high blood pressure (hypertension) prevention and control sash – september 25, 2012 suzanne...
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High Blood Pressure (Hypertension)Prevention and Control
SASH – September 25, 2012
Suzanne Lapointe, RN, BA, CNN
Fletcher Allen Health Care, Nephrology
Robin Edelman, MS, RD, CDE
Vermont Department of Health
Topics for Today• How are we doing with blood pressure
control?• Measuring and monitoring blood pressure• Management of high blood pressure
– Medications– Lifestyle changes
• Self-management options for SASH enrollees
• Self-management support by SASH staff
High blood pressure is an independent risk factor for CVD*, Stroke and Kidney Disease = Vascular Disease
Hypertension can affect the heart, brain, and kidneys
Hypertension promotesatherosclerosis and arteriosclerosis
*CVD = cardiovascular disease
7
High Blood Pressure in US– “a neglected disease”
Institute of Medicine (IOM) February 2010
“High blood pressure is out of control for too many Americans”
Centers for Disease Control and Prevention (CDC) September 2012
1/3 adults have it; 1/2 > 60y, 3/4 >70y
More than half have uncontrolled high blood pressure
~ 40% aren’t aware that they have high blood pressure
1/6 die from uncontrolled blood pressure (~ 1000 per day)
easy to prevent, simple to diagnose, inexpensive to treat
The Lancet, 361:2149-2151
genetic predisposition
environmental factors
Causes of high blood pressure are multi-factorial
saltobesitysmoking
Lifestyle modification – patient specific achievable goals
Weight reduction (10 - 20 lbs helps) – SBP 5-20 mmHg
Physical activity (30 minutes/day as part of ADL) – SBP 4-9mmHg
Avoid excessive alcohol ingestion, stop tobacco – SBP 2-4 mmHg
Avoid high sodium intake – SBP 3-5 mmHg for 2 g reduction
DASH diet – SBP 8-14 mmHg
Avoid high sodium intake – shop around the edges of the supermarket except for the deli
12%
6%
5%
77%
CDC
Optimal medication regimen should…
Reduce volume thiazide diuretic (for all unless eGFR < 30 ml/min, hyponatremia, CHF) K sparing diuretic (K< 4 meq/l & eGFR >30 m/min) in addition to thiazide loop diuretics in CKD patients (edema, eGFR < 30 m/ml)
Reduce renin/angiotensin effect ACEi/ARB; renin inhibitors (DM, CKD, proteinuria/albuminuria, CAD, LVH)
Reduce myocardial activity Beta or Alpha/Beta blocker (titrate dose to keep HR in the 60’s) Vasodilate CCB (dihydropyridines best for BP) or vasodilator (hydralazine, minoxidil)
Add central or peripheral SNS agents as fifth line Clonidine, alpha methyldopa, alpha blockers
Use medications in multiple classes. Two to 4 are commonly needed. (e.g. Diuretics + ACEi/ARB + Beta and alpha blockers + CCB)
Inadequate Response to Therapy
Volume overload: medications (NSAIDs), excessive salt intake, kidney dysfunction
Non adherence to therapy: too frequent dosing,
expense, intolerable side effects. - Use several drugs in low doses to maximize
effectiveness and minimize side effects rather than maximum doses of one drug
Drug problems: wrong drug or dose; combinations of drugs that don’t work well together Other medical conditions: smoking, excess alcohol,
anxiety, pain, sleep apnea, obesity
Approaches to improving BP Control
patient participation and ownership having a goal
knowing when not at goal (measuring BP at home) having a way to modify treatment to get to goal
Self-management is what people do to take care of themselves.
Self-management support is what staff do to help people take care of themselves.
Steps in Self-Management Support
• Collaborative setting of goals and action plans
• Identification of barriers and challenges
• Personalized problem-solving
• Follow-up support
Action Plan (a short term plan for doing something measurable) that fits into a longer range goal
1. Something a person WANTS to do
2. Describes:
What (the doable behavior)
How Much How Often (# of days)
When (time of day)
3. Confidence rating (1-10)
1 = no confidence; 10 = total confidence
Examples: (Long range) Goals & (shorter term) Action Plans
• Improve fitness to lower blood pressure– Walk for 20 minutes in
the morning on 4 days this week
– Ride the stationary cycle after lunch on 5 days this week
• Eat better to lower blood pressure– Have 1 cup of
vegetables at lunch & supper on 3 days this week
– Have 1 cup of oatmeal in place of salty breakfast sandwich on 4 days this week
Benefits of self-monitoring blood pressure
• Avoid faulty high readings from “white coat hypertension”
• See quicker changes in response to improved behavior
• Easy and safe to measure
• Encourages behavior improvement
• Builds self-efficacy (self-confidence in one’s ability to self-manage)
Recommended Website
http://www.nhlbi.nih.gov/
U.S Department of Health and Human Services
National Institutes of Health
National Heart, Lung, and Blood Institute