Post on 29-Dec-2015
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WHAT IS BLOOD PRESSURE
Blood pressure is the force with which blood pushes against the artery walls as it travels through the body. Systolic pressure measures cardiac output and refers to the pressure in the arterial system at its highest. Diastolic pressure measures peripheral resistance and refers to arterial pressure at its lowest .Normal blood pressure for an adult is 120/80 (on average).
DEFINITION
Defined as a repeatedly elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above 140 with a diastolic pressure above 90.
INCIDENCE
It is world wide epidemic with an estimated 690 million people
Increases with age More prevalent in male. Higher in African Whites than in whites
Primary Hypertension: A condition which is characterized by high blood pressure not associated with any identifiable pathological cause Secondary Hypertension: Secondary hypertension is high blood pressure resulting from an underlying cause such as kidney disease
TYPES
CLASSIFICATION
Classification of blood pressure for adults
Categorysystolic, mmHg
diastolic, mmHg
Hypotension < 90 < 60
Normal 90 – 119 60 – 79
Prehypertension 120 – 139 80 – 89
Stage 1 Hypertension
140 – 159 90 – 99
Stage 2 Hypertension
≥ 160 ≥ 100
The following classification of blood pressure applies to adults aged 18 and older. It is based on the average of seated blood pressure readings that were properly measured during 2 or more office visits.
White coat hypertension: White coat hypertension is a term used to describe a condition where patients have increased blood pressure readings when measured in a clinical setting such as a doctor's office. Blood pressure readings taken in the home environment while the patient is relaxed are normal. The underlying cause is believed to be tension and anxiety associated with visiting health professionals such as general practitioners. Isolated systolic hypertension: Often in older adults the first number (the upper or systolic number) is high while the second (the lower or diastolic) number is normal.
Malignant hypertension: Malignant hypertension is a condition characterized by very high blood pressure and swelling of the optic nerve. This type of hypertension is more common in people with kidney problems such as narrowed kidney blood vessels. The condition is a medical emergency which can cause organ damage if not treated promptly
RISK FACTORS
o Stress.o Obesity. o Lack of vitaminDo Excess intake of salto Alcoholism o Cigarettesmokingo Diabetes mellitus o Elevated serum
lipids
o Age.o Gender.o Family historyo Ethnicity.
MODIFIABLE FACTORS NONMODIFIABLE
FACTORS
CLINICAL MANIFESTATIONS
Severe head acheFatigue or confusion Dizziness Nausea Problems with vision Chest pains Breathing problems Irregular heartbeat Blood in the urine
The medical and family history help the physician determine if the patient has any conditions or disorders that might contribute to or cause the hypertension. A family history of hypertension might suggest a genetic predisposition for hypertension. The physical exam may include several blood pressure readings at different times and in different positions. The physician uses a stethoscope to listen to sounds made by the heart and blood flowing through the arteries. The pulse, reflexes, and height and weight are checked and recorded. Internal organs are palpated, or felt, to determine if they are enlarged.Because hypertension can cause damage to the blood vessels in the eyes, the eyes may be checked with a instrument called an ophthalmoscope. The physician will look for thickening, narrowing, or hemorrhages in the blood vessels.A chest x ray can detect an enlarged heart, other vascular (heart) abnormalities, or lung disease.An electrocardiogram (ECG) measures the electrical activity of the heart. It can detect if the heart muscle is enlarged and if there is damage to the heart muscle from blocked arteries.Urine and blood tests may be done to evaluate health and to detect the presence of disorders that might cause hypertension.
NON PHARMACHOLOGICAL MANAGEMENT Weight reduction . Increased physical activity Limited alcohol consumption Reduced salt (sodium
chloride) intake Increased potassium intake Stress reduction technique
PHARMACHOLOGICAL MANAGEMENT Drug classes Commonly used classes of
antihypertensive drugs are the Thiazide diuretics (e.g.,
bendroflumethiazide) Beta-blockers (e.g., propranolol, atenolol) Angiotensin-converting enzyme inhibitors
(e.g., captopril, enalapril), Angiotensin II antagonists (e.g.,
candesartan, losartan), Calcium channel blockers (e.g.,
amlodipine, nifedipine) and alpha-blockers (e.g., doxazosin
DEFINITION
Hypertensive crises encompass a spectrum of clinical situations that have in common severely elevated blood pressure (BP), usually higher than 180/110 mm Hg, together with progressive or impending target organ damage.
CAUSESoChronic hypertension with acute exacerbation (most common) oReno vascular hypertension oParenchymal Renal Disease
Acute glomerulonephritis Renal Infarction Vasculitis
oScleroderma Renal Crisis oDrug Ingestion
Tricyclic anti-depressants Monoamine Oxidase (MAO) Inhibitors Cocaine Amphetamines
oAnti-hypertensive drug withdrawal or failed compliance
Centrally acting anti-hypertensives (eg. clonidine) Peripheral alpha blockers (eg. prazosin) Beta-Blocker acute withdrawal
oPre-eclampsia and Eclampsia oAutonomic hyperactivity
Guillain-Barre Syndrome Spinal Cord Injury
oPheochromocytoma
HYPERTENSIVE URGENCY
Hypertensive Urgency is defined as a clinical setting of severe hypertension with minimal or no symptoms, where severe elevation of BP are not causing immediate end-organ damage but should be effectively lowered within 24 hours to reduce potential risk to the patient.
HYPERTENSIVE EMERGENCY
Hypertensive emergencies are severe elevations in BP, often higher than 220/140 mm Hg, complicated by clinical evidence of progressive target organ dysfunction. These patients require immediate admission and BP reduction (not necessarily to normal ranges) to prevent or limit further target organ damage. Examples include hypertensive encephalopathy, intracranial hemorrhage, acute myocardial infarction, acute left ventricular failure with pulmonary edema, dissecting aneurysm, acute renal failure, and eclampsia of pregnancy
CLINICAL MANIFESTATIONS
Blood Pressure (mm Hg)
Funduscopic Findings
Neurologic Status
Cardiac Findings
Renal Symptoms
Gastrointestinal
Symptoms
Usually >220/140
Hemorrhages, exudates, papilledema
Headache, confusion, somnolence, stupor, visual loss, seizures, focal neurologic deficits, coma
Prominent apical pulsation, cardiac enlargement, congestive heart failure
Azotemia, proteinuria, oliguria
Nausea, vomiting
Table 1: Clinical Characteristics othe Hypertensive Emergency
Severe Hypertension (Urgency)
Parameter Asymptomatic SymptomaticHypertensive Emergency
Blood pressure (mm Hg)
>180/110 >180/110 Usually >220/140
SymptomsHeadache, anxiety; often asymptomatic
Severe headache, shortness of breath
Shortness of breath, chest pain, nocturia, dysarthria, weakness, altered consciousness
Examination
No target organ damage, no clinical cardiovascular disease
Target organ damage; clinical cardiovascular disease present, stable
Encephalopathy, pulmonary edema, renal insufficiency, cerebrovascular accident, cardiac ischemia
Therapy
Observe 1-3 hr; initiate, resume medication; increase dosage of inadequate agent
Observe 3-6 hr; lower BP with short-acting oral agent; adjust current therapy
Baseline laboratory tests; intravenous line; monitor BP; may initiate parenteral therapy in emergency room
Plan
Arrange follow-up within 3-7 days; if no prior evaluation, schedule appointment
Arrange follow-up evaluation in less than 72 hr
Immediate admission to ICU; treat to initial goal BP; additional diagnostic studies
Intravenous Drugs:Sodium Nitroprusside •Standard rapidly acting agent effective in many cases •Dose is 0.25-8 µg/kg/minute as IV infusion, start with 0.3- 0.5 ug/kg/min (about 20-50 ug/min), then 1- 3 ug/kg/min IV (max:<10 ug/kg/min) (50 mg in 250 ml D5W) •Onset: 0.5 -1 min ; Duration: 2 - 5 min •Adverse effects: hypotension, N&V, apprehension, cyanide (thiocyanate level>10 mg/dl is toxic; >20 mg/dl may be fatal) toxicity convulsion, twitching, psychosis, dizziness, etc.
•Nitroprusside has decreased efficacy in renal failure Toxic levels of cyanide build
Nitroglycerin Highly effective in setting of coronary ischemia, acute coronary syndromes Dose is 5-100µg/min as IV infusion Nitroglycerin IV infusion start 5- 10 ug/min then may be up to >200 ug/min prn esp. in pts where Na nitroprusside is relatively contraindicated & in pts with ischemic heart disease, impaired renal or hepatic function. Onset: immediate; Duration:1- 5 min May cause headache, tachycardia, vomiting, methemoglobinemia Excellent for titrating blood pressure in setting of coronary ischemia
Labetalol (Trandate) •Mixed alpha/beta blocker, excellent for most hypertensive emergencies •Dose is 20-80mg IV bolus every 10 minutes or 0.5-2mg/min infusion IV .Start 20 mg IV, then 20- 80 mg q10 min prn, or start with 0.5 mg/min infusion, then 1- 2 mg/min (may be up to 4 mg/min) IV infusion up to 300 mg/d max.
Onset: 5 -10 min; Duration: 3- 6 h Adverse effects: hypotension, bradycardia, dizziness, scalp tingling
•Avoid in patients with heart block, bradycardia, CHF, severe asthma or bronchospasm •First or second line for eclampsia; excellent in catecholamine surges
Enalaprilat •Intravenous formulation of enalapril (ACE inhibitor) •Dose is 1.25-5.0mg q6 hour IV (duration of action ~6 hours) •Onset of action in 15-30 minutes; Duration 6 hours or more •Highly variable response; precipitous BP drop in high-renin states, rarely angioedema, hyperkalemia, or acute renal failure. •May be most useful in acute cardiogenic pulmonary edema •Avoid in acute myocardial infarction
Diltiazem (Cardizem) •Initial dose 0.25 mg/kg over 2 min, followed by infusion of 0.35 mg/kg at an initial rate of 10 mg/hour •Onset: 3-30 min •Adverse effects: excessive hypotension, flushing; rarely amblyopia
Treatment of Hypertensive Emergency •Encephalopathy: Nitroprusside, Labetolol, Diazoxide •Cerebral Infarction: no treatment (hemorrhage control), Nitroprusside, Labetolol •Myocardial Ischemia, Infarction: Nitroglycerine, Labetolol, ß-adrenergic blockers •Acute Pulmonary Edema: Nitroprusside (or Nitroglycerin) and Loop Diuretic •Aortic Dissection: Nitroprusside and ß-adrenergic blockers, Labetolol •Eclampsia: Hydralazine, Labetolol, Diazoxide •Acute Renal Insufficiency: Nitroprusside, Labetolol, Ca antagonists •Funduscopic changes: Nitroprusside, Labetolol, Ca antagonists •Hemolytic Anemia, Microangiopathic: Nitroprusside, Labetolol, Ca antagonists .
i. Check the B.P hourlyii. Administer the medicationiii. Provide low sodium and caloric dietiv. Encourage the patient for cessation of
smoking.v. Check the weight of the patient.vi. Teach about the stress reduction
technique.vii. Provide health education.
In effective therapeutic regimen management related to new diagnosis.
Imbalanced nutrition; more than body requirement related to high sodium and caloric intake.
In effective health maintenance related to lack of regular exercise
Hypertension is a silent killer disorder.Un treated hypertension lead to hypertensive crisis. It is an emergency. It is prevented by adequate life style modification.