Introduction III Benefits of Treating to Target

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Introduction IIIBenefits of Treating to Target

• Older than 60 with isolated systolic hypertension
  (SBP ? 160 mm Hg and DBP lt 90 mm Hg)
• 36 reduction in the risk of stroke
• 25 reduction in the risk of coronary events

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Hypertension

• 1. Primary - 90 of all cases
• - cause unknown
• - essential or idiopathic
• Benign ? gradual onset with prolonged
  course
• Malignant ? abrupt with short course
• can be fatal
• severely damages

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Hypertension

• 2. Secondary ? cause identifiable
• - C.V., renal, pregnancy, drugs,
  corticosteroids
• - retain Na H2O

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Hypertension

• Isolated hypertension
• If the patient has increased systolic BP with
  normal diastolic BP

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Complications

• Heart - CAD - ? atherosclerotic changes
• Angina, M.I., (? C.A. blood flow)
• CHF - ? afterload, ? O2 need
• Arrhythmias
• Brain - stroke ? microaneurysms ? hemorrhage

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Complications

• Kidneys ? renal failure
• Eyes ? visual disturbances
• blindness
• Peripheral Vessels ? intermittent claudication
• dissecting aortic aneurysm

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Mechanisms of 1 Hypertension

• 1. Overactive SNS stimulation
• - excite ? with nonepinephrine
• - ? contractions
• - vasoconstriction with? workload ? B/P

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Mechanisms of 1 Hypertension

• 2. Na H2O retention by kidneys
• - excessive secretion of renin
• - H2O Na retained
• - ? volume ? perfusion ? B/P
• - Most likely cause

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Hypertension

• Causes are however numerous
  interrelated
• - environment
• - psychological
• - physiologic

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Hypertension

• No obvious changes at first
• Changes widespread with time
• Large vessels sclerosed (narrowed)
• Small vessel damage

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• Vasoconstriction ? ? heart contractions
  (?afterload) to maintain C.O.
• ?
• chronic overwork
• ?
• L.V. hypertrophy
• ? ?
• coronary insufficiency M.I.
• ?

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Cont

• LVF eventually
• ?
• ? renal perfusion
• ?
• Na H2O retention
• ?
• ? blood flow to kidneys, heart, eyes, brain
• ?
• Progressive Impairment

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Secondary Hypertension

• Causes are numerous
• diabetes
• glomerulonephritis
• corticosteroid Rx
• Drugs - BCP - Amphetamines
• - Estrogens - Thyroid hormones

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Secondary Hypertension

• Causes are numerous
• ? ICP
• anemia
• aortic regurgitation

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Secondary Hypertension

• Mechanisms
• 1. ? secretion catecholamines
• 2. ? release renin
• 3. ? Na blood volume
• Dx B/P high over several readings
• averages gt140
• gt 90

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Assessment

• 1. Extent of organ involvement
• 2. Presence of C.V. risk factors
• 3. ID type

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History

• Family Hx
• Diabetes
• Previous ? B/P
• results of hypertensives
• angina, dyspnea hx
• use of BCP, alcohol, steroids, diet pills

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History cont

• Weight gain
• Na intake
• stress, cultural food practices
• Risk factors ? ? chol.
• Obesity
• ? history of exercise

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Physical Exam

• Retina ? edema, hemorrhage
• Neck ? distended veins, bruit
• Heart ? ? HR, murmurs
• Extremities ? ? p.p., edema

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Interventions

• Nonpharmacological - weight reduction
• - exercise
• - ? Na
• - relaxation
• - monthly BP checks
• - ? Ethol, coffee
• - smoking cessation

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Non Pharmacologic Recommendations for
HypertensionLifestyle Dietary
Dietary Sodium
For age over 44, Restricted to a target range of
90-130 mmol/day. (Limitation of salt additives
and foods with excessive added salt)
Hypertensive patient
Fresh fruits, Vegetables, Low fat dairy
products, Low fat diet, in accordance
with Canada's Guide to Healthy Eating
Dietary Potassium
Daily dietary intake 60 mmol
Calcium supplementation
No conclusive studies for hypertension
Magnesium supplementation
No conclusive studies for hypertension
Jan 18, 2001
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Pharmacological Diastolic gt 95

• 1. Diuretics
• a) thiazides - promote excretion Na H2O
• - Diuril, hydrodiuril
• - hypokalemia possible
• b) loop diuretics - loop of Henle
• - minimize H2O Na reabsorption
• - Lasix

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Pharmacological Diastolic gt 95

• 1. Diuretics
• c) Potassium sparing - promote H2O Na
  excretion
• - hyperkalemia
• - aldactone
• 2. Sympatholytic Agents
• - interrupt activity SNS with ? renin activity
• - catapres aldomet

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Pharmacological Diastolic gt95

• 3. Vasodilators
• - dilate peripheral blood vessels
• - Apresoline, minipres
• 4. Angiotension converting enzyme inhibitor
• - inhibit Angio 1 to Angio 2
• - ? afterload i.e. captopril

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Pharmacological Diastolic gt95

• 5. Ca channel blockers
• - ? C.O. ? rate
• - nipedine

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Hypertensive CrisisReduction in BP needed stat

• Malignant hypertension
• hypertensive encephalopathy - ? LOC
• heart failure
• toxemia
• dissecting aneurysm
• intracranial hemorrhage

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Interventions for Crisis

• ICU
• IV Drugs
• Monitoring
• Continuous EKG

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Management Long-term

• Assess Knowledge - disease process
• - consequences
• - administration drugs
• - diet
• - exercise
• - home monitoring
• Compliance
• Ineffective coping

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Drugs

• Never ? dose
• Never miss dose
• Take on time
• Side effects
• Never discontinue

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Hypotensive Alert

• Lie down with legs elevated
• No hot baths
• No excessive alcohol

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Reasons for Noncompliance

• Asymptomatic
• Difficult lifestyle changes
• Annoying side effects
• Costs