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Hypertension

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BP KOIRALA INSTITUTE OF HELATH SCIENCS,, NEPAL
BP KOIRALA INSTITUTE OF HELATH SCIENCS,, NEPAL

The document discusses hypertension including its definition, classification, risk factors, symptoms, complications, diagnosis, and management. It provides details on lifestyle modifications and drug therapies used to treat hypertension as well as the management of hypertensive crises. The document is intended to serve as an educational reference for healthcare providers on the topic of hypertension.

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HTN Dr. Ram Sharan Mehta Medical-Surgical Nursing Department Dr. RS Mehta, MSND, BPKIHS 1
Definition • Hypertension is a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg over a sustained period, based on the average of two or more blood pressure measurements taken in two or more contacts with the health care provider after an initial screening. Dr. RS Mehta, MSND, BPKIHS 2
Dr. RS Mehta, MSND, BPKIHS 3
New Facts For persons over age 50, SBP is a more important than DBP as CVD risk factor. Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications Dr. RS Mehta, MSND, BPKIHS to prevent CVD. 4
International Health Survey: Harrison Prevalence of hypertension is 22% in Canada, of which 16% is controlled; 26.3% in Egypt, of which 8% is controlled; and 13.6% in China, of which 3% is controlled. Hypertension is a worldwide epidemic; in many countries, 50% of the population older than 60 years has hypertension. Overall, approximately 20% of the world's adults are estimated to have hypertension. The 20% prevalence is for hypertension defined as blood pressure in excess of 140/90 mm Hg. The prevalence dramatically increases in patients older than 60 years.RS Mehta, MSND, BPKIHS Dr. 5
Dr. RS Mehta, MSND, BPKIHS 6
Dr. RS Mehta, MSND, BPKIHS 7
Classification of HIN 1. Systolic HTN / Diastolic HTN - Systolic BP > 140/ Diastolic BP > 90 2. Primary [essential] HTN/Secondary HTN - Majority idiopathic cause/cause known 3. White coat HTN: Normotensive otherwise 4. Malignant HTN: DBP > 120 mg, Retinal hemorrhage, papilledema, ARF, Rapid vascular deterioration Dr. RS Mehta, MSND, BPKIHS 8
Classification of HTN according to Type Cause/etiology Degree of severity • borderline/liable •White coat Systolic /Diastolic Primary/secondary •Benign •Malignant •accelerated Dr. RS Mehta, MSND, BPKIHS 9
Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50% Dr. RS Mehta, MSND, BPKIHS 10
Dr. RS Mehta, MSND, BPKIHS 11
Use of holter Dr. RS Mehta, MSND, BPKIHS 12
Source:RS Mehta, MSND, BPKIHS Dr. Bruner, May be western countries 13
Aetiology of Hypertension • Primary – 90-95% of cases: essential or idiopathic • Secondary – about 5% of cases – Renal or renovascular disease – Endocrine disease • Cusings syndrome • Acromegaly • hypothyroidism – Coarctation of the aorta – Iatrogenic • Hormonal / oral contraceptive • NSAIDs Dr. RS Mehta, MSND, BPKIHS 14
Dr. RS Mehta, MSND, BPKIHS 15
Risk Factors • Modifiable: weight/obesity, stress, diet-cholesterole/ coffee/ salt, alcohol, smoking, sedentary job, Diabetes, Durgs-OCP. • Non-Modifiable: Hereditary, sex, age, race. Dr. RS Mehta, MSND, BPKIHS 16
Dr. RS Mehta, MSND, BPKIHS 17
CVD Risk Factors Hypertension (Major Risk Factor) Cigarette smoking Obesity* (BMI >30 kg/m2) 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 CVD (men under age 55 or women under age 65) *Components of the metabolic syndrome. Mehta, MSND, BPKIHS Dr. RS 18
Dr. RS Mehta, MSND, BPKIHS 19
Pathophysiology • Primary HTN: the actual pathogenesis of HTN remain unknown. Failure to maintain Normal blood pressure. Elderly: atherosclerosis, loss of connective tissue elasticity, decrease in relaxation of vascular smooth muscle, which reduce ability of vessels to distend and recoil. Dr. RS Mehta, MSND, BPKIHS 20
Pathophysiology Four control systems plays a major role in maintaining BP. They are: • arterial baroreceptor system • regulation of body fluid volume • renin angiotensin system • vascular autoregulation. Dr. RS Mehta, MSND, BPKIHS 21
C/F: General • Early stage of HTN is asymptomatic • Morning occipital headache • Fatigue • Dizziness • Palpitation • Flushing • Blurred vision gradually blindness occur • epistaxis Dr. RS Mehta, MSND, BPKIHS 22
C/F • Mild to moderate: asymptomatic except intermittent risk of BP • Moderate to severe: headache with dizziness, flushing, fatigue, vertigo, palpitations. • Severe: Morning-throbbing subocipital headache, blurred vision, epistaxis, hematuria, papilledema Dr. RS Mehta, MSND, BPKIHS 23
• Malignant HTN: retinopathy, papilledema • HTN encephalopathy is manifested by: restlessness, blurred vision, dizziness, headache, N/V. • Renal insufficiency manifested by: proteinuria, hematuria, hemolytic anemia, LVF, Pulmonary edema. Dr. RS Mehta, MSND, BPKIHS 24
Hypertensive crisis • It includes hypertensive urgencies and emergencies: 1. Hypertensive urgencies: DBP> 120-130, with optic disc edema, end organ complication etc) 2. Hypertensive emergencies: a. Accelerated HTN: SBP>210, DBP>130, with headache, blurred vision, focal neurological symptom and pailloedema. b. Malignant HNT: SBP>210, DBP>140 (130), with headache, blurred vision, papilloedema, arterial fibrisis, renal failre etc. Dr. RS Mehta, MSND, BPKIHS 25
Dx • BP: 2 separate visit, at least 2 weeks apart • CxR/ECG: LVH, Cardiomegaly, arrythmias • Blood chemistry: BUN (>20 mg %), Creatinin (>1.5%) • CBC, lipid profile, sugar profile • Urine analysis • Special examination: IVP, Fundoscopy Dr. RS Mehta, MSND, BPKIHS 26
Hypertensive Retinopathy Grade I Grade II • Narrowing of arterioles • Hemorrhages Dr. RS Mehta, MSND, BPKIHS 27
Hypertensive Retinopathy Grade III Grade IV • Extensive hemorrhages • Exaggerated changes of • Retinal exudates grade III • Cotton wool patchesRS Mehta, MSND,Disk edema (not Dr. • BPKIHS 28 papilledema)
Hypertension: Reason to Treat • Reduce incidence of stroke: 35-40% • Reduce incidence of MI: 20-25% • Reduce incidence of Heart failure: 50% Dr. RS Mehta, MSND, BPKIHS 29
Dr. RS Mehta, MSND, BPKIHS 30
Dr. RS Mehta, MSND, BPKIHS 31
Management of HTN A. Non-pharmacological 1.Salt restriction 2.Relief of stress 3.Weight reduction 4.Avoid alcohol and cigarette 5.Dietary fat modification 6. Exercises 7.Caffeine restriction 8.Relaxation technique BPKIHS Dr. RS Mehta, MSND, 32
B. Drug therapy a. Beta-blockers b. Calcium channel blockers c. ACE (angiotensin converting enzyme) inhibitors d. Angiotensin II receptors blockers e. Diuretics Stepped care approach/ Step down therapy/ Combination therapy Dr. RS Mehta, MSND, BPKIHS 33
Dr. RS Mehta, MSND, BPKIHS 34
• Beta-blockers: Atenolol 50-100 mg od/bd Contraindications: COPD, Br. Asthma, CCF, Heart block • Calcium channel channel blockers: Nifedipine 10-20 mg 8 hrly if diastolic BP more than 110 mm of Hg, may use S/L 5- 10 mg cap but not practice now a days. S/E: Palpitation, headache, flushing, pedal edema. Dr. RS Mehta, MSND, BPKIHS 35
ACE inhibitors: a. Catopril 25-50 mg tds b. Enalpril 5-20 mg OD c. Lisnopril 5-20 mg OD S/E: Sudden hypotension, neutropenia, albunninuria Note: ACE inhibitor are more preferred when HTN is associated with heart failure, IHD, DM and renal disease with protenurea. Dr. RS Mehta, MSND, BPKIHS 36
Angiotensin II receptor blockers 1. Losartan 20-100 mg/day 2. Valsartan 80mg/day 3. Candesartan 8-16mg/day S/E: angioedema, allergic reaction, rashes Dr. RS Mehta, MSND, BPKIHS 37
Management of hypertensive crisis Parenteral IV agents: 1. Sodium nitropruside 2. Nitroglycerine 3. Esmolol 4. etc Dr. RS Mehta, MSND, BPKIHS 38
Dr. RS Mehta, MSND, BPKIHS 39
Dr. RS Mehta, MSND, BPKIHS 40
Hypertensive crises • Abnormal elevated blood pressure: 20% of emergency department patients • Hypertensive crisis: 1% Dr. RS Mehta, MSND, BPKIHS 41
•History • Duration of hypertension • Duration of current symptoms • Other medical problems –CNS manifestations –Cardiovascular manifestations –Renal manifestations –Medications Dr. RS Mehta, MSND, BPKIHS 42
• Neurologic symptoms –Headache (85%) –New-onset blurred vision (60%) –Weight loss (75%) –Nausea and vomiting –Weakness and fatigue (30%) –Change in mental status Dr. RS Mehta, MSND, BPKIHS 43
• Imaging studies –Chest x-ray • Signs of CHF, pulmonary edema, or coarctation of aorta –Head CT scan • Abnormal neurologic exam intracranial bleeding, edema, or infarction Dr. RS Mehta, MSND, BPKIHS 44
Dr. RS Mehta, MSND, BPKIHS 45
Dr. RS Mehta, MSND, BPKIHS 46
Dr. RS Mehta, MSND, BPKIHS 47
Hypertension and Diabetes • Hypertension co-exists with type II in about 40% at age 45 rising to 60% at age 75. • 70% of type II patients die from cardio- vascular disease. • At least 60% of patients will require 2 or 3 antihypertensive agents to achieve tight control. Dr. RS Mehta, MSND, BPKIHS 48
Follow-up • For patients with BP stabilised by management, follow up should normally be three monthly (interval should not exceed 6 months), at which the following should be assessed by a trained nurse/Doctor: * Measurement of BP and weight * Reinforcement of non-pharmacological advice * General health and drug side-effects * Test urine for proteinuria (annually) Dr. RS Mehta, MSND, BPKIHS 49
Thank-You Dr. RS Mehta, MSND, BPKIHS 50

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Hypertension

  • 1. HTN Dr. Ram Sharan Mehta Medical-Surgical Nursing Department Dr. RS Mehta, MSND, BPKIHS 1
  • 2. Definition • Hypertension is a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg over a sustained period, based on the average of two or more blood pressure measurements taken in two or more contacts with the health care provider after an initial screening. Dr. RS Mehta, MSND, BPKIHS 2
  • 3. Dr. RS Mehta, MSND, BPKIHS 3
  • 4. New Facts For persons over age 50, SBP is a more important than DBP as CVD risk factor. Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications Dr. RS Mehta, MSND, BPKIHS to prevent CVD. 4
  • 5. International Health Survey: Harrison Prevalence of hypertension is 22% in Canada, of which 16% is controlled; 26.3% in Egypt, of which 8% is controlled; and 13.6% in China, of which 3% is controlled. Hypertension is a worldwide epidemic; in many countries, 50% of the population older than 60 years has hypertension. Overall, approximately 20% of the world's adults are estimated to have hypertension. The 20% prevalence is for hypertension defined as blood pressure in excess of 140/90 mm Hg. The prevalence dramatically increases in patients older than 60 years.RS Mehta, MSND, BPKIHS Dr. 5
  • 6. Dr. RS Mehta, MSND, BPKIHS 6
  • 7. Dr. RS Mehta, MSND, BPKIHS 7
  • 8. Classification of HIN 1. Systolic HTN / Diastolic HTN - Systolic BP > 140/ Diastolic BP > 90 2. Primary [essential] HTN/Secondary HTN - Majority idiopathic cause/cause known 3. White coat HTN: Normotensive otherwise 4. Malignant HTN: DBP > 120 mg, Retinal hemorrhage, papilledema, ARF, Rapid vascular deterioration Dr. RS Mehta, MSND, BPKIHS 8
  • 9. Classification of HTN according to Type Cause/etiology Degree of severity • borderline/liable •White coat Systolic /Diastolic Primary/secondary •Benign •Malignant •accelerated Dr. RS Mehta, MSND, BPKIHS 9
  • 10. Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50% Dr. RS Mehta, MSND, BPKIHS 10
  • 11. Dr. RS Mehta, MSND, BPKIHS 11
  • 12. Use of holter Dr. RS Mehta, MSND, BPKIHS 12
  • 13. Source:RS Mehta, MSND, BPKIHS Dr. Bruner, May be western countries 13
  • 14. Aetiology of Hypertension • Primary – 90-95% of cases: essential or idiopathic • Secondary – about 5% of cases – Renal or renovascular disease – Endocrine disease • Cusings syndrome • Acromegaly • hypothyroidism – Coarctation of the aorta – Iatrogenic • Hormonal / oral contraceptive • NSAIDs Dr. RS Mehta, MSND, BPKIHS 14
  • 15. Dr. RS Mehta, MSND, BPKIHS 15
  • 16. Risk Factors • Modifiable: weight/obesity, stress, diet-cholesterole/ coffee/ salt, alcohol, smoking, sedentary job, Diabetes, Durgs-OCP. • Non-Modifiable: Hereditary, sex, age, race. Dr. RS Mehta, MSND, BPKIHS 16
  • 17. Dr. RS Mehta, MSND, BPKIHS 17
  • 18. CVD Risk Factors Hypertension (Major Risk Factor) Cigarette smoking Obesity* (BMI >30 kg/m2) 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 CVD (men under age 55 or women under age 65) *Components of the metabolic syndrome. Mehta, MSND, BPKIHS Dr. RS 18
  • 19. Dr. RS Mehta, MSND, BPKIHS 19
  • 20. Pathophysiology • Primary HTN: the actual pathogenesis of HTN remain unknown. Failure to maintain Normal blood pressure. Elderly: atherosclerosis, loss of connective tissue elasticity, decrease in relaxation of vascular smooth muscle, which reduce ability of vessels to distend and recoil. Dr. RS Mehta, MSND, BPKIHS 20
  • 21. Pathophysiology Four control systems plays a major role in maintaining BP. They are: • arterial baroreceptor system • regulation of body fluid volume • renin angiotensin system • vascular autoregulation. Dr. RS Mehta, MSND, BPKIHS 21
  • 22. C/F: General • Early stage of HTN is asymptomatic • Morning occipital headache • Fatigue • Dizziness • Palpitation • Flushing • Blurred vision gradually blindness occur • epistaxis Dr. RS Mehta, MSND, BPKIHS 22
  • 23. C/F • Mild to moderate: asymptomatic except intermittent risk of BP • Moderate to severe: headache with dizziness, flushing, fatigue, vertigo, palpitations. • Severe: Morning-throbbing subocipital headache, blurred vision, epistaxis, hematuria, papilledema Dr. RS Mehta, MSND, BPKIHS 23
  • 24. • Malignant HTN: retinopathy, papilledema • HTN encephalopathy is manifested by: restlessness, blurred vision, dizziness, headache, N/V. • Renal insufficiency manifested by: proteinuria, hematuria, hemolytic anemia, LVF, Pulmonary edema. Dr. RS Mehta, MSND, BPKIHS 24
  • 25. Hypertensive crisis • It includes hypertensive urgencies and emergencies: 1. Hypertensive urgencies: DBP> 120-130, with optic disc edema, end organ complication etc) 2. Hypertensive emergencies: a. Accelerated HTN: SBP>210, DBP>130, with headache, blurred vision, focal neurological symptom and pailloedema. b. Malignant HNT: SBP>210, DBP>140 (130), with headache, blurred vision, papilloedema, arterial fibrisis, renal failre etc. Dr. RS Mehta, MSND, BPKIHS 25
  • 26. Dx • BP: 2 separate visit, at least 2 weeks apart • CxR/ECG: LVH, Cardiomegaly, arrythmias • Blood chemistry: BUN (>20 mg %), Creatinin (>1.5%) • CBC, lipid profile, sugar profile • Urine analysis • Special examination: IVP, Fundoscopy Dr. RS Mehta, MSND, BPKIHS 26
  • 27. Hypertensive Retinopathy Grade I Grade II • Narrowing of arterioles • Hemorrhages Dr. RS Mehta, MSND, BPKIHS 27
  • 28. Hypertensive Retinopathy Grade III Grade IV • Extensive hemorrhages • Exaggerated changes of • Retinal exudates grade III • Cotton wool patchesRS Mehta, MSND,Disk edema (not Dr. • BPKIHS 28 papilledema)
  • 29. Hypertension: Reason to Treat • Reduce incidence of stroke: 35-40% • Reduce incidence of MI: 20-25% • Reduce incidence of Heart failure: 50% Dr. RS Mehta, MSND, BPKIHS 29
  • 30. Dr. RS Mehta, MSND, BPKIHS 30
  • 31. Dr. RS Mehta, MSND, BPKIHS 31
  • 32. Management of HTN A. Non-pharmacological 1.Salt restriction 2.Relief of stress 3.Weight reduction 4.Avoid alcohol and cigarette 5.Dietary fat modification 6. Exercises 7.Caffeine restriction 8.Relaxation technique BPKIHS Dr. RS Mehta, MSND, 32
  • 33. B. Drug therapy a. Beta-blockers b. Calcium channel blockers c. ACE (angiotensin converting enzyme) inhibitors d. Angiotensin II receptors blockers e. Diuretics Stepped care approach/ Step down therapy/ Combination therapy Dr. RS Mehta, MSND, BPKIHS 33
  • 34. Dr. RS Mehta, MSND, BPKIHS 34
  • 35. • Beta-blockers: Atenolol 50-100 mg od/bd Contraindications: COPD, Br. Asthma, CCF, Heart block • Calcium channel channel blockers: Nifedipine 10-20 mg 8 hrly if diastolic BP more than 110 mm of Hg, may use S/L 5- 10 mg cap but not practice now a days. S/E: Palpitation, headache, flushing, pedal edema. Dr. RS Mehta, MSND, BPKIHS 35
  • 36. ACE inhibitors: a. Catopril 25-50 mg tds b. Enalpril 5-20 mg OD c. Lisnopril 5-20 mg OD S/E: Sudden hypotension, neutropenia, albunninuria Note: ACE inhibitor are more preferred when HTN is associated with heart failure, IHD, DM and renal disease with protenurea. Dr. RS Mehta, MSND, BPKIHS 36
  • 37. Angiotensin II receptor blockers 1. Losartan 20-100 mg/day 2. Valsartan 80mg/day 3. Candesartan 8-16mg/day S/E: angioedema, allergic reaction, rashes Dr. RS Mehta, MSND, BPKIHS 37
  • 38. Management of hypertensive crisis Parenteral IV agents: 1. Sodium nitropruside 2. Nitroglycerine 3. Esmolol 4. etc Dr. RS Mehta, MSND, BPKIHS 38
  • 39. Dr. RS Mehta, MSND, BPKIHS 39
  • 40. Dr. RS Mehta, MSND, BPKIHS 40
  • 41. Hypertensive crises • Abnormal elevated blood pressure: 20% of emergency department patients • Hypertensive crisis: 1% Dr. RS Mehta, MSND, BPKIHS 41
  • 42. •History • Duration of hypertension • Duration of current symptoms • Other medical problems –CNS manifestations –Cardiovascular manifestations –Renal manifestations –Medications Dr. RS Mehta, MSND, BPKIHS 42
  • 43. • Neurologic symptoms –Headache (85%) –New-onset blurred vision (60%) –Weight loss (75%) –Nausea and vomiting –Weakness and fatigue (30%) –Change in mental status Dr. RS Mehta, MSND, BPKIHS 43
  • 44. • Imaging studies –Chest x-ray • Signs of CHF, pulmonary edema, or coarctation of aorta –Head CT scan • Abnormal neurologic exam intracranial bleeding, edema, or infarction Dr. RS Mehta, MSND, BPKIHS 44
  • 45. Dr. RS Mehta, MSND, BPKIHS 45
  • 46. Dr. RS Mehta, MSND, BPKIHS 46
  • 47. Dr. RS Mehta, MSND, BPKIHS 47
  • 48. Hypertension and Diabetes • Hypertension co-exists with type II in about 40% at age 45 rising to 60% at age 75. • 70% of type II patients die from cardio- vascular disease. • At least 60% of patients will require 2 or 3 antihypertensive agents to achieve tight control. Dr. RS Mehta, MSND, BPKIHS 48
  • 49. Follow-up • For patients with BP stabilised by management, follow up should normally be three monthly (interval should not exceed 6 months), at which the following should be assessed by a trained nurse/Doctor: * Measurement of BP and weight * Reinforcement of non-pharmacological advice * General health and drug side-effects * Test urine for proteinuria (annually) Dr. RS Mehta, MSND, BPKIHS 49
  • 50. Thank-You Dr. RS Mehta, MSND, BPKIHS 50