blood pressure
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Clinical Guidelines—Lowering High Blood Pressure in Adults
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HypertensionScope
High Blood Pressure (hypertension)•is the most common primary diagnosis in the U.S.,•affects approximately 1 in 3 adults in the U.S., and•affects more than 65% of people over 65 years old.
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HypertensionEffects
BrainIt’s the most important risk factor
for stroke.
HeartIt’s a major risk factor for heart attack and the #1 risk for congestive heart failure.
KidneysIt can cause the kidneys to fail, resulting in dialysis or a kidney transplant.
ArteriesIt’s associated with stiffer arteries, causing the heart and kidneys to work harder.
Hypertension can damage the
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HypertensionAdults at Risk
Percentage of adults with hypertension by age
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HypertensionAdults at Risk
Percentage of adults with hypertension by ethnicity
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HypertensionAdults at Risk
Percentage ofadults withhypertensionby state
(Source: CDC BehavioralRisk Factor SurveillanceSystem)
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Blood PressureKnow the Numbers
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Blood PressureCardiovascular Disease (CVD)
According to the 7th Report from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7)
•BP relationship to risk of CVD is “continuous, consistent, and independent of other risk factors.”
•For people 40-70 years old, each increment of 20/10 mmHgdoubles the risk of CVD across the entire BP range, starting from 115/75 mmHg.
•Hypertension can be prevented if prehypertension isdiscovered.
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Blood PressureBenefits of Lowering
(Source: JNC7)
HeartFailure
StrokeIncidence
MyocardialInfarction
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HypertensionEvaluation
1. Assess lifestyle and identify major CVD risk factors or concomitant disorders that affect prognosis and
guide treatment.
2. Identify causes of hypertension.
3. Assess the presence or absence of target organdamage and CVD.
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Hypertension Evaluation1. Assess Lifestyle & CVD Risk Factors
Assess Lifestyle•Weight•Eating routine•Sodium intake•Physical activity•Alcohol consumption•Smoking habits
Identify CVD Risk Factors•Hypertension•Obesity•Dyslipidemia•Diabetes mellitus•Microalbuminuria or estimated glomerular filtration rate <60 ml/min•Age•Family history of premature CVD*
*CVD is considered premature when it occurs in men <55 years and women age <65 years.
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Hypertension Evaluation2. Identify Causes of Hypertension
Identify Causes of Hypertension•Sleep apnea•Drug-related causes•Chronic kidney disease (CKD)•Primary aldosteronism•Renovascular disease•Chronic steroid therapy and Cushing’s syndrome•Pheochromocytoma•Coarctation of the aorta•Thyroid or parathyroid disease
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Hypertension Evaluation3. Assess Presence of Target Organ Damage
Brain• Stroke or transient ischemic attack
Heart• Left ventricular hypertrophy• Angina or prior myocardial infarction• Prior coronary revascularization• Heart failure
Kidneys• CKD
Arteries• Peripheral arterial disease
Eyes• Retinopathy
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TreatmentGoal of Therapy
• Reduce CVD and renal morbidity and mortality.
• Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or CKD.
• Achieve the systolic BP (SBP) goal, which is especially important in persons ≥50 years old.
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TreatmentLifestyle Modification
Modify Lifestyle to Reduce SBP approximately•Reduce weight 5-20 mmHg/10kg weight loss•Adopt healthy eating plan 8-14 mmHg•Reduce dietary sodium intake 2-8 mmHg•Increase physical activity 4-9 mmHg•Moderate alcohol intake 2-4 mmHg
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TreatmentPharmacological
• Lowering BP with several classes of drugs will reduce the complications of hypertension.
• Most hypertension patients will need two or more antihypertensive medications to achieve BP goals.*
(*See algorithm for Treatment of Hypertension in the JNC7 report)
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TreatmentOther Considerations
• CVD risk factors should be treated and tobacco avoided.
• Low-dose aspirin therapy should be considered but only when BP is controlled (risk of hemorrhagic strokes increases in patients with uncontrolled hypertension).
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Care ManagementFollow-Up
Patients should be checked:
•monthly for follow-up and medication adjustment until BP goal is reached•more frequently for Stage 2 Hypertension or complicating comorbid conditions•1-2 times/year to check serum potassium and creatinine•every 3-6 months after BP is stable
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Care ManagementFollow-Up
Comorbidities Other special considerations• Ischemic heart disease• Heart failure• Diabetic hypertension• CKD• Cerebrovascular disease
• Minorities• Obesity• Left ventricular hypertrophy• Peripheral arterial disease• Hypertension in older persons• Postural hypotension• Dementia• Gender and age• Urgencies and emergencies
Need for additionallab tests
Additional factors that can affect how often patients shouldfollow-up with their physicians:
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The Patient’s Choice
The patient must be motivated to follow his/her care management plan and to establish and maintain a healthy lifestyle.
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The Patient’s Choice
Barriers to motivationThe patient might•not understand the condition or treatment•deny the illness•dislike taking medication•feel uninvolved in his/her healthcare plan•feel uncomfortable talking to the healthcare team
•not afford the medication•not have transportation to appointments
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Patient Tools and ResourcesFor Motivation and Self-Management
Lifestyle Managementhttp://www.nhlbi.nih.gov/hbp/prevent/h_eating/h_eating.htm
Medications – Types & Tipshttp://www.nhlbi.nih.gov/hbp/treat/treat.htm
Understanding Blood Pressure Readingshttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Understanding-Blood-Pressure-Readings_UCM_301764_Article.jsp
HBP Risk Calculatorhttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/WhyBloodPressureMatters/Assess-Your-High-Blood-Pressure-Related-Risks_UCM_301829_Article.jsp
HBP Trackerhttp://www.heart.org/HEARTORG/Conditions/HighBloodPressure/HighBloodPressureToolsResources/Blood-Pressure-Trackers_UCM_303465_Article.jsp
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Resources
• The 7th Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7)
• Million Hearts Blood Pressure Toolkit
• National Heart Lung and Blood Institute (NHLBI)
• NHLBI: Culturally Appropriate Education Materials