SOAP. – Hypertension

Definition

A.Hypertension (HTN) is considered a systolic blood pressure (SBP) of 130 mmHg or more, or a diastolic blood pressure (DBP) of 80 mmHg or more, or taking antihypertensive medications. The American Heart Association (AHA) and American College of Cardiology (ACC; Whelton et al., 2018) define HTN in adults as shown in Table 13.6.

B.Resistant HTN is defined as follows:

1.Blood pressure (BP) that is not at target despite a three-drug regimen, including an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blockers (ARBs) + a calcium channel blocker (CCB) + a diuretic appropriate for the patient’s glomerular filtration rate (GFR).

2.Controlled BP while taking four or more medications is also considered resistant HTN.

C.Standing and supine BPs should be measured before the initiation of combination antihypertensive therapy. Orthostatic (postural) hypotension is diagnosed when, within 2 to 5 minutes of quiet standing, one or more of the following is present:

1.At least a 20 mmHg fall in systolic pressure.

2.At least a 10 mmHg fall in diastolic pressure.

3.Symptoms of cerebral hypoperfusion, such as dizziness.

D.The average nocturnal BP is approximately 15% lower than daytime values. Failure of BP to fall by at least 10% during sleep is called nondipping and is a stronger predictor of adverse cardiovascular outcomes than daytime BP.

TABLE 13.6 Whelton 2017 High Blood Pressure Clinical Practice Guideline Classifications

BP, blood pressure; DBP, diastolic blood pressure; HTN, hypertension; SBP, systolic blood pressure.

Source: Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr., Collins, K. J., Dennison Himmelfarb C., . . . Wright, J. T., Jr. (2018). ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/MNA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension, 71(6), e13–e115. doi:10.1161/HYP.0000000000000065

E.Isolated systolic hypertension (ISH) is defined when the SBP is greater than or equal to 140 with the DBP normal or below normal (<90 mmHg). ISH usually affects the elderly, increasing their risk of stroke or myocardial infarction (MI).

F.Isolated diastolic hypertension (IDH) is defined as a diastolic pressure greater than or equal to 90 mmHg with a systolic pressure less than 140 mmHg. IDH is more common in younger men who are overweight/obese and in individuals younger than 40 years.

G.Malignant HTN is marked HTN with retinal hemorrhages, exudates, or papilledema. Malignant HTN is usually associated with diastolic pressures above 120 mmHg.

Incidence

A.Worldwide, HTN affects about one billion people, and is the leading preventable risk factor for premature death and disability worldwide.

B.Approximately one in three adults in the United States have HTN.

C.The incidence of resistant HTN is rising. The data indicates a 21.7% incidence.

D.African American women have the highest death related from HTN (37.7 deaths per 100,000 population).

Pathogenesis

Over 90% of cases have no identifiable cause, thus constituting the category of primary or essential HTN. The remaining 10% of cases have the following secondary causes.

A.Renal causes:

1.Glomerulonephritis.

2.Pyelonephritis.

3.Polycystic kidney disease.

B.Endocrine causes:

1.Primary hyperaldosteronism.

2.Pheochromocytoma.

3.Hyperthyroidism.

4.Cushing’s syndrome.

C.Vascular causes:

1.Coarctation of aorta.

2.Renal artery stenosis.

D.Obstructive sleep apnea (OSA).

E.Chemical/medication-induced HTNs:

1.Oral contraceptives.

2.Nonsteroidal anti-inflammatory drugs (NSAIDs).

3.Decongestants.

4.Antidepressants.

5.Sympathomimetics.

6.Corticosteroids.

7.Lithium.

8.Ergotamine alkaloids.

9.Cyclosporine.

10.Monoamine oxidase inhibitors (MAOIs), in combination with certain drugs or foods.

11.Appetite suppressants, in combination with certain drugs or foods.

12.Cocaine.

13.Amphetamines.

Predisposing Factors

When making a diagnosis, consider not only the absolute BP reading, but also the presence or absence of other cardiovascular risk factors. Factors include the following:

A.Family history of HTN.

B.Obesity.

C.Alcohol consumption.

D.Stress.

E.Sedentary lifestyle.

F.African American ancestry.

G.Male gender.

H.Age older than 30 years.

I.Excessive salt intake.

J.Medications.

K.Drug use.

Common Complaints

A.HTN is asymptomatic in the majority of patients.

Other Signs and Symptoms

A.Headaches.

B.Advanced disease: Organ-specific complaints with endorgan damage.

C.Retinopathy.

Potential Complications

A.Cerebrovascular accident (CVA).

B.MI.

C.Renal failure.

D.Heart failure (HF).

E.Peripheral arterial disease (PAD).

Subjective Data

A.Ask the patient about any family history of HTN or cardiac or renal disease.

B.Ask if the patient has ever been diagnosed with HTN or cardiac or renal disease.

C.Ask if the patient ever had any high BP readings.

D.Ask if the patient has ever been treated for any of the earlier problems.

E.Ask about other risk factors, such as smoking, drinking, high fat intake, obesity, and/or diabetes.

F.Inquire about the patient’s lifestyle, exercise regimen, work environment, and stress level.

G.Ask the patient about symptoms that suggest secondary etiology:

1.Palpitations, headache, diaphoresis (pheochromocytoma).

2.Anxiety, weight gain or loss (thyroid abnormality).

3.Muscle weakness, polyuria (primary aldosteronism).

H.Find out if the patient is taking drugs that elevate BP (noted under section Pathogenesis).

I.Ask if the patient feels nervous when having his or her BP taken in the office (white coat HTN).

J.Review current medications, including prescription, over-the-counter (OTC), and herbal products.

K.Review current recreational/illicit drug use.

Physical Examination

A.Check pulse, BP, height, weight, waist circumference, and distribution of body fat. Calculate body mass index (BMI):

1.The diagnosis of HTN is made after averaging two or more properly measured readings at each of two or more visits after an initial screen.

2.When patient’s SBP and DBP fall into two different categories, use the higher category to classify his or her BP.

3.For accurate measurement, use correct size cuff for patient (adult, large adult, or thigh cuff).

B.Inspect:

1.Observe overall appearance.

2.Conduct funduscopic exam; look for papilledema, exudates, AV nicking, anterior nicking.

3.Inspect the neck for jugular vein distension.

4.Observe for pedal edema.

C.Palpate:

1.Palpate the neck; check thyroid for enlargement.

2.Palpate the abdomen for masses or organomegaly.

3.Palpate the extremities; assess peripheral pulses and note edema.

4.Assess deep tendon reflexes (DTRs).

D.Auscultate:

1.Auscultate heart, noting the point of maximal impulse (PMI).

2.Auscultate lungs; check for bronchospasm and rales.

3.Auscultate neck; assess carotid arteries for bruits.

Diagnostic Tests

A.Hematocrit.

B.Liver function tests (LFTs), lactate dehydrogenase (LDH), uric acid.

C.Chemistry profile.

D.Fasting lipid profile (total and high-density lipoprotein (HDL) cholesterol and triglycerides).

E.Urinalysis for proteinuria.

F.Estimated GFR.

G.ECG.

H.If history, physical exam, or lab tests indicate the need, obtain the following:

1.Intravenous pyelography (IVP).

2.Renal arteriogram.

3.Plasma renin.

4.Catecholamines.

5.Chest radiography.

6.Aortogram.

7.Ultrasonography.

8.Sleep study.

I.Monitor potassium levels if on ACEIs/ARBs or spironolactone.

Differential Diagnoses

A.Primary HTN.

B.Secondary HTN.

C.Drug-induced HTN.

D.White coat syndrome.

Plan

A.General interventions (see Table 13.7):

1.Advise overweight patients to lose weight. Loss of as little as 10 pounds reduces BP in many patients.

2.Advise the patient to limit or discontinue alcohol intake.

3.Encourage the patient to stop smoking.

4.Encourage increased physical activity. The 2017 ACC/AHA guidelines on lifestyle management outline the newest physical activity recommendation, which advises adults to engage in 40 minutes of aerobic physical activity three to four times a week. The aerobic exercise should involve moderate to vigorous intensity.

5.Encourage some form of relaxation technique.

B.Patient teaching:

1.Stress asymptomatic nature of disease.

2.Stress importance of ongoing monitoring and treatment under the direction of a healthcare provider.

3.Review risk factors for cardiac, renal, and cerebrovascular disease and possible preventive measures.

4.The ACC maintains the CardioSmart Patient Education Portal for an online BP and other heart conditions management tool to educate and motivate patients. ACC’s CardioSmart is a free resource located at www.cardiosmart.org. CardioSmartTXT PREVENT is a 6-month program of health tips and reminders sent via two text messages a week. CardioSmartTXT QUIT is a 2-month program to assist patients in smoking cessation. Four text messages are sent a day with information and assistance with smoking cessation.

C.Dietary management: Review specific dietary measures. Give dietary recommendation sheets. See Appendix B for low-fat/low-cholesterol and dietary approaches to stop hypertension (DASH) diets:

1.Diet alone will only make the smallest incremental change in BP; therefore, it should be combined with lifestyle modification and lower sodium intake; stopping smoking, weight loss, and exercise are essential.

2.It is essential for the patient/family to read labels for sodium, fat content, and serving sizes.