4. 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

7. 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

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

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

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

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

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

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

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

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

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

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

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

20. Secondary Hypertension Causes are numerous  ICP anemia aortic regurgitation

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

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

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

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

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

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

29. 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 90-130 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

30. Pharmacological Diastolic > 95 1. Diuretics a) thiazides - promote excretion Na & H2O - Diuril, hydrodiuril - hypokalemia possible b) loop diuretics - loop of Henle - minimize H2O & Na reabsorption - Lasix

31. Pharmacological Diastolic > 95 1. Diuretics c) Potassium sparing - promote H2O & Na excretion - hyperkalemia - aldactone 2. Sympatholytic Agents - interrupt activity SNS with  renin activity - catapres & aldomet

32. 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

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

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

35. Interventions for Crisis ICU IV Drugs Monitoring Continuous EKG

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

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

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

39. Reasons for Noncompliance Asymptomatic Difficult lifestyle changes Annoying side effects Costs