Hypertension

“Silent killer” (Hoel & Howard, 1997)

HTN

Significance
Definition
Classification
Risk factors
Manifestation
Treatment
Nursing care
Complications

M. Daniel
Problem Magnitude

Hypertension( HTN) is the most common public health problem in the world
(30% adults)
 Ethiopia 20- 30%
Worldwide prevalence estimates for HTN may be as much as 1 billion.
>7 million deaths per year may be attributable to hypertension.
“Silent killer”
Definition

Hypertension: is defined as persistently elevated, systolic and/or diastolic blood

pressure of 140/90 mmHg or more in subjects aged 18 years and above.
The definition also applies to those individuals who are already taking
antihypertensive medications even if their current blood pressure is less than
140/90mmHg
Systolic blood pressure (SBP) is the pressure exerted when the heart
contracts and diastolic blood pressure (DBP) is the pressure exerted when
the heart muscle relaxes
Cont…

Average of two or more properly measured, seated BP readings each time.

On two or more separate office visits.
Systolic BP is more important CV risk factor after age 50.
Diastolic BP is more important before age 50.
Pathophysiology
Factors Influencing BP
BP = CO x SVR

PVR
 Is the force opposing the movement of blood
 Primarily affects diastolic BP (DBP)
CO
 Stroke volume & heart rate
 Primarily affects the systolic BP (SBP)
 R/Ship of factors in the control of BP

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Accurate Blood Pressure Measurement

The BP apparatus should be regularly inspected and validated.

Blood pressure can be measured either by a conventional sphygmomanometer,
using a stethoscope, or by an automated electronic device.
Well trained and regularly retrained professional.
Patient properly prepared and positioned and seated quietly for at least 5 minutes
in a chair.
The auscultatory method should be used.
Noxious avoided (Caffeine, exercise, and smoking) should be avoided for at least
30 minutes before BP measurement.
Cuff size- appropriate
How to measure blood pressure

Effective treatment algorithms for hypertension are dependent on accurate blood

pressure measurement.
The following advice should be followed for measuring blood pressure:
Use the appropriate cuff size, noting the lines on the cuff to ensure that it is
positioned correctly on the arm. (If the arm circumference is >32 cm, use large
cuff.)
On initial evaluation it is preferable to measure blood pressure on both arms and
use the arm with the higher reading thereafter
The patient should be sitting with back supported, legs uncrossed, empty bladder,
relaxed for 5 minutes and not talking.
It is preferable to take at least two readings at each occasion of measurement and
to use the second reading.
Diagnosing Hypertension
The diagnosis of hypertension should be confirmed at an additional patient visit,
usually 1 to 4 weeks after the first measurement depending on the measured
values and other circumstances.
In general, hypertension is diagnosed if, on two visits, on different days:
 Classification

www.nhlbi.nih.gov
Prehypertension

SBP 120 -139mmHg and/or DBP 80 - 89 mmHg.

Pre-HTN is not a disease category rather a designation for individuals at high risk
of developing HTN.
Individuals who are prehypertensive are not candidates for drug therapy but
should be firmly and unambiguously advised to practice lifestyle modification
Pre-HTN with diabetes/kidney disease, drug therapy is indicated if a trial of
lifestyle modification fails to reduce their BP to 130/80 mmHg or less.
Hypertensive Crises

Hypertensive Urgencies: No progressive target-organ dysfunction(Accelerated

Hypertension)
Hypertensive Emergencies: Progressive end-organ dysfunction(Malignant
Hypertension)
Hypertensive Urgencies
Severely elevated BP in the upper range of stage II HTN.
Without progressive end-organ dysfunction.
E.g., Highly elevated BP without severe headache, shortness of
breath or chest pain.
Usually due to under-controlled HTN.
Hypertensive Emergencies

Severely elevated BP (>180/120mmHg).

With progressive target organ dysfunction.
Require emergent lowering of BP.
Examples: Severely elevated BP with:
 Hypertensive encephalopathy
 Acute left ventricular failure with pulmonary edema
 Acute MI or unstable angina pectoris
 Dissecting aortic aneurysm
 Types of HTN

 Primary HTN:  Secondary HTN:

Essential HTN. less common cause of HTN
( 5%-10%).
accounts for 90%-95% cases of HTN.
Potential cause –identifiable.
unknown etiology.
Risk Primary HTN
Age
Sex
Family history
Race
Smoking
Sedentary lifestyle
Obesity :BMI
Diet
Stress
Diabetes mellitus
 Raised Cholesterol
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Causes of Secondary HTN

Common
Intrinsic renal disease
Renovascular disease
Endocrine
Coarctation of Aorta
Pheochromocytoma
Target Organs

CVS (Heart and Blood Vessels)

The kidneys
Nervous system
The Eyes
 Renin-angiotensin-aldosterone mechanism

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Effects On CVS

Ventricular hypertrophy, dysfunction and failure.

Arrhithymias
Coronary artery disease, Acute MI
Arterial aneurysm, dissection, and rupture.
Effects on The Kidneys

Glomerular sclerosis leading to impaired kidney function and finally end stage
kidney disease.
Ischemic kidney disease especially when renal artery stenosis is the cause of
HTN.
Nervous System

Stroke, intracerebral and subaracnoid hemorrhage.

Cerebral atrophy and dementia.
The Eyes
Retinopathy, retinal hemorrhages and impaired vision.
Vitreous hemorrhage, retinal detachment
Neuropathy of the nerves leading to extraoccular muscle
paralysis and dysfunction
Clinical manifestations of hypertensions

General
 Usually asymptomatic
Slow progressive rise in BP
With severity symptoms involves systems
Headache
Fatigability
Dizziness
Palpitation
Blurring of vision
Epistaxis

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Systemic effects of HPN

Arteries/vascular effect
Worsens atheroma
Narrowed lumen
Blurring of vision
Epistaxis
Aneurysm

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 HTN

Endothelial ncreased
I
injury afterload

Atheroscler LV hypertrophy
osis

Vascular lumen Worsening of Increased myocardial

narrowing and demand and decreased diastolic
HTN coronary flow
occlusion

CHD M ischemia

Figure : Pathophysiological link between hypertension and CHD.

Systemic effects cont.
Kidneys
Arterial changes cause chronic glomerular ischemia with
subsequent glomerulosclerosis, tubular atrophy and scarring
which destroys individual nephrons one by one
Nocturia
Increased BUN & serum creatinine

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Systemic effects cont.

Heart
Left ventricular hypertrophy
Congestive cardiac failure
Ischemic heart disease
Angina pectoris

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Systemic effects cont.

Brain
Cerebral infarction; micro-infarcts (lacunae)
Cerebral hemorrhage
Dizziness
Weakness
Faintness (sudden fall)
TIA
CVA/stroke

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Systemic effects cont.

Aorta
Atheroma and aneurysms
Dissecting aneurysms
Eyes
Arterial changes, retinal exudates, hemorrhages
Progression: long course but eventually serious side effects
Papilloedema

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Systemic effects cont.

Death may be due to:

Cardiac failure
MI
Stroke
Renal failure

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Diagnostic tests
History and Physical Examination
BP measurement
Ophthalmologic examination
 Laboratory Ix
Urinalysis for blood, proteins, glucose, Urine catecholamine
Renal panel for electrolytes, urea and creatinine , BUN
Fasting Lipids and Glucose
ECG
Vascular ultrasonography
Echocardiography
Chest X-ray
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Patient evaluation

Assess lifestyle and identify other CV risk factors or concomitant disorders that
may affect prognosis and guide treatment
To identify causes of high BP- secondary HTN
To assess the presence or absence of target organ damage and CVD
Lifestyle and CV Risk factors

Cigarette smoking
Obesity
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimated GFR <60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men under age 55 or women
under age 65)
Target Organ Damage
Heart
 Left ventricular hypertrophy
 Angina or prior myocardial infarction
 Prior coronary revascularization
 Heart failure
Brain; Stroke or transient ischemic attack
Chronic kidney disease
PVD
Retinopathy
Goals of Treatment

Goal of management
To reduce overall CV risk factors and control BP to target level by
possible means. < 140/90 mm Hg; <130/80 if diabetic or renal d/s.
 The primary focus should be on attaining the SBP goal.
 To reduce CV and renal morbidity and mortality
 Rx benefits
Reductions in stroke incidence, averaging 35–40 percent
Reductions in MI, averaging 20–25 percent
Reductions in HF, averaging >50 percent.
Management of HTN

Non drug intervention (Patient Education and Lifestyle Modification

Pharmacological Treatment
Follow up
Hypertension treatment is indicated for adults diagnosed with hypertension, as
defined above (SBP ≥140 mmHg and/or DBP ≥90 mmHg).
Patients with SBP ≥180 mmHg or DBP ≥110 mmHg may be indicated for
immediate treatment based on one assessment

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Lifestyle modification
Modification Recommendation Approximate
SBP reduction
(range)
Body Wt reduction Maintain normal body wt BMI (18.5-24.9 kg/M2 5-20mmHg
Adoption of DASH Consume diet rich in fruits, veg, and low fat dairy products 8-14 mmHg
eating plan with a reduced content of saturated and total fat
Dietary Na+ Reduce daily sodium intake to less than 2.4 gm (<5-6gm 2-8mmHg
reduction NACL)
Physical activity Engage in regular aerobic physical exercise such as brisk 4-9mmHg
walking (at least 30 minutes per day for most of days of
weeks
Moderation of Limit consumption to no more than 2 drinks eg 24 Oz beer, 2-4mmHg
alcohol 10 Oz wine, ) per day men and no more than one drink
women.
Drugs Available for Treatment of Hypertension

Diuretics
ACE inhibitors/ARBs
Calcium channel blockers (CCBs)
Alpha-blockers
Central acting agents
Vasodilators

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Cont’…
Choice of antihypertensive drug for Primary Health Care in Ethiopia: Who should receive
hypertension drug treatment and when?
Indicated for adults diagnosed with hypertension, as defined above (SBP ≥140 mmHg
and/or DBP ≥90 mmHg) who couldn’t achieve target blood pressure with three months of
life style modification.
For grade 2 hypertension (SBP 160-179 and/or DBP 100-109mmHg)
Confirm diagnosis within one week and Start antihypertensive treatment with CCB.
Immediate treatment is Indicated for adults diagnosed with hypertension at initial
presentation in those with :
End-organ damage
High CVD risk (Lab based WHO cardiovascular risk >20% or non-Lab based WHO
cardiovascular risk >10%
Hypertensive Crises (SBP ≥180 mmHg or DBP ≥110 mmHg)
Initial Monotherapy In Uncomplicated Hypertension:

Long-acting dihydropyridine calcium channel blocker such as amlodipine as first

line drug for the treatment of uncomplicated essential hypertension:- Amlodipine
5 mg daily, escalate to 10 mg if BP is uncontrolled.
Thiazide diuretics such as hydrochlorothiazide to be used as add on when target
BP not achieved on long-acting dihydropyridine calcium channel blocker such as
amlodipine:- Hydrochlorothiazide 25 mg Po daily
If a third agent is needed, the alternative class of medication is ACE inhibitors:-
Lisinopril 5 mg daily, escalate dose to 40 mg Po daily if BP is uncontrolled or
Enalapril 5 mg Po BID, escalate to 20 mg Po BID if BP is uncontrolled
Pregnant women and women of childbearing age not on effective contraception
CCBs should be used.
Hypertensive Emergencies Requiring Immediate BP
Lowering
First Line Treatment:- Labetalol 20-40mg IV every 10min to 300mg (2mg/min
infusion)
Alternative :- Hydralazine 5-20mg IV repeat after 20min
Nursing Management
Assessment
 Comprehensive nursing assessment focusing CVD and systemic manifestations
 Including history of
Angina/MI Stroke: Complications of HTN, Angina may improve with b-blokers
Asthma, COPD: Preclude the use of b-blockers
Claudication: May be aggravated by b-blockers
Gout: May be aggravated by diuretics
Family history of HTN: Important risk factor
Family history of premature death: May have been due to HTN
Cigarette smoker: Aggravate HTN, independently a risk factor for CAD and
stroke
High alcohol: A cause of HTN
High salt intake: Advice low salt intake; dietary likes and dislikes
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Nursing diagnosis
Risk for decreased CO related to Increased vascular resistance, vasoconstriction,
Myocardial ischemia, or Ventricular hypertrophy/ rigidity
Activity intolerance related
Pain
Knowledge deficit
Risk non compliance with therapeutic regiment related to side effects of
prescribed drugs
Nursing intervention

 Improving cardiac output

 Improving activity tolerance
 Alleviating pain
 Patient education
 Compliance to therapeutic regimens

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Potential complications of hypertension
Hypertensive Heart Disease
 CAD
 Left ventricular hypertrophy
 Heart failure
Cerebrovascular Disease
 Stroke
 PVD
 Nephrosclerosis
 Retinal Damage
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Thank you!!!!!!!