This lecture is gonna talk about the overview
and presentation of hypertension
and it's one of four mini lectures
for you to review prior to class.
The objectives for this particular mini lecture are
in the first four bullets, but these are the objectives
for all of the mini lectures
for class to prepare for in class case studies.
So we're gonna really just kind of review a little bit
about hypertension, its implications
for you as a primary care provider.
Really very briefly talk about the pathophysiology
from kind of that bird's eye view.
So I would encourage you to go back to your patho notes
or your textbook and review the patho that's associated
with the onset of hypertension.
And then we're gonna spend some time looking at risk factors
and some pertinent history and
physical exam assessments when you are faced
with evaluating an individual that has
either known hypertension or has an elevated blood pressure.
So we'll talk a little bit about
your hypertension and health,
and here's a slide that I like that shows how complicated
and how much different things play
into the onset of hypertension.
So clearly we see the effect of the social determinants
of health combined with the built environment
and then also the genetics and epigenetic effect.
So we can see this real great overlap
of all of those things.
So what we try and do in the treatment
of hypertension is really help mitigate areas
that we have control over to assist people
in minimizing their risk of developing hypertension
or preventing the morbidity mortality associated
with hypertension.
A little bit about the epidemiology.
Nearly half of all of adults in the US
have a diagnosis of hypertension.
I would imagine that's probably even a little bit
higher post Covid,
but yet only a quarter of them have it under control.
So this is really what we call that bread and butter
of primary care and where you can have a lot
of impact on the future health of individuals
by addressing their hypertension and getting it to goal.
We still see a higher percentage of men than women
however, excuse me, as older women, older adult
that are identify as female
or biologically as female, 44% premenopausal let's say,
and it goes even higher.
So that eventually it over time there it tends to equal out.
We do see this more common in individuals
that are not considered white Caucasian
with non-Hispanic black adults being mostly affected.
There's many reasons for that.
There may be some genetic, but it's mostly has to do
with some of the social determinants of health, diet,
lifestyle and whatnot that poses them more risk factors
for the development of hypertension.
And unfortunately in 2019
there were half a million individuals that died
with hypertension listed as a primary
or contributing cause of death.
So that's pretty significant.
So you can see how if we can really reduce one's risk
of developing or risk of mortality morbidity associated
with it, that's really pretty significant.
It still is reportedly one of the most preventable deaths.
This is kind of in the middle of the epidemic.
So it may be that in the post Covid years
that it drops down to in the lower top 10,
but it does cost a significant amount of money.
And we'll see that in the slide in the future.
So this is just another visual way of looking
at the prevalence of high blood or hypertension
excuse me, and or individuals that are taking medications.
So kind of combined and as I said before
we can see here non-Hispanic black populations
are most significantly affected.
But then we also see the individuals
from the federal poverty level
of less than a hundred percent, 130% more affected.
And we can also see the individuals greater than 30.
Here is men, this is,
and here is the total adjusted age adjusted.
So when you kind of think about, hmm,
I have a man who happens to be older than 60 and maybe
has an ethnicity that's not considered Caucasian,
white Caucasian and comes from a lower federal poverty level
that they're gonna, you know,
that you need to really assess them
from a much more holistic standpoint.
Not that you don't do that with everyone,
but you really wanna take a deeper dive
into things that you can help to mitigate their risk
and their, and the progression to overt disease.
When we talk about costs, we see that the percentage
of costs are actually higher for hypertension than diabetes.
And that's because there are more patients
with hypertension than diabetes.
So if you put it on as equal, you can see how
much incredible cost that's associated with this.
But here's the percentage of patients and cost per patients.
So a cost per patient is higher
than it is with hypertension.
We just happen to have more patients
that have hypertension than diabetes.
Now this is, I think this slide is a couple years old now
at this point, but as we see diabetes increase,
we also see the fiscal ramifications.
And these are just of individuals
with diabetes and individuals with hypertension.
You put an individual with hypertension and diabetes
your cost is gonna be more than $6,000 per individual.
So what we do know is that if we don't treat hypertension
then it progresses to clinical disease
and a cardiovascular event within 10 years.
So that's, so what we see here is this percent risk.
So if we can decrease a risk, you know here in the 5%-10%,
then we can really change that 10 year risk here.
So with adequate treatment
we really are starting to reverse, well, we're not,
depending on where they are, we can reverse up to 25%.
So if we're treating here at clinical disease
if we can get them treated, then we're gonna prevent them
from going on to a cardiovascular event
with an overall risk reduction of 25%, if that makes sense.
The big take home, what I want you to get of this slide
is that this is essentially a 10 year trajectory and
at any point if we can treat them adequately
we may be reducing their overall risk
of 25% regardless of what that treatment might be.
So this is really, hypertension is really a cardiorenal
continuum because we know
that hypertension is probably the leading cause
along with diabetes for chronic kidney disease
which is outpacing the ability for nephrology
to actually care for the volume of patients
that are affected.
So here, this is the primary hallmark of what we do as NPs
in terms of prevention, but really here is the far majority
of what you're gonna be doing in clinical practice,
is treating or assessing target organ damage,
hopefully when it's not significant.
So here on this continuum, identifying any risk factors
new risk factors for chronic kidney disease
and really mitigating their atherosclerotic risk.
So we see lipids here and lipid treatment here
is really kind of, we do this through our diagnostic testing
and this can be through diagnostic testing
but also some history taken in a physical exam.
But we really wanna stop this from happening.
Again, this is a bird's eye view
of all of the physiologic mechanisms involved
in hypertension and certainly stress and age.
And we'll see that in the next slide, specifically age,
kind of augments or you see much more of an effect
of the pathophysiology on an individual of an older age,
and age and sex also determine what your vessels look like.
And, but on top of that, we also see stress and environment.
So again, the social determinants
of health kind of come into play here.
But what you also see is even
though there's genetic aspects
central CNS aspects, cardiac, renal, GI and endocrine
the medications that we use actually affect
kind into these organs here, for example
like when we talk about decreasing sympathetic activation
well we have medications that can do that.
Now that only affects one piece
of this really complicated patho, but certainly
if sympathetic activation we can use beta blockers, right?
So we hear is the genetics
behind angiotensinogen and whatnot.
We can actually use ACE inhibitors
and angiotensin receptor blockers to kind of help
with this aspect.
Sodium retention, we can use diuretics,
endocrine, with insulin resistance increasing
or aldosterone dysregulation we can use by spirolactam.
So those are examples of how knowing the physiology
and knowing the drugs and knowing how those drugs
affect different aspects will be helpful
in treating individuals.
This is just a nice little snapshot,
I think, about hypertension and aging.
So we have all of these things
that kind of affect our ability to care
for older adults but also affect risk associated with it.
So we have this classic like of course
we all are biologically aging
every second of every day
and then we use medications to kind
of combat this inflammatory processes
the endothelial dysfunction and the oxidative stress
all of which lead to functional decline, fractures,
cognitive decline, cardiovascular events,
which then lead to morbidity mortality.
So it kind of goes inward.
So these are the things that we can intervene on
that if we don't, create this, which then creates this
which then leads to this.
As you probably know in your clinical experiences,
as limited as they may be,
that there is a significant overlap
with other chronic health conditions.
And here we see this piece right here
of the individuals that have heart disease
and high blood pressure and dementia and Alzheimer's.
And so we see that the big chunk here is hypertension.
So if we can do something about that,
we're gonna actually affect all of this right here,
which is kind of exciting if you think about it that way.
So let's move on to talking
about how we evaluate an individual.
And this should be straightforward.
This is a recap of physical assessment
advanced health assessment and your history taking.
So these are key areas that are very specific
but overlap a lot with other things that we're doing.
So we wanna know if anybody has a personal history
of hypertension at one point in their life because
if they do and for some reason they were able to control it
with diet and healthy interventions
and it comes back that, you know,
we don't have to kind of really start that workup
from the very beginning of do they have hypertension
or do they not.
If they have any symptoms suggesting coronary artery disease
or any other comorbidity.
So we see a lot
of overlap as I had just mentioned, between hypertension
and diabetes, heart failure, dyslipidemia, renal disease
and peripheral vascular disease.
So we're really actually
when we're evaluating somebody with hypertension,
we also wanna know do they have any of these
or are they at risk for any of these because then
that will actually
affect your treatment plan for these individuals.
Family history, again, it's that genetic profile
if they use any modifiable risks, right?
So family history of premature disease is non-modifiable,
but use of tobacco, alcohol
or any other type of drug is definitely modifiable
and something that we can encourage them to think
about and hopefully decrease or eliminate as a risk factor.
Again, the same thing with dietary intake
and then medications,
because if we find that somebody's taking a medication,
for example pseudoephedrine or herbal medications
and that's causing their blood pressure to be high
we can find alternatives for them.
And we don't wanna treat somebody with hypertension
if they're using medications that elevate
their blood pressure.
So those are just some of the risk factors
that in the previous slide.
But we do know more and more about
how the social determinants
of health play on an individual's risk of hypertension.
So trauma as a child where you grew up,
you know what environment you grew up,
what your occupation is, is it high stress?
So these are some long lasting stressors,
could be subclinical stressors but are stressors
to the body that alter that HPA access
which then over term, over time, excuse me, increase risk.
And then there's your classic ones, you know,
if somebody has like reduced amount of nephrons
from some sort of kidney injury,
if they have diabetes or high lipids,
if their lifestyle is high in salt, low in exercise,
sleep has been paid a little bit more attention
to than it ever has been 'cause we know
that sleep affects pretty much every aspect
of our life but has been actually implicated
in clinical disease and clinical disease management.
And we know that because of obstructive sleep apnea
and the role of obstructive sleep apnea with hypertension
and then the classic ones that we think about.
So things that you wanna think about
if for some reason your patient has a very
high blood pressure, and you wanna make sure
that this isn't something that is kind of been high
for a very long time, we call that malignant hypertension
or in danger of actually causing immediate harm.
And that's, you know, mentation, weakness, visual changes,
chest pain, cough and shortness of breath.
Obviously, those are classic ones.
Nausea, vomiting, fatigue is a little bit of
a difficult one because I think everybody is tired
these days but certainly if they're more lethargic.
So these are considered more the commonly
uncommon forms of secondary hypertension "CHAPS,"
a pneumonic that I kind of found when
I was updating this lecture.
So it's easy to remember, this is not inclusive,
but it's just some of the more common ones that you see.
And I say common meaning they're really not very common,
they're very uncommon, but they're classically attributed
to secondary hypertension and that's Cushing's syndrome,
hyperaldosteronism, aortic coarctation,
stenosis of the arteries and a pheochromocytoma.
And there will be history taking elements
and physical exam findings of each of these
that will kind of point you away
from primary hypertension and more
towards the secondary hypertension, for example,
history taking that suggests that they're having a lot
of palpitations, flushing, headache, exertional headache,
you know, you might think more about a pheochromocytoma
which is incredibly rare.
Cushing's syndrome is much more likely to be exogenous
than endogenous with steroid use, chronic steroid use.
But you know, there are certain things that we see
in that such as, you know, weight gain,
central adiposity, increased striae,
so those aren't physical exam, facial,
the facies that they have they call it,
which is a horrible description of moon facies.
Sometimes with renal artery stenosis you don't know that
until you find that their hypertension is treated
and you're trying to treat it and it's refractory.
So those are some caveats
as you move forward in your clinical experiences,
you can kind of put in your back pocket.
So when we talk about assessing somebody for the first time,
or even actually somebody who's coming in for a follow up
or maybe has not had a kind of that diagnostic workup
or has not had a really well thought through
physical history and physical is really looking
at a good solid risk and assessment.
And this is the hallmark of this entire course
is assessing them for risk because if they are a high risk,
you are gonna be more aggressive than if they're low risk.
And then the next step is assessing the presence of any type
of target organ disease or damage that we'll talk about.
And then we'll bring that out a lot
in the case-based scenario.
And then do you wanna evaluate them
for any secondary causes of hypertension?
And generally the answer is no,
because they don't happen very often.
So always think horses,
sometimes you'll see a zebra here and there
but it is good to have that CHAPS in the back of your mind
pneumonic in the back of your mind
back pocket to kind of think, "Oh this just doesn't sound
like regular primary or essential hypertension."
So when we talk about the organs
that we're gonna specifically assess
that are associated with hypertension
is the brain, eyes, blood vessels,
heart and kidneys, and also making sure
that that blood pressure is actually accurate
which a lot of the times it is not.
And there are different ways that we can assess these organs
on physical through history taking,
physical exam and diagnostic testing.
This is just a nice little slide.
This should be a very much a recap
of your advanced physical assessment
but it kind of talks you through
and I'm not gonna spend a lot of time on this,
what you're supposed to be looking for
on a physical exam that might lead you to an assessment
of hypertension and help you gauge how aggressive
that you're going to be in terms of treatment.
And again, this is a slide that you can refer back to
but if you don't have a blood pressure that is
assessed correctly, then you can't interpret
that blood pressure for what it means.
And that includes home measuring, but it includes in office.
So a lot of times you'll see that patient rushed
into the room that hopefully it's not you
as the nurse practitioner and hopefully it's not the nurse
and hopefully it's not the MA,
but they're taking the blood pressure
over clothing and using that
as a valid blood pressure when it is actually not.
So up next in a future mini-lecture is the evaluation
and management of hypertension.
So if you have any questions, please post those
to the discussion board or better yet, bring them to class.