Hypertension - BMH/Tele

Clinical Educator for TelemetryNatalie Bermudez, RN, BSN, MS

HypertensiHypertensionon

Telemetry Telemetry CourseCourse

Course ObjectivesCourse Objectives Discuss the incidence & prevalence of hypertension in the USDiscuss the incidence & prevalence of hypertension in the US Review blood pressure regulation: baroreceptors, endotehlium, Review blood pressure regulation: baroreceptors, endotehlium,

R-A-A-SR-A-A-S Discuss the stages of hypertension and primary versus Discuss the stages of hypertension and primary versus

secondarysecondary Understand the difference between hypertension and Understand the difference between hypertension and

hypertensive criseshypertensive crises Review pathophysiology, etiologies, risk factors (controllable Review pathophysiology, etiologies, risk factors (controllable

vs. uncontrollable), epidemiological data, signs and symptoms, vs. uncontrollable), epidemiological data, signs and symptoms, and risks of uncontrolled hypertensionand risks of uncontrolled hypertension

Discuss diagnostic evaluation of hypertensionDiscuss diagnostic evaluation of hypertension Discuss treatment regimen for patients with hypertension with Discuss treatment regimen for patients with hypertension with

and without contributing factorsand without contributing factors

Blood Pressure Blood Pressure RegulationRegulation

Systemic arterial pressure is a function of stroke Systemic arterial pressure is a function of stroke volume, heart rate, and total peripheral volume, heart rate, and total peripheral

resistanceresistance

The major organs involved in regulation of The major organs involved in regulation of blood pressure are the heart (HR & SV), the blood pressure are the heart (HR & SV), the SNS (TPR), and the kidneys (ECF volume & SNS (TPR), and the kidneys (ECF volume &

secretion of renin).secretion of renin).

(Wynne, Woo, & Olyaei, 2007, p. 1093)(Wynne, Woo, & Olyaei, 2007, p. 1093)

BP Regulation: BP Regulation: BaroreceptorsBaroreceptors

A change in blood pressure is sensed by A change in blood pressure is sensed by baroreceptors located in the carotid arteries baroreceptors located in the carotid arteries

and the arch of the aortaand the arch of the aorta

They are sensitive to stretch and they inhibitory They are sensitive to stretch and they inhibitory impulses to the sympathetic vasomotor center impulses to the sympathetic vasomotor center

in the brainstem with increased B/Pin the brainstem with increased B/P


BP Regulation: BP Regulation: BaroreceptorsBaroreceptors

Long-standing hypertension, the baroreceptors Long-standing hypertension, the baroreceptors adapt to the elevated B/P levels and “rests” adapt to the elevated B/P levels and “rests”

what the body accepts as “normal” B/P. what the body accepts as “normal” B/P.

Diminished responsiveness to these Diminished responsiveness to these baroreceptors is one of the most significant baroreceptors is one of the most significant cardiovascular effects of aging and a major cardiovascular effects of aging and a major factor in the lifetime risk of hypertension factor in the lifetime risk of hypertension


BP Regulation: BP Regulation: EndotheliumEndothelium

Nitric oxide is secreted by endothelial cells Nitric oxide is secreted by endothelial cells which results in relaxation of blood vesselswhich results in relaxation of blood vessels

It also produces local vasodilators, such as It also produces local vasodilators, such as prostacylcin and endothelium-derived prostacylcin and endothelium-derived

hyperpolarizing factorhyperpolarizing factor

Endothelin is an extremely potent Endothelin is an extremely potent vasoconstrictor and also stimulates vascular vasoconstrictor and also stimulates vascular

smooth muscle growthsmooth muscle growth


BP Regulation: BP Regulation: KidneysKidneys

RAAS = Renin-Angiotensin-Aldosterone SystemRAAS = Renin-Angiotensin-Aldosterone SystemRenin is relased by the juxtaglomerular appartus Renin is relased by the juxtaglomerular appartus

of the kidney – renin converts AT1 to AT2 – of the kidney – renin converts AT1 to AT2 – resulting in vasoconstrictionresulting in vasoconstriction

AT2 triggers the adrenal gland to release AT2 triggers the adrenal gland to release aldosterone which causes retention of water aldosterone which causes retention of water

and sodiumand sodium

(Wynne, Woo, & Olyaei, 2007)(Wynne, Woo, & Olyaei, 2007)

Angiotensin IIAngiotensin II

““Recent evidence suggests that Recent evidence suggests that angiotensin II also stimulates growth angiotensin II also stimulates growth of vascular smooth muscle and may of vascular smooth muscle and may

contribute to atherosclerosis and contribute to atherosclerosis and hypertension” hypertension”


BP Regulation: BP Regulation: GeneticsGenetics

B/P levels are strongly familial!B/P levels are strongly familial!

However, exact mechanisms are unknownHowever, exact mechanisms are unknown

Genetic polymorphisms have been discovered Genetic polymorphisms have been discovered that may harbor genes contributing to primary that may harbor genes contributing to primary

hypertension hypertension


What Is Hypertension?What Is Hypertension?

Hypertension as a diagnosis is considered when Hypertension as a diagnosis is considered when the average of TWO or more consecutive the average of TWO or more consecutive

clinical visits documents a DBP of 90 mmHg clinical visits documents a DBP of 90 mmHg or greater or a SBP of 140 mmHg or greater.or greater or a SBP of 140 mmHg or greater.

Elevated SBP is the main contributor of target Elevated SBP is the main contributor of target organ damage.organ damage.

(McCance et al, 2006, p. 1086)(McCance et al, 2006, p. 1086)

Stages of Stages of Hypertension Hypertension

77thth Report of the Joint National Commission of Report of the Joint National Commission of Prevention, Detection, Evaluation, and Treatment of Prevention, Detection, Evaluation, and Treatment of

High Blood Pressure (JNC-VII)High Blood Pressure (JNC-VII)

Stages of Hypertension:Stages of Hypertension:

Normal SBP < 120 mmHg or DBP < 80 mmHg

Pre-Hypertension SBP 121 – 139 mmHg or DBP 81 – 89 mmHg

Stage 1 SBP 140 – 159 mmHg or DBP 90 – 99 mmHg

Stage 2 SBP > 160 mmHg or DBP > 100 mmHg

Hypertensive Hypertensive CrisesCrises

2 Types:2 Types:

Hypertensive EmergencyHypertensive Emergency

and and

Hypertension UrgencyHypertension Urgency

Hypertensive Hypertensive EmergencyEmergency

It is extremely elevated B/P and must be lowered It is extremely elevated B/P and must be lowered immediately in order to prevent target organ immediately in order to prevent target organ

damagedamage

SBP SBP >> 180 or DBP 180 or DBP >> 110 110

Assessment will reveal actual or developing Assessment will reveal actual or developing clinical dysfunction of the target organclinical dysfunction of the target organ

(Smeltzer et al, 2008, p. 1033)(Smeltzer et al, 2008, p. 1033)

Hypertensive Hypertensive EmergencyEmergency

Treatment:Treatment:

Gradually decrease blood pressure usually with fast-acting intravenous medications

Reduction Goals:

Reduction of B/P by up to 25% within the 1st hour

160/100 within 6 hours

Then gradual reduction over a period of days

Hypertensive Hypertensive UrgencyUrgency

Extremely elevated B/P but without evidence of Extremely elevated B/P but without evidence of impending or progressive target organ damageimpending or progressive target organ damage

SBP SBP >> 180 and/or DBP 180 and/or DBP >> 110 110

S/S: Severe HA’s, nosebleeds, anxietyS/S: Severe HA’s, nosebleeds, anxiety


Hypertensive Hypertensive UrgencyUrgency

Treatment:Treatment:

Gradually decrease blood pressure usually with fast-Gradually decrease blood pressure usually with fast-acting oral medicationsacting oral medications

Fast-Acting PO Agents:Fast-Acting PO Agents:

Beta-blockers: labetololBeta-blockers: labetolol

ACEI’s: captopril, enalaprilACEI’s: captopril, enalapril

AlphaAlpha22-agonists: clonidine-agonists: clonidine

PathophysiologyPathophysiology

2 Types of Hypertension2 Types of Hypertension

* Primary (Essential) Hypertension** Primary (Essential) Hypertension*Primary cause is unknownPrimary cause is unknown

*Secondary Hypertension**Secondary Hypertension*Caused by another disease processCaused by another disease process

Primary HypertensionPrimary Hypertension

Etiological TheoriesEtiological Theories

Inability of kidneys to excrete sodiumInability of kidneys to excrete sodiumOveractive renin/angiotensin systemOveractive renin/angiotensin system

Overactive sympathetic nervous systemOveractive sympathetic nervous systemDecreased vasodilatory reactionDecreased vasodilatory reaction

Resistance to insulin actionResistance to insulin actionGenetic Inheritance (polygenic)Genetic Inheritance (polygenic)

Prevalence & Prevalence & IncidenceIncidence

The estimated global prevalence of hypertension for the The estimated global prevalence of hypertension for the year 200 was 26.4% or 972 million adults worldwideyear 200 was 26.4% or 972 million adults worldwide

The national prevalence for the Unites States is similar The national prevalence for the Unites States is similar at 28.7% of adults (approximately 65 million persons.at 28.7% of adults (approximately 65 million persons.

The JNC-VII estimates that about 1 in 5 persons in the The JNC-VII estimates that about 1 in 5 persons in the United States (1 in 3 adults) has hypertension.United States (1 in 3 adults) has hypertension.

(Moser & Riegel, 2008, p. 431)(Moser & Riegel, 2008, p. 431)


The JNC-VII estimates that about 1 in 5 persons The JNC-VII estimates that about 1 in 5 persons in the United States (1 in 3 adults) has in the United States (1 in 3 adults) has

hypertension. hypertension. (Moser & Riegel, 2008, p. 431)(Moser & Riegel, 2008, p. 431)

““Approximately 73.6 million people in the Approximately 73.6 million people in the United States aged 20 years and older are United States aged 20 years and older are

affected by hypertension.” affected by hypertension.” (Smithburger et al, 2010, p. 24)(Smithburger et al, 2010, p. 24)


28% to 31% of U.S. adults have hypertension28% to 31% of U.S. adults have hypertension

Of these people…Of these people…

90% - 95% of people diagnosed with 90% - 95% of people diagnosed with hypertension have primary hypertension!hypertension have primary hypertension!


Prevalence Prevalence

Of the 28% to 31% of people Of the 28% to 31% of people diagnosed with hypertension…diagnosed with hypertension…

5% to 10% have secondary 5% to 10% have secondary hypertension!hypertension!


Secondary Secondary Hypertension Hypertension

It is caused by another disease process such as:It is caused by another disease process such as:

Renal FailureRenal FailureDiabetes MellitusDiabetes Mellitus

Cushing’s SyndromeCushing’s SyndromePrimary AldosteronismPrimary Aldosteronism

Coarctation of the AortaCoarctation of the AortaPheochromocytomaPheochromocytoma

Sleep ApneaSleep Apnea

Prevalence of Prevalence of Hypertension Hypertension

The prevalence of hypertension increases The prevalence of hypertension increases with advancing age to the point where with advancing age to the point where

more than half of people 60 – 69 years of more than half of people 60 – 69 years of age and approximately three-fourths of age and approximately three-fourths of

those 70 years of age and older are those 70 years of age and older are affected.affected.

(JNC-VII, p. 8)(JNC-VII, p. 8)

Risk Factors Risk Factors The American Heart Association has The American Heart Association has

identified several risk factors that lead to identified several risk factors that lead to the development of hypertension with the development of hypertension with

increased risk of cardiovascular disease.increased risk of cardiovascular disease.

They are separated into two categories:They are separated into two categories:Uncontrollable Risk FactorsUncontrollable Risk FactorsControllable Risk FactorsControllable Risk Factors

Controllable Risk Controllable Risk FactorsFactors

SmokingSmoking**Smoking alone does not cause hypertension****Smoking alone does not cause hypertension**

Cholesterol LevelCholesterol Level

Sedentary LifestyleSedentary Lifestyle

ObesityObesity

Diabetes MellitusDiabetes Mellitus

Uncontrollable Risk Uncontrollable Risk FactorsFactors

Increasing AgeIncreasing Age

Gender (Male)Gender (Male)

Heredity (including Race)Heredity (including Race)Highest prevalence among African AmericansHighest prevalence among African Americans

Epidemiological DataEpidemiological Data

The prevalence, impact, and control of The prevalence, impact, and control of hypertension differ across racial and ethnic hypertension differ across racial and ethnic

subgroups of the U.S. populationsubgroups of the U.S. population



““Hypertension is one of the most common Hypertension is one of the most common chronic medical conditions, and it occurs chronic medical conditions, and it occurs

almost twice as frequently in African almost twice as frequently in African Americans as in whites.” Americans as in whites.” (Smithburger et al, 2010, p,24)(Smithburger et al, 2010, p,24)

““Approximately 60% of American adults have Approximately 60% of American adults have prehypertension or hypertension, and some prehypertension or hypertension, and some

groups, such as blacks, older persons, those in groups, such as blacks, older persons, those in low socioeconomic groups, and overweight low socioeconomic groups, and overweight persons, are disproportionately affected.”persons, are disproportionately affected.”



The pathogenesis of hypertension in different The pathogenesis of hypertension in different racial subgroups may differ with respect to the racial subgroups may differ with respect to the contributions of such factors as salt, potassium, contributions of such factors as salt, potassium, stress, cardiovascular reactivity, body weight, stress, cardiovascular reactivity, body weight,

nephron number, sodium handling, or nephron number, sodium handling, or hormonal systems, but in all subgroups, the hormonal systems, but in all subgroups, the

etiology is multifactorialetiology is multifactorial


Epidemiological DataEpidemiological DataMore than 40% of African Americans have high More than 40% of African Americans have high

blood pressureblood pressure

This includes both females and males This includes both females and males

The 2004 overall death rate from hypertension The 2004 overall death rate from hypertension was 18.1. Death rates were 15.7 for white was 18.1. Death rates were 15.7 for white

males, 14.5 for white females, 51.0 for black males, 14.5 for white females, 51.0 for black males and 40.9 for black females.males and 40.9 for black females.

American Heart Association, updated 1/14/08American Heart Association, updated 1/14/08


In African Americans, hypertension is more In African Americans, hypertension is more common, more severe, develops at an earlier common, more severe, develops at an earlier age and leads to more clinical sequelae that age and leads to more clinical sequelae that

in age-matched non-Hispanic Whitesin age-matched non-Hispanic Whites

African Americans have a greater prevalence African Americans have a greater prevalence of other CV disease risk factors, especially of other CV disease risk factors, especially

obesityobesity



Mexican Americans and Native Mexican Americans and Native Americans have lower control rates Americans have lower control rates

than non-Hispanic Whites and African than non-Hispanic Whites and African AmericansAmericans



Variance in hypertension-related sequelae in Variance in hypertension-related sequelae in ethnic or racial groups may be attributable ethnic or racial groups may be attributable to differences in socioeconomic conditions; to differences in socioeconomic conditions; access to healthcare services; or attitudes, access to healthcare services; or attitudes,

beliefs, and deficits in accurate health-beliefs, and deficits in accurate health-related informationrelated information


Signs & Symptoms Signs & Symptoms

Hypertension is most often asymptomaticHypertension is most often asymptomatic

Commonly the only sign is the elevation of the blood Commonly the only sign is the elevation of the blood pressure itselfpressure itself

The following signs or symptoms may occur with The following signs or symptoms may occur with severe hypertension:severe hypertension:

Headaches Headaches

Blurred Vision Blurred Vision

Target Organ DamageTarget Organ Damage

Also Known As… Also Known As…

Because hypertension is commonly asymptomatic, it Because hypertension is commonly asymptomatic, it often goes undiagnosed until its advanced stages. often goes undiagnosed until its advanced stages.

For this reason, hypertension is known as…For this reason, hypertension is known as…

The Silent KillerThe Silent Killer

31% of people with B/P exceeding 140/90 were 31% of people with B/P exceeding 140/90 were asymptomatic and unaware of having asymptomatic and unaware of having

hypertensionhypertension (Smeltzer et al, 2008, p. 1022)(Smeltzer et al, 2008, p. 1022)

StatisticsStatisticsOf All of the People With Of All of the People With

High Blood Pressure:High Blood Pressure:

71.8% are aware of their condition71.8% are aware of their condition61.4% are under current treatment61.4% are under current treatment

35.1% have it under control35.1% have it under control65.9% do not have it under control65.9% do not have it under control


Risks of Uncontrolled Risks of Uncontrolled Chronic Hypertension Chronic Hypertension

The major risks of uncontrolled The major risks of uncontrolled hypertension are damage to target hypertension are damage to target organs and ultimately death due to organs and ultimately death due to

secondary processessecondary processes

Target Organ DamageTarget Organ DamageCaused by damage to the body’s blood vessels which Caused by damage to the body’s blood vessels which

particularly affect the following organs:particularly affect the following organs:

Blood Vessels Blood Vessels HeartHeart

KidneysKidneysBrainBrainEyesEyes

Target Organ: Blood Target Organ: Blood Vessel DamageVessel Damage

Hypertension causes damage to the smooth muscles Hypertension causes damage to the smooth muscles of the vessel lining resulting in weakening and of the vessel lining resulting in weakening and

vasoconstriction leading to decreased blood flow vasoconstriction leading to decreased blood flow to the periphery and target organs…to the periphery and target organs…

Peripheral Artery DiseasePeripheral Artery Disease

Target Organ DamageTarget Organ Damage

Target Organ: Kidney Target Organ: Kidney DamageDamage

Hypertension causes damage to the vessels Hypertension causes damage to the vessels that supply the kidneys which leads to:that supply the kidneys which leads to:

Acute and/or Chronic Renal FailureAcute and/or Chronic Renal FailureManifested by increased BUN/creatinine levels and nocturiaManifested by increased BUN/creatinine levels and nocturia

Target Organ: ESRDTarget Organ: ESRD

““Hypertension is Hypertension is second only to second only to diabetes as the diabetes as the most common most common

cause of ESRD”cause of ESRD”

(Wynne, Woo, & Olyaei, 2007, p. 1093).(Wynne, Woo, & Olyaei, 2007, p. 1093).

Hypertension & Renal Hypertension & Renal DiseaseDisease

Approximately 90% of Approximately 90% of persons with end-stage persons with end-stage renal disease have a renal disease have a history of hypertensionhistory of hypertension

Stage 4 hypertension Stage 4 hypertension imparts a 22 times imparts a 22 times greater risk of greater risk of developing ESRDdeveloping ESRD


Target Organ: Heart Target Organ: Heart DamageDamage

Hypertension causes damage to vessels that Hypertension causes damage to vessels that supply the heart which leads to:supply the heart which leads to:

Left Ventricular Hypertrophy & Heart FailureLeft Ventricular Hypertrophy & Heart FailureDue to increased workload of the heartDue to increased workload of the heart

Coronary Artery Disease & Angina or MICoronary Artery Disease & Angina or MIDue to decreased blood flow to the coronary vesselsDue to decreased blood flow to the coronary vessels


LVH lowers the threshold for MI by the following LVH lowers the threshold for MI by the following mecahnisms:mecahnisms:

Increasing demand for blood flow to the larger Increasing demand for blood flow to the larger muscle massmuscle mass

Reducing the ability of the coronary circulation to Reducing the ability of the coronary circulation to vasodilatevasodilate

Shifting the lower range of coronary flow Shifting the lower range of coronary flow autoregulation upwardautoregulation upward



Hypertension more than doubles the risk of Hypertension more than doubles the risk of symptomatic coronary artery disease, including AMI symptomatic coronary artery disease, including AMI and sudden death, and more than triples the risk of and sudden death, and more than triples the risk of HFHF

Hypertension is the leading cause of HFHypertension is the leading cause of HF

Persistent increased afterload imposed by HTN leads Persistent increased afterload imposed by HTN leads to LVH in order to compensateto LVH in order to compensate



Hypertension reduces the supply and increases the Hypertension reduces the supply and increases the demand and therefore greatly increases the incidence demand and therefore greatly increases the incidence of MI.of MI.

Contributing factors include the following:Contributing factors include the following: Atherosclerotic narrowing of the coronary arteriesAtherosclerotic narrowing of the coronary arteries High resistance of coronary microvasculatureHigh resistance of coronary microvasculature Impaired endothelium dependent vasodilationImpaired endothelium dependent vasodilation Limited coronary reserveLimited coronary reserve


Target Organ: Brain Target Organ: Brain DamageDamage

Hypertension causes damage to vessels that Hypertension causes damage to vessels that supply the brain which leads to:supply the brain which leads to:

HeadachesHeadachesIncreased ICPIncreased ICP

Transient Ischemic AttackTransient Ischemic Attack

Cerebral Vascular AccidentCerebral Vascular AccidentIschemic or HemorrhagicIschemic or Hemorrhagic

DementiaDementia

Target Organ: Brain Target Organ: Brain DamageDamage

Hypertension is the premier risk factor for Hypertension is the premier risk factor for stroke (cerebral infarction and hemorrhagic).stroke (cerebral infarction and hemorrhagic).

The risk of stroke increases in proportion to The risk of stroke increases in proportion to increases in BP”increases in BP”

Smoking significantly increases this risk in Smoking significantly increases this risk in hypertensive patientshypertensive patients

In the elderly, the risk of stroke is related more In the elderly, the risk of stroke is related more clearly to SBP than to DBPclearly to SBP than to DBP

Treatment of HTN reduces stroke incidencesTreatment of HTN reduces stroke incidences(Moser & Riegel, 2008, p. 440)(Moser & Riegel, 2008, p. 440)

Target Organ: Eye Target Organ: Eye DamageDamage

Hypertension causes damage to vessels that supply Hypertension causes damage to vessels that supply the eyes which leads to:the eyes which leads to:

RetinopathyRetinopathy

Manifested as “blurred vision”Manifested as “blurred vision”

PapilledemaPapilledema (swelling of the optic disc) (swelling of the optic disc)

Cerebral Vascular AccidentCerebral Vascular Accident

Myocardial InfarctionMyocardial Infarction

Hypertensive CardiomyopathyHypertensive Cardiomyopathy

Congestive Heart FailureCongestive Heart Failure

Chronic Renal FailureChronic Renal Failure

Hypertensive RetinopathyHypertensive Retinopathy

Hypertensive NeuropathyHypertensive Neuropathy

Coronary Artery DiseaseCoronary Artery Disease

Complications of Uncontrolled Complications of Uncontrolled HypertensionHypertension

Hypertension & Hypertension & MortalityMortality

From 1994 to 2004 the death rate from hypertension From 1994 to 2004 the death rate from hypertension increased 26.6%, and the actual number of deaths increased 26.6%, and the actual number of deaths

rose 56.1%.rose 56.1%.

54,707 Americans had hypertension listed as a primary 54,707 Americans had hypertension listed as a primary cause of death in 2004cause of death in 2004

Of the 2.4 million U.S. deaths, 300,000 had Of the 2.4 million U.S. deaths, 300,000 had hypertension as a contributing factorhypertension as a contributing factor


Diagnostic Studies Diagnostic Studies

Thorough Health History and PhysicalThorough Health History and Physical

Retinal ExaminationRetinal ExaminationTo assess possible target organ damage of retinal structuresTo assess possible target organ damage of retinal structures

Routine LabsRoutine LabsUrinalysis, blood chemistry including a cholesterol panelUrinalysis, blood chemistry including a cholesterol panel

12-Lead EKG12-Lead EKG

EchocardiogramEchocardiogramDetermines Presence of Left Ventricular Hypertrophy and/or Heart FailureDetermines Presence of Left Ventricular Hypertrophy and/or Heart Failure

Additional Diagnostic Additional Diagnostic StudiesStudies

Serum BUN/creatinine LevelSerum BUN/creatinine Level

Creatinine ClearanceCreatinine Clearance

24-Hour Urine Protein24-Hour Urine ProteinTo determine target organ kidney damageTo determine target organ kidney damage

Renin LevelRenin LevelHigh levels of renin activate the angiotensin-renin system leading to increased High levels of renin activate the angiotensin-renin system leading to increased

vasoconstrictionvasoconstriction

Treatment of Treatment of Hypertension Hypertension

Diet Modification (DASH Diet)Diet Modification (DASH Diet)Exercise RegimenExercise Regimen

Weight LossWeight LossControl of Secondary CausesControl of Secondary Causes

Antihypertensive Medication RegimenAntihypertensive Medication RegimenRoutine Measurement of B/P and Follow-Routine Measurement of B/P and Follow-

up Appointmentsup Appointments

Diet Modification, Diet Modification, Exercise, Exercise,

& Weight Loss& Weight LossResearch findings demonstrate that weight loss, reduced Research findings demonstrate that weight loss, reduced

alcohol and sodium intake, and regular physical activity alcohol and sodium intake, and regular physical activity are effective lifestyle adaptations to reduce blood are effective lifestyle adaptations to reduce blood

pressurepressure

Studies also show that diets high in fruits, vegetables, and Studies also show that diets high in fruits, vegetables, and low-fat dairy products can prevent the development of low-fat dairy products can prevent the development of

hypertension and can lower elevated blood pressurehypertension and can lower elevated blood pressure


DASH DietDASH Diet

Dietary Approaches to Stop HypertensionDietary Approaches to Stop HypertensionRecommends four servings of fresh fruits and fresh

vegetables per day (Herman, 2010, p. 45)(Herman, 2010, p. 45)

Exercise Regimen Exercise Regimen

An exercise regimen of at least 30 minutes An exercise regimen of at least 30 minutes of a cardiovascular workout 3 – 5 times a of a cardiovascular workout 3 – 5 times a week is recommended as a compliment to week is recommended as a compliment to diet modification and medication regimendiet modification and medication regimen

Medication RegimenMedication Regimen

DiureticsDiureticsAldosterone Receptor BlockersAldosterone Receptor Blockers

Beta-Adrenergic BlockersBeta-Adrenergic BlockersACE InhibitorsACE Inhibitors

Angiotensin II Receptor BlockersAngiotensin II Receptor BlockersCalcium Channel BlockersCalcium Channel Blockers

Alpha-1 BlockersAlpha-1 BlockersVasodilatorsVasodilators

Combination DrugsCombination Drugs

Stage 1 HypertensionStage 1 HypertensionWithout Any other Without Any other

ComplicationsComplicationsSBP 140 – 159 mmHg or DBP 90 – 99 mmHgSBP 140 – 159 mmHg or DBP 90 – 99 mmHg

Common Medication Regimen:Common Medication Regimen:Thiazide DiureticsThiazide Diuretics

Considered Drug Therapy:Considered Drug Therapy:ACEI, ARB, BB, CCB, or combinationACEI, ARB, BB, CCB, or combination


Stage 2 HypertensionStage 2 HypertensionWithout Any other Without Any other

ComplicationsComplicationsSBP SBP >> 160 mmHg or DBP 160 mmHg or DBP >> 100 mmHg 100 mmHg

2-Drug Combination:2-Drug Combination:

Thiazide Diuretic with ACEI, or ARB, or Thiazide Diuretic with ACEI, or ARB, or BB, or CCBBB, or CCB


HypertensionHypertensionWith Other With Other

ComplicationsComplicationsHEART FAILUREHEART FAILURE

Recommended Therapy Options:Recommended Therapy Options:

Thiazide Diuretics, BB, ACEI, ARB, Aldosterone Thiazide Diuretics, BB, ACEI, ARB, Aldosterone AntagonistAntagonist

(Clinical Trials and Guideline Basis for Drug Classes, JNC-VII, p. 33)(Clinical Trials and Guideline Basis for Drug Classes, JNC-VII, p. 33)

Caution: Use of BB may produce many side effects and Caution: Use of BB may produce many side effects and may exacerbate symptoms of HF.may exacerbate symptoms of HF.



ComplicationsComplications

POSTMYOCARDIAL INFARCTIONPOSTMYOCARDIAL INFARCTION

Recommended Therapy Options:Recommended Therapy Options:BB, ACEI, Aldosterone AntagonistBB, ACEI, Aldosterone Antagonist

HIGH CORONARY DISEASE RISKHIGH CORONARY DISEASE RISK

Recommended Therapy Options:Recommended Therapy Options:Thiazide Diuretic, BB, ACEI, ARB, CCBThiazide Diuretic, BB, ACEI, ARB, CCB

(Clinical Trials and Guideline Basis for Drug Classes, JNC 7, p. 33)(Clinical Trials and Guideline Basis for Drug Classes, JNC 7, p. 33)


ComplicationsComplicationsDIABETESDIABETES

Recommended Therapy Options:Recommended Therapy Options:

Clinical trials with diuretics, ACEIs, ARBs, and CCBs Clinical trials with diuretics, ACEIs, ARBs, and CCBs have a demonstrated benefit in treatment of have a demonstrated benefit in treatment of

hypertension in both type 1 and type 2 diabeticshypertension in both type 1 and type 2 diabetics



ComplicationsComplications

CHRONIC KIDNEY DISEASECHRONIC KIDNEY DISEASERecommended Therapy Options:Recommended Therapy Options:

ACEI or ARBACEI or ARB

RECURRENT STROKE PREVENTIONRECURRENT STROKE PREVENTION

Recommended Therapy Options:Recommended Therapy Options:Thiazide Diuretics or ACEIThiazide Diuretics or ACEI

(Clinical Trials and Guideline Basis for Drug Classes, JNC-VII, p. 33)(Clinical Trials and Guideline Basis for Drug Classes, JNC-VII, p. 33)

Treatment of Treatment of Hypertension in Ethnic Hypertension in Ethnic

or Racial Groupsor Racial GroupsWeight reduction and sodium retention are Weight reduction and sodium retention are

recommended for all prehypertensive and recommended for all prehypertensive and hypertensive patients but may be hypertensive patients but may be

particularly effective in minoritiesparticularly effective in minorities

The salt content of many of minorities’ The salt content of many of minorities’ foods may be very highfoods may be very high



or Racial Groupsor Racial GroupsThe low-sodium DASH eating plan was The low-sodium DASH eating plan was associated with greater reductions in B/P associated with greater reductions in B/P

in African Americans than in other in African Americans than in other demographic subgroupsdemographic subgroups



or Racial Groupsor Racial GroupsClinical trials with more that 15,000 Blacks Clinical trials with more that 15,000 Blacks

showed that ACEIs were less effective in showed that ACEIs were less effective in lowering B/P than either thiazide-type lowering B/P than either thiazide-type

diuretics or CCBsdiuretics or CCBs

African Americans and Asians have a three- to African Americans and Asians have a three- to four-fold higher risk of angioedema and have four-fold higher risk of angioedema and have

more cough attributed to ACEIs than more cough attributed to ACEIs than CaucasiansCaucasians

(JNC 7, p. 39)(JNC 7, p. 39)


or Racial Groupsor Racial GroupsIn minority groups the use of combination In minority groups the use of combination

or multiple antihypertensive drug therapy or multiple antihypertensive drug therapy that usually includes a thiazide-type that usually includes a thiazide-type

diuretic will lower B/P and reduce the diuretic will lower B/P and reduce the burden of hypertension-related CV burden of hypertension-related CV

disease and renal diseasedisease and renal disease

(JNC 7, p. 39)(JNC 7, p. 39)

Nonadherence to Nonadherence to Treatment of Treatment of HypertensionHypertension

The JNC-VII recognizes the seriousness of poor adherence and suggests the following reasons for nonadherence:

Misunderstanding of condition or treatment Denial of illness because of lack of symptoms or

perception of drugs symbols ill health Lack of patient involvement in plan of care Unexpected adverse effects of medications Cost of medications Complexity of care (Moser & Riegel, 2008, p. (Moser & Riegel, 2008, p.

443)443)

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easy. easy. Ambler, PA: Lippincott Williams & Wilkins. Ambler, PA: Lippincott Williams & Wilkins.

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Hypertension - BMH/Tele

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