Identification and Management of Hypertension. Definition of HTN

Transcription

1 1 Hypertensin (HTN) is ne f the mst cmmn diagnses in America. One in three individuals has HTN. Bth systlic and diastlic rise in bld pressure frm childhd t adulthd each are independent risk factrs fr cardivascular (CVD) disease. The ppulatin is aging and as HTN develps in individuals > 65 years f age, the risk f rgan damage and CVD rises. This jb aid is a guideline that will prvide best practice infrmatin related t identificatin and management f HTN. Definitin f HTN Bld pressure is the frce within arterial structures created by the interplay f vlume, flw, and cnstrictin. HTN, r high bld pressure, is defined as determining the levels f bld pressure that cause target rgan damage, mrtality, and mrbidity. The Natinal Heart, Lung, and Bld Institute (NHLB) has issued guidelines thrugh the advisry f The Jint Natinal Cmmittee n Preventin, Detectin, Evaluatin, and Treatment f High Bld Pressure (JNC) designed t increase awareness, preventin, and treatment/cntrl f hypertensin. JNC has prvided classificatins f bld pressure values based n risk thrugh clinical trials. In 2003, the JNC 7 th reprt added a new categry that was designated as prehypertensin. These patients are cnsidered at increased risk fr prgressin t hypertensin. Classificatin and management f bld pressure fr adults: BP SBP DBP Lifestyle Withut indicatin With Indicatins Classificatin mmhg mmhg Mdificatin Nrmal <120 and <80 Encurage N medicatin Meds fr cmpelling indicatins* Prehypertensin Or Yes N medicatin Meds fr cmpelling indicatins* Stage 1 HTN Or Yes Thiazide-type diuretics. May cnsider ACEI, ARB, BB, CCB, r cmbinatin Drug fr the cmpelling indicatins.* Other antihypertensive drugs (diuretics, ACEI, ARB, Stage 2 HTN >160 Or >100 Yes Tw drug cmbinatin (Thiazide-type diuretics and ACEI r ARB r BB r CCB) BB, CCB) as needed Drug fr the cmpelling indicatins.* Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed *treatment determined by highest BP categry. DBP, diastlic bld pressure; SBP, systlic bld pressure Drug abbreviatins: ACEI, angitensin cnverting enzyme inhibitr; ARB, angitensin receptr blcker; BB, beta-blcker; CCB, calcium channel blcker *NHLB is leading the develpment f the updated JNC 8 guidelines expected release in 2012 The recmmended gal fr bld pressure in uncmplicated hypertensive patients is <140/90, hwever this may nt necessarily be the target fr an elderly patient with HTN. A lwer bld pressure target may be cnsidered ptimal fr special ppulatins. ACCF/AHA BP Recmmendatins fr Preventin and Management f Heart Disease in Elderly Disease BP Gal (mmhg) Left ventricular dysfunctin <120/80 Diabetes <130/80 Chrnic renal disease <130/80 Cartid artery disease <130/80 Peripheral artery disease <130/80 Abdminal artic aneurysm <130/80 Uncmplicated HTN <140/80

2 2 Physical Assessment Accrding t the updated AHA/ACC guidelines, the diagnsis f HTN shuld nw be based n at least three different bld pressure measurements, taken n tw r mre separate ffice visits. Physical assessment f the patient with a histry f HTN includes: identifying lifestyle and cardivascular risk factrs; measurement f accurate bld pressure values; evaluating fr ptential causes f HTN during histry taking (i.e. sleep apnea r chrnic kidney disease); calculatin f bdy mass index (BMI) r measurement f waist circumference; auscultatin fr cartid, abdminal, and femral bruits; thrugh examinatin f the abdmen fr enlarged kidneys, masses, and abnrmal artic pulsatin; palpatin f the lwer extremities fr edema and pulses with circumference measurements fr peripheral and central edema; and a neurlgical assessment. Accurate measurement f bld pressure includes: Use a prperly calibrated and validated instrument Patient shuld be seated quietly fr at least 5 minutes in a chair with feet n the flr and arm supprted at heart level (measurement in the standing psitin fr thse at risk fr pstural hyptensin) Smking and caffeine shuld be avided fr 30 minutes prir t measuring An apprpriate size cuff (cuff bladder encircling at least 80% f the arm) t ensure accuracy At least tw bld pressure measurements shuld be taken Risk Factrs The risk factrs fr HTN are significant fr bth systlic and diastlic measurements. The develpment f HTN is multifactrial and requires a thughtful apprach twards preventin, diagnsis, and treatment. Althugh cntrl f bld pressure is significant t preventin, risk factr cntrl is mst relevant t preventing mrtality. Literature des nt suggest that lder adults shuld differ frm yunger adults in respnse t multiple risk interventins. An interdisciplinary apprach is the best apprach fr reducing risk and develping a treatment plan with bth subsets f patients. There are varius mdifiable and nnmdifiable risk factrs that increase an individual s chance f develping HTN. Nnmdifiable Risk Factrs Risk Factr Age and Aging Gender Heredity Race Cmments Increased risk with age > 35 years: Men between 35-55, Females after menpause Befre age 55, prevalence higher in men; after 55, prevalence higher in wmen Parents r clse relatives increases risk; strng influence in develpment at yunger age Highest risk in African Americans; 41.8% in men and 45.4% in wmen

3 Mdifiable Risk Factrs Risk Factr Obesity Dietary Sdium Lack f physical activity Stress Alchl Cnsumptin Smking Cmments 3 Bdy mass index f 30.0 r higher High sdium intake in daily lifestyle habit Inactivity and sedentary lifestyle can increase weight and risk f HTN Can be a factr, hwever stress levels are difficult t measure and respnses vary Heavy and regular use f alchl can increase bld pressure dramatically Smking adversely affects vasculature, prmting athersclersis and risk f strke Evaluatin f the patient with a histry f HTN shuld include assessment f risk factrs. Identified mdifiable risk factrs shuld be incrprated int the plan f treatment t supprt the patient in weight management, dietary discretin, stress reducing activities, smking cessatin, and hme activity prgram. Cmmunity referral fr excessive alchl cnsumptin may be a cnsideratin. Strategies t engage the patient in behavir change will be discussed in the Management f HTN sectin f this jb aid. Differentiate Between Primary and Secndary HTN Primary HTN, als called essential HTN, tends t develp gradually ver the years and the underlying cause is cnsidered idipathic. The vast majrity f individuals fall int the categry f primary vs. secndary HTN. There are ften interrelated genetic and envirnmental factrs that play a rle in the develpment f essential HTN. Cnsideratin has been prpsed fr pathlgical mechanisms that may be invlved in the initiatin f primary HTN: excessive mycardial cntractility as a result f neurhrmnal stimulatin; excessive dietary sdium intake with a ptential inability t excrete sdium via kidneys ver several years; dysfunctinal rennin-angitensin feedback lps; vascular capillary rarefactin; and central besity. Secndary HTN, high bld pressure that develps frm a clear, identifiable cause is called secndary HTN. Althugh secndary HTN accunts fr apprximately 5% f all cases, it is imprtant t recgnize that this translates t almst 3 millin cases. Secndary HTN tends t be acute in nature and can cause uncntrlled HTN r hypertensive emergencies. Varius cnditins r drugs that lead t secndary HTN are: Renvascular cnditins Sleep apnea Adrenal gland tumrs Hyperaldsternism Cushing s Syndrme Thyrid disease Carctatin f the arta Drugs such as ral cntraceptives, sterids, alchl, ccaine, amphetamines These cnditins are generally identified when taking the patient histry. It is imprtant t evaluate if there are cmplicatins that need t be addressed in the plan f treatment.

4 4 Pathphysilgy f HTN in the Elderly The pathphysilgy behind the increase in HTN prevalence with age can be cntributed t age related changes in the arterial structure and functin. Large vessels such as the arta, becme less distensible frm fatigue f elastin, cllagen depsitin, and calcificatin. This leads t increases in vessel diameter and intima-media thickness. There are als several functinal alteratins that impact the aging cardivascular system in the elderly including increased stiffening and decline in flw mediated dilatin. As a result f these changes, there is a gradual rise in systlic bld pressure acrss the life span with aging. Link t Vascular Diseases HTN is a majr risk factr fr vascular diseases, specifically heart failure, strke, renal disease, and mycardial infarctin (MI). The cmplicatins can be divided int tw basic categries: hypertensive r athersclertic. Hypertensive cmplicatins include such cnditins as heart failure, left ventricular hypertrphy, renal insufficiency, and artic dissectin. Athersclertic cmplicatins can lead t cerebral thrmbsis, MI, crnary artery disease, and claudicatin syndrmes. These vascular changes play a primary rle in specific rgan damage that accmpanies sustained HTN. The lnger the bld pressure remains elevated, the greater the mrbidity and mrtality. The classificatin f prehypertensin was develped t recgnize the relatinship between sustained elevated bld pressure and the risk f CVD and cmplicatins. The need fr a mre aggressive apprach t preventin and increased educatin f healthcare prfessinals and the general public has becme a fcus. Thus it is essential fr clinicians in the hme care setting t becme advcates f bld pressure management t decrease mrtality and mrbidity related t HTN. Management f HTN The apprach t management f patients with HTN is maintaining cntrl f bld pressure levels thrugh lifestyle mdificatin, pharmaclgic therapy and daily self-mnitring. Nnpharmaclgic Therapy Lifestyle mdificatins may be the nly treatment necessary t cntrl HTN r reduce the need fr multiple cmbinatins f antihypertensive therapy. There are several interventins aimed at secndary preventin t reduce cntrllable risks such as Weight management Sdium restrictin Physical activity Smking cessatin Cping with stress

5 5 Pharmaclgic Therapy There are several classes f drugs utilized t treat HTN. The ultimate gal f antihypertensive therapy is the reductin f cardivascular and renal mrtality and mrbidity. Mst patients that have participated in antihypertensive trials in the lder adult age grup were <80 years f age, thus limiting clinical infrmatin relevant t ctgenarians. As a result, firm guidelines fr recmmendatins n drug treatment in the 80 years and lder age grup is still incnclusive. As clinicians caring fr patients in the hme setting, it is essential t be cgnizant f plypharmacy issues in the elderly and t evaluate fr adverse reactins related t their drug regimen. Educating patients n prescribed medicatin, dse, mechanism f actin, mnitring required, and side effects is critical. The teach-back methd is an excellent apprach t ensure patient understanding. Angitensin Cnverting Enzyme (ACE) Inhibitrs: relaxes bld vessels by blcking frmatin f the hrmne angitensin II that narrws bld vessels causing a rise in bld pressure (Captpril, Enalapril, Lisinpril, Fsinpril, Benazepril, Ramipril, Quinapril) Angitensin Receptr Blckers: relaxes bld vessels by blcking the actin, nt frmatin f angitensin II that narrws bld vessels causing a rise in bld pressure (Candesartan, Eprsartan, Lsartan, Valsartan, Olmesartan, Irbesartan, Telmisartan) Diuretics: eliminates sdium and water and reduces bld vlume Lp Diuretic: Fursemide, Bumetanide, Trsemide Thiazide Diuretic: Chlrthiazide, Hydrchlrthiazide, Metlazne, Plythiazide, Indapamide Ptassium-Sparing: Amiride, Triamterene Aldsterne Receptr Blckers: Eplerenne, Spirnlactne Beta Blckers: dilates bld vessels and reduces wrklad n the heart. Lwers heart rate and bld pressure (Atenll, Betaxll, Bisprll, Metrprll, Nadll, Prpranll, Timll, Carvedill, Labetall) Calcium Channel Blckers: relaxes muscles f bld vessels thrugh blcking f calcium exchange in the cells, thus reducing bld pressure (Diltiazem, Verapamil, Amldipine, Feldipine, Nifedipine) Self-Mnitring Bld Pressure Self-Mnitring Bld Pressure will benefit patients by prviding real time infrmatin n respnse t pharmaclgic therapy and adherence t diet. It wuld be imprtant t educate patients n their ptimum bld pressure levels, factrs affecting bld pressure, and the treatments necessary fr cntrl f bld pressure vs. cure f bld pressure. Interventins shuld include teaching abut symptms t recgnize if patients are ut f nrmal bld pressure parameters r cmplicatins related t hypertensive emergencies. Self-mnitring and dcumenting in a daily lg als prvides the physician infrmatin relevant t evaluating white-cat HTN.

6 Mtivating Behavir Change 6 A majr challenge in reducing HTN and cmplicatins is mtivating behavir change. In an effrt t tailr yur plan f treatment t imprve adherence and engage yur patient in participating in change, it may be imprtant t evaluate yur patients in terms f these fur subgrups: Subgrup Patients that strive t cntrl bld pressure thrugh lifestyle and medicatins Patients wh rely almst exclusively n medicatins t cntrl their bld pressure Patient wh rely almst exclusively n medicatins t cntrl their bld pressure but are likely t frget t take their medicatins Patients that are nt afraid f having HTN and d nt believe that nt taking medicatins will be a threat t their health Interventins Needs educatin and reinfrcement f their current ability t manage their HTN Needs educatin and assistance t engage in lifestyle mdificatin Needs assistance in incrprating their medicatins int their daily rutine and strategies n behavir change related t mdifiable risks Evaluate fr barriers such has health literacy, selfefficacy, finances, transprtatin, and supprt netwrk t develp individual strategies t engage patient in understanding the imprtance f bld pressure cntrl Patient attitudes are greatly influenced by cultural beliefs, health literacy, and previus experiences with the healthcare system. Evaluating the patient s self-efficacy in managing their bld pressure will prvide a basis fr pririties with develping gals and interventins fr the patient. Mtivatin imprves when patients have psitive experiences and small successes early n with self-management. Utilizing a Patientcentered apprach t achieve therapeutic bld pressure levels will lead t imprved patient utcmes.