Module 5 Flashcards
HTN
-Stats
- Leading risk factor for Cardiovascular disease
- 30% of Americans, 72 million people
- Prevalence of >65% in persons older than 60 yrs old
Cardiovascular Disease
-HTN
- BP level and the risk of CVD events are Continuous, consistent, and INDEPENDENT of other risk factors
- The night the BP the greater the risk of MI, HF, CVA, PAD, retinopathy, and kidney dz
Cardiovascular Risk Factors
- HTN
- Smoking
- Obesity
- Physical inactivity
- Dyslipidemia
- Diabetes
- Poor oral health
HTN
-How to Dx?
- Dx of HTN is based on average of blood pressure taken on 2 or 3 separate occasions
HTN Screening
-Factors that affect reading?
Some factors can transiently elevate BP. These include:
- Anxiety, cold, full bladder, recent exercise, Smoking or caffeine w/ 30 minutes of measurement
- Meds, oral contraceptives*, appetite suppressants, nicotine
Primary HTN
-Essential HTN
- Development of HTN w/out a reversible cause
2. Affects approximately 95% of the cases
Primary HTN
-Risk Factors?
- Age >55 yrs old
- Male Gender (ratio closes with age. 55-64 equal; 65-74 women are slightly higher rate)
- African American 2:1 to whites (African A usually don’t get treatment until end organ damage)
- Obesity
- Excessive sodium, low potassium diet, high dietary fat
- Physical inactivity
- Stress, smoking** and excessive alcohol intake
Primary HTN
-Patho
- Increase in peripheral arterial resistance resulting from increased cardiac output
- BP is a product of cardiac output and Peripheral resistance
Secondary HTN
-What is it?
- Development of HTN secondary to reversible cause
Clinical Clues:
-Presentation is ABRUPT and SEVERE
-Age <30 yrs and non-obese
-Negative Family Hx
-Failure to respond to empirical therapy despite compliance
Secondary HTN
-Causes
- Renal parenchymal Dz
- Creatinin level >1.5 mg/dl and GFR less than 50 ml/min - Renal artery stenosis
- 70-80% blockage in renal artery; renal artery murmur - Primary Hyperaldosteronism
- Biggest clue is unexplained Hyperkalemia** - Pheochromocytoma (catecholamine-producing tumor of adrenal gland)
- HTN, headache, excessive sweating, hyper metabolic state, & hyperglycemia - Sleep apnea
- Alcoholic
- Meds (NSAIDS associated w/ HTN, steroids, tricyclic antidepressants)
- Aortic Coarctation
- HTN in upper extremities; unattainable BP in lower extremities - Cushing’s Syndrome
- moon face, obesity, striae; urine cortisol needs to be ordered - Thyroid disorder
- Hypermetabolic state.
Patient Evaluation with HTN
-3 objectives?
- Assess lifestyle and identify other CVD risk
- Reveal identifiable causes of high BP
- Assess the presence or absence of target organ damage and CVD
HTN
-Medical Hx of Meds causing HTN
- Oral Contraceptives
- NSAIDS
- OTC cold remedies
- Anabolic steroids
- Licorice in excess
- Tricyclic antidepressants
- MAOI’s
- Diet pills ( 24 hour recall of dietary intake is helpful)
HTN
-ROS
- Vision change (Last eye exam)
- Thyroid problems
- SOB or difficulty sleeping at night
- Chest pain, edema, pain in legs
- Skin changes
- Sexual function (Impotence)
HTN
-Possible Differentials (4)
- White coat syndrome
- Isolated systolic HTN
- SBP of 160 or greater w/ diastolic <90
- Treat the same as normal HTN - Any one of the secondary causes
- Cocaine use
HTN
-Treatment Goal
- Ultimate public health goal of anti hypertensive therapy is the Reduction of cardiovascular, cerebrovascular, and renal morbidity and mortality! ***
- Treating to target systole and diastolic BP that are associated w/ decrease in HTN associated complications
HTN
-Lifestyle Modification
- Reduction of excess weight (BMI on every patient chart)
- Reduce Sodium intake
- 75% of once daily salt intake comes from processed food!
- Dash diet helpful as prescriptive pt education - Exercise 3-5x weekly
- Less Alcohol
- Men = 2 drinks daily
- Women = 1 drink daily
HTN
-Dash Diet
- Relationship between lower sodium intake and hypertension
- BP decreased in response to a universally recommended diet containing:
- Generous servings of fruits, veggies, and low-fat fairly
- Reduced sodium, saturated and total fat, and increased potassium
HTN
-BP and Sodium Intake
- 2300 mg of sodium tolerable upper intake level for general adult population
- Excessive sodium linked to high BP.
- Leading to CVD, stroke and cardiac-related mortality
HTN
-Categories JNC8
- Normal BP
- 120-129 SBP; and <80 DBP - Pre-Hypertension
- 130-139 SBP; 80-89 DBP - HTN under 60 yrs old
- 140/90 - HTN over 60
- 150/90
HTN
-Categories 2017 ACC/AHA
- Elevated BP
- 120-129 SBP; <80 DBP - Stage 1 HTN
- 130-139 SBP; 80-89 DBP - Stage 2 HTN
- 140-159 SBP; 90-99 DBP
HTN
-Thresholds for Treatment JNC-8
- Age 60 or greater
- Treat starting at >/= 150/90.
- Treatment goal is <150/<90 - Age 59 or less
- Treat starting at >/= 140/90
- Same recommendation fo CKD and DM
JNC-8 Evidence for Treatment Recommendations
- Grade A evidence for both general population above and below 60 years old
- Goals reduce risk of CVA, HF, and overall mortality/coronary heart disease.
- Grade A evidence for ages 30 and up
- Grade E “Expert Opinion” in ages 18-29 years old
BP Thresholds for Treatment AHA
-Normal BP <120/80
- Promote optimal lifestyle habits
2. Reassess in 1 year (Class IIa)
BP Thresholds for Treatment AHA
-Elevated BP (120-129/ <80)
- Nonpharmacologic Therapy (class I)
2. Reassess in 3-6 months (Class I)
BP Thresholds for Treatment AHA
-Stage 1 HTN (130-139/80-89)
- Clinical ASCVD or estimated 10y CVD risk factor >/= 10%
- If YES; Initiate Nonpharmacologic therapy and BP lowering Medication; reassess 1 month
- If NO; Initiate Nonpharmacologic therapy; reassess in 3-6 months
BP Thresholds for Treatment AHA
-Stage 2 HTN (>/= 140/90)
- Nonpharmacologic therapy
AND - BP-lowering medication (Class 1)
MAKE SURE BP has been measured and is average of 2-3 readings above 140/90
SBP Intervention Trial
-SPRINT
- Conducted in US and Puerto Rico at 102 clinical sites
- One group was treated to a BP of 135-139; second group treated to BP <120
- Lower reates of both CV deaths and CV events in group maintained BP at or below 120 SBP
Actions to Control CV Risk in Diabetes
-ACCORD TRIAL
- Multi center RCT, 4733 participants
- Primary composite outcome was non-fatal MI, CVA, or death from CV causes.
- Mean follow-up was 4.7 years - Pt’s with Type 2 diabetes at high risk for CV events:
- Targeting a SBP of less than 120 compared to less than 140, DID NOT reduce the rate of a composite outcome of fatal and non-fatal major CV events.
Evidence for treatment of Diastolic BP
- Expert Opinion recommendation for goal of <80 DBP
- Treatment of <90 DBP is based on RCT beginning in 1960’s
- Trials have shown improved CV outcomes
HTN Treatment
-American Academy of Family Physicians
- General population, 140/90 is the treatment threshold
- AAFP felt strongly that the JNC8 upheld the scientific rigor that provided strong recommendations to family providers
HTN Medications
-4 Types of Meds?
- Thiazides Diuretics
- Calcium Channel Blockers (CCB)
- Angiotensin-converting enzyme inhibitor (ACEI)
- Angiotensin Receptor Blocker (ARB)
HTN Medications
-Thiazides Diuretics
- Proven to be most effective out of all classes of HTN meds in improving HEART FAILURE outcomes
HTN
-Patient Education
- HTN is a risk factor for CVD and other poor outcomes
- Medication: purpose, dose, S/E
- Diet: DASH diet; cholesterol
- Provide low calorie diet
HTN
-When to Refer
- Pt’s Unresponsive to usual therapy
- Suspected secondary HTN
- Those w/ signs of renal failure or other target organ damage
HTN
-Follow-up and monitoring
- Once anti-hypertensive drug therapy is initiated
- Most Pt’s should return Monthly
- If Pt has comorbidities or severe elevation; see daily, few days, or weekly - Once Pt is at goal, see pt every 3-6 months
HTN Special Considerations
-Metabolic Syndrome
- Abdominal Obesity
- Waist circum >40 in men >35 in women - Glucose intolerance
- Fasting glucose >/= to 110mg/dl - BP >/= 130/85
- High triglycerides >/= 150mg/dl/ OR Low HDL <40 in men; <50 in females
HTN Special Considerations
-Left Ventricular Hypertrophy
- INDEPENDENT risk factor that increases risk of subsequent CVD
- REGRESSION occurs w/ aggressive BP mgmt, including:
- Weight loss
- Sodium restriction
- Treatment w/ previously mentioned drug therapies
HTN Special Considerations
-Peripheral vascular disease?
- Equivalent in risk to ischemic heart disease
2. Treat HTN, manage other risk factors aggressively
HTN Special Considerations
-Elderly Population
- Start low and Go SLOW!!
- Unsafe drop in BP can cause falls and fractures - HTN occurs in 2/3 of individuals older than 65
Postural Hypotention
- A decrease in standing SBP >10
- Associated w/ dizziness or fainting
- More frequent with:
- Older Patients with ISH, Diabetes, Pt’s on Diuretics, Vasodilators, and some psychotropic drugs
Hypertensive Crisis
-Definition
- Defined by SBP >/= to 180 and DBP >/= 120 **
2. Can be a Hypertensive Urgency or Hypertensive Emergency
Hypertensive Crisis
-Hypertensive Urgency
- Most patients with significantly elevated BP have NO acute, end organ damage
NO END ORGAN DAMAGE
-Most Common
Can be managed with:
- Loop diuretics, beta blockers, ACE inhibitors, calcium antagonists
- Lower over a 12 to 24 hour period
Hypertensive Crisis
-Hypertensive Emergency
- Significantly elevated BP w/ s/s of acute ongoing target-organ damage
- Neurologic
- Cardiac
- Vascular
- Renal
Transfer to ER immediately
