Hypertension

Hypertension

1. HYPERTENSION HYPERTENSION

2. Hypertension A World Wide Epidemic Nearly 1 billion hypertensive in the world Hypertension is poorly controlled, with less than 25% controlled in developed countries and less than 10% in developing countries. Hypertension which is responsible for 3 million death annually. May 14 th is World Hypertension Day

3. BLOOD PRESSURE ?

4. Factors Influencing Blood Pressure (BP) Cardiac output is total blood flow through systemic or pulmonary circulation per min. CO =stroke volume (amt pumped out of L ventricle per beat [70 ml]) times the HR for 1 min. SVR + force opposing movement of blood in vessels; determined primarily by radius of small arteries & arterioles Blood Pressure Cardiac Output Systemic Vascular Resistance = x Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

5. BLOOD PRESSURE

6. Normal regulation of blood pressure

7. Sympathetic Nervous System Baroreceptors Nerve cells in carotid artery & aortic arch Maintain BP during normal activities React to increases & decreases in BP elevated BP – impulse to brain to inhibit SNS; decrease HR & force of contraction; vasodilation of arterioles decreased BP – activates SNS; vasoconstriction of arterioles; increases HR & heart contractility

8. RENIN ANGIOTENSIN ALDOSTERONE MECHANISM (RAAS)

9. Produce vasoactive substances and growth factors nitric oxide- decreases the vascular tone endothelin - vasoconstrictor Vascular endothelium

10. Hypertension is a persistent systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg or current use of antihypertensive medication (Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC VI] DEFINITION

11. JNC 7 Blood Pressure Classification Category SBP (mm Hg) DBP (mm Hg) Normal < 120 < 80 Prehypertension 120–139 80–89 Stage 1 hypertension 140–159 90–99 Stage 2 hypertension > 160 or > 100 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

12. S ystolic blood pressure tends to rise and diastolic to fall. When the average systolic blood pressure is 140 mm Hg and diastolic blood pressure is <90 mm Hg, the patient is classified as isolated systolic hypertensive . COMMON IN OLDER ADULTS Isolated Systolic Hypertension

13. More commonly seen in some younger adults, the average systolic pressure remains <140 mm Hg but the diastolic is 90 mm Hg. Although diastolic pressure is generally thought to be the best predictor of risk in patients younger than age 50 years Common in younger adults Isolated Diastolic Hypertension

14. Accelerated hypertension is defined as a recent significant increase over baseline BP that is associated with target organ damage Accelerated hypertension/malignant hypertension

15. B lood pressure may only be elevated persistently in the presence of a health care worker, particularly a physician. When measured elsewhere, including while at work, the blood pressure is not elevated. it is referred to as white coat hypertension or isolated office hypertension The commonly used definition is a persistently elevated average office blood pressure of >140/90 mm Hg and an average awake ambulatory reading of <135/85 mm Hg. White coat hypertension

16. In some elderly patients the peripheral muscular arteries become very rigid from advanced, and sometimes calcified, arteriosclerosis. Consequently, the cuff has to be at a higher pressure to compress them, so that a falsely high blood pressure is recorded . It is difficult to detect clinically, so these patients may be overdosed with antihypertensive medications resulting in orthostatic hypotension and other side effects Pseudohypertension

17. Primary hypertension ( essential or idiopathic) - 90 % to 95% of allcases Secondary hypertension - 5-10% Classification by Cause

18. Etiology of Hypertension Primary (essential or idiopathic) hypertension Contributing factors ↑ SNS activity ↑ Sodium retaining, hormones and vasoconstrictors Diabetes mellitus > Ideal body weight ↑ Sodium intake Excessive alcohol intake

19. Risk Factors for - Primary Hypertension Age (>55) Alcohol Cigarette smoking Diabetes mellitus Elevated serum lipids Excess dietary sodium Gender Family history Obesity Ethnicity Sedentary lifestyle Stress

20. I. Renal A. Renal parenchymal disease 1. Acute glomerulonephritis 2. Chronic nephritis 3. Polycystic disease of kidney 4. Diabetic nephropathy B . Renovascular 1. Renal artery stenosis 2. Intrarenal vasculitis C. Renin producing tumors D. Primary sodium retention Secondary Hypertension

21. II. Endocrine A . Acromegaly B . hyperthyroidism C . Hyperparathyroidism D . Adrenal 1 . Cortical • Cushing’s syndrome • Primary hyperaldosteronism ( Conn’s syndrome ) • Congenital adrenal hyperplasia 2 . Medullary – pheochromocytoma

22. III . Vascular causes : Coarctation of aorta IV. PREGNANCY INDUCED HYPERTENSION V. NEUROLOGICAL DISORDERS a . Increased intracranial pressure • Brain tumours • Encephalitis b . Guillain-Barré syndrome

23. Clinical Manifestation Referred to as the “silent killer” Frequently asymptomatic until target organ disease Occurs Or recognized on routine screening Headache may occur when SBP rises above 200mmHg or when blood pressure is rapidly elevated.

24. S ymptoms secondary to the effects on blood vessels in the various organs and tissues or increased workload of the heart Fatigue Dizziness Palpitations Nosebleeds Angina Dyspnea etc.. Clinical Manifestation

25. Hypertension Complications Target organ diseases occur most frequently in: Heart Brain Peripheral vasculature Kidney Eyes

26. Complication of Hypertension 1. Cardiac : LVH LVF Systolic Diastolic IHD Arrhythmias 2. Vascular Peripheral arterial disease Aortic dissection 3. Cerebral Stroke TIA Encephalopathy 4. Renal Nephropathy Renal failure 5. Eye Retinopathy

27. Hypertension Complications Hypertensive heart disease Coronary artery disease Left ventricular hypertrophy Heart failure Fig. 33-3: Top, normal heart; Bottom, left ventricular hypertrophy Increased systemic vascular resistance causes left ventricle to work to hard; initially increases in size as compensatory mechanism; eventually becomes too large and requires more oxygen and energy; can’t keep up with demand and end up with heart failure

28. Hypertension Diagnostic Studies History and physical examination BP measurement in both arms Use arm with higher reading for subsequent measurements BP highest in early morning, lowest at night

29. Measuring Blood Pressure Patient seated quietly for at least 5minutes in a chair, with feet on the floor and arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80% of the arm) At least 2 measurements Continue…

30. Hypertension Diagnostic Studies Urinalysis, creatinine clearance Serum electrolytes, glucose BUN and serum creatinine Serum lipid profile ECG Echocardiogram

31. MANAGEMENT

32. Goals of Therapy Reduction of cardiovascular and renal morbidity and mortality. The primary focus should be on achieving the systolic BP goal. Systolic BP and diastolic BP to targets < 140/90 mmHg = decrease in CVD complications. In patients with hypertension with diabetes or renal disease, the BP goal is < 130/80 mmHg

33. Benefits of Lowering BP Average Percent Reduction Stroke incidence 35%–40% Myocardial infarction 20%–25% Heart failure 50%

34. JNC VII Algorithm for Treatment of Hypertension JNC - VII Report, JAMA , 2003;289:2560-2572 Lifestyle Modifications Not at Goal BP (< 140/90 mmHg or < 130/80 mmHg for Those with Diabetes or Chronic Kidney Disease Initial Drug Choices

35. Lifestyle Modification: 1 Socioeconomic condition in the world suggest that prevention through Lifestyle Modifications is the universal “vaccine” against Hypertension Weight Reduction Maintain normal body weight BMI: 18.5 – 24.9 BP reduction: 5-20 mmHg/10 kg loss DASH Eating Plan Dietary Approaches to Stop Hypertension Fruits, Vegetables, Low-fat dairy Reduce saturated and total fat 8-14 mmHg BP reduction

36. Lifestyle Modification: 2 Dietary Sodium Reduction 2.4 grams Sodium or 6 grams Sodium Chloride 2-8 mmHg BP reduction Physical Activity Regular aerobic physical activity 4-9 mmHg BP reduction

37. Lifestyle Modification: 3 Smoking Cessation Any independent chronic effect of smoking on BP is small Smoking cessation does not decrease BP BUT total cardiovascular risk is increased by smoking . Therefore hypertensives who smoke should be counselled on smoking cessation

38. Collaborative Care HTN Drug Therapy Primary actions Reduce SVR Reduce volume of circulating blood Review pharmacology and know drug classes & how they work to reduce BP; side effects

39. CLASSIFICATIONS DIURETICS LOOP DIURETICS Eg - furosemide- 40 mg PO t.i.d THIAZIDE DIURETICS Eg - Hydrochlorothiazide - 25–100 mg/d POTASSIUM SPARING DIURETICS Eg - Spirinolactone- 50–100 mg/d PO

40. ADRENERGIC inhibitors CENTRALLY ACTING α - ADRENERGIC ANTAGONISTS Eg - Clonidine- 50-100 mcg TID PERIPHERALLY ACTING α - ADRENERGIC ANTAGONISTS Eg - Reserpine- 100-250 mcg daily α - ADRENERGIC BLOCKERS Eg-Prazocin - 500 mcg BID

41. β - ADRENERGIC BLOCKERS Eg - Atenelol- 50-100 mg Calcium Channel Blockers Eg - Amlodipine Nifidipine

42. ANGIOTENSIN INHIBITORS ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS Eg - Captopril, Enalapril Angiotensin II–Receptor Blockers Eg - Losartan Telmisartan- 40–80 mg/d PO Vasodilators Eg - Nitroglycerin- 40-50 mg d

43. DIRECT VASODILATORS Eg - Nitroglycerin Sodium nitroprusside- 40-50 mg d

44. NURSING MANAGEMENT

45. Collaborative Care Nursing Management Assessment Subjective data Past health history Medications Functional health patterns Objective data Target organ damage

46. Collaborative Care Nursing Management Nursing Diagnoses Ineffective health maintenance R/T lack of knowledge of pathology,complication and management Anxiety r/t complexity of mgmnt regimen, lifestyle changes Ineffective therapeutic regimen management r/t lack of knwldge , unpleasent side effects, returns of bp to normal while on medication, inconvenient schedule

47. Hypertensive Crisis Severe, abrupt increase in DBP Defined as >140 mm Hg Rate of increase in BP more important than absolute value Often occurs in patients with Hx of HTN who failed to comply with medications or who have been undermedicated Monitor MAP mean arterial pressure: MAP = (SBP + 2DBP) 3