1
Q
HTN
-Stats
A
- Leading risk factor for Cardiovascular disease
- 30% of Americans, 72 million people
- Prevalence of >65% in persons older than 60 yrs old
2
Q
Cardiovascular Disease
-HTN
A
- 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
3
Q
Cardiovascular Risk Factors
A
- HTN
- Smoking
- Obesity
- Physical inactivity
- Dyslipidemia
- Diabetes
- Poor oral health
4
Q
HTN
-How to Dx?
A
- Dx of HTN is based on average of blood pressure taken on 2 or 3 separate occasions
5
Q
HTN Screening
-Factors that affect reading?
A
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
6
Q
Primary HTN
-Essential HTN
A
- Development of HTN w/out a reversible cause
2. Affects approximately 95% of the cases
7
Q
Primary HTN
-Risk Factors?
A
- 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
8
Q
Primary HTN
-Patho
A
- Increase in peripheral arterial resistance resulting from increased cardiac output
- BP is a product of cardiac output and Peripheral resistance
9
Q
Secondary HTN
-What is it?
A
- 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
10
Q
Secondary HTN
-Causes
A
- 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.
11
Q
Patient Evaluation with HTN
-3 objectives?
A
- Assess lifestyle and identify other CVD risk
- Reveal identifiable causes of high BP
- Assess the presence or absence of target organ damage and CVD
12
Q
HTN
-Medical Hx of Meds causing HTN
A
- 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)
13
Q
HTN
-ROS
A
- Vision change (Last eye exam)
- Thyroid problems
- SOB or difficulty sleeping at night
- Chest pain, edema, pain in legs
- Skin changes
- Sexual function (Impotence)
14
Q
HTN
-Possible Differentials (4)
A
- 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
15
Q
HTN
-Treatment Goal
A
- 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
16
Q
HTN
-Lifestyle Modification
A
- 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
17
Q
HTN
-Dash Diet
A
- 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
18
Q
HTN
-BP and Sodium Intake
A
- 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
19
Q
HTN
-Categories JNC8
A
- 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
20
Q
HTN
-Categories 2017 ACC/AHA
A
- 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
21
Q
HTN
-Thresholds for Treatment JNC-8
A
- 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
22
Q
JNC-8 Evidence for Treatment Recommendations
A
- 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
23
Q
BP Thresholds for Treatment AHA
-Normal BP <120/80
A
- Promote optimal lifestyle habits
2. Reassess in 1 year (Class IIa)
24
Q
BP Thresholds for Treatment AHA
-Elevated BP (120-129/ <80)
A
- Nonpharmacologic Therapy (class I)
2. Reassess in 3-6 months (Class I)
25
BP Thresholds for Treatment AHA
| -Stage 1 HTN (130-139/80-89)
1. 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
26
BP Thresholds for Treatment AHA
| -Stage 2 HTN (>/= 140/90)
1. Nonpharmacologic therapy
AND
2. BP-lowering medication (Class 1)
MAKE SURE BP has been measured and is average of 2-3 readings above 140/90
27
SBP Intervention Trial
| -SPRINT
1. Conducted in US and Puerto Rico at 102 clinical sites
2. One group was treated to a BP of 135-139; second group treated to BP <120
3. Lower reates of both CV deaths and CV events in group maintained BP at or below 120 SBP
28
Actions to Control CV Risk in Diabetes
| -ACCORD TRIAL
1. Multi center RCT, 4733 participants
2. Primary composite outcome was non-fatal MI, CVA, or death from CV causes.
- Mean follow-up was 4.7 years
3. 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.
29
Evidence for treatment of Diastolic BP
1. Expert Opinion recommendation for goal of <80 DBP
2. Treatment of <90 DBP is based on RCT beginning in 1960’s
- Trials have shown improved CV outcomes
30
HTN Treatment
| -American Academy of Family Physicians
1. 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
31
HTN Medications
| -4 Types of Meds?
1. Thiazides Diuretics
2. Calcium Channel Blockers (CCB)
3. Angiotensin-converting enzyme inhibitor (ACEI)
4. Angiotensin Receptor Blocker (ARB)
32
HTN Medications
| -Thiazides Diuretics
1. Proven to be most effective out of all classes of HTN meds in improving HEART FAILURE outcomes
33
HTN
| -Patient Education
1. HTN is a risk factor for CVD and other poor outcomes
2. Medication: purpose, dose, S/E
3. Diet: DASH diet; cholesterol
4. Provide low calorie diet
34
HTN
| -When to Refer
1. Pt’s Unresponsive to usual therapy
2. Suspected secondary HTN
3. Those w/ signs of renal failure or other target organ damage
35
HTN
| -Follow-up and monitoring
1. 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
2. Once Pt is at goal, see pt every 3-6 months
36
HTN Special Considerations
| -Metabolic Syndrome
1. Abdominal Obesity
- Waist circum >40 in men >35 in women
2. Glucose intolerance
- Fasting glucose >/= to 110mg/dl
3. BP >/= 130/85
4. High triglycerides >/= 150mg/dl/ OR Low HDL <40 in men; <50 in females
37
HTN Special Considerations
| -Left Ventricular Hypertrophy
1. INDEPENDENT risk factor that increases risk of subsequent CVD
2. REGRESSION occurs w/ aggressive BP mgmt, including:
- Weight loss
- Sodium restriction
- Treatment w/ previously mentioned drug therapies
38
HTN Special Considerations
| -Peripheral vascular disease?
1. Equivalent in risk to ischemic heart disease
| 2. Treat HTN, manage other risk factors aggressively
39
HTN Special Considerations
| -Elderly Population
1. Start low and Go SLOW!!
- Unsafe drop in BP can cause falls and fractures
2. HTN occurs in 2/3 of individuals older than 65
40
Postural Hypotention
1. A decrease in standing SBP >10
2. Associated w/ dizziness or fainting
3. More frequent with:
- Older Patients with ISH, Diabetes, Pt’s on Diuretics, Vasodilators, and some psychotropic drugs
41
Hypertensive Crisis
| -Definition
1. Defined by SBP >/= to 180 and DBP >/= 120 **
| 2. Can be a Hypertensive Urgency or Hypertensive Emergency
42
Hypertensive Crisis
| -Hypertensive Urgency
1. 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
43
Hypertensive Crisis
| -Hypertensive Emergency
1. Significantly elevated BP w/ s/s of acute ongoing target-organ damage
- Neurologic
- Cardiac
- Vascular
- Renal
Transfer to ER immediately
6030 Primary Care Test 2 Complete ☑️
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