About this course:
The purpose of this activity is to assist the APRN in safely and effectively managing patients with hypertension.
At the conclusion of this exercise, the APRN will be prepared to:
- Review the basic aspects of hypertension, including epidemiology.
- Identify the American Heart Association's latest guidelines for the management of hypertension.
- Develop a basic understanding of various lifestyle components used to treat hypertension.
- Define medical management for hypertension in adults with primary and secondary hypertension.
- Consider geriatric and specialty population implications for the management of hypertension.
The leading cause of cardiovascular disease and stroke is hypertension (HTN) and, therefore these are concerns for anyone with elevated blood pressure (BP). HTN is the most common health issue seen in the primary care setting, and if left untreated, stroke, cardiovascular disease, myocardial infarction (MI), kidney failure, and even death can occur (Ignatavicius et al., 2018). The American Heart Association (AHA, 2017), defines HTN as “the silent killer” since most people have no obvious symptoms, yet it is associated with several life-threatening diseases and conditions. This module will explore the current standards of practice and essential patient teaching points for healthcare providers to incorporate into their clinical practice.
Terms and Definitions
HTN is defined as a systolic BP that is at least 130 mm Hg or a diastolic BP of at least 80 mm Hg. Further definitions include anyone that is currently taking antihypertensive medications, even with blood pressure readings lower than the above definitions (AHA, 2017).
The most common type of HTN is essential hypertension, which is not caused by a currently existing health problem.
Secondary hypertension is caused by certain disease states or drugs that can increase the BP. A few of these contributing factors include:
- Kidney disease,
- Primary aldosteronism,
- Cushing’s disease
- Coarctation of the aorta,
- Brain tumors,
- Certain drugs, including:
- Glucocorticoids (i.e., prednisone [Sterapred], dexamethasone [Dexpak])
- Mineralocorticoids (i.e., aldosterone, spironolactone [Aldactone])
- Sympathomimetics (Ignatavicius et al., 2018)
Malignant hypertension or hypertensive crisis refers to a severe form of HTN where the BP elevates rapidly. This condition may present with morning headaches, blurred vision, dyspnea, or symptoms of uremia (the accumulation of urea and nitrogenous waste products in the blood that would normally be eliminated in the urine) (Ignatavicius et al., 2018). These patients are often in their 30s-50s; their systolic BP could be above 200 mm Hg. According to the AHA (2017), the defining characteristic is a systolic pressure above 180 mm Hg and a diastolic above 120 mm Hg. Immediate intervention is required with malignant HTN/hypertensive crisis or it can result in stroke, left ventricular heart failure, or kidney failure (AHA, 2017; Ignatavicius et al., 2018).
It was noted in 2016 that nearly 1/3 of the US population was impacted by HTN, and nearly 35 million of those affected were uncontrolled. Among the 35 million, as many as 11.5 million were unaware that they had HTN; 7 million recognized they were hypertensive but were not undergoing active treatment for it, and over 16 million were aware they had HTN, were taking treatment, but their HTN was still not properly controlled. This data was based on a diagnostic threshold of a blood pressure above 140/90 mm Hg (Merai et al., 2016). In 2017, the AHA updated their definition of hypertension, which resulted in an updated prevalence of 46% of the adult population. The new categories for BP classification are found in Table 1 (AHA, 2017).
According to a study by Zhang et al. (2017), the national estimate for HTN-related healthcare costs was over $68 billion in 2015, yet this estimate did not include the costs for complications such as stroke or cardiovascular disease. If those aspects are considered, the costs soared to over $130 billion. HTN accounts for more deaths related to atherosclerotic cardiovascular disease (ASCVD) than any other modifiable risk factor (American College of Cardiology [ACC], 2019). While the costs of treating HTN is high, the costs of leaving HTN untreated are higher. The study showed a much higher cost among the elderly (age 65 or older); this could be attributed to their increased risk of hypertension-related health outcomes (i.e., ASCVD, stroke) and an increased proportion of patients requiring antihypertensive medication. Further data identified that women had a higher expenditure on healthcare than men, as they tended to experience more severe HTN-related consequences than men, such as stroke (Zhang et al., 2017).
Demographically, the highest prevalence of HTN is among those 75 or older, female gender, and those who identify as non-Hispanic Blacks. African Americans in the US also seem to develop HTN earlier in life, increasing their risk of death from stroke and heart or kidney disease. Increasing education about this risk can greatly improve patient outcomes among this high-risk population (Ignatavicius et al., 2018). Table 2 shows the distribution of the prevalence of HTN in the US:
Management of Hypertension
The AHA Hypertension Guidelines Toolkit (2017) guides the diagnosis of each population, including sex, cultural, racial, and age characteristics, and gives further guidance for best practice in treatment. See Figure 1 for an algorithm for healthcare professionals in the treatment of HTN. We will explore these recommendations in depth (AHA, 2018).
HTN comes with modifiable and non-modifiable concerns. Those modifiable factors are opportunities for the patient to decrease their risk of the associated complications of HTN without the use of drugs. Among the modifiable factors are:
- Smoking/tobacco use (primary smoker or second-hand smoke exposure);
- Type 2 diabetes;
- Unhealthy diet (high in fats and triglycerides, low in fruits/vegetables);
- Lack of physical activity/fitness;
- Obstructive sleep apnea (OSA) (AHA, 2017).
Tobacco cessation is encouraged, and supportive resources should be shared with the patient. The Centers for Disease Control and Prevention (CDC) offers resources to support the patient in their journey towards a tobacco-free life. A hotline, called Quitline offers a 24/7 access to coaches that will support the journey to quit smoking or tobacco use. In addition to coaching, the Quitline can help with resources available within the patient's geographical area, including physicians and support groups. The coaching is available in several languages for the greatest level of support to those seeking it. Further tools available through the CDC include a quitSTART app, signing up for free texts to support quitting, and guidance on making a quit plan (CDC, 2019).
Patients with co-existing type 2 diabetes can decrease their risk of HTN-related complications with lifestyle changes. Type 2
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The role of ASCVD and HTN is clear and decreasing the risk for vascular damage includes lipid control. Controlling lipids includes a healthy diet low in saturated fats and avoiding trans-fatty acids. Dyslipidemia is a condition that includes harmful cholesterol (LDL) and triglycerides within the blood. Those with high levels of lipids are at a higher risk of coronary artery disease (CAD) and damage to the vessels, thus increasing the blood pressure. Those suffering from diabetic dyslipidemia have high levels of LDL and triglycerides, but also too little of the good cholesterol (HDL), leading to the worst outcomes. Dyslipidemia is treated through dietary and pharmacological interventions. To improve LDL, no more than 35% of daily calories should come from total fats and no more than 7% from saturated fats. Exercise and glycemic control will further improve cholesterol levels and decrease vascular damage. When lifestyle changes are not enough, statins, niacin, and fish oil may be integrated into the treatment regime (Johns Hopkins, n.d.).
Weight loss and weight management is a vital component in the patient’s journey to control BP and is considered the optimal non-pharmacological intervention for lowering the BP. Lowering the weight by only 1 kg (2.2 lbs) can lower the BP by 1 mm Hg in most overweight adults (Whelton et al., 2017). The Dietary Approaches to Stop Hypertension (DASH) diet described in Table 3 or the Mediterranean diet described in Table 4 have been proved to reduce BP. Sodium intake below 1,500 mg/d, a diet rich in potassium with supplements as needed, aerobic exercise, isometric resistance, weight lifting, and limited alcohol intake can also help to decrease BP and risk of HTN-related complications (ACC, 2019: Ignatavicius et al., 2018). While the optimal goal is to maintain a daily sodium intake under 1,500 mg, a goal of lowering sodium intake by 1000 mg/d can provide positive results and lower the BP. Simultaneously increasing potassium can provide a positive impact on BP with a suggested 3,500-5,000 mg/d consumed in a diet rich in potassium rather than supplements where possible (Whelton et al., 2017).
Exercise should be incorporated a minimum of three to four times per week for 40 minutes or more each day (Ignatavicius et al., 2018). The ACC and AHA further suggest that adults should engage in aerobic exercise five to seven days per week, supplemented by resistance exercises and flexibility exercises two to three days per week for best results in decreasing HTN (Whelton et al., 2017).
OSA should be addressed as it has been shown in trials to decrease patient’s BP, particularly in those with diabetes. OSA is recognized as a secondary cause of HTN and produces surges in both systolic blood pressure (SBP) and diastolic blood pressure (DBP) that cause continued HTN during the day as well as the night. Treatment of OSA through nasal continuous positive airway pressure (CPAP) prevents apneic episodes and the associated fluctuations in SBP and DBP (Whelton et al., 2017).
If lifestyle modifications are unsuccessful in decreasing BP, the primary healthcare provider should consider the use of antihypertensive medications. See Table 5 for the AHA’s (2017) suggested guidelines on the BP threshold for pharmacologic intervention.
Therapy will be individualized to each patient with a consideration of age, culture, co-existing illnesses, BP history, medication costs, personal insurance or ability to pay, and the ability to comply with the recommended follow-up plan. All goals and BP targets should be a collaboration between the healthcare team and the patient. A single dose per day option is preferred for compliance with medication, particularly for older patients. The more doses per day of a medication, the increased the likelihood of non-compliance exists. The largest hypertensive trial to date, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), began in 1994 and was completed 8 years later in 2002. This trial determined that diuretics are unmatched in preventing the cardiovascular-related complications of HTN (The National Institute of Health, n.d.). The AHA (2017) recommends the following four classes of oral antihypertensive medications as first-line agents against HTN:
- Thiazide or thiazide-type diuretics;
- Angiotensin-converting enzyme (ACE) inhibitors;
- Angiotensin receptor blockers (ARBs); and
- Calcium-channel blockers (CCBs) (AHA, 2017).
The following six medication classes are recommended as second-line agents against HTN:
- Diuretics including loop, potassium-sparing, and aldosterone antagonists;
- Beta-blockers including cardioselective, vasodilatory, non-cardioselective, intrinsic sympathomimetic activity, and combined alpha- and beta-receptors;
- Direct renin inhibitors;
- Alpha-1 blockers;
- Central alpha-2 agonists; and
- Direct vasodilators (AHA, 2017).
Let's look at medication recommendations in-depth for the healthcare provider. The initial treatment will depend on the severity of the SBP and DBP. For an individual with BP between 140/90- and 159/99-mm Hg, a single antihypertensive medication is recommended. For those with a BP greater than 160/100 mm Hg, initial pharmacological treatment of two antihypertensives is recommended. The initial drug therapy in the presence of cardiovascular risk or disease is most often an ACE Inhibitor, an ARB, a thiazide-like diuretic, or a dihydropyridine CCB. In the absence of cardiovascular co-morbidities, the use of beta-blockers for HTN is not supported by the evidence (Whelton et al., 2017). Other areas of risk that must be considered are kidney disease, diabetes, or atrial fibrillation (deBoer, 2017). See Table 6 for primary agents used in HTN and Table 7 secondary agents used in HTN.
There is evidence to support evening versus morning dosing of antihypertensives in relation to cardiovascular events during sleep. When a patient is currently taking at least two medications, one can be moved to the evening. Diuretics should always be taken in the morning. Monitoring recommendations should include ongoing home monitoring of BP. Studies show that this makes patients more compliant with medication therapy and reduces cardiovascular complications (deBoer, 2017; Whelton et al., 2017).
Multiple drug therapy is often needed to achieve therapeutic BP targets, especially in the presence of renal disease. The use of an ACE inhibitor combined with an ARB is not generally recommended within primary care as it can lead to hyperkalemia, syncope, and acute kidney injury. The Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial found a decreased mortality and morbidity rate with the ACE inhibitor benazepril (Lotensin) in addition to the dihydropyridine CCB amlodipine (Norvasc) versus benazepril (Lotensin) and HCTZ (Hydrodiuril) (deBoer, 2017; Whelton et al., 2017).
Further considerations should be given to the role of concomitant medications prescribed for other conditions, such as medications for diabetes. For instance, insulin stimulates the sympathetic nervous system promoting renal sodium retention and stimulates vascular smooth muscle hypertrophy, which can increase the blood pressure. Sodium-glucose cotransport 2 inhibitors such as canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance) cause a mild diuretic effect and reduce the SBP 3-6 mm Hg and DBP 1-2 mm Hg. Glucagon-like peptide 1 receptor agonists such as liraglutide (Victoza) or dulaglutide (Trulicity) are also associated with a reduction in SBP of 2-3 mm Hg and DBP of 0-1 mm Hg (deBoer, 2017; Drugs.com, 2019; Whelton et al., 2017).
Treating HTN in patients with diabetic kidney disease can be a challenge for primary healthcare providers as well. Patients with diabetes and albuminuria benefit from the use of an ACE inhibitor or ARB as these drugs slow down the progression of renal disease in comparison to placebos and other classes of antihypertensives. Hyperkalemia risk increases with renal failure, and if an ACE inhibitor, ARB, or spironolactone (Aldactone) are used, the risk increases up to eight times. This should be considered before prescribing these medications in the presence of hyperkalemia and inform the frequency of screening of systemic potassium levels. Thiazide-like diuretics such as HCTZ (Hydrodiuril) can be effective in reducing volume as well as reducing systemic potassium levels. With advanced renal disease and an eGFR of 30 mL/min/1.73 m2 or less, a long-acting loop diuretic is preferred, such as torsemide (Demadex) (deBoer, 2017; Whelton et al., 2017).
Follow-up visits to the primary healthcare provider for the reassessment of BP and to monitor for adherence and response to the medication regime is recommended at the following schedule in Table 8 per the AHA (2017).
Patients with resistant HTN who are not meeting BP targets on conventional drug therapy with three drugs that include a diuretic should be referred to a hypertension specialist. Prior to determining a diagnosis of resistant HTN, the healthcare provider should confirm that medication compliance is not a contributing issue. Common causes for noncompliance include medication cost, side effects, or the need to take multiple medications. Aldosterone antagonist diuretics can be effective in patients with resistant HTN and type 2 diabetes who are already on the treatment of an ACE/ARB, a diuretic, and a CCB. An increased risk for hyperkalemia should be discussed and screened for regularly (Whelton et al., 2017).
Pregnant women with mild gestational HTN (SBP under 160 or DBP under 110) should not be treated with antihypertensives. However, for those with an SBP over 160 or a DBP over 110, methyldopa (Aldomet), labetalol (Trandate), hydralazine (Apresoline), or long-acting nifedipine (Procardia XL) are recommended. Diuretics, including thiazides, can be used in late-stage pregnancy for volume control; however, spironolactone (Aldactone) is not recommended due to potential fetal antiandrogen effects (Brown & Garovic, 2014). Postpartum patients with preeclampsia or gestational hypertension should be monitored for at least 72 hours in the hospital and again at 7-10 days postpartum. These patients will need life-long BP monitoring as they have increased risk throughout their life for cardiovascular complications (deBoer, 2017; Whelton et al., 2017).
Due to the increased risk of HTN for African Americans, meticulous screening, aggressive management with specific medications, and education are crucial. In a randomized controlled trial of 728 African American patients aged 30-79 with a baseline SBP of 150-179 mm Hg and no previous treatment, researchers found that patients are typically well-controlled at six months on a regime of the CCB amlodipine (Norvasc) plus the thiazide diuretic hydrochlorothiazide (HCTZ) or perindopril (Aceon). The same study suggests that in patients of African descent, adequate control typically requires two or more agents and improved control is achieved on a CCB and thiazide diuretic versus an ACE or an ARB (Ojji et al., 2019).
Geriatric patients (65 years of age and older) have multiple co-morbidities due to the aging process, and their drug therapy may require adjustments. For those patients who are considered in good physical shape with few co-morbidities, the treatment regime is similar to other adult patients. For those with major functional limitations, a higher SBP goal should be considered due to the risks associated with orthostatic HTN. The tolerance of antihypertensive therapies should be monitored closely to avoid complications (deBoer, 2017; Whelton et al., 2017).
Patient education materials can be found at the AHA and CDC websites. CDC fact sheets can be found about HTN, medications for HTN, and conditions or behaviors related to HTN. The AHA provides fact sheets to guide patients in their quest to control their BP (AHA, 2017; CDC, 2020).
American College of Cardiology. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/03/07/16/00/2019-acc-aha-guideline-on-primary-prevention-gl-prevention
American Heart Association. (n.d.) Blood pressure fact sheets. Retrieved on February 6, 2020 from https://www.heart.org/en/health-topics/high-blood-pressure/find-high-blood-pressure-tools--resources/blood-pressure-fact-sheets
American Heart Association. (2017). Hypertension guideline toolkit. http://aha-clinical-review.ascendeventmedia.com/books/aha-high-blood-pressure-toolkit/4/
American Heart Association. (2018). Diagnosing and managing hypertension in adults. https://www.heart.org/-/media/files/health-topics/high-blood-pressure/tylenol-hbp/aha18hyperpocketguideprint3final-approved.pdf?la=en&hash=BD37D70CEFAA0B1A57465E507F912F6B6B22800B
Brown, C. M. & Garovic, V. D. (2014). Drug treatment of hypertension in pregnancy. Drugs, 74(3), 283-296. https://doi.org/10.1007/s40265-014-0187-7
The Centers for Disease Control and Prevention. (2019). How to quit smoking. https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/index.html?s_cid=OSH_tips_GL0004&utm_source=google&utm_medium=cpc&utm_campaign=TipsQuit%3BS%3BWL%3BBR%3BIMM%3BDTC%3BCO&utm_content=Cessation_E&utm_term=smoking+cessation+resources&&gclid=EAIaIQobChMIzL7T286_5wIVEfDACh1dxQXfEAAYASAAEgKTf_D_BwE&gclsrc=aw.ds
The Centers for Disease Control and Prevention. (2020). Hypertension resources for health professionals. https://www.cdc.gov/bloodpressure/educational_materials.htm
deBoer, I.H., Bangalore, S., Benetos, A., Davis, A.M., Michos, E.D>, Muntner, P., Rossing, P., Zoungas, S., & Bakris, G. (2017). Diabetes and hypertension: A position statement by the American Diabetes Association. Diabetes Care, 40(9), 1273-1284. https://doi.org/10.2337/dci17-0026
Drugs.com. (2019). Insulin side effects. https://www.drugs.com/sfx/insulin-side-effects.html
Ignatavicius, D., Workman, L., & Rebar, C. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. Elsevier.
Jennings, A., Berendsen, A. M., deGroot, L., Feskens, E., Brzozowska, A., Sicinska, E., Pietruszka, B., Meunier, N., Caumon, E., Maluech-Brugere, C., Santoro, A., Ostan, R., Franceschi, Cl, Gillings, R., O’Neill, C., Fairweather-Tait, S., Minihane, A., & Cassidy, A. (2017). Mediterranean-style diet improves systolic blood pressure and arterial stiffness in older adults. Hypertension, 73(3). 578-586. https://doi.org/10.1161/HYPERTENSIONAHA.118.12259
Johns Hopkins. (n.d.). Patient guide to diabetes. Retrieved on February 3, 2020 from http://hopkinsdiabetesinfo.org/dyslipidemia/
Ojji, D. B., Mayosi, B., Francis, V., Cornelius, V., Smythe, W., Kramer, N., Barasa, F., Damesceno, A., Dzudie, A., Jones, E., Mondo, C., Ogah, O., Ogola, E., Sani, M. U., Shedul, G. L., Shedul, G., Rayner, B., Okpechi, I. G., Sliwa, K., & Poulter, N. (2019). Comparison of dual therapies for lowering blood pressure in black Africans. The New England Journal of Medicine, 380(25), 2429-2439. https://doi.org/ 10.1056/NEJMoa1901113
Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Colling, K. J., Himmelfarb, C. D., DePalma, S. M., Gidding, S., Jameson, K. A., Jones, D.W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., Williamson, J. D., & Wright, J. T. (2017). 2017 Clinical practice guideline: ACC/AHA/AAPA/ABC/ACPM/AGS/AphA/ASH/ASPC/MA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Hypertension (71), e13-115. https://doi.org/10.1161/HYP.0000000000000065