HYPERTENSION

November 13, 2017

 Readings
 Chapter 33 – Krause (pg 865- 880)
 Pgs. 343-347 – Escott-Stump
 Know key terms on page 865
 Epidemiology
 ~65 million Americans have hypertension
(HTN), an additional 59 million have pre-
HTN.
 HTN occurrence = 1 in 3 Americans
 In 2003, HTN contributed directly or
indirectly to the death of 277,000 Americans
(Am Heart Assoc 2006)
 Emphasis on lifestyle modifications have
given diet prominent role in both primary
preventative and management of hypertension.
 Ethnic / Gender Distribution
Male Female

AA AA
41.8% 45.4%
EA EA
30.6% 31.0%
Mexican- Mexican-
27.8% American 28.7% American
Hispanics/ Hispanics/
19.0% Latinos 19.0% Latinos
 Ethnic / Gender Distribution
 The rates of high blood  Seen across life span
pressures in blacks is 5% in pediatric
the highest in the world population or approx
 Develop HTN earlier in 7million American
life children have high
 Maintain higher bp blood pressure
levels  Increase with age
 Risk for fatal stokes,
heart disease, ESRD
 More men than women
higher than in whites  After age 55 rates
among women of all
racial groups surpass
 Etiology
 Essential or Primary HTN –
 90-95% of persons with HTN
 idiopathic (unknown ) etiology (but may be affected by
lifestyle factors)
 Environmental factors
 appears to have a strong genetic component – i.e. genes
have been identified which contribute to sodium balance,
imflammatory responses, and other metabolic controls of
bp.

 Secondary HTN - results from another condition,

often renal or endocrine disease; may be curable
 Ethnic / Gender Distribution
 >65 in any racial group have HTN
 Early intervention programmes provide the
greatest long term potential for reducing the
overall burden of blood pressure related
complications
 Lower bp in pt with DM, HTN, is associated
with decrease in CVD events and renal failure
 Target bp for people with diabetes is 130/80
mmHg
Risks Factors for Essential HTN
 Heritability
 Smoking – impairs nitrous oxide’s role in endothelial
relaxation and vasodilation
 Hyperinsulinemia – relationship unclear
 Diet
 ↑sodium, SFA
 ↓potassium, magnesium, calcium
 Stress
 Inactivity
 Obesity
 Classification

SPB (mmHg) DPB (mmHg)

Normal <120 and <80
Pre-HTN 120-139 or 80-89
HTN, stage I 140-159 90-99
HTN, stage II ≥160 ≥ 100

*SBP=systolic blood pressure (contraction); DBP=diastolic blood pressure(relaxation)

Ref: Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation and Treatment of High Blood Pressure (JNC-7)
 Morbidity & Mortality
 Asymptomatic
 Chronically elevated bp is detrimental to many
systems.
 Can cause:
 Congestive heart failure (CHF), myocardial infarction
(MI), arrhythmias, sudden cardiac death, aneurysms
 Cerebrovascular accident (stroke), peripheral vascular
disease and ischemic injury
 Kidney failure
 Vision problems from ruptured blood vessels
 Physiology
 bp = cardiac output X peripheral
resistance

 Decreased vessel diameter = increased

resistance, ex: atherosclerosis

 Conversely, when the diameter is

increased as with vasodilator drug therapy,
resistance decreases and bp is lowered
 Physiology - Major regulators
 Many systems maintain homeostatic
control of bp
 Nervous systems (short-tem control)
 Sympathetic – epinephrine stimulates release
of norepinephrine and increases heart rate and,
therefore, bp.
 Parasympathetic – decreases heart rate through
vagus nerve, which stimulates release of
acetylcholine and causes heart rate and bp to
decline
Physiology - Major regulators (cont.)
 Kidney (long-term control)- ↓serum
sodium, plasma volume, or arterial BP
stimulates release of renin from the kidneys.
 Renin converts angiotensinogen → angiotensin I,
Angiotensin converting enzyme (ACE) converts
angiotensin I → angiotensin II. Angiotensin II
causes adrenal cortex to secrete aldosterone which
causes sodium and chloride reabsorption in
kidneys, resulting in water retention and ↑ blood
volume/bp.
Physiology - Major regulators (cont.)
 Vasopressin (antidiuretic hormone/ADH)
- released from the posterior pituitary gland
when there is a water deficit in the body (i.e. ↓
bp). Causes vasoconstriction and retention of
water by the kidneys → increasing blood
volume and bp.
 Intervention & Management
 Longterm GOAL: Reduce morbidity & mortality
from stroke, heart disease, and renal disease
 For children: prevent adoption of risky lifestyle
factors, wt gain, increased salt intake, sedentary habit
 Lifestyle Changes = Cornerstone of prevention
and management
 Intervention & Management
 Treatment goals:
1. Reduce heart and renal disease risk
2. Reduce BP to <140/80 (<130/80 mmHg if DM or
renal disease present)
 Comprehensive approach:
 wt reduction
 lifestyle modification
 nutrition therapy
 pharmacologic interventions
 Weight reduction
Meta-analyses of studies from 1966-2002
provide strong evidence that:
 wt loss of 5-10% of body wt has a sustained effect
on bp, and
 >5 kg loss reduces both DBP and SBP

For all patients with BMI <35 (even normal

BMI), newer evidence suggests measuring
waist circumference as a predictor of HTN
 Interpreting Waist Circumference

High risk:
 Men: >102 cm ( >40 in)
 Women: >88 cm ( >35 in)

Rationale: High waist circumference is associated with

an increased risk for DM2, dyslipidemia,
hypertension, and CVD in patients with a BMI
between 25 - 34.9 kg/m2
An increase in waist circumference may also be
associated with increased risk in persons of normal
weight/BMI.
 Lifestyle modification
 Physical activity 30-60 min/d 5-6
days/week reduces bp and decreases
relative workload of heart by improving
cardiorespiratory fitness
 Smoking cessation benefits bp almost
immediately
 Stress management – decreases
sympathetic nervous system activity
 MNT - DASH Diet
 Used for both preventing and controlling HTN
 Not your typical “limit sodium” diet.
 Considered the ideal diet for most adults.
 Does allow limited Na+, but also relies on high
mineral intake, high fiber, and lower fat
 2-3 f/v consumed per meal
 Limits usual red meat intake by 1/3

 Cuts usual fat intake by 1/2

 MNT - DASH Diet (cont.)
 For a 2000 kcal diet:
 7-8 servings of whole grains
 8-10 servings of fruits & vegetables
 2-3 servings of fat-free or low-fat dairy products
(Lactaid?)
 No more than 6 oz. of lean meat
 ½ - 1 serving of nuts/seeds/legumes
 2-3 servings of fats/oils
 Sweets – ≤5/week
 Institute slowly to avoid gastric discomfort.
 Na+ Restriction
 Sodium restriction to healthful levels is
suggested to benefit blood pressure
across the population, regardless of the
presence of “salt sensitivity”
 Salt sensitivity is genetic, and will require
a more aggressive salt restriction
 Clinical Trials Support Na+ Restriction
 TONE (Trial of Non-pharmacologic
intervention in the Elderly) - ~700
participants, aged 60-80 y.o. Na+ restriction
allowed the majority of patients to be removed
from pharmacologic tx after 3 months
 TOHP (Trial of Hypertension Prevention) –
~4500 participants. Na+ restriction, with or
without weight loss, can reduce incidence (i.e.
initial onset) of HTN by 20%
 MNT – Limit Na+
 Average Na+ intake for Americans = 3000-4500 mg/d
(8-10 g/d salt), mostly from processed foods
 Dietary Guidelines rec. <2400 mg Na+/d (6 g salt):
 No (or very little) salt added to cooking
 No added salt at table
 Avoidance of salty snack & processed foods
 Avoid foods with >300 mg Na+/serving
 Note – the Institutes of Medicine actually recommend
a range of 1200 – 1500 mg Na+ for adults to “promote
good health”
 MNT – Limit Alcohol
 5-7% of HTN is the result of EtOH
consumption
 HTN risk increases in a dose-dependent
fashion as alcohol intake exceeds 2
drinks/day for men, 1 drink/day for
women
 A “drink” = 5 oz. wine, 12 oz. beer, 1.5 oz.
distilled spirits
 MNT– Increase Dietary K+ / Ca++ / Mg++

 Important to note – studies (such as the DASH

diet) supporting positive effects of these
minerals on blood pressure were a result of
dietary patterns, not supplements.
 Suggests possibility of a synergistic effect with
other aspects of DASH, such as Na+ restriction,
exercise, ↓saturated fat, and ↑ fiber.
 MNT– Increase Dietary K+ / Ca++ / Mg++
(cont.)
 Potassium - strong inverse relationship
between intake and blood pressure.
 Has a natriuretic effect; inhibits renin release;
relaxes smooth muscle lining of arterioles
 DASH diet provides 4-6 g K+/day.
 MNT– Increase Dietary K+ / Ca++ / Mg++
(cont.)
 Calcium - Specific intake recommendations
beyond the DRI have not been established for
HTN
 DASH diets provided 3 cups low-fat dairy
products/day
 Magnesium – DASH diet also high in Mg ++;
similar inverse relationship with BP as
potassium
 Avoid Natural Hypertensives
 Natural (real) licorice
 Increases renal Na+ retention.
 The active compound of licorice, glycyrrhizic acid,
is hydrolyzed to form glycyrrhetinic acid, which
inhibits renal 11beta-HSD2 (a steroid metabolizing
enzyme) and by that mechanism increases access
of cortisol to its receptors to produce renal Na +
retention and K+ loss
 Ephedra (ma-huang, Ephedra sinensis)
 Pharmacologic Therapy
 If lifestyle/NTR modification does not produce
results w/in 2 weeks, consider adding short- or long-
term pharmacologic tx:
 Angiotensin-Converting Enzyme (ACE) Inhibitors
 Angiotensin II Receptor Antagonists
 Beta-Blockers
 Ca+-channel blockers
 Central Adrenergic inhibitors
 Diuretics
 Diuretic-antihypertensives
 Melatonin
 Typically need to monitor Na+, K+ (supplement or
restrict), avoid EtOH. (see Escott-Stump Table 6-12)
 RD Role in Pharmacologic Therapy

 Encourage compliance with drug therapy in

order to consistently control blood pressure
and minimize end-organ damage
 Assess food-medication interactions, e.g. need
for Na+ restriction and K+ supplement with
diuretics, effect of alcohol, side effects on
appetite, etc.