Presented by Annie Ingram, MSN, NP-C Hypertension is the chronic elevation in blood pressure that, long term, causes end- organ damage, and increases morbidity and mortality. It occurs due to the abnormal functioning of the arterial pressure related to the central nervous system, renin- angiotensin-aldosterone system, endothelial dysfunction, genetics, and environmental factors. Hypertension in the most common primary diagnosis in America, estimating 35 million office visits per year The National Health and Nutrition Examination Survey estimates that 50 million or more Americans have hypertension Hypertension affects half of people age 60-69, and ¾ of people aged 70 and greater Worldwide hypertension is estimated to be 1 billion people, with approximately 7.1 million deaths per year related to hypertension The Framingham heart study found that those with normal BP at age 55 have a 90% risk of developing hypertension in their lifetime The World Health Organization reports that hypertension causes 62% of cerebrovascular disease and 49% of ischemic heart disease It is estimated that 30% of adults are unaware that they have hypertension, 40% with hypertension are not on medications, and 2/3 of individuals with hypertension are not controlled to BP <140/90 For people age 40-70, for every 20mmHg increase in systolic BP or 10mmHg increase in diastolic BP, there is a doubled risk of Cardiovascular disease The higher the BP, the greater the risk of stroke, heart attack, heart failure, and kidney disease Estimations state that for people with stage 1 hypertension, sustaining a 12mmHg reduction in SBP over 10 years will prevent 1 death in 11 people Antihypertensive therapy is associated with reductions in MI of approximately 20-25%, stroke 35-40%, and heart failure approximately 50% Recent data suggests that the majority of people with hypertension with require two or more antihypertensive medications to achieve goal The pathophysiology of hypertension involves cardiac output, peripheral vascular resistance, the renin- angiotensin-aldosterone system, and the autonomic nervous system To maintain a normal blood pressure, a balance of cardiac output and peripheral vascular resistance must be maintained. Most patients with primary hypertension have a normal cardiac output, but a raised peripheral resistance. Peripheral vascular resistance is determined by small arterioles, the walls of which contain smooth muscle cells. Contraction of these cells is thought to be related to a rise in intracellular calcium concentration. This may explain the vasodilatory effects of medications that block the calcium channels. Prolonged smooth muscle constriction causes thickening of the arteriolar vessel, leading to a rise in peripheral vascular resistance. The renin-angiotensin system is probably the most important endocrine system that affects blood pressure control. Renin is secreted from the juxtaglomerular apparatus of the kidney in response to glomerular underperfusion or a reduced salt intake. It is also released in response to stimulation from the sympathetic nervous system. Renin is responsible for converting renin substrate (angiotensinogen) to angiotensin I, a physiologically inactive substance which is rapidly converted to angiotensin II by angiotensin converting enzyme. Angiotensin II is a potent vasoconstrictor, thus a rise in blood pressure is seen. In addition it stimulates the release of aldosterone from the adrenal gland, which results in a further rise in blood pressure related to sodium and water retention. Sympathetic nervous system stimulation can cause both arteriolar constriction and arteriolar dilatation. Thus the autonomic nervous system has an important role in maintaining a normal blood pressure. It is also important in the mediation of short- term changes in blood pressure in response to stress and physical exercise. Most likely, hypertension is related to an interaction between the autonomic nervous system and the renin-angiotensin system, together with other factors such as sodium, circulating volume, and genetics. Normal - < 120/80 mm Hg Pre-hypertension - 120-139/80-89 mm Hg Hypertension Stage I - 140-159/90-99 mm Hg Hypertension Stage II - >or= 160/100 mm Hg The diagnosis of hypertension should be made from at least 2 blood pressure readings one to two weeks apart Patients should not smoke or consume caffeine for at least two hours before blood pressure measurement. The blood pressure should be measured in both arms, and the higher reading should be used Ambulatory blood pressure monitoring is an important tool if “white coat” hypertension is suspected, which occurs in about 15% of the population. Normal ambulatory blood pressure for awake periods is <135/85, asleep periods <120/70, and average over 24 hours of <130/80. I have diagnosed hypertension… now what do I do??? past known blood pressure readings family history past or current symptoms or diagnosis of heart disease, CKD, asthma, COPD, diabetes, dislipidemia, or sleep apnea smoking history physical activity or inactivity excessive alcohol, fat, or sodium intake all medications currently prescribed or over-the-counter Risk factors for hypertension include: family history race (most common in blacks) stress obesity a high diet in saturated fats or sodium tobacco use sedentary lifestyle aging Secondary hypertension may result from: renal vascular disease primary hyperaldestoronism Cushing’s syndrome thyroid, pituitary, or parathyroid dysfunction coarctation of the aorta pregnancy neurologic disorders use of hormonal contraceptives, cocaine, or some medications Clozapine Corticosteroids Haemopoietic agents (darbepoetin, epoetin) Immunomodifiers (cyclosporin, tacrolimus) Leflunomide Monoamine oxidase inhibitors: reversible Non-steroidal anti-inflammatory drugs Oral contraceptives Oral decongestants (e.g. pseudoephedrine) Sibutramine Stimulants (dexamphetamine sulfate, methylphenidate hydrochloride) Venlafaxine (dose-related) Rebound hypertension may occur following abrupt withdrawal of the following: • bromocriptine • clonidine American mistletoe Angel’s trumpet Butcher’s broom Caffeine-containing products (e.g. guarana, black tea, cola nut, green tea, mate) Ephedra (ma huang) Gentian Ginger preparations Ginseng preparations Licorice Melatonin Peyote Phenylalanine Sage St John’s wort Appropriate BP measurement An optic fundi exam A BMI calculation Pulse rate, rhythm, and character Jugular venous pulse and pressure Ascultation for carotid, abdominal, and femoral bruits Palpation of the thyroid gland Evidence of cardiac enlargement (displaced apex, extra heart sounds) Crackles or wheezing in the lungs Exam of the abdomen for enlarged kidneys, masses, or pulsations Palpation of lower extremity pulses Assessment for pedal edema A neurologic assessment ECG Urinalysis Blood glucose GFR Serum potassium, hemaglobin, and calcium Lipid panel Urine albumin and creatinine The goal of antihypertensive treatment is to reduce cardiovascular and renal morbidity and mortality. Therefore the goal BP should be <140/90 for healthy adults, or <130/80 for those with diabetes or renal disease. Weight reduction in those overweight Adopting a DASH diet Lowering dietary sodium intake Increasing physical activity Smoking cessation Moderating alcohol consumption The DASH (Dietary Approaches to Stop Hypertension) involves reducing dietary sodium and eating a variety of foods rich in nutrients that help lower blood pressure, such as potassium, calcium and magnesium. It centers around eating whole grains, fruits, vegetables, and low-fat dairy items. A 1600mg sodium DASH diet has been shown to be similar in its antihypertensive effects to single drug therapy. Regular physical activity has a strong cardioprotective effect. Regular aerobic exercise can lower SBP by an average of 4mmHg and DBP by 2.5mmHg. The recommended amount of activity is at least 30 minutes of moderate-intensity physical activity 3-5 days per week. For persons who are overweight, every 1% reduction in body weight lowers systolic BP by an average of 1mmHg. Weight loss of 10kg can reduce SBP by 6-10mmHg. Moderate to heavy alcohol intake can increase blood pressure, therefore in these patients, limiting alcohol consumption can substantially lower blood pressure. Alcohol intake should be limited to a maximun of 2 drinks per day for men, and 1 drink per day for women, with at least 2 alcohol free days per week. Initial drug choice should be based on the patient’s age, presence of associated comorbid conditions or end-organ damage, interactions with other medications, cost, and compliance. Most clinical trials have found Thiazide-type diuretics to be the basis of antihypertensive therapy In trials such a the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial, diuretics were shown to be number one in preventing the cardiovascular complications of hypertension Diuretics are also more affordable than many other antihypertensive agents Thiazide-type diuretics should be used as initial therapy for most newly diagnosed hypertensive patients Other first-line treatment options are an ACE Inhibitor, ARB, or dihydropyridine Calcium Channel Blocker Thiazide diuretics inhibit the sodium and chloride transporter in the distal convoluted tubule of the kidney, thus increasing the excretion of sodium and water, as well as increasing potassium loss. This diuresis decreases blood volume and blood pressure. Side effects include: Hyperglycemia Hypokalemia