Introduction III Benefits of Treating to Target Older than 60 with isolated systolic hypertension (SBP  160 mm Hg and DBP < 90 mm Hg) –36% reduction in the risk of stroke –25% reduction in the risk of coronary events

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

Hypertension 2. Secondary  cause identifiable - C.V., renal, pregnancy, drugs, corticosteroids - retain Na & H2O

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

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

Complications Kidneys  renal failure Eyes  visual disturbances blindness Peripheral Vessels  intermittent claudication dissecting aortic aneurysm

Mechanisms of 1° Hypertension 1. Overactive SNS stimulation - excite with nonepinephrine -  contractions - vasoconstriction with  workload &  B/P

Mechanisms of 1° Hypertension 2. Na & H2O retention by kidneys - excessive secretion of renin - H2O & Na retained -  volume &  perfusion =  B/P - Most likely cause

Hypertension Causes are however numerous & interrelated - environment - psychological - physiologic

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

Vasoconstriction   heart contractions (  afterload) to maintain C.O.  chronic overwork  L.V. hypertrophy   coronary insufficiency M.I. 

Con’t LVF eventually   renal perfusion  Na & H2O retention   blood flow to kidneys, heart, eyes, brain  Progressive Impairment

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

Secondary Hypertension Causes are numerous  ICP anemia aortic regurgitation

Secondary Hypertension Mechanisms 1.  secretion catecholamines 2.  release renin 3.  Na & blood volume Dx: B/P high over several readings averages >140 > 90

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

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

History con’t Weight gain Na intake stress, cultural food practices Risk factors   chol. Obesity  history of exercise

Physical Exam Retina  edema, hemorrhage Neck  distended veins, bruit Heart   HR, murmurs Extremities   p.p., edema

Interventions Nonpharmacological - weight reduction - exercise -  Na - relaxation - monthly BP checks -  Ethol, coffee - smoking cessation

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

Pharmacological Diastolic > Diuretics a) thiazides - promote excretion Na & H2O - Diuril, hydrodiuril - hypokalemia possible b) loop diuretics - loop of Henle - minimize H2O & Na reabsorption - Lasix

Pharmacological Diastolic > Diuretics c) Potassium sparing - promote H2O & Na excretion - hyperkalemia - aldactone 2. Sympatholytic Agents - interrupt activity SNS with  renin activity - catapres & aldomet

Pharmacological Diastolic >95 3. Vasodilators - dilate peripheral blood vessels - Apresoline, minipres 4. Angiotension converting enzyme inhibitor - inhibit Angio 1 to Angio 2 -  afterload i.e. captopril

Pharmacological Diastolic >95 5. Ca channel blockers -  C.O. &  rate - nipedine

Hypertensive Crisis Reduction in BP needed stat Malignant hypertension hypertensive encephalopathy -  LOC heart failure toxemia dissecting aneurysm intracranial hemorrhage

Interventions for Crisis ICU IV Drugs Monitoring Continuous EKG

Management Long-term Assess Knowledge- disease process - consequences - administration drugs - diet - exercise - home monitoring Compliance Ineffective coping

Drugs Never  dose Never miss dose Take on time Side effects Never discontinue

Hypotensive Alert Lie down with legs elevated No hot baths No excessive alcohol

Reasons for Noncompliance Asymptomatic Difficult lifestyle changes Annoying side effects Costs