Editor's Note: Last issue, we took a look at pediatric hypertension. Join us this issue as we explore hypertension in adult patients.
The prevalence of hypertension (HTN) in the US adult population has neared an all-time high rate of nearly 45.4% in the past decade, which is significantly higher than the 26% of people diagnosed with HTN worldwide. These statistics are based on the American College of Cardiology (ACC)/American Heart Association (AHA) definition of HTN as a BP of greater than 130/80 mm Hg. This is more stringent than the Eighth Joint National Committee (JNC 8) guidelines, which recommend treating a BP of greater than 140/90 mm Hg in patients younger than age 60, including those with diabetes and/or chronic kidney disease (CKD). The JNC 8 guidelines define HTN in people age 60 and older as 150/90 mm Hg.
Younger adults who meet the more stringent criteria may be overlooked and underdiagnosed with HTN. Underdiagnosis can result from healthcare providers neglecting to screen this age group for HTN because younger adults often don't appear unhealthy. Another circumstance is when a healthcare provider fails to identify a patient with HTN because of his or her expectation of who should have HTN. This may occur in as many as one in three cases. Healthcare providers may assume that older patients should be screened while overlooking patients ages 20 to 30. Within the entire adult demographic, male patients and those without medical insurance also tend to be screened less for HTN. Although many healthcare providers may be concerned about patient overtreatment with lower threshold definitions of HTN, others feel that current recommendations will provide identification of those whose diagnosis is missed.
Increased screening, along with early diagnosis and treatment of adult patients across all demographics, can prevent or slow the progression of long-term HTN-related complications.
Significant epidemiology
Cardiovascular disease (CVD) accounts for almost one-third of deaths in the US every year, with costs expected to exceed $800 billion annually by 2030; HTN is the biggest contributor to CVD. It's important to identify common CVD risk factors that are frequently seen in patients with HTN. These risk factors are divided into two groups: modifiable and relatively fixed. Modifiable risk factors include currently smoking and secondhand smoke exposure, having low fitness levels or increased physical inactivity, and consuming an unhealthy diet (such as fried foods, salty foods, sugar-sweetened beverages, and red and processed meats). Diabetes mellitus, dyslipidemia, and hypercholesterolemia are additional modifiable risk factors. Relatively fixed risk factors include CKD, family history, increased age, low socioeconomic/educational status, male sex, obstructive sleep apnea (OSA), and psychosocial stress.
Recent discoveries in research related to risk factors and causes of HTN include immune mechanisms, systemic vasoconstriction and arterial stiffness, and understanding the role of microbiota in the gut. The REGARDS study revealed that the incidence of increased BP is higher in those who consume a high-sodium diet, particularly in Black men who are overweight and Black women with a larger waist circumference. Body mass index (BMI) is one of the greatest modifiable risk factors of HTN, especially for those who are morbidly obese. Nurses should consider the MAP framework (measure accurately, act rapidly, and partner with patients) for improving BP control. Education on the negative results of uncontrolled or untreated HTN in addition to expected adverse reactions of therapy is a significant step toward reducing disparities in treatment. Open and clear communication and being sensitive to the patient's belief system is necessary for patients who've often been disenfranchised from the healthcare system.
Guidelines for diagnosis
When exploring the translation of scientific evidence into everyday clinical practice, we find reliable guidance from the ACC/AHA guidelines for adult HTN. The ACC/AHA task force consistently updates these guidelines to deliver cardiovascular support and improvement opportunities to prevent CVD.
Systolic and diastolic BP are based on the average of two or more readings obtained on two or more separate occasions. BP in adults is classified as normal, elevated, stage 1, or stage 2:
* normal: systolic <120 mm Hg and diastolic <80 mm Hg
* elevated: systolic 120 to 129 mm Hg and diastolic <80 mm Hg
* stage 1: systolic 130 to 139 mm Hg or diastolic 80 to 89 mm Hg
* stage 2: systolic >=140 mm Hg or diastolic >=90 mm Hg.
It's critical that accurate measurement and recording of BP take place to minimize errors in diagnosis and treatment. The patient should sit quietly for 5 minutes before taking his or her BP. Selecting the correct cuff size, supporting the limb used to measure the BP, ensuring that the cuff is at the level of the heart, and deflating the cuff slowly while auscultating are necessary steps.
After an adult patient is diagnosed with HTN, he or she should be screened for secondary causes of HTN, including excessive use of alcohol, nonsteroidal anti-inflammatory drug use, illicit drug use, OSA, and CKD. If any of these issues are identified, the clinician should include a plan to mitigate each problem. The diagnostic evaluation of patients with HTN includes a fasting blood glucose level, complete blood cell count, lipid profile, serum creatinine with estimated glomerular filtration rate (eGFR), complete metabolic panel, thyroid-stimulating hormone, urinalysis, and an ECG. Additional testing, such as an echocardiogram, should be considered in patients with significant comorbidities or concern for secondary HTN.
Guidelines for treatment
Treatment plans correlate with each category and should be individualized to the patient. The lifetime risk for atherosclerotic CVD (ACVD) must be considered when establishing a treatment plan for an adult patient with HTN. Patients with a lifetime ACVD score of greater than 10%, as calculated per ACC/AHA guidelines, should be treated more aggressively. Patients with confirmed HTN and an ACVD risk of 10% or higher should have a targeted BP goal of less than 130/89 mm Hg (see ACC/AHA ASCVD risk estimator).
Elevated BP is treated with lifestyle modifications and monitoring. Lifestyle modifications include the addition of the Dietary Approaches to Stop Hypertension, or DASH, diet, which is inclusive of lower sodium food choices, a variety of food groups, and portion control. Additional modifications include appropriate exercise (90 to 150 minutes of aerobic exercise per week), weight loss when appropriate, and alcohol use in moderation. Recommendations also include adequate dietary intake of potassium, 3,500 to 5,000 mg/dL per day if not contraindicated by CKD or medications that promote potassium excretion. BP should be rechecked after 3 to 6 months of lifestyle modifications.
Stage I HTN management includes lifestyle modifications and initial pharmacotherapy with the option of thiazide diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, or calcium channel blockers. Per guideline recommendations, these patients should initially be started on single medication therapy. An individual medication's efficacy and the source of an adverse drug reaction are easier to determine when using a single medication regimen.
The patient's comorbidities must always be considered when selecting a medication. For instance, a patient with a reduced ejection fraction due to heart failure shouldn't be treated with a nondihydropyridine calcium channel blocker. Teach the patient how to properly check his or her BP at home routinely and keep a log of readings. The log should be brought to each office visit. Instruct the patient on proper medication administration, potential adverse reactions, and target BP parameters. After drug therapy is initiated, the patient should be seen in 1 month for follow-up.
Stage 2 HTN treatment also incorporates lifestyle modification strategies and pharmacotherapy. Patients with a baseline BP of 20/10 mm Hg above their goal should be treated with dual medication therapy. Two medications from the aforementioned first-line drug list should be prescribed. These patients should also be taught to monitor their BP regularly at home and keep a BP log. They should be seen back in the office in 1 month for follow-up and then monthly until their goal BP is achieved.
Patients with uncontrolled BP of greater than 140/90 mm Hg may need immediate intervention to prevent additional sequelae. Hypertensive emergencies, if left untreated, may result in significant consequences, up to and including death (see Hypertensive emergencies).
Nursing implications
The nursing role in improving BP control in adults includes detection, referral, and patient education (see Understanding hypertension). Nurses are at the heart of the multidisciplinary team, providing holistic care and addressing social and ethnic disparities. Nurses have been recognized over decades for their participation in BP management.
With all ages, selection of an appropriate cuff is imperative to obtain an accurate measurement of auscultatory BP and detect HTN. Appropriate technique is also critical for accurate BP measurement. Ensure that the patient is sitting comfortably with his or her back supported, legs uncrossed, and arms supported at the heart level. The cuff bladder must encircle 80% or more of the arm circumference and the mercury should be deflated at 2 to 3 mm per second. A mercury sphygmomanometer is the preferred device when available. BP may appear elevated if the cuff is too small, if the patient isn't sitting comfortably, or if his or her legs are crossed. A low pressure may result if the arm is elevated above the heart or if deflation of the mercury is too fast.
Provide education to patients about their medications, including the best time to take the medication; the appropriate route; the correct dosage, particularly if there's more than one pill; and potential adverse reactions, such as a cough when taking an ACE inhibitor and dizziness or hypotension with antihypertensive medications. Patients need to be aware of when to report serious reactions. Education on HTN must include teaching patients to take their BP accurately at home. Patients should compare their BP cuff with those used in the clinic to ensure accuracy. You may also provide nutritional, exercise, and relaxation techniques to help lower BP. Follow-up appointments with the healthcare provider must continue regularly to ensure that BP is within range, especially if patients experience changes in diet and weight. The nurse is vital in ensuring that patients understand the importance of continued follow-up care.
Case study
LT, a 23-year-old male, is seen for a sexually transmitted infection screening and has a BP reading of 146/94 mm Hg. He reports that he's had previous BP results that were similar when he was seen for sports physicals while in high school. He was advised to monitor his BP, but states that he didn't follow through. He doesn't snore and he denies daytime sleepiness suggestive of OSA.
LT is a graduate student who typically drinks four to five alcoholic beverages, two to three times a week. He doesn't smoke tobacco, but he reports vape use on occasion when out with friends. His only exercise is walking on campus. He prefers to play video games when he isn't busy with school. He smoked marijuana while in high school but denies any past or present use of stimulants or other recreational drug use.
LT's family history is as follows:
* father: HTN since age 25, obesity, diabetes mellitus diagnosed at age 45
* mother: healthy
* paternal grandfather: HTN, diabetes mellitus, deceased at age 74 of uncertain cause
* paternal grandmother: stroke at age 68, deceased at age 70 due to second stroke
* maternal grandfather: history of obesity, deceased at age 80 due to hepatocellular carcinoma
* maternal grandmother: healthy, deceased at age 84 due to pneumonia.
LT has the following risk factors: obesity, BMI of 39.3, sedentary lifestyle, family history, and male sex. He's instructed to have his BP checked at the local pharmacy or campus health clinic several times over the next 2 weeks; decrease his salt, fast food, and alcohol consumption and increase consumption of fruits and vegetables; avoid vaping; exercise 150 minutes weekly; and practice mindfulness strategies for decreased stress.
At his follow-up appointment 2 weeks later, LT's out-of-office BP readings are documented as 142/94 mm Hg and 148/88 mm Hg. His office BP reading is 154/92 mm Hg. An ECG, urinalysis, fasting lipid panel, and comprehensive metabolic panel with eGFR are ordered and he's referred for an eye exam with fundoscopy. Screening for secondary HTN isn't initiated immediately due to multiple positive risk factors for primary HTN younger than age 30.
LT's diagnostic results are all within normal limits. He has cut back his alcohol consumption; however, he plans to continue to drink in moderation in social situations. He also agrees to continue to work on diet modifications but isn't interested in changing his sedentary lifestyle. He agrees to start antihypertensive medication, with a BP goal of less than 130/80 mm Hg. He's prescribed an ACE inhibitor plus a calcium channel blocker given his diagnosis of stage 2 HTN. He's instructed to routinely check his BP at home and keep a written log to bring with him to his follow-up appointment in 1 month.
Diligence needed
The identification, diagnosis, and management of adult HTN is multifaceted. With the rate of HTN diagnosis in the US significantly higher than in other parts of the world, we should be acutely aware of the risk factors, diagnostic parameters, and treatment guidelines for identifying and treating adult HTN. We must be diligent in recognizing possible external barriers and healthcare provider biases related to plausibility of an HTN diagnosis in younger patient populations. It's essential to understand the stages of HTN and use guideline parameters for initiation of treatment using both nonpharmacologic and pharmacologic methods.
cheat sheet
ACC/AHA ASCVD risk estimator
The ASCVD risk estimator provides a percentage score for each individual based on his or her unique information. Data used to calculate the score include age, sex, race, total cholesterol, high-density lipoprotein cholesterol, presence of HTN, systolic and diastolic BP readings, presence of diabetes, and current smoking status. Scores of 10% or higher equate to an increased 10-year probability of heart disease or stroke. The risk estimator can be found at https://tools.acc.org/ldl/ascvd_risk_estimator/index.html.
INSTRUCTIONS Hypertension across the lifespan: Adults
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