1. HYPERTENSION MANAGEMENT IN THE Cv disease PATIENT
Mary J. Hackbarth MSN,FNP, ARNP-C

2. OBJECTIVES
Define potential modifiable and non- modifiable risk factors for the development of hypertension
Describe medication guidelines for the treatment of hypertension
Discuss key components of lifestyle modification critical to adequate blood pressure control in the hypertensive patient

3. INTRODUCTION
Treatment of HTN is the Most Common Reason for Office Visits in Non-Pregnant Adults
Number of Patients with HTN is Likely Growing (Advancing Age & Obesity)
Control of the Disease is Far from Adequate

4. STATISTICS
Approximately 75 Million American Adults (32%) or 1 of Every 3 Adults with HTN
ONLY HALF (54%) with HTN are Considered to Have HTN Controlled
Another 1 in Every 3 Adults is Considered to Have Elevated Blood Pressure (Pre- Hypertension) Not Yet Treated
HTN Costs the United States 46 Billion Dollars Each Year for Health Care Services, Medications, and Missed Days of Work
(CDC.GOV)

5. STATISTICS
More than 410,000 American Deaths in Included HTN as a Primary Contributing Cause (More Than 1,100 Deaths Each Day)
About 7 of Every 10 People Having their First MI Have HTN
About 8 of Every 10 People Having their First CVA Have HTN
About 7 of Every 10 People with Chronic CHF Have HTN
About 1 in 5 Adults Unaware of their HTN
(CDC.GOV)

6. PREVALENCE BY RACE African Americans 44.3% Caucasian Americans 32.6%
Hispanic Americans %

7. STATISTICS

8. TYPES OF HYPERTENSION Primary (Essential) Hypertension
95% of all Hypertension Cases
Cause of Hypertension not Known
Genetic Factors – Inappropriate High Activity of Renin-Anigotensin-Aldosterone System and Sympathetic Nervous System Activation
Environmental Factors – Excessive Salt Intake, Obesity, or Sedentary Lifestyle

9. TYPES OF HYPERTENSION Secondary Hypertension
5% of all Hypertension Cases – Cause Identifiable and sometimes treatable
OTC Medications - Oral Contraception with High Estrogen, NSAIDs, Decongestants – Pseudoephedrine, Weight Loss Medications
Prescription Medications – TCAs, SSRIs, Prescription Weight Loss Medications, Cyclosporine, Stimulants – Methylphnidate & Amphetamines, Erythropoietin, Glucocorticoids
Illicit Drug Use (Methamphetamines & Cocaine)
Renal Disease (Acute and Chronic)
Renal Artery Stenosis
Obstructive Sleep Apnea
Pheochromocytoma
Thyroid Disorders
Coarctation of the Aorta

10. hypertension RISK FACTORS
Advancing Age
Obesity
Family History
Race – African Descent 2 x as Common
High Sodium Diet
Excessive ETOH Consumption
Physical Inactivity
Diabetes
Dyslipidemia
Personality Traits (Depression, Hostility, Impatience, etc.)
Nicotine Abuse

11. DIAGNOSIS OF HYPERTENSION
Systolic Blood Pressure
Diastolic Blood Pressure
Normal Blood Pressure
<120mmHg
<80mmHg
Pre-Hypertension
mmHg
80-89mmHg
Stage I Hypertension
mmHg
90-99mmHg
Stage II Hypertension
>160mmHg
>100mmHg

12. DIAGNOSIS OF HYPERTENSION
<150/90mmHg for most patients 60 years and older with NO diabetes or CKD
<140/90mmHg for patients without comorbidities or >60 WITH diabetes or CKD
Diagnosis of hypertension usually made after 2 elevated readings at 2 separate visits (Unless dangerously high >180/110mmHg)
Arm cuffs preferred vs. Wrist or finger cuffs
Automatic cuffs preferred vs. Manual cuffs
Proper cuff size with bilateral arm measurements on initial evaluation – Arm with higher reading utilized

13. HYPERTENSION WORK-UP Electrolytes BUN / Creatinine Lipids Hgb / Hct
Elevated K+ Possible Kidney Disease
Low K+ Possible Aldosterone Excess
BUN / Creatinine
Evaluate for Kidney Disease (GFR)
Lipids
Elevated LDL / Low HDL – Increased CV Risk
Hgb / Hct
Anemia secondary to CKD etc.
RBCs / WBCs
Infections etc.
Norepinephrine / Norepinephrine Levels
Pheochromocytoma
LFTs
Fatty Liver Disease
Urine Sample
Aluminuria – CKD and Associated with Increased CV Events
EKG –
LVH / MI / Cardiac Arrhythmias – Atrial Fibrillation
Echocardiography –
LVH / Valvular Disease

14. Complications of uncontrolled hypertension
LVH – EARLY and Common Finding (Lead to CHF, MI, Sudden Death)
Ischemic Heart Disease (MI & PCI)
Ischemic CVA
Aneurysms / Dissection / PVD
Intracranial Bleed
Chronic Kidney Disease / ESRD
Retinopathy

15. LVH – LEFT VENTRICULAR HYPERTROPY BY EKG

16. LVH – LEFT VENTRICULAR HYPERTROPHY BY ECHO

17. LEFT VENTRICULAR HYPERTROPHY

18. LEFT VENTRICULAR HYPERTROPHY

19. FIRST LINE MEDICATION THERAPY
ACE-Inhibitor Therapy (Zestril - Lisinopril, Lotensin - Benazepril)
ARB-Therapy (Cozaar - Losartan, Diovan - Valsartan, Benicar - Olmesartan)
Thiazide-Type Diuretic Therapy (HCTZ, Chlorthalidone)
Calcium Channel Blockers (Norvasc - Amlodipine)

20. later-line alternative medication therapy
Beta-blockers (metoprolol, atenolol)
Alpha-blockers (doxazosin)
Alpha1/beta-blockers (carvedilol)
Vasodilating beta-blockers (nebivolol)
Central alpha2-adrenergic agonists (clonidine)
Direct vasodilators (hydralazine)
Loop diuretics (furosemide)
Aldosterone antagonists (spironolactone)
Peripherally acting adrenergic antagonists (reserpine)

21. Rationale for medication selection
ALL patients with CKD regardless of ethnicity
ACE-Inhibitor Therapy
ARB Therapy
Can use the ACE-Inhibitor or ARB as first the line therapy or in addition to first line therapy
Avoid the use of ACE-Inhibitor Therapy simultaneously with ARB Therapy
Calcium Channel Blockers and Thiazide Type Diuretics – Preferred if Age > 75 with CKD
African American Descent WITHOUT CKD
Calcium Channel Blocker Therapy
Thiazide Diuretic Therapy
ACE-Inhibitory – Less blood pressure response

22. RATIONALE FOR MEDICATON SELECTION

23. Beers criteria
Updated / Maintained by the American Geriatric Society (AGS)
Guide for Potentially Inappropriate Medication Usage in Adults > 65 Years of Age
Leading Source of Information About the Safety of Prescribing Drugs for Older Adults
Help Prevent Medication Side Effects and Other Drug-Related Problems in Older Adults
Identifies Medications with Risks that may be Greater than their Potential Benefit in People over the Age of 65

24. BEERS CRITERIA
34 Medications are Identified as “Potentially Inappropriate” for Individuals > 65
Medications used for 14 Common Health Problems are Potentially Inappropriate OR may not be Completely Effective OR make the Condition Worse
Drugs on the Beers Criteria may still be Utilized in the Adult > 65 as they may still be the Best Choice but may need more Careful Monitoring While Administered

25. BEERS CRITERIA

26. LIFESTYLE MODIFICATIONS
DASH Diet
Emphasize – Fruits, Vegetables, Whole Grains, Low Fat Dairy Products, Poultry, Fish, Legumes,Nuts
Limit – Intake of Sweets, Sugar Beverages, Red Meats
Aim for Dietary Pattern with 5-6% of Calories from Saturated Fat
Sodium Restriction
Sodium – 2,400mg (1,500mg Further BP Reduction)
(ACC)

27. LIFESTYLE MODIFICATIONS
PHYSICAL ACTIVITY
3-4 Sessions per Week Lasting 40 Minutes per Session
Moderate to Vigorous Intensity
Helps with Weight Control and Lipid Management as well as Hypertension
(ACC)

28. Thank you