Whole New Ballgame for
Hypertension Treatment

By Susanne J. Pavlovich-Danis, RN, MSN, ARNP-C, CDE
December 13, 2004

When taking on a formidable opponent, a strong offense is often the best defense. This kind of strategy might well serve nurses caring for patients with hypertension. Much in the same way a team “sizes up” a new opponent and develops a game plan, the uniqueness of each person’s hypertension must be scrutinized before the right treatment components can be selected.

While hypertension is simply an elevation of blood pressure (BP), all hypertension is not, and should not be, treated with the same approach.

You can get in the game — and stay in it — by learning the latest information about hypertension and its treatment.

It’s well known that obesity, genetics, and other disease processes (such as diabetes, renal disorders, adrenal tumors, and hyperthyroidism) all contribute to the incidence of hypertension.

Circadian rhythms regulate the rise and fall of BP and heart rate. Both BP and heart rate drop during the night (a phenomenon known as “ dipping”) and rise in the early morning hours upon awakening. Some individuals, however, do not “dip”— they still experience morning elevation in BP and heart rate, a phenomenon common among African Americans.¹

Look who’s hypertensive now

BP classifications have been simplified by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).² More individuals now satisfy the diagnostic criteria of hypertension, and even more people fall into a new classification that bears close watch — prehypertension.

To have a “normal” BP, both an individual’s systolic and diastolic pressures must fall into parameters below 120/80. Isolated systolic or diastolic pressures above these parameters classify an individual as prehypertensive or hypertensive.

Classification is based upon inclusion rather than exclusion — individuals fall into the classification matching their highest reading. For example, consider the chart which details the new classification system. An individual with a pressure of 118/92 would be classified as having stage 1 hypertension, even though the systolic reading falls within the “normal” range.

New rules, new strategies

For years, practitioners have shared concerns over the accuracy of BP readings taken in a health care setting. The so-called “white coat hypertension” phenomenon, or the elevation of BP in a clinical environment despite normal pressures elsewhere, has caused diagnostic and management dilemmas.

Evaluating patients treated for hypertension for effectiveness in reducing poor outcomes is also changing. The “rule book” for hypertension diagnosis and management has expanded with a more reliable and long-term option.

Recent research has revealed ambulatory blood pressure monitoring involving patients tracking their own blood pressure readings twice daily either at home or at work for a week makes for a better predictor of stroke and myocardial infarction than the traditional office BP measurement.³

Beyond known risk factors

Hypertension is unequivocally equated with a high-sodium diet. For most nurses, the thought of hypertension conjures up images of an overweight middle-aged individual with a high-stress job and a sedentary lifestyle who probably reports a family member with hypertension. This stereotypical image may minimize the cautious eye they cast others at equal or greater risk for hypertension at much earlier ages.

Nurses should consider these additional hypertensive-predisposing risk factors:^1,2,4

• Low birth weight
• Smoking
• High-fat diet
• Excessive alcohol intake
• Geographical location (whites from the Northeast, African Americans from the South)
• Lower dietary intake of magnesium
• Lower dietary intake of calcium

Nurses warn patients about sodium, which remains the primary culprit behind hypertension. But research indicates a word of caution is also needed regarding caffeine consumption — even when BP is well-controlled. Caffeine has been shown to raise aortic stiffness and place hypertensive individuals at greater risk for cardiovascular events.⁵

A black-and-white issue

The onset of hypertension among African Americans occurs earlier than among whites — a measurable difference exists even before age 10 among African Americans and is especially pronounced for African-American girls.⁶ With that taken into account, nurses caring for children have yet another reason to stress physical exercise, a balanced diet, and appropriate health screenings.

As a nation rich with caregivers, we simply aren’t meeting the mark when it comes to reducing hypertension among African Americans. Despite raised public awareness and educational efforts, analysis of recent National Health and Nutrition Examination Survey (NHANES) data reveal that the prevalence of hypertension among non-Hispanic blacks rose 33.5% between 1988 and 2000.⁷

Expanded game plan

Beyond lifestyle recommendations, adequately controlling hypertension often involves the careful prescription of medications selected on the basis of both an individual’s pattern of hypertension and other disorders present. Some antihypertensive drugs are selected based not only on their ability to combat hypertension, but also the positive impact these medications have on other disorders. One such example would be the use of ACE inhibitors when diabetes is present along with hypertension.

Diuretics and calcium channel blockers provide a controlled response during the day, and extended-release calcium channel blockers offer 24-hour control.⁸ Drugs also have been developed that selectively block the different systems responsible for BP control, namely those involved in the renin angiotensin system.

Often a single medication will not adequately control an individual’s BP, and combination therapy using lower doses of two or more drugs may be necessary. The sidebar “Combating Hypertension” on page 18 describes some of the most commonly prescribed medications for hypertension, along with adverse events of which nurses should be aware.

Beta-blockers offer another treatment option for hypertension; however, they should be used with caution among diabetic individuals, especially those prone to hypoglycemia. In diabetics who take beta-blockers, the medications may mask the warning signs of an impending hypoglycemic reaction such as diaphoresis, anxiety, or increased heart rate.

When it comes to the treatment of hypertension, nurses need to do more of what nurses do best — developing therapeutic relationships with patients and encouraging patients to ask questions and become involved in their hypertension management care plan. No longer should patients with hypertension sit on the sidelines. Nurses must facilitate a solid game plan, one based on education that promotes healthy lifestyle changes, to defeat hypertension.

Lifestyle changes and drug therapy individualized to target patients’ unique circumstances afford the best chance to reduce the risk for devastating consequences of uncontrolled hypertension, namely, cardiovascular events and renal failure, particularly for African Americans.¹

Nurses should develop familiarity with the various classifications of medications used to treat hypertension, including their common adverse effects. They should also encourage patients to report any adverse effects, even if those effects are minimal, to their care provider. Patients should be reassured that there are many different treatment options for hypertension and that finding the right strategy may take a little time. Nurses can encourage them to be proactive members of a team approach to controlling hypertension.

Editor’s Note: Visit Education/CE to view our self-study modules on hypertension at http://www.nursingspectrum.com/ContinuingEducation/NSSelfStudy/index.cfm.

Susanne J. Pavlovich-Danis, RN, MSN, ARNP-C, CDE, maintains a private adult health practice in Plantation, Fla. She is also a professor and area chair for nursing at the University of Phoenix, Fort Lauderdale, Fla.

References

1. Douglas JG, Bakris GL, Epstein M, et al. Management of high blood pressure in African Americans. Consensus statement of the Hypertension in African-Americans Working Group of the International Society on Hypertension in Blacks. Arch Intern Med. 2003;163:525-541.

2. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 Express). NIH Publication No. 03-5233. May 2003.

3. Clement DI, De Buyzere ML, De Bacquer DA, et al, for the Office Versus Ambulatory Pressure Study Investigators. Prognostic value of ambulatory blood pressure recordings in patients with treated hypertension. N Engl J Med. 2003;348: 2407-2415.

4. Fox CH, Mahoney MC, Ramsoomair D, Carter CA. Magnesium deficiency in African Americans: does it contribute to increased cardiovascular risk? J Natl Med Assoc. 2003;95(4):257-262.

5. Vlachopoulos C, Hirata K, Stefanadis C, Toutouzas P, O’Rourke MF. Caffeine increases aortic stiffness in hypertensive patient. Am J Hypertens. 2003;16(1):63-66.

6. Hoq S, Chen W, Srinivasan S, Berenson GS. Childhood blood pressure predicts adult microalbuminuria in African Americans but not in Whites: the Bogalusa Heart Study. Am J Hypertens. 2002;15:1036-1041.

7. Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000. JAMA. 2003;290(2):199-206.

8. Morgan TO, Anderson A. Different drug classes have variable effects on blood pressure depending on the time of day. Am J Hypertens. 2003;16(1):46-50.

9. U.S. National Library of Medicine. (2004). Medline Plus Drug Information. Available: http://www.nlm.nih.gov/medlineplus/druginformation.html. Accessed 1/15/04.