Hypertension
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.According to 2017 guidelines from the American College of Cardiology and American Heart Association, normal blood pressure (BP) is defined as a systolic blood pressure (SBP) less than 120 mmHg and diastolic blood pressure (DBP) less than 80 mmHg. An elevated BP is now defined as a SBP between 120 and 129 mmHg and a DBP less than 80 mmHg; Stage I hypertension (HTN) is now defined as an SBP between 130 and 139 mmHg or a DBP between 80 and 90 mmHg. Stage II HTN is any SBP of 140 mmHg or more or a DBP of 90 mmHg or more.
B.Condition applies to anyone taking antihypertensive medication or a person who is told by a clinician on two separate occasions that his or her BP is greater than or equal to 140 mmHg/90 mmHg.
Incidence
A.According to the National Health and Nutrition Examination Survey (NHANES), HTN affects 86 million U.S. adults (age ≥20 years) with a prevalence of 34%.
B.Majority of patients (90%–95%) are diagnosed with primary (idiopathic) HTN.
C.Global prevalence of approximately 972 million individuals (26% of world’s population).
D.Globally, African Americans maintain the highest prevalence rate of HTN and experience the highest mortality rates from associated complications including cardiovascular disease, end-stage renal disease, and cerebrovascular accidents (CVAs).
Pathogenesis
A.Believed to be multifactorial, with many sites of target organ damage.
1.Cardiac: Left ventricular hypertrophy (LVH), myocardial infarctions (MIs), congestive heart failure (CHF), and acceleration of atherosclerosis.
2.Central nervous system (CNS): CVAs, transient ischemic attacks (TIA).
3.Renal: Chronic kidney disease (CKD).
4.Vascular: Peripheral vascular disease (PVD).
5.Ophthalmological: Retinopathy.
B.In increased systemic vascular resistance (cardiac afterload), concentric LVH, and decreased left ventricular function secondary to left ventricular dilatation: Leads to a weakened heart muscle and eventual CHF.
C.Decreased stroke volume and cardiac output.
D.Endothelial cell dysfunction due to altered renin–aldosterone–angiotensin cascade.
Predisposing Factors
A.Nonmodifiable risk factors.
1.Age: Both SBP and DBP increase with age.
2.Gender.
a.Until age 45, more males are affected than females.
b.From ages 45 to 64, males and females are affected equally.
c.After age 65, more females are affected than males.
3.Race and ethnicity: Most common in African Americans.
4.Hereditary: Heritable component between 33% and 57% according to Framingham Heart Study.
B.Modifiable risk factors.
1.Sedentary lifestyle; obesity (BMI ≥30 kg/m²).
2.Increased sodium intake.
3.Increased alcohol consumption (8 oz. wine or 24 oz. beer per day).
4.Tobacco use.
5.Hyperlipidemia: Elevated low-density lipoprotein (LDL) cholesterol (or total cholesterol ≥240 mg/dL) or low HDL cholesterol.
6.Diabetes mellitus as a component of metabolic syndrome.
Subjective Data
A.Common complaints/symptoms.
1.Headache (particularly headache upon awakening) and dizziness.
2.Visual changes; subconjunctival hemorrhages.
3.Epistaxis.
B.History of the present illness.
1.Documented elevated BP on three separate occasions (three clinic visits required for HTN diagnosis).
a.Based on average of two or more readings at each follow-up visit after initial screening.
2.HTN-related comorbidities and evidence of target end-organ damage.
3.Possible evaluation for secondary causes of HTN based on patients’ symptomatology.
a.Pheochromocytoma: Facial flushing, labile HTN, and palpitations.
b.Hypothyroidism: Cold intolerance, lethargy, and bradycardia.
c.Hyperthyroidism: Heat intolerance, tachycardia, and diaphoresis.
d.Obstructive sleep apnea: Snoring and daytime sleepiness.
e.Hyperparathyroidism: Nephrolithiasis, gastrointestinal symptoms, osteitis fibrosa cystica.
f.Cushing disease: Weight gain, hirsutism, abdominal striae.
C.Family and social history.
1.Family history of HTN and premature history of cardiovascular disease (males <55 years and females <65 years).
2.Use of alcohol, tobacco, anabolic steroids, and illicit drugs, particularly cocaine and amphetamines.
3.Diet (salt, fat, caloric intake), exercise, and life stressors.
D.Review of systems (focus should be on target organ damage).
1.General: Weight gain/obesity.
2.Integumentary: Edema and ulcerations.
3.Neurological: Headache, dizziness, lightheadedness, syncope/near-syncope, and weakness.
4.Ophthalmological: Visual changes.
5.Cardiovascular and respiratory: Chest pain, palpitations, tachycardia, shortness of breath, and dyspnea on exertion.
6.Gastrointestinal/genitourinary: Abdominal pain and changes in urinary habits.
Physical Examination
A.Measure accurate BP: Average of three readings taken 2 minutes apart; on first visit, BP should be taken in both arms and one leg to evaluate for coarctation of aorta and subclavian artery stenosis.
B.Evaluate pulse, oxygen saturation, respiratory rate, and temperature.
C.Assess skin for changes related to venous stasis: Brawny appearance with red/blue discoloration and possible venous stasis ulcerations.
D.Check the following body systems.
1.Ophthalmological: Perform visual acuity; funduscopic examination for arteriovenous nicking, copper/silver wiring, cotton wool spots, retinal hemorrhages, and papilledema.
2.Neck: Evaluate thyroid, carotid bruits, and jugular venous distention.
3.Respiratory: Auscultate all lung fields.
4.Cardiac: Assess for point of maximum impulse (PMI) displacement, sustained/enlarged apical impulse, presence of S3 or S4, evidence of murmurs, rubs or gallops, femoral pulse
abnormalities, and peripheral edema.
5.Abdomen: Evaluate for pulsatile abdominal mass over aorta, presence of bruits (aortic, renal, femoral, and iliac), and assess radial–femoral delay.
6.Neurological: Perform complete mental status examination.
Diagnostic Tests
A.BP measurement (diagnostic criteria): Two or more diastolic BP measurements on at least two subsequent visits (after initial screening) of greater than or equal to 90 mmHg or when the average of systolic BP readings on two or more subsequent visits is consistently greater than or equal to 140 mmHg.
B.Initial laboratory evaluation.
1.Complete blood count.
2.Complete metabolic panel, including renal function and glomerular filtration rate (GFR).
3.Fasting lipid panel.
4.Hemoglobin A1C.
5.Urinalysis (microalbumin levels correlate with clinical BP readings).
6.Can also consider ECG, echocardiogram, and stress testing to further evaluate cardiac status.
C.Additional diagnostic tests for secondary causes of HTN.
1.Pheochromocytoma: 20-hour urinary metanephrine level.
2.Primary aldosteronism: Plasma aldosterone-to-renin activity ratio.
3.Renal artery stenosis (RAS): Doppler flow ultrasound or computed tomographic angiography (CTA).
4.Obstructive sleep apnea: Sleep study with oxygen saturation measurements.
5.Thyroid and parathyroid disease: Thyroid and parathyroid hormone levels.
6.Cushing disease: Dexamethasone suppression test.
7.Coarctation of the aorta: CTA.
Differential Diagnosis
A.Primary idiopathic HTN.
B.Secondary HTN.
1.Drug/toxin: Nicotine, alcohol, cocaine, amphetamines, ephedrine-containing decongestants, herbal supplements containing licorice, nonsteroidal anti-inflammatory drugs (NSAIDs), and oral contraceptives.
2.Cardiovascular: MI, CHF.
3.Endocrine: Primary hyperaldosteronism, Cushing disease, pheochromocytoma, hyperthyroidism or hypothyroidism, and hyperparathyroidism.
4.Neurological: CVA, TIA, obstructive sleep apnea, intracranial HTN, brain tumor, and serotonin syndrome.
5.Vascular: Coarctation of aorta, vasculitis, collagen vascular diseases, and subclavian artery stenosis.
6.Renal: CKD, polycystic kidney disease (PCKD), and RAS.
Evaluation and Management Plan
A.General plan.
1.Lifestyle modification.
a.Diet modification: Dietary approaches to stop hypertension (DASH) diet; no-added-salt diet (4 g/d) or low-sodium diet (2 g/d).
b.Limit alcohol and encourage tobacco cessation.
c.Exercise regularly (30 minutes/day for 5–7 days/week).
d.Engage in stress-reduction activities.
e.Discontinue unnecessary medications that can raise BP.
B.Patient/family teaching points.
1.Encourage family support with regard to lifestyle modifications and medication compliance.
C.Pharmacotherapy.
1.Appropriate medications.
a.Thiazide diuretics: Initial medication of choice (especially important to use in African Americans).
b.Angiotensin-converting enzyme (ACE) inhibitors: Preferred in patients with diabetes mellitus because of its renal protective properties (can use angiotensin II receptor blocker [ARB] if patient intolerant to ACE inhibitor).
c.Beta-blockers: Decrease heart rate, cardiac output, and renin release.
d.Calcium channel blockers: Work by vasodilatation of atrial vasculature.
2.Patients with HTN and diabetes mellitus often require two medications for control.
3.If BP is greater than 20/10 mmHg above goal, consider use of two agents—one of which is usually a thiazide diuretic.
4.Often a combination drug of a thiazide with either an ACE inhibitor or ARB is used because thiazides increase the effectiveness of other antihypertensive medications.
5.Note that if the patient has poor response to one medication, experts recommend changing to another first-line agent in an alternative class before adding a second agent.
6.Medications such as hydralazine and minoxidil are not commonly used; if initiated, it is typically done with beta-blockers or diuretics for resistant HTN.
7.Caution: With clonidine, it is important to educate about not stopping abruptly due to risk of rebound HTN.
Follow-Up
A.Encourage patients to monitor BP at home and keep a log.
B.Emphasize medication compliance and clinic appointment follow-up with cardiologist or primary care provider.
Consultation/Referral
A.Consider consultation with a cardiologist for patients with multiple cardiovascular risk factors and/or comorbidities.
B.Consider consultation with a nephrologist for patients with resistant HTN and/or comorbid renal disease.
C.Based on etiology of secondary HTN, consultation with an appropriate specialist is advised.
Special/Geriatric Considerations
A.BP goals for special populations.
1.Renal insufficiency: Less than 130/80 mmHg.
2.Diabetes mellitus: Less than 130/80 mmHg.
3.Age 65 years or older and high burden comorbidities; provider judgment and patient preferences.
4.HTN/CHF: Less than 130/80 mmHg.
B.Complications
1.Thoracic and abdominal aortic aneurysms.
2.MI.
3.Hypertensive urgency and emergency.
4.CVA, TIA.
5.Target end-organ damage (eyes, kidneys, nervous system).
C.Urgent and emergent hypertensive situations.
1.Hypertensive urgency: BP of 180/110 mmHg or greater without end-organ damage.
a.Patients should seek immediate evaluation and treatment.
b.Avoid rapid lowering of BP to prevent neurological complications; initiate treatment of BP using oral agents for gradual reduction of BP over 24 to 48 hours.
c.Ensure close follow-up and BP monitoring in addition to regulation of antihypertensive medications to prevent future recurrence.
2.Hypertensive emergency: BP greater than 180/120 mmHg with symptoms of end-organ damage.
a.Goal is to reduce BP safely to reverse target organ damage without iatrogenic malperfusion. Maintained to less than 180/105 mmHg for the first 24 hours.
b.Hypertensive emergency in pregnancy is defined as acute onset, with BP greater than 160/110 mmHg persisting more than 15 minutes.
c.Patients should be monitored in the ICU with use of intravenous antihypertensive medications until stabilized.
D.Geriatric considerations: Structural changes due to aging.
1.Changes in venous system due to aging.
a.Reflex alterations in venous vasomotor tone.
b.Vasoconstriction.
c.Stiffness and loss of elasticity of valves in veins.
2.Arterial changes due to aging.
a.Thickening of the intimal and medial layers of the vasculature.
b.Lipid deposits.
c.Over time, the intimal and medial layers of the arteries acquire collagen deposits that subsequently decrease their elasticity and cause hardening of the vasculature walls.
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