Diagnosis
• Ambulatory BP Monitoring
– For “white coat” phenomenon, hypotensive or
hypertensive episodes, app...
Treatment Goals
• Goal is to reduce overall cardiovascular
risk factors and control BP by the least
intrusive means possib...
Benefits of Lowering BP
Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%
Table 3. Lifestyle Modifications to Manage Hypertension*
Algorithm for Treatment of Hypertension
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or...
Hypertension
Collaborative Care
• Lifestyle Modifications
- Weight reduction
- Dietary changes (DASH diet)
- Limitation of...
Hypertension
Collaborative Care
• Nutritional Therapy: DASH Diet =
Dietary Approahes to Stop HTN
- Sodium restriction
- Ri...
Hypertension
Collaborative Care
• Drug Therapy
- Reduce SVR
- Decrease volume of
circulating blood
Hypertension
Collaborative Care
• Drug Therapy
• Diuretics
• Adrenergic inhibitors
• β - Adrenergic blockers
• ACE Inhibit...
Hypertension: Drug Therapy
• Thiazide-type Diuretics
– Inhibit NaCl reabsorption
– Side effects:
• Electrolyte imbalances:...
Hypertension: Drug Therapy
• Adrenergic Inhibitors
– Reduce sympathetic effects that cause HTN by:
• Reducing sympathetic ...
Hypertension: Drug Therapy
• β – adrenergic blockers (suffix “olol”)
– (metoprolol, propranolol)
– Block β – adrenergic re...
Hypertension: Drug Therapy
• ACE Inhibitors (suffix “pril)
– Enalapril, captopril
– Prevents conversion of angiotensin I t...
Hypertension: Drug Therapy
• Calcium Channel Blockers
– Block movement of calcium into cells, causing
vasodilation
– Side ...
ASH/ISH HTN Guidelines 2014
Hypertension
Collaborative Care
• Drug Therapy and Patient Teaching
- Identify, report, and minimize side effects
• Orthos...
Primary Hypertension
Nursing Management
Nursing Diagnoses
- Ineffective health maintenance
- Anxiety
- Sexual dysfunction
...
Primary Hypertension
Nursing Management
Nursing Implementation
Health Promotion
• Individual patient evaluation
• Screenin...
Hypertensive Crisis
• Severe, abrupt elevation in BP
• The rate of  in BP is more important than
the absolute value
• Mos...
Hypertensive Crisis
Clinical Manifestations
- Hypertensive encephalopathy (H/A, N & V,
seizures, confusion, coma)
- Renal ...
Hypertensive Crisis
Nursing and Collaborative
Management
Hospitalization
- IV drug therapy
- Monitor cardiac and renal fun...
This is not the end…
Controversy
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HYPERTENSION

  1. 1. HYPERTENSIONDr Rajesh T Eapen ATLAS Hospital Muscat
  2. 2. History of Hypertension
  3. 3. History of Hypertension • Historical records as far back as 2600 B.C. hold mention of “hard pulse disease” • First treatments: Leeching/phlebotomy, acupuncture • Hippocrates recommended phlebotomy • 120 AD – cupping of the spine to draw animal spirits down and out was recommended
  4. 4. Lithograph showing the leeching of a patient, date unknown. National Library of Medicine, Bethesda, Maryland
  5. 5. Measurement of HTN • No way to measure prior to 1700s • Physicians could estimate by feeling pulse
  6. 6. Measurement of HTN • 1733 – Reverend Stephen Hales measured the intra- arterial BP of a horse
  7. 7. • 1905 – N.C. Korotkoff reported on the method of auscultation of brachial artery, the method which is widely used today • Allowed auscultation of diastolic BP as well
  8. 8. Factors Influencing Blood Pressure Blood Pressure = Cardiac Output x Systemic Vascular Resistance
  9. 9. Factors Influencing BP • HR • SNS/PNS • Vasoconstriction/vasodilation • Fluid volume – Renin-angiotensin – Aldosterone – ADH
  10. 10. Hypertension Definition • Hypertension is sustained elevation of BP – Systolic blood pressure  140 mm Hg – Diastolic blood pressure  90 mm Hg
  11. 11. Classification (JNC7) Systolic pressure Diastolic pressure mmHg mmHg Normal 90–119 60–79 High normal or prehypertension 120–139 80–89 Stage 1 hypertension 140–159 90–99 Stage 2 hypertension ≥160 ≥100 Isolated systolic hypertension ≥140 <90
  12. 12. Accurate BP measurement • Who checks your patients BP? – You or Staff • IF Staff – Do they know what to listen for or do they use automated equipment – Seated quietly for 5 minutes – Appropriate size cuff – Inflate 20-30 mmHg above loss of radial pulse – Deflate at 2mmHg per second – 1st sound SBP ; Disappearance of Korotkoff sound (phase 5) is DBP – Confirm Elevated blood pressure within 2months(stage 1) – shorter for stage 2 if new onset
  13. 13. Hypertension • For persons over age 50, SBP is more important than DBP as a CVD risk factor • Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range
  14. 14. Classification of Hypertension • Primary (Essential) Hypertension - Elevated BP with unknown cause - 90% to 95% of all cases • Secondary Hypertension - Elevated BP with a specific cause - 5% to 10% in adults
  15. 15. Classification of Hypertension • Primary Hypertension - Contributing factors: •  SNS activity • Diabetes mellitus •  Sodium intake • Excessive alcohol intake
  16. 16. Classification of Hypertension • Secondary Hypertension - Contributing factors: • Coarctation of aorta • Renal disease • Endocrine disorders • Neurologic disorders - Rx: Treat underlying cause
  17. 17. Risk Factors for Primary Hypertension • Age (> 55 for men; > 65 for women) • Alcohol • Cigarette smoking • Diabetes mellitus • Elevated serum lipids • Excess dietary sodium • Gender
  18. 18. Risk Factors for Primary Hypertension • Family history • Obesity (BMI > 30) • Ethnicity (African Americans) • Sedentary lifestyle • Socioeconomic status • Stress
  19. 19. Hypertension Clinical Manifestations • Frequently asymptomatic until severe and target organ disease has occurred – Fatigue, reduced activity tolerance – Dizziness – Palpitations, angina – Dyspnea
  20. 20. How to Prevent HTN Lifestyle modifications prevent HTN and include:  Maintaining a Healthy Weight  Reduce Salt/Sodium Intake  Increase Physical Exercise  Smoking Cessation  Limit Alcohol Consumption  Limit Fat Intake  Control Diabetes  Stress Relieving Techniques
  21. 21. Hypertension: Complications • Complications are primarily related to development of atherosclerosis (“hardening of arteries”), or fatty deposits that harden with age
  22. 22. Hypertension Complications The common complications are target organ diseases occurring in the Heart Brain Kidney Eyes
  23. 23. Hypertension Complications Hypertensive Heart Disease • Coronary artery disease • Left ventricular hypertrophy • Heart failure
  24. 24. Hypertension Complications  Cerebrovascular Disease • Stroke  Peripheral Vascular Disease  Nephrosclerosis  Retinal Damage
  25. 25. Left Ventricular Hypertrophy
  26. 26. TO SUMMARISE
  27. 27. Hypertension Diagnosis • Diagnosis requires several elevated readings over several weeks (unless > 180/110) • BP measurement in both arms - Use arm with higher reading for subsequent measurements
  28. 28. Hypertension Diagnosis • Ambulatory BP Monitoring – For “white coat” phenomenon, hypotensive or hypertensive episodes, apparent drug resistance
  29. 29. Treatment Goals • Goal is to reduce overall cardiovascular risk factors and control BP by the least intrusive means possible – BP < 140/90 – In patients with diabetes or renal disease, goal is < 130/80
  30. 30. Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%
  31. 31. Table 3. Lifestyle Modifications to Manage Hypertension*
  32. 32. Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Lifestyle Modifications Stage 2 Hypertension (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.
  33. 33. Hypertension Collaborative Care • Lifestyle Modifications - Weight reduction - Dietary changes (DASH diet) - Limitation of alcohol intake (< 2 drinks/day for men; < 1/day for women) - Regular physical activity - Avoidance of tobacco use - Stress management
  34. 34. Hypertension Collaborative Care • Nutritional Therapy: DASH Diet = Dietary Approahes to Stop HTN - Sodium restriction - Rich in vegetables, fruit, and nonfat dairy products - Calorie restriction if overweight
  35. 35. Hypertension Collaborative Care • Drug Therapy - Reduce SVR - Decrease volume of circulating blood
  36. 36. Hypertension Collaborative Care • Drug Therapy • Diuretics • Adrenergic inhibitors • β - Adrenergic blockers • ACE Inhibitors • Calcium channel blockers
  37. 37. Hypertension: Drug Therapy • Thiazide-type Diuretics – Inhibit NaCl reabsorption – Side effects: • Electrolyte imbalances: ↓ Na, ↓ Cl, ↓ K** (advise K rich foods) • Fluid volume depletion (monitor for orthostatic hypotension) • Impotence, decreased libido
  38. 38. Hypertension: Drug Therapy • Adrenergic Inhibitors – Reduce sympathetic effects that cause HTN by: • Reducing sympathetic outflow • Blocking effects of sympathetic activity on vessels – Side effects • Hypotension • Varied, depending on specific drug
  39. 39. Hypertension: Drug Therapy • β – adrenergic blockers (suffix “olol”) – (metoprolol, propranolol) – Block β – adrenergic receptors • ↓ HR, ↓ inotropy, reduces sympathetic vasoconstriction) – Side effects • Bradycardia, hypotension, heart failure, impotence
  40. 40. Hypertension: Drug Therapy • ACE Inhibitors (suffix “pril) – Enalapril, captopril – Prevents conversion of angiotensin I to angiotensin II, thereby preventing the vasoconstriction associate with A II. – Side effects • Hypotension, cough
  41. 41. Hypertension: Drug Therapy • Calcium Channel Blockers – Block movement of calcium into cells, causing vasodilation – Side effects • Brdaycardia, heart block
  42. 42. ASH/ISH HTN Guidelines 2014
  43. 43. Hypertension Collaborative Care • Drug Therapy and Patient Teaching - Identify, report, and minimize side effects • Orthostatic hypotension • Sexual dysfunction • Dry mouth • Frequent urination
  44. 44. Primary Hypertension Nursing Management Nursing Diagnoses - Ineffective health maintenance - Anxiety - Sexual dysfunction - Ineffective therapeutic regimen management r/t - lack of S/S of HTN, side effects of Rx, cost of Rx, etc.
  45. 45. Primary Hypertension Nursing Management Nursing Implementation Health Promotion • Individual patient evaluation • Screening programs • Cardiovascular risk factor modification
  46. 46. Hypertensive Crisis • Severe, abrupt elevation in BP • The rate of  in BP is more important than the absolute value • Most common in patients with a history of HTN who have failed to comply with medications or who have been under- medicated
  47. 47. Hypertensive Crisis Clinical Manifestations - Hypertensive encephalopathy (H/A, N & V, seizures, confusion, coma) - Renal insufficiency - Heart failure - Pulmonary edema
  48. 48. Hypertensive Crisis Nursing and Collaborative Management Hospitalization - IV drug therapy - Monitor cardiac and renal function - Neurologic checks - Determine cause - Education to avoid future crises
  49. 49. This is not the end…
  50. 50. Controversy
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