hypertension: an overview - nursece4less.com an overview dana bartlett, bsn, msn, ma, ......

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1

HYPERTENSION: AN OVERVIEW

Dana Bartlett, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material and textbook chapters, and

done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and pharmacy students.

ABSTRACT Primary hypertension, sometimes called essential hypertension, is far

more common than secondary hypertension. There are many distinct

and separate causes of secondary hypertension, which requires a more

thorough discussion than would be possible in a short study. Primary

hypertension is primarily discussed, as well as the topics of

hypertensive emergencies, isolated diastolic hypertension, and isolated

systolic hypertension is briefly highlighted.

!


Accreditation Statement

This activity has been planned and implemented in accordance with

the policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's

Commission on Accreditation for registered nurses.

Credit Designation

This educational activity is credited for 3 hours. Nurses may only claim

credit commensurate with the credit awarded for completion of this

course activity.

Pharmacology content is 0.5 hours (30 minutes).

Course Author & Planner Disclosure Policy Statements

It is the policy of NurseCe4Less.com to ensure objectivity,

transparency, and best practice in clinical education for all continuing

nursing education (CNE) activities. All authors and course planners

participating in the planning or implementation of a CNE activity are

expected to disclose to course participants any relevant conflict of

interest that may arise.

Statement of Learning Need

Nurses in various practice settings need to know the definitions and

statistics of hypertension, including the etiologies of primary and

secondary hypertension, risk factors of primary hypertension, as well

as the complications and treatments used for primary hypertension in

order to properly educate patients to prevent and to recognize

hypertension.


Course Purpose The provide nurses with knowledge about primary hypertension and

secondary hypertension, including the risk, prevention and treatment

of primary hypertension.

Target Audience

Advanced Practice Registered Nurses, Registered Nurses, Licensed

Practical Nurses and Nursing Associates

Course Author & Director Disclosures

Dana Bartlett, BSN, MA, MSN, CSPI, William S. Cook, PhD,

Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC -all have

no disclosures.

Acknowledgement of Commercial Support: There is none.

PLEASE TAKE TIME TO COMPLETE A SELF-ASSESSMENT OF KNOWLEDGE, ON

PAGE 4, SAMPLE QUESTIONS BEFORE READING THE ARTICLE.

OPPORTUNITY TO COMPLETE A SELF-ASSESSMENT OF KNOWLEDGE LEARNED WILL BE PROVIDED AT THE END OF THE COURSE.


1. Elevated blood pressure that does not have an identifiable cause is known as

a. primary hypertension. b. isolated diastolic hypertension. c. secondary hypertension. d. systolic hypertension.

2. Elevated blood pressure that is caused by heart and lung

disease, or other illness, is known as

a. primary hypertension. b. chronic hypertension. c. secondary hypertension. d. acute hypertension.

3. If only the diastolic blood pressure is elevated when

measured, then the patient is understood to have


4. The majority of people who have hypertension have:

a. primary hypertension. b. isolated diastolic hypertension. c. secondary hypertension. d. acute hypertension.

5. Primary hypertension is defined as:

a. SBP > 110 mm Hg or DBP > 70 mm Hg. b. SBP ≥ 160 mm Hg or DBP ≥ 110 mm Hg. c. SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg. d. SBP 120-139 mm Hg, DBP 80-89 mm Hg.


Introduction

Hypertension, often referred to as high blood pressure, is one of the

most common chronic diseases. Approximately one in three adult

Americans has hypertension. This means that 66 to 78 million

Americans have the disease. Hypertension is typically and most

usefully classified as primary or secondary. Primary hypertension

accounts for the great majority of the cases of hypertension. The

terms primary hypertension and hypertension refer to the same

disease and they will be used interchangeably throughout this study.

Etiology Of Hypertension

The etiology of primary hypertension is not known. There is a genetic

component to the development of the disease, but age and lifestyle

factors contribute significantly to its development and progression.

Secondary hypertension is much less common than primary

hypertension, and in secondary hypertension there are identifiable

causes. The causes of secondary hypertension include, but are not

limited to:

• endocrine, neurologic, renal, and vascular diseases

• medical conditions, such as obstructive sleep apnea, rare

cancers, and rare genetic diseases

• pregnancy

• drugs such as alcohol, cocaine, non-steroidal anti-

inflammatories, and oral contraceptives

The majority of people who have hypertension (aside from secondary

hypertension) have no characteristic signs or symptoms except for an

elevated blood pressure, and this is one of the most harmful features


of the disease. Untreated, unrecognized hypertension slowly causes

progressive damage to the heart, the eyes, the kidneys, the

neurological system, and the vascular system and by the time the

patient is symptomatic, the damage is extensive and often irreversible.

The presence of hypertension

significantly increases the risk for

developing cardiovascular diseases

such as atrial fibrillation, coronary

artery disease, congestive heart

failure, myocardial infarction,

stroke, renal disease, and

retinopathy. Morbidity and mortality

are directly related to the duration

and severity of hypertension.

Hypertension cannot be cured but it

can be controlled with lifestyle

modifications and antihypertensive

drug therapy; however, initiating

and maintaining these lifestyle

modifications are very difficult and

patient compliance with antihypertensive drug therapy is often poor,

as well. The problem is worsened because a large number of people

who are at risk for developing hypertension are not screened for the

disease, and many people who have been diagnosed with hypertension

are not being adequately treated. As the population ages and as

obesity becomes more common, the incidence of hypertension will

grow.


Definitions of Hypertension

The term hypertension refers to chronic increases in blood pressure.

These measured increases can be of both the systolic and diastolic

blood pressure, which is called primary hypertension. If only the

diastolic blood pressure is elevated when measured, then the patient is

understood to have isolated diastolic hypertension. If only the systolic

blood pressure is elevated when measured, then the patient is

understood to have isolated systolic hypertension.

Whether a patient has primary diastolic or systolic hypertension

depends on the particular level of blood pressure. Pre-hypertension is

present when the systolic blood pressure and/or diastolic blood

pressure are elevated, but not to a degree that is considered to fit the

criteria for primary hypertension. Primary Hypertension is also divided

into Stage I and Stage II, as seen below.1,2,5

Definitions of Hypertension

Pre-hypertension: SBP 120-139 mm Hg, DBP 80-89 mm Hg

Stage I hypertension: SBP ≥ 140-159 mm Hg or DBP ≥ 90-99 mm Hg

Stage II hypertension: SBP ≥ 160 mm Hg or DBP ≥ 100 mm Hg

Isolated diastolic hypertension: DBP ≥ 90 mm Hg and SBP < 160 mm Hg

Isolated systolic hypertension: SBP ≥ 140 mm HG and DBP < 90 mm Hg

Hypertensive Emergencies

Blood pressure measurements that require immediate medical care

and/or are causing significant signs and symptoms or organ damage

are considered to be diagnostic of hypertensive emergencies.


Hypertensive emergencies are a spectrum of clinical presentations that

are usually characterized by a systolic blood pressure > 220 mm Hg or

a diastolic blood pressure > 120 mm Hg.4 The situation is considered

urgent (not necessarily an emergency) if the patient has no significant

signs and symptoms and no evidence of end-organ damage.

Patients in whom the blood pressure elevation is considered to be

urgent may be managed with initiation of antihypertensive therapy or

a change to the existing antihypertensive therapy and outpatient

follow up. Rapid control of blood pressure is typically not needed.6 If

the patient has significant signs and symptoms such as chest pain,

headache, or shortness of breath, or evidence of end-organ damage

such as aortic dissection, hypertensive encephalopathy, intracranial

hemorrhage, myocardial infarction, papilledema, or retinal

hemorrhages, hospitalization and rapid control of blood pressure would

be required.6,7

Scope of the Problem

One in three American adults or approximately 66-78 million

Americans have hypertension.1,2 It is one of the most common and

well-known public health problems in the U.S., but many people who

have hypertension are either unaware that they have hypertension,

are not receiving treatment, or are inadequately treated.1,2,4

The incidence of hypertension increases with age. Until age 45 men

are more likely than women to have hypertension.1 As discussed in the

next section, race is an important factor with hypertension. For

example, hypertension is much more common in African Americans.


This population also suffers disproportionately from the complications

of hypertension.

Risk Factors And Pathogenesis Of Primary Hypertension

Primary hypertension accounts for approximately 80%-95% of all

cases of hypertension.4 It is a disease that is multifactorial in origin,

and it is caused by genetic and environmental factors. Many of the risk

factors that contribute to the development and progression of primary

hypertension are closely related and cannot be easily separated.

Genetics

The genetic contribution to the development of hypertension is

unclear. Studies that have controlled environmental factors have

estimated the heritability of blood pressure to be 15%-35%,4 and it

may be that susceptibility to end-organ damage from hypertension is

also influenced by genetics.4 But heritability measures phenotype

variability that is attributed to genetic variability; it does not mean

that a specific percentage of an individual’s phenotype is caused by

genetics.

Genetic abnormalities have been identified in people who have

hypertension but these have not been shown to be a primary cause of

the disease1 and because environmental factors clearly contribute to

the development of primary hypertension, genetic identification of

those at risk is not feasible at this time and may not be.8


Age

Hypertension should not be considered to be an inevitable part of

getting older, but the statistics of aging and hypertension are not

comforting. The likelihood of developing hypertension increases as an

individual ages and it has been estimated that the probability is 90%

of a middle-aged or elderly person developing hypertension in his or

her lifetime.1

The high prevalence of hypertension in the elderly can be explained by

a diet high in sodium, obesity, and a sedentary lifestyle.9 Hypertension

in this age group can also be explained by physiological factors that

occur during aging such as increased arterial stiffness, decreased

baroreceptor sensitivity, increased activity of the sympathetic nervous

system, and a decreased ability of the kidneys to excrete sodium.10

Race

The incidence and severity of hypertension is higher in African

Americans than in other ethnic groups in the U.S.11 African Americans

develop hypertension at an earlier age and the rate of progression

from pre-hypertension to hypertension is increased.11 In addition,

African Americans suffer disproportionately from the cardiovascular

and renal complications of hypertension11 and optimal control of blood

pressure is more difficult for African Americans, even when awareness

of the problem and the level of treatment are equivalent to other

ethnic groups.12

These disparities can be partially explained by socio-economic status,

suboptimal maternal nutrition that causes low birth weight, the

increased incidence of obesity in the African American community,


diet, and differences in salt sensitivity. However, even when income,

body mass, and diet are considered, hypertension is a particular

problem for African Americans and the reasons for this are not clear.

Obesity

Obesity increases the risk of developing hypertension13,14 and weight

reduction can help reduce blood pressure, but the mechanisms by

which obesity contributes to the development of hypertension are not

clearly understood.14 Insulin resistance and obstructive sleep apnea

(OSA) are common in people who are obese, and there is some

evidence that these are contributory causes of hypertension.15

However, there appears to be significant inter-individual variation in

the degree to which insulin resistance, OSA, and obesity itself

contribute to the risk of developing hypertension.15 For example, not

all people who are obese develop high blood pressure. It may be the

distribution of body fat, not body weight per se, which is the factor

that determines who will or will not become hypertensive.13

Smoking

The relationship between cigarette smoking and hypertension is

complex. Cigarette smoking increases arterial stiffness,16 and the

incidence of hypertension is increased in people who smoke more than

15 cigarettes a day.17 Smoking increases the risk of developing

atherosclerosis and atherosclerosis and contributes to the development

of hypertension.


Alcohol

Alcohol appears to be an independent risk factor for hypertension.

Moderate alcohol intake may have a protective effect;18 excessive

alcohol intake increases the risk of developing hypertension.18-20

Physical Inactivity

Physical inactivity and a sedentary lifestyle increase the risk for

developing hypertension,1,21,22 and a high level of fitness and physical

activity are inversely associated with the development of

hypertension.22

Sodium Intake

Dietary sodium intake is closely associated with hypertension. Excess

dietary sodium increases the risk of developing hypertension23 and

reducing salt intake will lower blood pressure.24

Other factors that may be risk factors for the development of primary

hypertension are Vitamin D deficiency,25-27 dyslipidemia,28 low dietary

intake of calcium and magnesium4 and fruits and vegetables,29 and

psycho-social variables such as depression, occupational stress,

personality type, sleep quality, and the individual’s level of isolation

and social support.30-33

All of the risk factors that were discussed are or may be contributing

causes to the development of hypertension. How much each one

influences the risk for hypertension and how they interact is not

known. It is clear however that many of these risk factors such as

obesity, smoking, and a sedentary lifestyle, regardless of their effect

on hypertension, are very unhealthy and they are primary causes of


many other serious chronic diseases. Losing weight, smoking

cessation, physical exercise, and a healthy diet improve health, lower

blood pressure and may prevent hypertension, as well.

Screening And Initial Evaluation Of Hypertensive Patients

Screening for hypertension significantly reduces the incidence of

cardiovascular events and poses very little harm.34 Blood pressure can

be measured in a physician’s office, at home by the patient, or by

using ambulatory blood pressure monitoring (ABPM). The U.S.

Preventive Services Task Force (USPSTF) recommendations for blood

pressure screening are outlined below.34

1. Annual screening for everyone ≥ 40 years of age and for people

who have risk factors for the development of hypertension.

2. The USPSTF considers a high-normal blood pressure (130-

139/85-89 mm Hg), African American ethnicity, and obesity and

being overweight as risk factors.

3. Adults aged 18 to 39 years with normal blood pressure (<130/85

mm Hg) who do not have other risk factors should be rescreened

every 3 to 5 years.

4. The USPSTF recommends rescreening with properly measured

office blood pressure and, if blood pressure is elevated,

confirming the diagnosis of hypertension with ABPM.

Ambulatory Blood Pressure Monitoring

Ambulatory blood pressure monitoring is considered to be the most

accurate method for diagnosing hypertension, it is the preferred

technique for diagnosing hypertension,34-36 and it is especially helpful


at detecting masked hypertension.37 A portable blood pressure monitor

device is worn by the patient and the measurements are recorded at

fixed intervals for 24-48 hours, sometimes less.

Home Measurement

Home measurement of blood pressure with an automated device is an

acceptable method for detecting hypertension. The technique is the

same as off-based measurement (discussed below). It is

recommended that at least 12-14 measurements should be taken

during the day and the evening35 but there is no consensus about the

optimal schedule.38

Office-based Measurement

Office-based measurement of blood

pressure for hypertension screening

requires proper technique to obtain

accurate results. Close attention

must be paid to the following details

when performing office-based blood

pressure measures.35

Cuff Size

Incorrect cuff size can result in an inaccurate reading. The American

Heart Association (AHA) recommendations for cuff size are: 1) Upper

arm circumference 22-26 cm, small adult cuff/12 x 22 cm, 2) Upper

arm circumference 27-34 cm, adult cuff/16 x 30 cm, 3) Upper arm

circumference 35-44 cm, large adult cuff/16 x 36 cm, and 4) Upper

arm circumference 45-52 cm, adult thigh cuff/16 x 42 cm.39


Cuff Placement and Inflation/Deflation

The cuff bladder should be midline over the brachial artery and it

should not be placed over clothing. Place the cuff so that the

stethoscope does not touch the bladder; this will prevent noise from

cuff deflation from interfering with an accurate measurement.

When inflating and deflating the cuff, inflate the cuff 20 mmHg above

the systolic pressure; and, deflate the cuff 3 mmHg per second. Use

the disappearance of sound - the Korotkoff V phase - as the diastolic

pressure.

Device

The same device should be used for each measurement; different

devices will give different results.

Number of Measurements

At least three measurements should be taken. It is very important that

multiple readings should be taken and these readings must be

separated by the appropriate length of time. This will avoid white coat

hypertension, which is when a person experiences high blood pressure

only when he or she visits their medical provider’s office, or masked

hypertension, which is when a person’s blood pressure is normal when

being measured by a medical professional but otherwise abnormally

high.

Patient Position

The patient should be seated with the back supported, and the legs

should not be crossed. If the back is unsupported or the legs are


crossed the measurement will be falsely elevated. The patient’s arm

should be at the level of the heart; if the arm is below heart level the

reading will be elevated.

Time

Each measurement in the office should be done at the same time.

Other Variables

The patient should be sitting for at least five minutes before a

measurement is taken. There should be no smoking or ingestion of

caffeine prior to the measurement. Also, the room where the patient is

sitting should not be too cool, and the patient should not be talking

while blood pressure is being measured. If the above variables are not

observed, an elevated blood pressure could result.

When it has been confirmed that the patient has hypertension, the

patient should be assessed for secondary hypertension and he or she

should be evaluated for end-organ damage. Renal function should be

assessed, neurologic and ophthalmologic exams should be performed,

and an evaluation of the patient’s cardiovascular status should be

done.

Complications Of Hypertension

Primary hypertension is a progressive disease and the first stage in its

development is pre-hypertension. Pre-hypertension is a condition in

which the blood pressure is elevated above normal levels but not to

the measurements that define hypertension. In addition, the patient is

asymptomatic and he or she has not yet developed organ damage.


Pre-hypertension greatly increases

the risk of developing hypertension40

and by itself it is a significant risk

factor for the development of

cardiovascular disease and

stroke.41,42 Pre-hypertension is

followed by early hypertension, and

by 30-50 years of age, primary

hypertension is well established.

If the patient who has primary hypertension is not diagnosed and

treated, he or she will eventually develop complicated hypertension

and, potentially, damage to the eyes, heart, kidneys, nervous system,

and central and peripheral vasculature.4 The chance of developing

complications increases as the level of blood pressure elevation

increases;4,43 the risk of developing heart disease doubles for every 20

mmHg increase in systolic pressure and every 10 mmHg increase in

diastolic pressure.4 Complications of primary hypertension include

those highlighted below.

Atherosclerosis

Hypertension greatly increases the risk for developing

atherosclerosis,44-47 and in younger adults, hypertension contributes

more to the development of atherosclerosis and cardiovascular disease

than diabetes, dyslipidemia, or smoking.48


Stroke

Hypertension and pre-hypertension are associated with a significant

increase in the risk for stroke.43,49 The incidence of stroke increases in

direct proportion to increases in blood pressure.4

Kidney Disease

Hypertension is a major risk factor for the development of chronic

kidney disease, and the risk of chronic kidney disease increases in

direct proportion to elevations in blood pressure.4

Heart Disease

Hypertension increases the risk of developing atrial fibrillation,

congestive heart failure, myocardial infarction, and other

cardiovascular and heart pathologies.4,10,45 Heart disease is the most

common cause of death in people who have hypertension.

Retinal Damage

The incidence of retinopathy in patients who have hypertension has

been reported to be as high as 66.3% to 80.3%,50,51 and the level of

systolic blood pressure and the duration of hypertension are significant

risk factors for developing retinal damage. The presence of diabetes in

many hypertensive patients and the particular methods used to detect

retinal damage may skew these figures but, even when these factors

are considered, hypertensive retinopathy is still a problem of

considerable magnitude.


Isolated Diastolic And Isolated Systolic Hypertension

Hypertension refers to elevations of both systolic and diastolic blood

pressure, but elevations of diastolic pressure or systolic pressure alone

are well described and isolated systolic blood pressure is relatively

common.

Isolated diastolic blood pressure primarily affects adults and young

men who are obese, and it is the most common form of hypertension

in adults less than age 40.52,53 Isolated diastolic hypertension is

strongly related to increases in cardiovascular morbidity and

mortality52 and most people who have isolated diastolic hypertension

will develop hypertension.54 However, the importance of isolated

diastolic hypertension as a cause of hypertensive complications is not

completely understood52 nor are the best treatment options.53 Patients

who have isolated diastolic hypertension should be treated with

lifestyle modifications, and if they are considered to be at risk for

hypertensive complications and/or there is evidence of organ damage

they should be treated with antihypertensive medication.53

Isolated systolic hypertension is caused by reduced compliance and

elasticity of large arteries, and it is quite common in the elderly.52

Isolated systolic hypertension is considered to be a significant cause of

cardiovascular disease52 and patients who have isolated systolic

hypertension should be closely monitored and treated.

Treatment Of Primary Hypertension

The benefits of treating primary hypertension are clear and significant.

It has been estimated that lowering systolic blood pressure 10 mmHg

and diastolic blood pressure 5 mmHg will reduce the risk of congestive


heart failure by 50%, the risk of coronary heart disease and

myocardial infarction by 20%-25%, the risk of stroke by 35%-40%,

and overall mortality rate by 10%-20%.10,45

Recommendations for the treatment of patients who have

hypertension have changed and evolved. Given the complexity and

multifactorial nature of the disease it is not surprising that there is

some disagreement in the medical community as to who should be

treated, when treatment should be started, the best therapies and

medications, and what level of benefits treatment can provide.

However, the basic approach to treating hypertension is essentially the

same, regardless of the source of the recommendations.

This section will discuss the treatment recommendations published in

2014 by the Eighth National Joint Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood Pressure, an expert panel

appointed by the National Heart, Lung, and Blood Institute.55

Additionally, articles from the medical literature will be used that will

provide background information on these recommendations.

Once the diagnosis of hypertension has been confirmed and goal blood

pressure has been determined, treatment can begin and as with most

medical conditions, it is prudent to start with simple measures first.

The first step in treating hypertension is to establish a goal blood

pressure. The table below lists the goal blood pressures recommended

by the 2014 Eighth National Joint Committee.55


Setting Goals for Blood Pressure

General population: Age ≥ 60

↓

Systolic pressure < 150 mm Hg; diastolic pressure < 90 mm Hg

__________________________________________

General population, age < 60, and patients of any age who have chronic

kidney disease (CKD) and/or diabetes

↓

Systolic pressure < 140 mm Hg, diastolic pressure < 90 mm Hg

Lifestyle Modifications

Lifestyle modifications are the first intervention when treating and

controlling hypertension.56 these changes must be considered to be

life-long commitments. The use of antihypertensives can at times be

decreased but adherence to an exercise program, moderate use of

alcohol, salt restriction, smoking cessation, and maintaining optimal

body weight are essential for the successful treatment of hypertension.

If the risk factors are not eliminated or modified, then treating

hypertension will be an uphill battle.

Exercise

Aerobic exercise has been shown to reduce blood pressure for 24

hours post-exercise and to reduce resting blood pressure, as well.57

Patients who have hypertension should perform 30-40 minutes of

moderate to vigorous aerobic exercise four to seven days a week.58,59

Resistance exercise, i.e., weight lifting, is also recommended for


patients who have hypertension. However, the blood pressure lowering

effects of resistance training appear to be much less than for aerobic

exercise and the level of proof of its usefulness for lowering blood

pressure is not as robust as for aerobic exercise.58,60

Resistance training is still recommended for patients who have

hypertension and if it is determined that resistance training can be

done safely, it will not be harmful and patients should be encouraged

to start a weight lifting program. Before starting an exercise program,

patients should consult with a physician, especially if he or she is

greater than 40 years of age, has chest pain at rest or during activity,

bone or joint pain, a balance disorder, or is taking medications for

hypertension or a cardiac disorder. The American College of Sports

Medicine has published exercise program recommendations for people

who have hypertension.

Diet

Patients who have hypertension should be instructed to follow the

Dietary Approaches to Stop Hypertension (DASH) eating pattern.4 The

DASH program is a diet that stresses consumption of fruits,

vegetables, whole grains, and low-fat dairy products while reducing

intake of saturated fats and total fats and restricting sodium intake.

The DASH program has been shown to significantly reduce systolic and

diastolic blood pressure. The guidelines of the DASH diet 2000 calorie

and varied nutritional intake are outlined below.61


DASH Diet Guidelines, 2000 Calorie Daily Diet

Calcium: 1250 mg

Carbohydrates: 55% of daily calories

Cholesterol: 150 mg

Fiber: 30 grams

Magnesium: 500 mg

Potassium: 4700 mg

Protein: 18% of daily calories

Saturated fat: 6% of daily calories

Sodium: 2300 mg, 1500 mg in African American and older adults

Total fats: 27% of daily calories

Weight Loss

Obesity is strongly associated with hypertension, and weight loss has

been shown to produce significant reductions in blood pressure.62,63

Smoking Cessation

Smoking cessation has been shown to decrease blood pressure and

arterial stiffness.64-66

Decreased Alcohol Consumption

The association between alcohol consumption and hypertension is

strong and well established,67,68 and an alcohol consumption of more

than 30 grams a day (a drink of alcohol is 14 grams - this is the

amount of alcohol in 6 ounces of wine) is associated with an increased

risk for hypertension.67 The mechanism by which alcohol causes


hypertension is not known,67,68 but stopping or cutting down drinking

has been shown to be effective at lowering blood pressure.4,67

Antihypertensive Therapy

The following recommendations are from the 2014 report by the

Eighth National Joint Committee on Prevention, Detection, Evaluation,

and Treatment of High Blood Pressure.55 The mechanism of action of

each class of drug will be discussed in the next section. Most patients

who have hypertension will eventually require more than one type of

drug in order to reach the blood pressure goal.

Non-black patients, no diabetes or diabetes present, no CKD:

Start therapy with a thiazide diuretic, angiotensin converting enzyme

inhibitor (ACEI), angiotensin II receptor blocker (ARB), or a calcium

channel blocker (CCB), alone or in combination. The ACEIs and ARBs

should not be used together.

Black patients, no diabetes or diabetes present, no CKD:

Start therapy with a thiazide diuretic or a CCB.

All races, CKD present:

Start therapy with an ACEI or an ARB, alone or with another anti-

hypertensive. The ACEIs and ARBs should not be used together.

After the patient has been started on an antihypertensive, the

medications can be adjusted using one of the following strategies:55

1. maximize the first medication dose before adding a second


2. add a second medication before reaching the maximum dose of

the first medication

3. start with two medication classes separately or as fixed-dose

combination

If the blood pressure goal is not attained using this first approach, the

following extension to the above treatment recommendations should

be applied.

Reinforce Medication and Lifestyle Adherence

For strategies 1 and 2, add and titrate thiazide-type diuretic or ACEI or

ARB or CCB; use a medication not previously selected, and avoid the

combined use of an ACEI and an ARB. For strategy 3, titrate doses of

initial medications to the maximum. If the blood pressure goal is not

attained using this approach, the following medication changes may be

instituted:

• Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use

a medication class previously selected, avoid combined use of an

ACEI and an ARB).

• If the blood pressure goal is not attained using the above

approach, a medication from another class (i.e., β-blocker,

aldosterone antagonist, or others) and/or refer to medical

provider with expertise in hypertension management.

The drugs that are most commonly used to treat primary hypertension

are the ACEIs, ARBs, beta-blockers, CCBs, and the thiazide diuretics.

These medications are available as single drugs or in combination (i.e.,

Enalapril Maleate-Hydrochlorothiazide, which is a combination of

enalapril and hydrochlorothiazide). They are typically given orally but


intravenous preparations of some of them are available. Although

primarily used to treat hypertension, some of them have other labeled

uses, as well.

Angiotensin Converting Enzyme Inhibitors

The Angiotensin Converting Enzyme Inhibitors (ACEIs) currently

available in the U.S. are benazepril, captopril, enalapril, lisinopril,

moexipril, perindopril, quinapril, ramipril, and trandolapril. The ACEIs

lower blood pressure by their effect on the renin-angiotensin system,

one of the primary mechanisms of blood pressure homeostasis. These

drugs inhibit the activity of the angiotensin-converting enzyme (ACE).

Angiotensin converting enzyme inhibits the conversion of angiotensin I

to angiotensin II, and angiotensin II is a potent vasoconstrictor.

Common side effects of the ACEIs include cough, hyperkalemia,

hypersensitivity reactions, and skin rash. Angioedema is an uncommon

but potentially life-threatening side effect of these drugs that can

occur even after months and years of use of an ACEI. African

Americans do not generally respond well to monotherapy with an

ACEI.55

Angiotensin II Receptor Blockers

The Angiotensin II Receptor Blockers (ARBS) currently available in the

U.S. are azilsartan, candesartan, irbesartan, losartan, olmesartan,

telmisartan, and valsartan. The ARBs lower blood pressure by their

effect on the renin-angiotensin system, and they do so by

antagonizing the effect of angiotensin II at receptor sites on the blood

vessels resulting in vasodilation of the peripheral vasculature.

Common side effects of these drugs include dizziness, headache,


lightheadedness, and nasal congestion. Cough and angioedema are

uncommon, unlike the ACEIs.

Beta-blockers

The beta-blockers currently available in the U.S. are acebutolol,

atenolol, betaxolol, bisoprolol, carvedilol, esmolol, labetalol,

metoprolol, nadolol, propranolol, nebivolol, and sotalol. The beta-

blockers can be beta-selective, non-selective, some have intrinsic

sympathomimetic properties, and others have alpha blocking effects,

as well. The beta-blockers lower blood pressure by antagonizing the

effects of catecholamines at beta-receptors in the heart and the

peripheral vasculature, decreasing the force of myocardial contraction

and causing vasodilation.

Beta-blocker side effects include bradycardia, bronchospasm,

depression, dizziness, exercise intolerance, fatigue, hypotension, and

sexual dysfunction. These drugs must be used very cautiously in

patients who have asthma, diabetes, or peripheral vascular disease as

they can cause bronchospasm, blunt the signs and symptoms of

hypoglycemia, and aggravate and/or cause arterial insufficiency.

Calcium Channel Blockers

The calcium channel blockers currently available in the U.S. are

amlodipine, clevidipine, diltiazem, felodipine, nicardipine, nifedipine,

nisoldipine, and verapamil. Similar to the beta-blockers, the CCBs are

a diverse group of medications and there are slight differences in their

respective mechanisms of action. However, all of the CCBs lower blood

pressure by antagonizing the movement of calcium through calcium

ion channels in the conducting tissues and pathways of the heart, the


myocardium, and the peripheral vasculature, thus lowering the heart

rate, decreasing the force of myocardial contraction, and causing

vasodilation.

The common side effects include bradycardia, constipation, dizziness

headache, hypotension, edema, fatigue, and rash.

Diuretics

There are several classes of diuretics: aldosterone receptor

antagonists, carbonic anhydrase inhibitors, loop diuretics, osmotic

diuretics, potassium-sparing diuretics, and thiazide diuretics. Each of

these has a specific and distinct mechanism of action. The thiazide

diuretics are the first choice for the treatment of primary hypertension,

and those currently available in the U.S. include chlorothiazide,

hydrochlorothiazide, and methylchlothiazide.

The thiazide diuretics lower blood pressure by inhibiting sodium re-

absorption in the distal tubules, causing increased sodium excretion

and diuresis. Common side effects of the thiazide diuretics include

blurred vision, dehydration, dizziness, hypokalemia, hyponatremia,

hypomagnesemia, hypotension, and orthostatic hypotension.

Other Antihypertensive Medication

There are a variety of other medications that may be used to treat

hypertension when other drugs have not worked or multi-drug therapy

is indicated. Alpha-1 blockers such as doxazosin and prazosin are

peripheral alpha-blockers that lower blood pressure by causing

dilatation of the peripheral blood vessels.


The alpha-2 agonists clonidine, guanfacine, and methyldopa reduce

blood pressure by stimulating central alpha-2 receptors and decreasing

sympathetic outflow from the brain. Hydralazine and minoxidil lower

blood pressure by dilating arterioles. Aliskiren is a renin inhibitor that

lowers blood pressure by preventing the conversion of angiotensinogen

to angiotensin I.

Alternative Therapies

A wide variety of alternative and

complementary therapies have been

used to treat primary hypertension

including, but not limited to,

acupuncture, biofeedback, meditation,

and yoga.69-74 Evidence for the

effectiveness of these therapies is

weak and/or conflicting,69 but as they

are generally safe when done correctly

and they may have other health benefits aside from lowering blood

pressure, their use can be recommended.

Nursing Considerations

Approximately 52% of people who have hypertension have the

condition under control75 and one in five adults who have hypertension

are undiagnosed. There is a multitude of reasons why treatment of

hypertension is suboptimal; such as, inadequate screening, poor

patient compliance, incomplete patient education, unpleasant side

effects of the antihypertensive medication, lack of medical and patient

resources, lack of patient knowledge, and, the well documented


difficulty many people have in losing weight, stopping smoking, using

alcohol in moderation and adhering to an exercise regimen.

Nurses can and should have an

active role in the identification,

prevention and treatment of

hypertension. Patients who are at

risk for developing hypertension

should be encouraged to have

their blood pressure checked. The

nurse should assess these

patients to determine if there is a

family history of hypertension and

if the patient has lifestyle issues

such as poor diet, obesity,

sedentary lifestyle, or smoking

that increase the risk for

developing hypertension. If these or other risk factors are present, the

nurse should provide the patient with information about such

deleterious lifestyle choices and with the education, referrals,

resources, and support needed to make needed changes, such as

setting up an exercise program, making proper dietary changes, losing

weight, and smoking cessation.

If the patient has hypertension, he or she should be carefully assessed

for signs and symptoms of end-organ damage, i.e., blurred vision or

other ocular abnormalities, chest pain, dizziness, hematuria, numbness

or tingling in the extremities, or palpitations. These patients should

also be assessed for the presence of risk factors, for their level of


knowledge about how lifestyle factors can influence hypertension, and

how well they understand their role in self-care.

Nursing considerations appropriate for the patient with hypertension

address the following concerns: 1) deficient knowledge regarding the

relationship between the treatment regimen and control of the disease

process, 2) ineffective therapeutic regimen management related to

medication adverse effects and difficult lifestyle adjustments, 3)

ineffective coping, and 4) noncompliance with the therapeutic regimen.

The following table addresses key points for patient education. Key Points for Patient Teaching

• Know the blood pressure goal – ideally less than 120/80 mmHg.

• Understand which lifestyle changes are helpful in treating and preventing

hypertension. • Hypertension cannot be cured but it can be managed and patient involvement

and self-care are absolutely critical. • Know how often to follow up with the health care provider; typically, monthly

until blood pressure is well controlled and every three to six months thereafter. • Know which blood tests are important to monitor based on the medications

taken. • Maintain a record of blood pressure readings. • Contact the healthcare provider for signs/symptoms of end-organ damage. • To change or stop medications, or for side effects difficult to tolerate, contact

the primary health care provider. • Understand common side effects and report them to the health care provider. • For a missed dose of medication, contact the primary health care provider, or

pharmacist. Do not take an extra dose to “catch up” as this could be dangerous.


Summary

Hypertension significantly increases the risk for developing

cardiovascular diseases, which include atherosclerosis, cardiac

arrhythmias, congestive heart failure, myocardial infarction, stroke and

organ disease. Morbidity and mortality are directly related to the

duration and severity of hypertension. Hypertension is typically

classified as primary or secondary. Primary hypertension accounts for

the great majority of the cases of hypertension. Whereas, secondary

hypertension is much less common than primary hypertension, and

identifiable causes of secondary hypertension are multifactorial, such

as endocrine, neurologic, renal, and vascular diseases, medical

conditions (i.e., obstructive sleep apnea), pregnancy, and drug-

induced.

While there is no cure for hypertension, certain lifestyle modifications

and antihypertensive drug therapy can help to control it. Screening for

hypertension is key to identifying those individuals at risk for having

hypertension. Additionally, patient knowledge of and compliance with

hypertension drug therapy and the needed lifestyle changes are

important to successful treatment. Nurses have a fundamental role in

educating patients on the prevention and treatment of hypertension,

and in closing gaps in patient knowledge to obtain appropriate care.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement.




2. Elevated blood pressure that is caused by heart and lung

disease, or other illness, is known as

a. primary hypertension. b. chronic hypertension. c. secondary hypertension. d. acute hypertension.

3. If only the diastolic blood pressure is elevated when

measured, then the patient is understood to have



a. primary hypertension. b. isolated diastolic hypertension. c. secondary hypertension. d. acute hypertension.


a. SBP > 110 mm Hg or DBP > 70 mm Hg. b. SBP ≥ 160 mm Hg or DBP ≥ 110 mm Hg. c. SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg. d. SBP 120-139 mm Hg, DBP 80-89 mm Hg.

6. In the beginning stages of hypertension

a. most people experience chest pain and shortness of breath. b. most people are asymptomatic. c. most people have blurred vision and dizziness. d. most have mild and non-specific symptoms.


7. True or False: African Americans suffer disproportionately from hypertension.

a. True b. False

8. Which of the following answers lists correctly the risk

factors for hypertension?

a. Age < 20 years, obesity, and diet high in fiber. b. Heavy drinking, high level of physical activity, and age. c. Family history, sedentary lifestyle, and abstinence from

tobacco. d. Obesity, smoking, and excessive sodium intake.

9. Complications of primary hypertension include:

a. Hepatic and pulmonary damage. b. Stroke and kidney damage. c. Atherosclerosis and hypokalemia. d. Thyroid disorders and retinopathy.

10. A diagnosis of hypertension is confirmed if the patient’s

blood pressure is elevated

a. and orthostatic changes are present. b. and risk factors for hypertension are present. c. on at least 3 separate occasions, separated by the

appropriate length of time. d. with readings of SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg.

11. Isolated systolic hypertension is very common in

a. the elderly. b. African Americans c. people < 40 years of age. d. men.


12. The first intervention when treating and controlling hypertension is

a. aggressive diuresis with a thiazide diuretic. b. starting therapy with an ACEI and a CCB. c. starting therapy with low-dose aspirin and a beta-blocker. d. lifestyle modifications.

13. The first-line drug(s) of choice for treating patients who

have hypertension is/are:

a. ACEIs and ARBs. b. Thiazide diuretics. c. Beta-blockers and loop diuretics. d. Vasodilators and alpha1 blockers.

14. Hypertension can be ________ with lifestyle modifications

and anti-hypertensive drug therapy.

a. cured b. controlled c. diagnosed d. eliminated

15. Which of the following defines pre-hypertension?

a. SBP ≥ 160 mm Hg or DBP ≥ 100 mm Hg b. SBP ≥ 140 mm HG and DBP < 90 mm Hg c. SBP 120-139 mm Hg, DBP 80-89 mm Hg d. SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg

16. True or False: A patient who has elevated blood pressure is

considered to be in a hypertension emergency.

a. True b. False

17. Patients in whom the blood pressure elevation is

considered to be urgent may be managed with

a. hospitalization and rapid control of blood pressure. b. rapid control of blood pressure. c. maintaining the same anti-hypertensive therapy. d. initiation of anti-hypertensive therapy.


18. Hospitalization and rapid control of blood pressure would be required in cases where a patient has significant signs and symptoms such as

a. chest pain. b. evidence of end-organ damage such as aortic dissection. c. hypertensive encephalopathy. d. All of the above

19. The most important factor related to obesity, which

contributes to an increased risk of developing hypertension, appears to be

a. body weight. b. distribution of body fat. c. insulin resistance. d. obstructive sleep apnea.

20. The incidence of hypertension is increased in people who

smoke because smoking increases the risk of developing

a. atherosclerosis. b. obesity. c. encephalopathy. d. decreased activity of the sympathetic nervous system.

21. The incidence of retinopathy in hypertension patients may

be skewed by the presence of

a. metabolic syndrome. b. sympathetic nervous system abnormalities. c. diabetes. d. physical inactivity.

22. The high prevalence of hypertension in the elderly can be

explained physiological factors that occur during aging such as

a. increased arterial stiffness. b. decreased activity of the sympathetic nervous system. c. a diet high in sodium. d. obesity.


23. Studies show that with the development of hypertension in an individual, genetic

a. factors are primary causes of the disease. b. factors play no role. c. factors will predict hypertension in over half the cases. d. identification of those at risk is not feasible at this time.

24. Hypertensive emergencies are a spectrum of clinical

presentations that are usually characterized by

a. SBP ≥ 160 mm Hg or DBP ≥ 100 mm Hg b. SBP ≥ 140 mm HG and DBP < 90 mm Hg c. SBP > 220 mm Hg or a DBP > 120 mm Hg d. SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg

25. True or False: Until age 45 men are more likely than

women to have hypertension.

a. True b. False

26. Other factors that have been identified as possible

independent contributors to the development of primary hypertension include(s)

a. high-fiber diet. b. Vitamin D deficiency. c. decreased activity of the sympathetic nervous system. d. All of the above

27. The incidence of retinopathy in patients who have

hypertension has been reported to be a. due to Vitamin D deficiency. b. statistically insignificant because retinopathy is usually caused

by diabetes. c. below 20%. d. as high as 66.3% to 80.3%.


28. _________________________ is the most common form of hypertension in adults less than age 40.

a. Isolated diastolic blood pressure b. Isolated systolic blood pressure c. Acute hypertension d. Genetic hypertension

29. Isolated systolic hypertension is caused by

a. Vitamin D deficiency. b. decreased sympathetic neural activity. c. reduced compliance and elasticity of large arteries. d. conforming nephron mass.

30. True or False: An alcohol consumption of more than 30

grams a day is associated with an increased risk for hypertension.

a. True b. False

31. Common side effects of Angiotensin Converting Enzyme

Inhibitors (ACEIs) include

a. cough. b. hyperkalemia. c. hypersensitivity reactions, and skin rash. d. All of the above

32. The Angiotensin II Receptor Blockers (ARBs) lower blood

pressure by their effect on

a. the renin-angiotensin system. b. sympathetic neural activity. c. hypertensive encephalopathy d. retinal hemorrhages.


33. Common side effects of Angiotensin II Receptor Blockers (ARBs) include

a. cough. b. angioedema. c. dizziness. d. All of the above

34. The nurse should assess these patients to determine if

there is/are ________________________________ that increase(s) the risk for developing hypertension.

a. a family history of hypertension b. lifestyle issues such as obesity c. lifestyle issues such as smoking d. All of the above

35. True or False: Beta-blockers must be used very cautiously

in patients who have asthma, diabetes, or peripheral vascular disease. a. True b. False

CORRECT ANSWERS:


a. primary hypertension. p. 5: “The etiology of primary hypertension is not known. There is a genetic component to the development of the disease, but age and lifestyle factors contribute significantly to its development and progression. Secondary hypertension is much less common than primary hypertension, and in secondary hypertension there are identifiable causes.”


2. Elevated blood pressure that is caused by heart and lung disease, or other illness, is known as

c. secondary hypertension. p. 5: “The etiology of primary hypertension is not known. There is a genetic component to the development of the disease, but age and lifestyle factors contribute significantly to its development and progression. Secondary hypertension is much less common than primary hypertension, and in secondary hypertension there are identifiable causes.”

3. If only the diastolic blood pressure is elevated when measured, then the patient is understood to have

b. isolated diastolic hypertension. p. 6: “If only the diastolic blood pressure is elevated when measured, then the patient is understood to have isolated diastolic hypertension.”


a. primary hypertension. p. 5: “Primary hypertension accounts for the great majority of the cases of hypertension.”


c. SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg. p. 7: “Stage I Hypertension: SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg.”

6. In the beginning stages of hypertension

b. most people are asymptomatic. pp. 5-6: “The majority of people who have hypertension (aside from secondary hypertension) have no characteristic signs or symptoms except for an elevated blood pressure, and this is one of the most harmful features of the disease.”


p. 16: “Pre-hypertension is a condition in which the blood pressure is elevated above normal levels but not to the measurements that define hypertension. In addition, the patient is asymptomatic and he or she has not yet developed organ damage.”

7. True or False: African Americans suffer disproportionately

from hypertension.

a. True p. 10: “The incidence and severity of hypertension is higher in African Americans than in other ethnic groups in the U.S.”

8. Which of the following answers correctly lists risk factors for hypertension?

d. Obesity, smoking, and excessive sodium intake. See discussion at pages 9-12.

9. Complications of primary hypertension include:

b. Stroke and kidney damage. pp. 16-17: “Complications of primary hypertension include … Kidney disease. Hypertension is a major risk factor for the development of chronic kidney disease, and the risk of chronic kidney disease increases in direct proportion to elevations in blood pressure. Hypertension is the second leading cause of kidney failure in the U.S.”

10. A diagnosis of hypertension is confirmed if the patient’s blood pressure is elevated

c. on at least 3 separate occasions, separated by an appropriate length of time. p. 15: “At least three measurements should be taken. It is very important that multiple readings should be taken and these readings must be separated by the appropriate length of time.”


11. Isolated systolic hypertension is very common:

a. in the elderly. p. 18: “Isolated systolic hypertension is caused by reduced compliance and elasticity of large arteries, and it is quite common in the elderly.”

12. The first intervention when treating and controlling hypertension is

d. lifestyle modifications. p. 20: “Lifestyle modifications are the first intervention when treating and controlling hypertension.”

13. The first-line drugs of choice for treating patients who have hypertension are:

b. Thiazide diuretics. p. 27: “The thiazide diuretics are the first choice for the treatment of primary hypertension, and those currently available in the U.S., include chlorothiazide, hydrochlorothiazide, and methylchlothiazide.”

14. Hypertension can be ________ with lifestyle modifications and anti-hypertensive drug therapy.

b. controlled p. 6: “Hypertension cannot be cured but it can be controlled with lifestyle modifications and anti-hypertensive drug therapy.”

15. Which of the following defines pre-hypertension?

c. SBP 120-139 mm Hg, DBP 80-89 mm Hg p. 7: “Pre-hypertension: SBP 120-139 mm Hg, DBP 80-89 mm Hg.”


16. True or False: A patient who has elevated blood pressure is considered to be in a hypertension emergency.

b. False p. 7: “Hypertensive emergencies are a spectrum of clinical presentations that are usually characterized by a systolic blood pressure > 220 mm Hg or a diastolic blood pressure > 120 mm Hg. The situation is considered urgent (not necessarily an emergency) if the patient has no significant signs and symptoms and no evidence of end-organ damage.”

17. Patients in whom the blood pressure elevation is considered to be urgent may be managed with

d. initiation of anti-hypertensive therapy. pp. 7-8: “Patients in whom the blood pressure elevation is considered to be urgent may be managed with initiation of anti-hypertensive therapy or a change to the existing anti-hypertensive therapy and outpatient follow up.”

18. Hospitalization and rapid control of blood pressure would be required in cases where a patient has significant signs and symptoms such as

a. chest pain. b. evidence of end-organ damage such as aortic dissection. c. hypertensive encephalopathy. d. All of the above

p. 8: “If the patient has significant signs and symptoms such as chest pain, headache, or shortness of breath, or evidence of end-organ damage such as aortic dissection, hypertensive encephalopathy, intracranial hemorrhage, myocardial infarction, papilledema, or retinal hemorrhages, hospitalization and rapid control of blood pressure would be required.”


19. The most important factor related to obesity, which contributes to an increased risk of developing hypertension, appears to be

b. distribution of body fat. p. 11: “It may be the distribution of body fat, not body weight, which is the factor that determines who will or will not become hypertensive.”

20. The incidence of hypertension is increased in people who smoke because smoking increases the risk of developing

a. atherosclerosis. p. 11: “Smoking increases the risk of developing atherosclerosis and atherosclerosis contributes to the development of hypertension.”

21. The incidence of retinopathy in hypertension patients may be skewed by the presence of

c. diabetes. pp. 17-18: “The incidence of retinopathy in patients who have hypertension has been reported to be as high as 66.3% to 80.3%, and the level of systolic blood pressure and the duration of hypertension are significant risk factors for developing retinal damage. The presence of diabetes in many hypertensive patients and the particular methods used to detect retinal damage may skew these figures but, even when these factors are considered, hypertensive retinopathy is still a problem of considerable magnitude.”


22. The high prevalence of hypertension in the elderly can be explained physiological factors that occur during aging such as

a. increased arterial stiffness. pp. 9-10: “The high prevalence of hypertension in the elderly can be explained by a diet high in sodium, obesity, and a sedentary lifestyle. Hypertension in this age group can also be explained by physiological factors that occur during aging such as increased arterial stiffness, decreased baroreceptor sensitivity, increased activity of the sympathetic nervous system, and a decreased ability of the kidneys to excrete sodium.”

23. Studies show that with the development of hypertension in

an individual, genetic

d. identification of those at risk is not feasible at this time. p. 9: “Genetic abnormalities have been identified in people who have hypertension but these have not been shown to be a primary cause of the disease and because environmental factors clearly contribute to the development of primary hypertension, genetic identification of those at risk is not feasible at this time and may not be.”

24. Hypertensive emergencies are a spectrum of clinical presentations that are usually characterized by

c. SBP > 220 mm Hg or a DBP > 120 mm Hg p. 7: “Hypertensive emergencies are a spectrum of clinical presentations that are usually characterized by a systolic blood pressure > 220 mm Hg or a diastolic blood pressure > 120 mm Hg.”

25. True or False: Until age 45 men are more likely than

women to have hypertension.

a. True p. 8: "Until age 45 men are more likely than women to have hypertension.”


26. Other factors that have been identified as possible independent contributors to the development of primary hypertension include(s)

b. Vitamin D deficiency. p. 12: “Other factors that may be risk factors for the development of primary hypertension are Vitamin D deficiency, dyslipidemia, low dietary intake of calcium and magnesium and fruits and vegetables, and psycho-social variables such as depression, occupational stress, personality type, sleep quality, and the individual’s level of isolation and social support.”

27. The incidence of retinopathy in patients who have hypertension has been reported to be

d. as high as 66.3% to 80.3%. pp. 17-18: “The incidence of retinopathy in patients who have hypertension has been reported to be as high as 66.3% to 80.3%, and the level of systolic blood pressure and the duration of hypertension are significant risk factors for developing retinal damage. The presence of diabetes in many hypertensive patients and the particular methods used to detect retinal damage may skew these figures but, even when these factors are considered, hypertensive retinopathy is still a problem of considerable magnitude.”

28. _________________________ is the most common form of hypertension in adults less than age 40.

a. Isolated diastolic blood pressure p. 18: “Isolated diastolic blood pressure primarily affects adults and young men who are obese, and it is the most common form of hypertension in adults less than age 40.”


29. Isolated systolic hypertension is caused by

c. reduced compliance and elasticity of large arteries. p. 18: “Isolated systolic hypertension is caused by reduced compliance and elasticity of large arteries, and it is quite common in the elderly.”

30. True or False: An alcohol consumption of more than 30

grams a day is associated with an increased risk for hypertension.

a. True p. 22: “The association between alcohol consumption and hypertension is strong and well established, and an alcohol consumption of more than 30 grams a day (a drink of alcohol is 14 grams - this is the amount of alcohol in 6 ounces of wine) is associated with an increased risk for hypertension.”

31. Common side effects of Angiotensin Converting Enzyme Inhibitors (ACEIs) include

d. All of the above p. 25: “Common side effects of the ACEIs include cough, hyperkalemia, hypersensitivity reactions, and skin rash.”

32. The Angiotensin II Receptor Blockers (ARBs) lower blood pressure by their effect on

a. the renin-angiotensin system. p. 25: “The ARBs lower blood pressure by their effect on the renin-angiotensin system.”


33. Common side effects of Angiotensin II Receptor Blockers (ARBs) include

c. dizziness. pp. 25-26: “The ARBs lower blood pressure by their effect on the renin-angiotensin system, …. Common side effects of these drugs include dizziness, headache, lightheadedness, and nasal congestion. Cough and angioedema are uncommon, unlike the ACEIs.”

34. The nurse should assess these patients to determine if

there is/are ________________________________ that increase(s) the risk for developing hypertension.

d. All of the above

p. 29: “The nurse should assess these patients to determine if there is a family history of hypertension and if the patient has lifestyle issues such as poor diet, obesity, sedentary lifestyle, or smoking that increase the risk for developing hypertension. If these or other risk factors are present, the nurse should provide the patient with information about such deleterious lifestyle choices and with the education, referrals, resources, and support needed to make needed changes, such as setting up an exercise program, making proper dietary changes, losing weight, and for smoking cessation.”

35. True or False: Beta-blockers must be used very cautiously in patients who have asthma, diabetes, or peripheral vascular disease.

a. True p. 26: “Beta-blocker side effects include bradycardia, bronchospasm, depression, dizziness, exercise intolerance, fatigue, hypotension, and sexual dysfunction. These drugs must be used very cautiously in patients who have asthma, diabetes, or peripheral vascular disease as they can cause bronchospasm, blunt the signs and symptoms of hypoglycemia, and aggravate and/or cause arterial insufficiency.”


References Section

The reference section of in-text citations includes published works

intended as helpful material for further reading. Unpublished works

and personal communications are not included in this section, although

may appear within the study text.

1. Basile J, Bloch MJ. Overview of hypertension in adults. UpToDate. March 2, 2016. Retrieved September 23, 2016 from http://www.uptodate.com/contents/overview-of-hypertension-in-adults.

2. Sutters M. Systemic hypertension. In: Papadakis MA, McPhee SJ, Rabow MW, eds. Current Medical Diagnosis & Treatment 2016. 55rd ed. New York, NY: McGraw-Hill Education; 2016. Online edition, retrieved September 23, 2016 from www.UCHC.edu.

3. Kaplan NM. Prehypertension. UpToDate. July 2, 2014. Retrieved September 19, 2014 from http://www.uptodate.com/contents/prehypertension?source=search_result&search=prehypertension&selectedTitle=1%7E29.

4. Kotchen TA. Hypertensive vascular disease. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 19th ed. New York, NY: McGraw-Hill; 2015. Online edition, retrieved September 23, 2016 from www.UCHC.edu.

5. Mann JFE, Hilgers KF. Hypertension: Who should be treated? UpToDate. September 16, 2014. Retrieved September 19, 2014 from http://www.uptodate.com/contents/hypertension-who-should-be-treated?source=search_result&search=isolated+diastolic+hypertension&selectedTitle=1%7E4.

6. Cooper CM, Fenves AZ. Hypertensive urgencies and emergencies in the hospital setting. Hosp Pract (1995). 2016;44(1):21-27.

7. Taylor DA. Hypertensive crisis: A review of pathophysiology and treatment. Crit Care Nurs Clin North Am. 2015;27(4):439-447.

8. Natekar A, Olds RL, Lau MW, Min K, Imoto K, Slavin TP. Elevated blood pressure: Our family’s fault? The genetics of essential hypertension. World J Cardiol. 2014;26:327-337.

9. Syed Q, Messinger-Rapport. B Hypertension. In: Williams BA, Chang A, Ahalt C, Chen H, Conant R, Landefeld CS, Ritchie C,


Yukawa M, eds. Current Treatment & Diagnosis: Geriatrics, 2nd ed. New York, NY: McGraw-Hill; 2014.

10. Supiano MA. Hypertension. In: Halter JB, Ouslander JG, Tinetti ME, Studenski S, High KP, Asthana S, eds. Hazzard’s Geriatric Medicine and Gerontology. 6th ed. New York, NY: McGraw-Hill; 2009. Online edition, retrieved September 18, 2014 from www.UCHC.edu.

11. Kaplan NM. Hypertensive complications in blacks. UpToDate. January 2, 2014. Retrieved September 20, 2014 from http://www.uptodate.com/contents/hypertensive-complications-in-blacks?source=search_result&search=Hypertensive+complications+in+blacks&selectedTitle=1%7E150.

12. Lackland DT. Racial differences in hypertension: implications for high blood pressure management. Am J Med Sci. 2014;348(2):135-138.

13. Chandraa A, Neeland IJ, Berry jd, ET AL. The relationship of body mass and fat distribution with incident hypertension. J Am Coll Cardiol. 2014;64(10):997-1002.

14. Kokubo Y. Prevention of hypertension and cardiovascular diseases: A comparison of lifestyle factors in Westerners and East Asians. Hypertension. 2014;63:655-660.

15. Kaplan NM. Obesity and weight reduction in hypertension. UpToDate. June 30, 2014. Retrieved September 19, 2014 from http://www.uptodate.com/contents/obesity-and-weight-reduction-in-hypertension?source=search_result&search=Obesity+and+weight+reducton+in+hypertension&selectedTitle=1%7E150.

16. Yu-Jie W, Hui-Lang L, Lu, Z, Zhi-Geng J. Impact of smoking and smoking cessation on arterial stiffness in healthy participants. Angiology. 2013;64(4):273-280.

17. Kaplan NM. Smoking and hypertension. UpToDate. February 5, 2014. Retrieved September 19, 2014 from http://www.uptodate.com/contents/smoking-and-hypertension?source=search_result&search=smoking+and+hypertension&selectedTitle=1%7E150.

18. Mostofsky E, Mukamal KJ, Giovannucci EL, Stampfer MJ, Rimm EB. Key findings on alcohol consumption and a variety of health outcomes from the nurses' health study. Am J Public Health. 2016;106(9):1586-1591.

19. Tangney CC, Rosenson RS. Cardiovascular benefits and risks of moderate alcohol consumption. UpToDate. July 8, 2015.

20. Lawlor DA, Nordestgaard BG, Benn M, Zuccolo L, Tybjaerg-Hansen A, Davey Smith G. Exploring causal associations


between alcohol and coronary heart disease risk factors: findings from a Mendelian randomization study in the Copenhagen General Population Study. Eur Heart J. 2013; 34(32):2519-2528.

21. Sharman JE, La Gerche A, Coombes JS. Exercise and cardiovascular risk in patients with hypertension. Am J Hypertens. 2015;28(2):147-158.

22. Christofaro DG, De Andrade SM, Cardoso JR, Mesas AE, Codogno JS, Fernandes RA. High blood pressure and sedentary behavior in adolescents are associated even after controlling for confounding factors. Blood Press. 2015;24(5):317-323.

23. Leyvraz M, Taffé P, Chatelan A, et al. Sodium intake and blood pressure in children and adolescents: protocol for a systematic review and meta-analysis. BMJ Open. 2016 Sep 21;6(9):e012518. doi: 10.1136/bmjopen-2016-012518.

24. He FJ, Li J, Macgregor GA. Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ. 2013 Apr 3;346:f1325. doi: 10.1136/bmj.f1325.

25. Van Ballegooijen A, Van Schoor N, Brouwer I, Visser M, Beulens J. OS 06-09 THE Synergistic association between vitamin D and vvitamin K with incident hypertension. J Hypertens. 2016;34 Suppl 1:e64

26. Tamez H, Kalim S, Thadhani RI. Does vitamin D modulate blood pressure? Curr Opin Nephrol Hypertens. 2013;22(2):204-209.

27. Vimaleswaran KS, Cavadino A, Berry DJ, et al. Association of vitamin D status with arterial blood pressure and hypertension risk: a mendelian randomisation study. Lancet Diabetes Endocrinol. 2014;2(9):719-729.

28. Otsuka T, Takada H, Nishiyama Y, et al. Dyslipidemia and the risk of developing hypertension in a working-age male population. J Am Heart Assoc. 2016 Mar 25;5(3):e003053. doi: 10.1161/JAHA.115.003053.

29. Wu L, Sun D, He Y. Fruit and vegetables consumption and incident hypertension: dose-response meta-analysis of prospective cohort studies. J Hum Hypertens. 2016;30(10):573-580.

30. Cuffee Y, Ogedegbe C, Williams NJ, Ogedegbe G, Schoenthaler A. Psychosocial risk factors for hypertension: an update of the literature. Curr Hypertens Report. 2014; 16:483. doi: 10.1007/s11906-014-0483-3.

31. Zambrana RE, López L, Dinwiddie GY, et al. Association of baseline depressive symptoms with prevalent and incident pre-hypertension and hypertension in postmenopausal Hispanic


women: Results from the Women's Health Initiative. PLoS One. 2016 Apr 28;11(4):e0152765. doi: 10.1371/journal.pone.0152765. eCollection 2016.

32. Jackson CA, Pathirana T, Gardiner PA. Depression, anxiety and risk of hypertension in mid-aged women: a prospective longitudinal study. J Hypertens. 2016;34(10):1959-1566.

33. Lin CL, Liu TC, Lin FH, Chung CH, Chien WC. Association between sleep disorders and hypertension in Taiwan: a nationwide population-based retrospective cohort study. J Hum Hypertens. 2016 Aug 11. doi: 10.1038/jhh.2016.55. [Epub ahead of print]

34. Siu AL; U.S. Preventive Services Task Force. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163(10):778-786.

35. Kaplan NM, Thomas G, Pohl MA. Blood pressure measurement in the diagnosis and management of hypertension in adults. UpToDate. July 26, 2016. https://www.uptodate.com/contents/blood-pressure-measurement-in-the-diagnosis-and-management-of-hypertension-in-adults. Accessed September 25, 2016.

36. Piper MA, Evans CV, Burda BU, et al. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2015;162(3):192-204.

37. Kang YY, Li Y, Huang QF, Song J, et al. Accuracy of home versus ambulatory blood pressure monitoring in the diagnosis of white-coat and masked hypertension. J Hypertens. 2015 Aug;33(8):1580-7. doi: 10.1097/HJH.0000000000000596.

38. Niiranen TJ, Johansson JK, Reunanen A, Jula AM. Optimal schedule for home blood pressure measurement based on prognostic data: the Finn-Home Study. Hypertension. 2011; 57(6):1081-1086.

39. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005; 111(5):697-716.

40. Gupta P, Nagaraju SP, Gupta A, Mandya Chikkalingaiah KB. Prehypertension - time to act. Saudi J Kidney Dis Transpl. 2012; 23(2):223-233.


41. Sulayma Albarwani, Sultan Al-Siyabi, Musbah O Tanira. Prehypertension: Underlying pathology and therapeutic options. World J Cardiol. 2014; 26(8):728-743.

42. Huang Y, Cai X, Li Y, Su L, Mai W, Wang S, et al. Prehypertension and the risk of stroke: a meta-analysis. Neurology. 2014; 82:153-1161.

43. Rodriguez CJ, Swett K, Agarwal SK, Folsom AR, Fox ER, Loehr LR, et al. Systolic blood pressure levels among adults with hypertension and incident cardiovascular events: the Atherosclerosis Risk in Communities Study. JAMA Inter Med. 2014; 174(8):1252-1261.

44. Ogedebge G, Pickering TG. Epidemiology of hypertension. In: Fuster V, Walsh A, Harrington RA, eds. Hurst’s The Heart, 13th ed. New York, NY: McGraw-Hill; 2011. Online edition, retrieved September 26, 2016 from www.UCHC.edu.

45. Im TS, Chun EJ, Lee MS, Adla T, Kim JA, Choi SI. Grade-response relationship between blood pressure and severity of coronary atherosclerosis in asymptomatic adults: assessment with coronary CT angiography. Int J Cardiovasc Imaging. 2014 Dec;30 Suppl 2:105-12. doi: 10.1007/s10554-014-0522-9. Epub 2014 Sep 2.

46. Xie W, Liu J, Wang W, Wang M, Li Y, Sun J, et al. Five-year change in systolic blood pressure is independently associated with carotid atherosclerosis progression: a population-based cohort study. Hypertens Res. 2014;37(10):960-965.

47. Gorgui J, Gorshkov M, Khan N, Daskalopoulou SS. Hypertension as a risk factor for ischemic stroke in women. Can J Cardio. 2014; 30(7):774-782.

48. Carnethon MR, Evans NS, Church TS, et al. Joint associations of physical activity and aerobic fitness on the development of incident hypertension: coronary artery risk development in young adults. Hypertension. 2010;56(1):49-55.

49. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). High blood pressure and kidney disease. Retrieved September 22, 2014 from http://kidney.niddk.nih.gov/kudiseases/pubs/highblood/.

50. Bakalli A, Koçinaj D, Bakalli A, Krasniqi A. Relationship of hypertensive retinopathy to thoracic aortic atherosclerosis in patients with severe arterial hypertension. Clin Expl Hypertens. 2011; 33(2):89-94.

51. Erden S. Bicaki B. Hypertensive retinopathy. Incidence, risk factors, and co-morbidities. Clin Exp Hypertens. 2012;34(6):397-401.


52. Mann JFE, Hilgers KF. Hypertension: Who should be treated? UpToDate. September 16, 2014. Retrieved September 22, 2014 from http://www.uptodate.com/contents/hypertension-who-should-be-treated?source=search_result&search=Hypertension%3A+Who+should+be+treated%3F&selectedTitle=1%7E150.

53. Franklin SS, Pio JR, Wong ND, et al. Predictors of new-onset diastolic and systolic hypertension: the Framingham Heart Study. Circulation. 2005;111(9):1121-1127.

54. Staessen JA, Gasowski J, Wang JG, Thijs L, Den Hond E, Boissel JP, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet. 2000; 355(9207):865-872.

55. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 311;(5) (2014), pp. 507-520.

56. Millar PJ, Goodman JM. Exercise as medicine: Role in the management of primary hypertension. Appl Physiol Nutr Metab. 2014; 39(7):856-858.

57. Brook RRD, Appel LJ, Rubenfire M, Ogedegbe G, Bisognano JD, Elliot WJ, et al. Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association. Hypertension. 2013; 61(6):1360-1383.

58. Eckell RH, Jakicic JM, Ard JD, Miller NH, Hubbard VS, Nonas CA, et al. 2013 AHA/ACC Guideline on Life Style Management to Reduce Cardiovascular Risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 129(25 Suppl 2):576-599.

59. Rossi AM, Moullec G, Lavoie KL, Gour-Provençal G, Bacon SL. The evolution of the Canadian Hypertension Education Program recommendation: The impact of resistance training on resting blood pressure in adults as an example. Can J Cardiol. 2013; 29(5):622-627.

60. Saneei P, Salehi-Abargouei A, Esmaillzadeh A, Azadbakht L. Influence of Dietary Approaches to Stop Hypertension (DASH) diet on blood pressure: A systematic review and meta-analysis on randomized controlled trials. Nutr Metabol Cardiovasc Dis. 2014;24(12):1253-1261.

61. Chiu S, Bergeron N, Williams PT, Bray GA, Sutherland B, Krauss RM. Comparison of the DASH (Dietary Approaches to Stop


Hypertension) diet and a higher-fat DASH diet on blood pressure and lipids and lipoproteins: a randomized controlled trial. Am J Clin Nutr. 2016;103(2):341-347.

62. Ho AK, Bartels CM, Thorpe CT, Pandhi N, Smith MA, Johnson HM. Achieving Weight Loss and Hypertension Control Among Obese Adults: A US Multidisciplinary Group Practice Observational Study. Am J Hypertens. 2016;29(8):984-991.

63. Poorolajal J, Hooshmand E, Bahrami M, Ameri P. How much excess weight loss can reduce the risk of hypertension? J Public Health (Oxf). 2016 Aug 13. [Epub ahead of print]

64. Oren S, Isakov I, Golzman B, et al. The influence of smoking cessation on hemodynamics and arterial compliance. Angiology. 2006;57(5):564-568.

65. Takeshi Takami T, Saito Y. Effects of smoking cessation on central blood pressure and arterial stiffness. Vasc Health Risk Manag. 2011; 7:633-638.

66. Oncken CA, White WB, Cooney JL, Van Kirk JR, Ahluwalia JS, Giacco S. Impact of smoking cessation on ambulatory blood pressure and heart rate in postmenopausal women. Am J Hypertens. 2001; 14(9 Pt 1):942-949.

67. Husain K, Ansari RA, Ferder L. Alcohol-induced hypertension: Mechanism and prevention. World J Cardiol. 2014;6(5):245-252.

68. Marchi KC Muniz JJ, Tirapelli CR. Hypertension and chronic ethanol consumption: What do we know after a century of study? World J Cardiol. 2014;6(5):283-294.

69. Eckell RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC Guideline on Life Style Management to Reduce Cardiovascular Risk: A report of the American College of Cardiology/American Heart Association Task Force. Circulation. 2014 129:576-599.

70. Posadzki P, Cramer H, Kuzdzal A, Lee MS, Ernst E. Yoga for hypertension: a systematic review of randomized clinical trials. Complement Ther Med. 2014; 22(3):511-522.

71. Cramer H, Haller H, Lauche R, Steckhan N, Michalsen A, Dobos G. A systematic review and meta-analysis of yoga for hypertension. Am J Hypertens. 2014; 27(9):1146-1151.

72. Blom K, Baker B, How M, Dai M, Irvine J, Abbey S, et al. Hypertension analysis of stress reduction using mindfulness meditation and yoga: results from the HARMONY randomized controlled trial. Am J Hypertens. 2014; 27(1):122-129.

73. Wang J, Xiong X, Liu W. Acupuncture for essential hypertension. Int J Cardiol. 2013; 169(5):317-326.

74. Li DZ, Zhou Y, Yang YN, Ma YT, Li XM, Yu J, et al. Acupuncture for ssential hypertension: a meta-analysis of randomized sham-


controlled clinical trials. Evid Based Complement Alt Med. 2014; 279478. doi: 10.1155/2014/279478. Ep2014 Mar 4.

75. Centers for Disease Control and Prevention. High blood pressure facts. February 19, 2015. Retrieved September 26, 2016 from http://www.cdc.gov/bloodpressure/facts.htm.

The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare. The information provided in this course is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from NurseCe4Less.com.

hypertension: an overview - nursece4less.com an overview dana bartlett, bsn, msn, ma, ......

Documents