Professional Documents
Culture Documents
Hypertension Notes
Hypertension Notes
Chapter 32
NORMAL REGULATION
HYPERTENSION
Stage 1: <159/99
Stage 2: <179/109
Stage 3: >180/110
African Americans at highest risk (more prevalent, younger age, more women, more severe, higher mortality, more
end-organ damage)
o African Americans produce less renin and do not respond as well to angiotensin inhibitors.
HTN risk increase with age; males more than females until age 55, then equal risk; education reduces risks.
Classification
Primary
o Essential.elevated BP without an identified cause and accounts for 90 to 95% of all HTN.
Secondary
o Elevated with a specific cause that can be identified and corrected. Accounts for 80% of HTN in children.
If under 20 or over 50 has sudden, severe HTN, a secondary cause should be suspected.
Hypokalemia
Abdominal bruit
Renal disease
Other causes
Sleep apnea
Pregnancy-induced HTN
Pathophysiology
For HTN, there must be an increase in either CO or SVR. The hallmark of classic HTN is increased SVR.
Heredity
Water/Sodium retention
o
o
o
o
o
o
o
o
o
o
o
Cigarette Smoking
Diabetes mellitus
Elevated serum lipids
Excess dietary sodium
Gender
Family history
Obesity
Ethnicity
Sedentary lifestyle
Socioeconomic status
stress
Signs/Symptoms
o Frequently asymptomatic (silent killer)
o Severe symptoms:
o Fatigue
o Reduced activity tolerance
o Dizziness
o Palpitations
o Angina
o Dyspnea
Complications
o Target Organ Diseases
o Heart (hypertensive heart disease)
Left ventricular hypertrophy (from high cardiac workload leading to heart failure)
Heart failure (shortness of breath on exertion, nocturnal dyspnea, fatigue, enlarged heart)
o Brain (cerebrovascular disease)
Stroke/transischemic attacks
Intermittent claudication (pain with activity or rest R/T lack of oxygen to tissues)
o Kidneys (nephrosclerosis)
Urinalysis
o Microalbuminuria
o Proteinuria
o Elevated blood urea nitrogen/elevated Serum creatinine
Microscopic hematuria
Signs/Symptoms
Blurry vision
Retinal hemorrhage
Loss of vision
Diagnostic Studies
o Hx and PE
o Urinalysis
o BUN/Serum creatinine
o Fasting blood glucose
o CBC
o Lipid profile, cholesterol, triglycerides
o
o
ECG
Echocardiogram
Collaborative Care
o Priorities
o Assess BP carefully over several months before initiating treatment
o Treat HTN in context of overall cardiovascular risk
o Lifestyle modifications should be tried first
o Treat HTN in adults up to age 85
o Pharmacology includes five first-line drugs
o
Restrict sodium
Reduce weight
Ambulatory BP Monitoring
o White Coat HTN
o Measure at home or in the community (fire stations/hospital auxiliaries)
o Use continuous, automated 24-hour ambulatory measurements
o Use a diary of activites that may affect BP
o Diurnal Variability
o In day-active people, BP is highest in the early morning, decreases during the day and is lowest at
night.
o If BP does not fall at night, then more target organ damage is likely.
o
Risk Classifications
o Dependent upon BP measurement, target organ damage, clinical cardiovascular disease and presence of other risk
factors.
o Group A
o No risk factors, no target organ damage, no c/v disease
Lifestyle Modification
o Dietary changes
o Restrict sodium
o
o
o
o
DRUG THERAPY
Goal: BP <131/85 in young adults; <140/90 in older adults
Action of drugs: Reduce SVR and decrease volume of circulating blood
Diuretics
S/E: Hypotension dependent on volume. May produce syncope within 90 minutes of initial dose; retention of
sodium and water; cardiac arrhythmias, tachycardia, weakness, flushing; abdominal pain; N/V and
exacerbation of peptic ulcer.
o Reduced resistance to the outflow of urine in benign prostatic hyperplasia. Take drugs at bedtime
(orthostatic hypotension); beneficial effects on lipid profile.
Beta Blockers (-olol)
o Reduces BP by antagonizing beta adrenergic effects. Decreases CO and reduces sympathetic
vasoconstrictor tone. Decreases renin secretion by kidneys.
o S/E: Bronchospasm, a/v conduction block; impaired peripheral circulation; nighmares; depression;
weakness; reduced exercise capacity; may exacerbate heart failure; Sudden withdrawal may cause
rebound hypertension and cause ischemic heart disease.
o Moniotr pulse regularly; use with caution in diabetics because drug may mask signs of hypoglycemia.
Combined Alpha/Beta Blockers (labetalol/Normodyne)
o Produces peripheral vasodilation and decreased heart rate.
o S/E: dizziness, fatigue, N/V, dyspepsia, paresthesia, nasal stuffiness, impotence, edema. HEPATIC
TOXICITY.
o Keep patient supine during IV administration. Assess pt tolerance of upright position (severe postural
hypotension) before allowing upright activities.
o
o
o
S/E: Nausea, headache, dizziness, peripheral edema. Reflex tachycardia (with dihydropyridines). Reflex decreased
heart rate; constipation.
Use with caution in patients with heart failure. Contraindicated in patients with second- or third-degree heart block.
IV use available for HTN crisis. Avoid grapefruit!
Orthostatic hypotension
BP is lowest during the night and highest after awakeningtake med with 24-hour duration as early in the morning as
possible.
Lack of Responsiveness to Therapy
Cost
Increasing obesity
Alcohol >1 oz/day
Secondary HTN
Volume overload (inadequate diuretics, excess sodium intake; fluid retention; renal damage)
Pseudohypertension
Use both arms (use arm with highest value from then on)
Check size and placement of cuff (width 40% and length 80% of upper arm circumference)
Hypertensive Crisis
A severe and abrupt elevation in BP with diastolic value above 120 to 130 mmHg
#1 cause: Non-compliance with med regimen
HTN Urgency
o Develops over days to weeks
o No evidence of target organ damage
o Allow patient to sit for 20 or 30 minutes in a quiet environment
Hypertensive encephalopathy: headache, nausea, vomiting, seizures, confusion, stupor and coma
Treatment lowers BP, but not too fast. Decrease MAP by 10% to 20% in the first 2 hours, with further reduction
over the next 24 hours.