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

Increased uric acid level

Hypercalcemia

Impotence

Photosensitivity

They should be used cautiously in patients at risk for developing diabetes.

ACE inhibitors block the conversion

of angiotensin I to angiotensin II,

thus lowering peripheral arteriolar

resistance and lowering blood

pressure.

Side effects include:

Hypotension

Cough

Hyperkalemia

Headache

Dizziness

Fatigue

Nausea

Renal impairment

ACE inhibitors are contraindicated in pregnancy

and bilateral renal artery stenosis.

ARBs are receptor antagonists that block angiotensin II receptors on blood vessels and other tissues such as the heart. These receptors stimulate vascular smooth muscle contraction.

Because ARBs do not inhibit ACE, they do not cause an increase in bradykinin, which produces some of the side effects of ACE inhibitors (cough and angioedema).

Side effects include:

Hyperkalemia

Hypotension

Dizziness

Headache

Drowsiness

Diarrhea

Abnormal taste sensation (metallic or salty taste)

Rash

ARBs are contraindicated in pregnancy and bilateral renal artery stenosis.

Calcium channel blockers work by blocking calcium channels in cardiac muscle and blood vessels. This decreases intracellular calcium leading to a reduction in muscle contraction.

In the heart, a decrease in calcium available for each beat results in a decrease in cardiac contractility, which in turn decreases cardiac output.

In blood vessels, a decrease in calcium results in less contraction of the vascular smooth muscle, causing vasodilatation and therefore decrease in peripheral vascular resistance.

There are two types of Calcium Channel Blockers:

Dihydropyridine, such as amlodipine, nifedipine, and felodipine

Non-dihydropyridine, such as verapamil and diltiazem.

Dihydropyridine CCBs reduce peripheral vascular resistance. Side effects include dizziness, tachycardia,

bradycardia, headache, flushing, edema, and constipation.

Non-dihydropyridine CCBs reduce myocardial oxygen demand and reverse coronary vasospasm. Side effects include excessive bradycardia,

impaired electrical conduction (e.g., atrioventricular nodal block), and depressed contractility.

Beta-adrenergic blocking agents, or

beta blockers, work by blocking the

neurotransmitters norepinephrine and

epinephrine (part of the sympathetic

nervous system) from binding to

receptors in different parts of the

body. This causes smooth muscle cells

to relax.

There are three types of beta

receptors:

Beta1, located mainly in the heart

and kidneys

Beta2, located in the lungs, GI tract,

liver, uterus, vascular smooth

muscle, and skeletal muscle

Beta3, located in fat cells

First generation beta blockers, such as propranolol and sotalol, are non-selective, therefore they will block the receptors of beta1 and beta2 cells.

Second generation beta blockers, such as metoprolol, are selective and will only block the receptors of beta1 cells. This reduces heart rate, force of contraction, and cardiac output.

Beta blockers also affect the production of renin, which in turn relaxes smooth muscle cells and lowers blood pressure.

Side effects of beta blockers include: Bradycardia

Cold extremities

Fatigue

Insomnia

Dizziness

Wheezing

Digestive problems

Rash

Erectile dysfunction

They should be used cautiously in patients with asthma.

Thiazide-type diretics have been shown to slow the progression of osteoporosis.

Beta Blockerss are also useful for the treatment of atrial tachyarrhythmias, migraine, thyrotoxicosis, essential tremor, and perioperative hypertension.

Calcium Channel Blockers can be useful in Raynaud’s syndrome and certain arrhythmias.

Thiazide diuretics should be used cautiously in patients with a history of gout or hyponatremia.

BBs should be avoided in patients with reactive airway disease or 2nd or 3rd degree heart block.

ACEIs and ARBs should not be given to women who are or may become pregnant. ACEIs should not be used in patients with a history of angioedema.

Thiazide diuretics have been associated with increased risk of new-onset diabetes, and should be used with caution in patients with glucose intolerance.

Start with the lowest recommended dose of the selected agent.

If the drug is not well tolerated, switch to a drug of a different class.

If target blood pressure is not reached, increase the first agent, or add a second agent.

Addition of a second agent should be considered when adaquate doses of the first agent have not produced adaquate results. It is better to add a second agent before maxing out a first, to decrease the likelihood of potential side effects that can be seen with higher doses.

If a patient is taking a midrange dose and is still >5-10mmHg above goal, adding a second agent is more litely to be effective than increasing the dose.

If blood pressure is still above target, increase one agent at a time. Trial each dose regimen for at leaset 6 weeks, because most drugs take at least 3-4 weeks to achieve maximum benefit.

Once a combination regimen is tolerated and doses are established, the patient could be switched to a combined preparation.

If blood pressure remains elevated

despite optimal doses of at least two

agents after a reasonable time, consider

the following potential reasons: Non-compliance to therapy- compliance decreases

as number of times per day dose increases (79%

once daily, 69% BID, 65% TID, 51% QID)

Use of medications that may increase blood

pressure (NSAIDS, stimulants, sympathomimetics,

alcohol, contraceptives, estrogen, corticosteroids,

licorice, caffeine pills, cold medicines, ephedra,

ginseng, St. John’s wort)

secondary hypertension, such as CKD/obstructive uropathy, renovascular hypertension, aortic coarctation, cushing’s syndrome, thyroid disease

undiagnosed sleep apnea

undisclosed alcohol, tobacco, or drug use

undisclosed or unrecognized high sodium diets

“white coat” hypertension- for which 24 hour ambulatory blood pressure monitoring may be helpful

Most people will require at lease two

medications to control their hypertension

Guidelines recommend a combination

therapy as initial therapy in high-risk

hypertensive individuals, when initial BP

is >20/10 above goal

Avoid: ACE Inhibitors plus potassium-

sparing diuretics, Beta-blockers plus

Verapamil, and ACE Inhibitors plus ARBs

ACEIs and CCBs: Lotrel (amlodipine-

benazepril), Lexxel (trandolapril-

verapamil)

ACEIs and diuretics: Lotensin HCT

(Benazepril-HCTZ), Zestoretic (Lisinopril-

HCTZ), Vaseretic (Enalapril-HCTZ)

ARBs and diuretics: Atacand HCT

(Candesartan-HCTZ), Hyzaar (Losartan-

HCTZ), Benicar HCT (Olmesartan-HCTZ),

Diovan HCT (Valsartan-HCTZ)

BBs and diuretics: Tenoretic (Atenolol-

chlorthalidone), Lopressor HCT (Metoprolol-

HCTZ)

Diuretic and diuretic: Aldactazide

(Aldactone-HCTZ), Maxzide (Triamterene-

HCTZ)

Follow-up should include monthly blood pressure checks until goal is reached. More frequent visits may be indicated for patients with stage II hypertension, or those with comorbid conditions.

After blood pressure is shown to be at goal, visits can generally be moved to every 3 to 6 months

Serum creatinine and potassium should be monitored 1-2 times per year

Tobacco avoidance should be strongly encouraged

Low dose aspirin therapy can be considered when a patient is at goal, but not sooner due to risk of hemorrhagic stroke with uncontrolled HTN

Patient motivation improves blood pressure control and should be encouraged at each visit. Home blood pressure monitoring can help patients take ownership of their hypertension, and so become motivated to adhere to treatment.

The cost of medications can also affect compliance. Wal-mart has a $4 drug list, that can be helpful for those without insurance.

Amiloride-HCTZ 5mg-50mg

Atenolol-Chlorthalidone 100mg

Atenolol 25, 50, 100mg tab

Benazepril 5, 10, 20, 40mg

Bisoprolol-HCTZ 2.5mg-6.25mg tab

Bisoprolol-HCTZ 5mg-6.25mg

Bisoprolol-HCTZ 10mg-6.25mg tab

Captopril 12.5, 25, 50, 100mg

Carvedilol 3.125, 6.25, 12.5, 25mg tab

Clonidine 0.1, 0.2mg tab

Diltiazem 30, 60, 90, 120mg tab

Doxazosin 1, 2, 4, 8mg tab

Enalapril-HCTZ 5mg-12.5mg

Enalapril 2.5, 5, 10, 20mg tab

Furosemide 20, 40, 80mg tab

Hydralazine 10, 25mg tab

Hydrochlorothiazide(HCTZ)12.5mg cap

Hydrochlorothiazide (HCTZ) 25, 50mg tab

Indapamide 1.25, 2.5mg tab

Isosorbide Mononitrate 30, 60mg ER tab

Lisinopril-HCTZ 10mg-12.5mg

Lisinopril-HCTZ 20mg-12.5mg

Lisinopril-HCTZ 20mg-25mg

Lisinopril 2.5, 5, 10, 20mg tab

Methyldopa 250mg tab

Metoprolol Tartrate 25, 50, 100mg tab

Nadolol 20, 40mg tab

Prazosin HCL 1mg cap

Propranolol 10, 20, 40, 80mg

Sotalol HCL 80mg tab

Spironolactone 25mg tab

Terazosin 1, 2, 5, 10mg cap

Triamterene-HCTZ 75mg-50mg tab

Triamterene-HCTZ 37.5mg-25mg tab

Verapamil 80, 120mg tab

Withdrawl of antihypertensives may be

considered in patients who have

achieved target blood pressure at low

doses and agree to continue lifestyle

modifications, undergo regular blood

pressure monitoring, and reinstitute

antihypertensives if necessary.

Ischemic heart disease The most common form of target organ

damage associated with hypertension is Ischemic heart disease.

In patients with hypertension and stable angina, beta-blockers or long acting calcium-channel blockers are indicated.

In patients with ACS, treatment should be beta blockers and ace inhibitors, as well as nitrates.

For patients post-MI, beta blockers, ACEIs, and aldosterone antagonists have shown to be the most benificial. Aspirin and lipid therapy should also be initiated.

Heart failure

For paitents with systolic heart failure, or left ventricular dysfunction, ACEIs and BBs are recommended.

For those who are symptomatic or at end-stage heart disease, ACEIS, BBs, ARBs, aldosterone blockers, and loop diuretics are indicated.

Diabetic Hypertension

Usually a combination of two or more antihypertensives will be needed to achieve a blood pressure of <130/80.

Thiazide diuretics, BBs, ACEIs, ARBs, and CCBs have been shown to reduce Cardiovascular disease and stroke in diabetic patients.

ACEIs and ARBs have been shown to slow the progression of diabetic nephropathy and reduce albuminuria.

Chronic Kidney Disease

In patients with CKD, the goal of therapy is to slow deterioration of renal function, and prevent cardiovascular disease.

Target blood pressure in these patients is <130/80.

ACEIs and ARBs have shown to slow the progression of renal disease. A rise of as much as 35% above baseline in serum creatinine is found to be acceptable and should not cause discontinuation of therapy unless hyperkalemia develops.

With advanced renal disease, loop diuretics will also be necessary in combination with other antihypertensives.

Cerebrovascular disease

In an acute stroke, blood pressure is recommended to be maintained around 160/100 until the condition has stabilized.

A combination of thiazide-type diuretics and ACEIs have been shown to lower recurrent stroke rates.

Aggressive antihypertensive therapy appears to be safe to reinitiate 1-2 weeks after the acute event, when the patient has been deemed clinically stable.

Pregnancy

Methyldopa, Beta Blockers, and

vasodialators are considered to be the

safest medications.

ACEIs and ARBs should not be used due to

the possibility of fetal defects.

Methydopa and labetalol are the most

widely used medications to treat pregnant

women.

Hypertensive Emergency Hypertensive Urgency is defined as SBP > or

=180 and/or DBP >or=120 without evidence of target organ dysfunction. These patients require immidiate intervention and may need to be hospitalized.

Hypertensive Emergency is defined as SBP >or= 180 and/or DBP >or=120 with evidence of target organ dysfunction, such as coronary ischemia, disordered cerebral function, cerebrovascular events, pulmonary edema, and renal failure. These patients require hospitalization and immediate treatment.

References Campbell, N. Hemmelgarn, B. (2012). New recommendations for the use of ambulatory

blood pressure monitoring in the diagnosis of hypertension. Canadian Medical

Association Journal, 184(6), 633-634.

Corrao, G., Nicotra, F., Parodi, A, Zambon, A. (2011). Cardiovascular protection by

initial and subsequent combination of antihypertensive drugs in daily life practice.

Hypertension, 58(4), 566-572.

Mukherjee, D. (2012). Atherogenic vascular stiffness and hypertension: Cause or effect?

The Journal of the American Medical Association, 308(9), 919-920.

Park, C., Youn, H., Chae, S. (2012). Evaluation of the dose-relationship of Amlodipine

and Losartan combination in patients with essential hypertension. American Journal

Cardiovascular Drugs, 12(1), 35-47.

References Sever, P., Messereli, F. (2011). Hypertension management 2011: Optimal medical

therapy. European Heart Journal, 32(20), 2499-2506.

http://www.heartfoundation.org.au/SiteCollectionDocuments/HypertensionGuidelines2008to2010

Update.pdf Retrieved December 11, 2012

http://www.icsi.org/hypertension_4/hypertension_diagnosis_and_treatment_4.html Retrieved

December 11, 2012

http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf Retrieved December 11, 2012

1. The percentage of adults in the United States with Hypertension is:

C )30%

2. Risk factors for Hypertension include all of the following except:

D) Cancer

3. Which of the following is a potential secondary drug-induced cause of hypertension?

C) Phenylpropanolamine

4. Which of the following patients is at very high risk for cardiovascular disease and should immediately receive a medication to lower blood pressure?

C) A 68-year-old man with heart failure and a baseline blood pressure of 150/88 mm Hg

5. Which of the following would be most appropriate for a patient with hypertension who has had a myocardial infarction?

C) Metoprolol

6. Which of the following is the most appropriate blood pressure goal for a 65-year-old African-American with hypertension and no other medical problems?

A) <140/90 mm Hg

7. In order to minimize the risk of hypokalemia from diuretics, the most appropriate strategy would include:

A) limiting the dose of hydrochlorothiazide to 12.5 to 25 mg

8. In a patient with heart failure, the best combination of medications would be:

C) Lisinopril and Coreg

9. Which of the following is an appropriate agent and starting dose for a patient with uncomplicated hypertension?

A) Atenolol 25 mg once daily

10. Which drug is most likely to cause vasodilation-type side effects (headache, flushing) because it blocks the movement of calcium across smooth muscle cells?

E) Verapamil

11. When patients with renal insufficiency develop severe cough from ACE inhibitors, what would be the best alternative to provide renal protection?

C) Losartan

12. Which of the following is true concerning clonidine?

A) It has been used for smoking cessation and narcotic withdrawal.

13. Which of the following is a contraindication to enalapril?

A) Bilateral renal artery stenosis

14. What potential side effects would you mention to a patient recently started on nifedipine?

D) Leg edema

15. A 39-year-old woman with hypertension is taking HCTZ, enalapril (Vasotec), and diltiazem (Cardizem). She desires to become pregnant. The most important step would be to

D) discontinue enalapril.

16. The agent of choice for a patient with diabetes is

E) enalapril.

17. Which one of the following nondrug measures is likely to be most effective to lower blood pressure chronically?

C) Lose 10-15 pounds