Chapter 33: Hypertension

Question 1

The force exerted by the blood against the walls of the blood vessel. It must be adequate to maintain tissue perfusion during activity and rest. Primarily a function of cardiac output and systemic vascular resistance.

Answer 1

Blood pressure

Question 2

The force opposing the movement of blood within the vessels.

Answer 2

Systemic vascular resistance

Question 3

Increases HR (chronotropic) and cardiac contractility (inotropic). Vasoconstriction. Release of renin from the kidneys. Net effect is to increase BP by increasing both CO and SVR. Norepi/epi.

Answer 3

Sympathetic NS

Question 4

Send inhibitory impulses to the sympathetic vasomotor center in the brainstem. Sensitive to stretch and, when stimulated by an increase in BP, send the inhibitory impulses. Inhibition results in decreased HR, decreased force of contraction, and vasodilation in peripheral arterioles. When a fall is detected, the SNS is activated.

Answer 4

Baroreceptors. Located in the carotid arteries and the arch of the aorta.

Question 5

Control sodium excretion and ECF volume, increasing venous return and SV.Sodium retention results in water retention, which causes an increased ECF volume. This increases the venous return to the heart and SV= increase CO and BP. Renin-angiotensin-aldosterone system (RAAS). Kidney secretes renin in response to SNS stimulation, decreased blood flow through kidneys, or decreased serum [sodium]. —> increased BP.

Answer 5

Renal system

Question 6

Stimulation of the SNS results in the release of epinephrine (increases HR and contractility–>increase CO). Increases blood sodium osmolarity stimulating the release of ADH. ADH increases the ECF volume by promoting the reabsorption of water in the distal and collecting tubules of the kidneys–> increase blood volume–> increase CO–>increase BP. Aldosterone causes kidneys to retain Na+ and H20–> increase BV–> increase CO–> increased BP

Answer 6

Endocrine system

Question 7

Persistent systolic BP (SBP) of 140 mmHg or more, diastolic BP (DBP) of 90 mmHg or more, or current use of antihypertensive medication

Answer 7

Hypertension. On more than one reading

Question 8

An average SBP of 140 mmHg or more, coupled with an average DBP of less than 90 mmHg or more. SBP increases with age. DBP rises until about age 55 then declines. Control of this decreases the incidence of stroke, HF and death

Answer 8

Isolated systolic HTN (ISH)

Question 9

Elevated BP without an identifiable cause. Accounts for 90% to 95% of all cases of HTN. Contributing factors: SNS activity, overproduction of Na+-retaining hormones and vasoconstricting substances, increased Na+ intake, greater-than-ideal body weight, diabetes mellitus, tobacco use, and excessive alcohol consumption.

Answer 9

Primary HTN

Question 10

Elevated BP with a specific cause that can be identified and corrected. 5-10% of HTN in adults. Suspect if >50 and suddenly develop high BP (hypertensive crisis). Causes: cirrhosis, congenital narrowing of aorta, drug-related (estrogen replacement therapy, oral contraceptives, corticosteroids), endocrine disorders, neurologic disorders, renal disease, sleep apnea

Answer 10

Secondary HTN

Question 11

Excessive ____ intake is linked to the start of HTN.

Answer 11

sodium

Question 12

Risk factors for HTN

Answer 12

Age (>50); Alcohol (>1oz/day); Cigarette smoking; Diabetes mellitus; High serum lipids; High dietary sodium; Gender (55 women); Family hx; obesity; Ethnicity (African americans 2x more likely); sedentary lifestyle; socioeconomic status; stress

Question 13

Often called the ______ because it is frequently asymptomatic until it becomes severe and target organ disease occurs.

Answer 13

Silent killer

Question 14

Secondary sx of HTN

Answer 14

fatigue, dizziness, palpitations, angina, dyspnea, activity intolerance, fatigue. Many d/t the increased workload on the heart

Question 15

Coronary artery disease (response to injury of atherogenesis suggests that HTN disrupts the coronary artery endothelium, results in a stiff arterial wall with a narrowed lumen and accounts for a high rate of CAD, angina and MI) 
left-ventricular hypertrophy (sustained high BP increases the cardiac workload and produces LVH- compensatory mechanism that strengthens cardiac contraction and increases CO. Increased contractility increases myocardial work and O2 demand. Assoc. with development of HF)
Heart failure (occurs when the heart's compensatory mechanisms are overwhelmed and the heart can no longer pump enough blood to meet the body's demands. Contractility is depressed, and SV and CO are decreased. Pt may c/o SOBOE, PND, and fatigue)

Answer 15

Hypertensive heart diseases

Question 16

Atherosclerosis, stroke, HTN encephalopathy

Answer 16

Cerebrovascular disease. Cx of HTN

Question 17

HTN speeds up the process of atherosclerosis in the peripheral blood vessels. This leads to the development of ___, aortic aneurysm, and aortic dissection. Intermittent claudation (ischemic leg pain precipitated by activity and relieved with rest) is a classic sx.

Answer 17

Peripheral vascular disease. Cx of HTN

Question 18

HTN is one of the leading causes of _____ ____ ____, especially among African Americans. Renal disease results from ischemia caused by the narrowing of the renal blood vessels. This leads to atrophy of the tubules, destruction of the glomeruli, and eventual death of the nephrons.

Answer 18

chronic kidney disease. Nephrosclerosis. Renal dysfunction. End-stage renal disease. Cx of HTN

Question 19

Blurred vision, retinal hemorrhage, blindness. Appearance of the ___ provides important information about the severity and duration of the HTN. Indication of related vessel damage.

Answer 19

retina. Retinal damage. Cx of HTN

Question 20

Diagnostic studies

Answer 20

Not much to be done since most have no cause, do baseline and assessments for VC risk. UA, BUN, creatinine; electrolytes; blood glucose; lipid profile; uric acid; ECG; echocardiogram

Question 21

______ should be the foundation of tx. Weight reduction, DASH eating plan, sodium reduction, limitation of alcohol, regular physical activity, avoidance of tobacco use, stress management

Answer 21

lifestyle modifications

Question 22

Emphasizes fruits, veggies, fat-free or low-fat milk, whole grains, fish, poultry, beans, seeds, nuts. Decreased red meat, salt, sweets, added sugars, sugared beverages. No restrictions on caffeine or protein.

Answer 22

DASH eating plan

Question 23

Lasix(Loop), hydrochlorothiazide (Thiazide), spironalactone (K+-sparing). Used for HTN, fluid overload. Decreases preload by decreasing fluid buildup.
S/e’s: low K+ (except spironolactone), low Mg++, dehydration (remember if K+ is low, digoxin toxicity is a higher risk). Orthostatic hypotension.
Take in the morning so they aren’t up all night!

Answer 23

Diuretics

Question 24

BB makes me LOL. “lols”. Used for HTN, angina, dysrhythmias, post-MI (prevents another MI). NOT RECOMMENDED FOR HF OR ASTHMATICS. Blocks the effects of epinephrine (SNS), decreases HR, lowers BP, lowers CO, vasodilates, decreases contractility (pumping strength).
S/E’s: fatigue, impotence, wheezing or SOB (why we don’t use in asthmatics).
Monitor pulse and BP regularly.

Answer 24

Beta blockers

Question 25

ACE is a real “pril”. “prils.” Used for HTN, HF, diabetes (to protect the kidneys); can prevent heart attack and stroke. Lowers levels of angiotensin II, lowers BP, vasodilator (decreases after load).
S/E’s: DRY COUGH, low BP, high K+, angioedema (swelling of the lips and face- MUST stop the drug if they have this side effect).
Don’t take with ASA of NSAIDs (may reduce effectiveness).

Answer 25

Angiotensin-converting enzyme (ACE) inhibitors

Question 26

“tartans.” Used for HTN, heart failure; give if unable to tolerate an ACE. Blocks angiotensin II from having any effect, lowers BP, vasodilates (decreases after load).
S/E’s: high K+, decreased kidney function
Can take awhile to work so don’t use it as first line tx for BP, can use for those on an ACE bothered by cough.

Answer 26

Angiotensin II receptor blockers (ARB)

Question 27

Van Diesel- verpamil, amlodipine, nifedipine, diltiazem. Used for angina, HTN, dysrhythmias; do NOT used after MI or with HF; NOT used as first line tx for BP. Interrupts the movement of calcium into the cells of the heart, vasodilates (decreases after load), decreases contractility
S/E’s: bradycardia, low BP, headache, dizziness, nausea
Do NOT give with grapefruit juice

Answer 27

Calcium channel blockers.

Question 28

Clonidine, Hytrin, Cardura. Used for HTN, BPH. Vasodilates, lowers BP, lowers CO.
S/E’s: dry mouth, sedation, fatigue, impotence, low BP
Don’t take with alcohol or sedatives, may need to take at bedtime to reduce orthostatic hypotension.

Answer 28

Alpha adrenergic blockers

Question 29

Nitrates. Used for angina, HTN (those who can’t take an ACE), MI, HF. Vasodilates (decreases after load), decreases preload.
S/E’s: headache, low BP, dizziness
Must monitor BP (needs to be above 100 to give), repeat every 5 minutes 3 times. Keep in dark area. MUST ask if they have taken any erectile dysfunction drugs prior to giving

Answer 29

Vasodilators.

Question 30

Drug therapy side effects. Many common side effects. Can be severe enough that pts won’t take the medication.

Answer 30

Orthostatic hypotension: check HR (>50) before giving. Use with caution first dose. Get up slowly.
Sexual dysfunction: change to another drug
Potassium: most make it low, but ACE or ARB can make it high
Dry mouth: gum or candy
Nocturia: take earlier in the day

Question 31

Gerontologic considerations

Answer 31

Higher incidence of isolated systolic HTN and white coat HTN. Be careful of ausculatory gap (wide gap between Korotkoff sound and subsequent beats). More sensitive to slight BP changes. Resistant to ACE inhibitors and ARBs. Orthostatic hypotension is common (start low with BP meds and go slow). Postprandial hypotension is more common (don’t give BP meds with meals).

Question 32

Can develop over hours or days. Rate of rise, not actual BP, is most important (MAP is also more important than actual BP). Most common cause is failure to take routine BP medications. Another cause is cocaine/crack use.
S/S: severe headache, n/v, seizures, confusion, coma, papilledema, tremors, decreased urine output, nose bleed
Can cause encephalopathy, intracranial or subarachnoid hemorrhage, acute LV failure, MI, renal failure, dissection aortic aneurysm, and retinopathy.

Answer 32

Hypertensive crisis

Question 33

Tx of hypertensive crisis

Answer 33

Goal is to slowly lower BP (decrease MAP by 25% in 1 hour). IV sodium nitroprusside (Nirtopress) along with oral BP meds. Check BP q 2-3 minutes. Monitor ECG for dysrhythmias. Hourly urine output. Bedrest. Frequent neuro checks.