Hypertension with AHA Classifications

1. Hypertension
Asst. Prof. Bhaumika Sharma

2. Hypertension - Introduction.
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• Hypertension is a condition in which blood
pressure in the arteries is chronically elevated
• The American Heart Association (AHA) defines
hypertension as blood pressure of 140 over 90
or higher.
• Healthy blood pressure levels are below 120
over 80.
• BP between 120/80 and 139/89 is called pre—
hypertension

3. Introduction ..
• Hypertension can be classified as follows: (AHA)
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Types Systolic Diastolic
Normal <120 mm of Hg <80 mm of Hg
Pre-hypertension 120—139 80—89
Stage 1 140-159 90-99
Stage 2 ≥160 ≥100

4. Forms of hypertension
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• Essential or primary hypertension
➢Common type of hypertension
➢Accounts for 95% of HTN
➢The causes of it is multi-factorial but the
basic cause is not always known
• Secondary hypertension
➢Hypertension due to specific disease or
abnormality
➢It accounts for 5% of HTN

5. Hypertensive Emergency
• A hypertensive emergency is a condition in
which elevated blood pressure (BP) results in
target organ damage.
• The systems primarily involved include the
central nervous system (CNS), the
cardiovascular system, and the renal system.
• Malignant hypertension and accelerated
hypertension are both hypertensive
emergencies, with similar outcomes and
therapies.

6. Accelerated Hypertension
• Accelerated hypertension is defined as a
recent significant increase over baseline BP
that is associated with target organ damage.
• This is usually seen as vascular damage on
funduscopic examination, such as flame-
shaped hemorrhages or soft exudates, but
without papilledema.

7. Hypertensive Urgency
• Hypertensive urgency must be distinguished
from hypertensive emergency.
• Urgency is defined as severely elevated BP (ie,
systolic BP >220 mm Hg or diastolic BP >120
mm Hg) with no evidence of target organ
damage.
• In order to diagnose malignant hypertension,
papilledema must be present.

8. Papilledema. Note the swelling of the optic
disc, with blurred margins.

9. Contd.
• Hypertensive emergencies necessitate
immediate therapy to decrease BP within
minutes to hours.
• In contrast, no evidence suggests a benefit
from rapidly reducing BP in patients with
hypertensive urgency.
• In fact, such aggressive therapy may harm the
patient, resulting in cardiac, renal, or cerebral
hypoperfusion.

10. Hypertensive Crisis
• It is a medical emergency and requires immediate
treatment
• It is defined as elevation of blood pressure (BP) over
180/120 mm Hg
• It is important to assess whether target-organ
dysfunction (mainly brain, heart, eyes, kidneys, as
well as the rest of the vasculature) is present or not
to differentiate hypertensive emergency from
urgency as there are no symptoms of target organ
dysfunction in hypertensive urgency.

11. Hypertensive Crisis contd.
• Hypertensive emergency should be treated with
parenteral therapy.
• Hypertensive urgency may be treated with oral
drugs, but the situation must be carefully assessed
• Ischemic stroke is a special situation. Blood
pressure should not be rapidly reduced nor should
it be lowered too far.
• Mean arterial pressure MAP = 1/3(SBP- DBP)+DBP

12. PATHOPHYSIOLOGY
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• For HTN to occur, there must be a change in
one or more factors affecting peripheral
resistance or cardiac output.
• In addition, there must be problem with the
body’s control system that monitor or regulate
pressure
• Many factors have been implicated as causes
of HTN:

13. PATHOPHYSIOLOGY
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1. Dysfunction of autonomic nervous system
Leads to increased sympathetic nervous system activity
2. Genetic variation in the pathways handlings Na+ in the
kidney, leads to increased reabsorption of Na, Cl and
water
3. Increased activity of renin angiotension aldosterone
system:
a. Results in expansion of extracellular fluid volume
b. Increased systemic vascular resistance

14. PATHOPHYSIOLOGY ..
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4.Dysfunction of vascular endothelium
Decreased vasodilatation of arteries
5.Resistance to insulin action leads to
hypertension

15. Contd.
• Insulin resistance and compensatory hyperinsulinaemia
commonly occur in patients with untreated essential
hypertension.
• The coexistence of insulin resistance and hypertension can be
viewed as a cause-effect relationship (insulin resistance as a
cause of hypertension or vice versa) or as a noncausal
association.
• Insulin can increase blood pressure via several mechanisms:
increased renal sodium reabsorption, activation of the
sympathetic nervous system, alteration of transmembrane ion
transport, and hypertrophy of resistance vessels.
• Conversely, hypertension can cause insulin resistance by
altering the delivery of insulin and glucose to skeletal muscle
cells, resulting in impaired glucose uptake, contribute to the
development of insulin resistance.

16. • For example, hypertension can impair
vasodilation of skeletal muscle as a result of
vascular structural changes and rarefaction,
and increased response to vasoconstrictor
stimuli.
• Also, the prevalence of muscle type 2b fibres
(fast twitch fibres) may

17. How does narrowing arteries cause HTN?
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Narrowed renal artery
Impairs blood circulation to affected kidneys
This deprivation of blood stimulates the kidney to produce
renin and angiotensin hormone
Increases peripheral resistance throughout body
Results in hypertension

18. Causes of hypertension (Essential)
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• GENETIC FACTORS
– Approximately 30% of cases of essential hypertension are
attributable to genetic factors
– Individual who have one or two parents with HTN is twice
as common as in general population
• ENVIRONMENTAL FACTORS:
– Obesity
– Alcohol intake
oIngestion of alcohol rises BP
oReduction of regular alcohol intake reduces BP(5-
10) mm of hg
– Salt intake :
ohigh intake of salts, exceeding 5.8 grams daily

19. Causes of HTN (Secondary)
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RENAL HYPERTENSION
– Causes of renal HTN is stenosis of the renal
Arteries
– Thickening of the muscular walls of renal arteries
causes narrowing in young people
– old people --due atherosclerotic plaque, that
blocks the renal artery
– Chronic kidney disease such as
• Chronic glomerulonephritis
• Chronic plyleonephritis
• Congenital polycystic kidneys

20. Causes of HTN (Secondary) contd.
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• Adrenal gland tumors such as
pheochromocytoma---
➢produces excessive catecholamines
and adrenaline related hormones.
• Co-arctation of aorta:
➢also called aortic narrowing, is a
congenital condition whereby the
aorta is narrow
➢usually in the area where the ductus
arteriosus inserts.

23. Symptoms of Hypertension
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• People with uncomplicated hypertension
➢Headache
➢Dizziness
➢SOB
➢Blurred vision
• Hypertensive crisis
➢Severe headache
➢Nausea
➢Dizziness
➢Sometimes kidney failure

24. Diagnosis
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• Chest x-ray
➢Cardiomegaly
• ECG—LVH
• ECHO
➢ Enlargement of left side of the heart
• RFT
➢Serum creatinine in a blood can assess how
well the kidney’s are functioning
➢Elevated creatinine level indicate damage
to kidney
• Proteinurea--Reflect chronic kidney damage

25. Diagnosis …
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• Intravenous urogram, USG – if renal disease
is suspected
• Renal arteriography—if there is evidence of
renal artery stenosis
• 24 hours urine catecholamines—if history
suggests phaeochromocytoma
• Angiography if COA is suspected

26. Treatment
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• Lifestyle modifications
• Medications
❖First line treatment of hypertension
➢Life style modifications
❖Dietary changes
❑Low sodium in diet
❑Encourages the consumption of nuts, whole grain,
fish, poultry, fruits and vegetables
❑Lowering the consumption of red meats, sweets
and sugar
❑Reducing the alcohol consumption
❑Stop smoking

27. Treatment…
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• Physical exercises
➢Encourage regular exercise program
➢Programs to reduce the psychological
stress:
❖Biofeedback training
❖Relaxation techniques
❖Meditation
❖Yoga
❖Humor and laughter

28. Treatment…
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• Medications
➢Low dose Thiazide based diuretic—first line
antihypertensive such as hydrochlorothiazide
➢Diuretics
❖Acetazolamide
❖Lasix
❖Indepamide
❖Aldactone
❖Torsemide

29. Treatment…
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• Beta blockers- decreases the force used to
pump blood into arteries
• Commonly used beta blockers are as follows
➢Atenolol
➢Carvedilol
➢Metoprolol
• Calcium channel blockers—dilate the arteries
➢Amlodepine
➢Felodepine

30. Treatment…
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• ACE- inhibitors—dilate the arteries, thereby
decreasing resistance to blood flow
• Commonly used ACE- I includes the following
➢Captopril
➢Enalapril
➢Lisinopril
➢Ramipril
• Angiotension receptor blockers, such as
➢Losartan

31. Treatment…
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• Centrally acting agents
➢These antihypertensive agents affects the
CNS( brain) to decrease blood pressure.
➢Such as methyldopa
• Alpha blockers
➢Prazosin
➢Terazosin
➢Doxazosin

32. • Beta blocker
• Calcium channel blocker
• Diuretics

33. Nursing management.
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Assessment
▪ Assess blood pressure at frequent intervals and note the
changes that would require a change in medication
▪ Assess symptoms such as nosebleeds., anginal pain, SOB,
alterations in vision, headaches etc.
Nursing diagnosis
▪ Deficient knowledge regarding relationship between the
treatment regimen and control of disease
▪ Non compliance related to side effects of prescribed
therapy

34. Nursing management..interventions
• Increasing knowledge
➢Encourage for controlling measures of hypertension
➢Lifestyle modifications
❖Diet
❖Exercise
❖Yoga
❖Meditation
➢Managing and monitoring potential complications
❖Ask about patient’s blurred vision, spots and diminished visual
acuity
❖Report any significant finding promptly to determine any
changes in medications are required
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35. Nursing management..interventions
• Promoting compliance with self care
➢Encourage active participation of patient in the
program for increased compliance
➢Encourage to avoid the use alcohol
➢Discourage use of tobacco and nicotine products
➢Provide information regarding expected effects of
medications
➢Teach patient and family how to measure blood
pressure
➢Assess for medication related problems(orthostatic
hypotension)
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