Hypertension: A discussion of the guidelines - Women's Healthcare
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Hypertension:
A discussion of the guidelines
C
By Daria Napierkowski, DNP, APN, RN, CNE, ardiovascular disease (CVD)
and Kimberly Buff Prado, DNP, APN, RN is the leading cause of mor-
tality in the United States
and is attributed to 1 in 4 deaths
The American College of Cardiology/American Heart Association across all races and ethnicities.1,2 The
Task Force published their clinical practice guidelines on economic burden for CVD is up to
200 billion dollars each year.2 Hyper-
hypertension in 2017. These guidelines hold important implications tension is linked to cardiovascular
for nurse practitioners as they care for these patients. Definitions of events and is the leading risk factor
hypertension, as well as related lifestyle changes, pharmacologic for conditions such as heart failure,
myocardial infarction, stroke, and
treatment, and financial implications to access to care, are
chronic kidney disease. Prevention
discussed. Differences in treatment modalities for women versus and effective treatment of hyperten-
men are also reviewed. sion have a significant impact on the
reduction of CVD mortality.
Key words: hypertension, DASH diet, pharmacologic treatment, Blood pressure increases with
financial implications age in men and women, having a
similar prevalence of hypertension
in both genders as they reach early
and middle adulthood. Women are
most likely to develop hypertension
after the fifth decade of life and have
higher rates than men later in life.3,4
This condition, however, is not lim-
ited to middle and late adulthood.
In fact, an estimated 45 million
women older than age 20 years have
hypertension.4 This has additional
importance for reproductive-aged
women, considering that 1% to 1.5%
of pregnant women present with
chronic hypertension that when un-
controlled may result in significant
maternal, fetal, and neonatal mor-
bidity and mortality.5
Updated definitions of
hypertension
Hypertension traditionally has
been defined as a blood pressure of
36 June 2020 Women’s Healthcare NPWomensHealthcare.comgreater than or equal to 140/90 mm
Hg. In 2017, however, the American Table 1. Updated definitions of hypertension3
College of Cardiology (ACC) and the
Blood pressure category SBP and DBP
American Heart Association (AHA)
jointly issued updated clinical prac- Normal blood pressure SBP < 120 mm Hg and DBP < 80 mm Hg
tice guidelines and changed the Elevated blood pressure (EBP) SBP 120–129 mm Hg and DBP < 80 mm Hg
standard definition for hypertension
Stage I hypertension SBP 130-139 mm Hg and DBP 80-89 mm Hg
by lowering the blood pressure
parameters. The term “prehyperten- Stage II hypertension SBP < 140 mm Hg and DBP < 90 mm Hg
sion” has also been replaced by ele- DBP, diastolic blood pressure; SBP, systolic blood pressure.
vated blood pressure (EBP), which is
now delineated as a systolic blood
pressure (SBP) of 120 to 129 mm Hg Table 2. Antihypertensive medication classifications3
and a diastolic blood pressure (DBP)
Medication classification Examples Usual dosage
of less than 80 mm Hg.3 See Table
1 for the updated categories.3 The Thiazide-type diuretics Hydrochlorothiazide 25–50 mg daily
Chlorthalidone 12.5–25 mg daily
ACC and AHA based the decision to
lower blood pressure parameters ACE inhibitors Captopril 12.5–150 mg twice a day
for the definition of hypertension Lisinopril 10–40 mg daily
on the knowledge that earlier treat- ARB Azilsartan 40–80 mg daily
ment with lifestyle changes and, Valsartan 80–320 mg daily
in some patients, medication can CCB Amlodipine 2.5–10 mg daily
reduce complications. Although Nifedipine LA 30–90 mg daily
the new definition is resulting in a
larger number of individuals being ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blockers; CCB, calcium channel blocker; LA,
long acting.
diagnosed with hypertension, the
expectation is that more individuals measurement of blood pressure. office measurements may be rec-
can be successfully treated with Step 1 advises that the patient rests ommended to confirm a diagnosis
lifestyle interventions and will not for 5 minutes in a chair and avoids of EBP or hypertension.3 The patient
require antihypertensive medica- caffeine, smoking, and exercise at should be provided with specific
tion. The new guidelines also place least 30 minutes prior to taking the instructions on how to correctly ob-
hypertensive crisis into the catego- blood pressure.3 Step 2 advises that tain an accurate reading. Decisions
ries of hypertensive urgency and hy- all equipment be calibrated for ac- regarding treatment should be based
pertensive emergency. Hypertensive curacy and that the blood pressure on more than two readings in the
urgency is an SBP of greater than cuff encircle 80% of the arm.3 Step 3 healthcare provider’s office as well as
180 mm Hg and a DBP of greater warrants that blood pressure is mea- home blood pressure records.
than 120 mm Hg.3 A hypertensive sured in both arms with the first visit
emergency is a blood pressure of and the healthcare provider records Management
systolic greater than 180 mm Hg the arm with the higher reading to Initial evaluation
and diastolic greater than 120 mm be used in subsequent visits.3 Step The initial evaluation of a patient
Hg with the presence of new, pro- 4 describes the correct technique of with newly diagnosed hyperten-
gressive, or worsening target organ taking blood pressure if using the sion has three primary objectives:
damage (TOD).3 auscultatory method, and step 5 sug- identify other CVD risk factors or
gests using an average of more than concomitant health conditions that
Proper measurement of two readings. Step 6 advises giving may define prognosis and guide
blood pressure the patient the reading verbally and treatment, assess for TOD (eg, eyes,
All staff who measure blood pressure in writing.3 White coat hypertension brain, blood vessels, heart, kidneys),
in the clinical setting should be in- is a phenomenon in which the blood and identify signs/symptoms of po-
structed on and follow proper tech- pressure in the healthcare provider’s tential secondary causes. The initial
nique. The ACC/AHA guidelines out- office is elevated but is normal when evaluation should include a com-
line six essential steps for the proper taken in another setting. Out-of- plete history to assess current health
NPWomensHealthcare.com June 2020 Women’s Healthcare 37conditions, current health behaviors follow healthy lifestyle behaviors to pressure. The DASH diet is rich in
(eg, diet, exercise, smoking, alcohol, reduce their risk for hypertension. If vegetables, fruit, whole grains,
drug use), current prescription and blood pressure is elevated, healthy low-fat dairy products, fish, poultry,
over-the-counter medications, fam- lifestyle changes should be recom- beans, nuts, and vegetable oils. It
ily history for hypertension and CVD, mended with a re-check of blood limits foods high in saturated fats
and symptoms of TOD. The physi- pressure in 3 to 6 months.3 The such as red meat and full-fat dairy
cal examination needs to include lifestyle changes recommended are: products, and in calories such as
height, weight, and body mass index weight loss if overweight or obese, sugar-sweetened beverages.7 Other
(BMI).6 Other components of the following the Dietary Approaches diets including the Mediterranean
physical examination should focus to Stop Hypertension (DASH) or dietary pattern have also been
on evaluation for signs of TOD, other similar diet, sodium reduction, shown to decrease blood pressure.3
complications, and indicators of po- exercise, smoking cessation, and al- Patients with hypertension can be
tential secondary causes for hyper- cohol moderation.3,7 The healthcare instructed about several options in
tension. This includes assessment of provider can use patient-centered dietary guidelines to reduce hyper-
the neck for carotid artery bruits and behavioral change strategies that in- tension and therefore reduce cardio-
jugular venous distention, heart for clude motivational interviewing and vascular mortality risk. Reduction of
abnormal sounds or rhythm, lower shared decision making to facilitate sodium should be discussed with an
extremities for edema, and eyes for success in modifying lifestyle behav- optimal goal of no more than 1,500
retinal hemorrhages. Basic labo- iors. Group education/counseling mg a day but an aim to reduce in-
ratory and diagnostic tests should can be helpful for some patients. To take by at least 1,000 mg a day.3 It is
include fasting glucose, complete promote maintenance of healthy essential to teach the patient how to
blood count, lipid profile, serum behaviors and monitor blood pres- read food labels and to avoid foods
sodium, potassium, and calcium, sure, the healthcare provider or high in sodium such as condiments,
creatinine or an estimated glomeru- appropriate staff should follow up canned products, and fast food.
lar filtration rate, thyroid stimulating with the patient on a regular basis The guidelines also recommend
hormone, urinalysis, and electrocar- through office visits, phone, elec- adequate potassium in the diet, as a
diogram.3 tronic messaging, and/or telehealth higher level of potassium appears to
A referral for further evaluation technology. dull the effect of excess intake of so-
of potential secondary causes is in- dium on blood pressure.8 The DASH
dicated when a patient with newly Weight loss diet and Mediterranean diet include
diagnosed hypertension has an For the overweight patient (BMI > intake of foods that are high in po-
abrupt onset, onset at younger than 25) or obese patient (BMI > 30), 1 kg tassium.3 Referral to a dietician and
age 30 years, disproportionate signs of weight loss leads to a reduction of inclusion of family members who
of TOD for severity of the hyperten- blood pressure of about 1 mm Hg.3 prepare meals can be helpful.
sion, new onset of diastolic hyper- This makes strategies for weight loss
tension in a patient age 65 years or a primary goal, with counseling to Physical activity
older, or severe hypokalemia.3 increase physical activity and reduce Blood pressure has been shown to
Common causes of secondary caloric consumption.3 be lowered with both low- and
hypertension are: renal parenchy- Weight should be assessed with high-intensity exercise, interval and
mal disease, renovascular disease, each office visit and the importance continuous training, and isometric
primary aldosteronism, obstructive of diet and physical activity rein- exercise.3 Low aerobic capacity is a
sleep apnea, and drug- and alco- forced. Patients with hypertension significant risk factor for hypertension
hol-induced hypertension.3 and a BMI of 35 or greater who are even among patients with a normal
unable to lose weight with diet and BMI.9 The goal for physical activity is
Nonpharmacologic lifestyle exercise may be candidates for bar- aerobic exercise, including dynamic
changes iatric surgery.6 resistance of 90 to 150 minutes per
The ACC/AHA guidelines recom- week and three sessions a week of
mend lifestyle changes and medica- DASH diet isometric resistance exercises.3 A dis-
tions that lower blood pressure. Pa- The DASH diet has been recom- cussion of interventions to promote
tients within normal range (< 120/80 mended since 1992 and is sup- physical activity should be discussed
mm Hg) should be encouraged to ported by evidence to lower blood with each blood pressure check.
38 June 2020 Women’s Healthcare NPWomensHealthcare.comSmoking cessation
Prior evidence revealed that blood
The healthcare
provider can
use patient-centered behavioral
pressure was not always reduced
after smoking cessation, but that
it is known that smoking tobacco
leads to arterial stiffness and possi- change strategies that include
bly raises central blood pressure.10
Current evidence, however, reveals
that smoking 10 cigarettes a day is
motivational interviewing and
a risk factor for developing hyper-
tension as well as respiratory disease
shared decision making to
and myocardial infarction.10,11 Being
exposed to secondhand smoke for
facilitate success in modifying
longer than 2 hours a day has also
been associated with the develop-
lifestyle behaviors.
ment of hypertension in women
who have never smoked.12 Smoking duction (2–3 mm Hg) of blood pres- greater systolic and 90 mm Hg or
cessation interventions should be sure with continuous positive airway greater diastolic.3 Along with lifestyle
individualized in relation to the pa- pressure (CPAP).3,15 changes, two antihypertensive med-
tient’s physical and psychological ications are recommended from two
dependence and stage of readiness Pharmacologic treatment different classes, with reassessment
to quit. Self-help materials (written Stage I hypertension of the patient in 1 month, and if the
and online), smoking cessation Stage I hypertension is a blood pres- goal is met, again in 3 to 6 months.3
classes, and pharmacologic aids may sure of 130 to 139 mm Hg systolic Hypertensive crisis (blood pressure >
be appropriate. or 80 to 89 mm Hg diastolic. For pa- 180/120 mm Hg) should be treated
tients with stage I hypertension and promptly, with the patient admit-
Alcohol moderation a calculated 10-year risk for athero- ted to the intensive care unit of the
The effect of alcohol intake on blood sclerotic CVD (ASCVD) of less than hospital to prevent organ damage.3
pressure is directly related to the 10%, lifestyle recommendations are Antihypertensive classifications and
amount ingested. Women should the first line of therapy.3 If the 10- examples are provided in Table 2.
limit alcohol intake to no more than year risk for ASCVD is 10% or greater Aspirin is not routinely recom-
one drink a day or not consume or if the patient has CVD, diabetes, mended for the primary prevention
any alcoholic beverages.3 Men can or chronic kidney disease, then one of hypertension. In a recent study,
consume two or less alcoholic drinks antihypertensive medication is rec- the efficacy of low-dose aspirin at
a day.3 Research has shown that for ommended.16 Agents that should 100 mg was found to have no effect
women with systolic blood pressure be considered first are thiazide on the incidence of death from a
greater than 140 mm Hg, a decrease diuretics, calcium channel blockers, cardiovascular event, but it was
in alcohol consumption leads to a and angiotensin-converting enzyme associated with an increased risk of
1% to 2% reduction in blood pres- (ACE) inhibitors or angiotensin II hemorrhagic stroke.16
sure.13 receptor blockers (ARB), with a fol-
low-up appointment to check blood Special considerations for
Sleep hygiene pressure in 1 month.3 Common side reproductive-aged women
Lack of sleep or excessive sleep has effects of antihypertensive medi- Women of all ages with hyper-
been associated with hypertension cation including cough with use of tension should be evaluated and
in women. Sleep length of less or ACE inhibitors and edema with use in general treated as previously
more than 7 hours has been shown of calcium antagonists are observed described. Because hypertension,
to be a risk factor for higher blood more often in women than men.3 especially when uncontrolled, can
pressure.14 The ACC/AHA guidelines lead to increased risks for maternal,
do not specifically mention sleep Stage II hypertension fetal, and neonatal morbidity and
amount but recommend treatment Stage II hypertension is defined as mortality, additional considerations
for sleep apnea with only a small re- blood pressure of 140 mm Hg or are critical.5,17
NPWomensHealthcare.com June 2020 Women’s Healthcare 39Reproductive-aged women with realistic plan of care. Conclusion
hypertension who could become The healthcare provider needs to Hypertension is one of the leading
pregnant should be counseled stress the importance of adherence causes of CVD and mortality. It is es-
regarding the risks of uncontrolled to all treatments, especially medica- sential that healthcare providers are
hypertension in pregnancy.5 In this tions. The provider must emphasize proficient in screening for EBP and
context, any antihypertensive med- that the patient cannot stop the hypertension, thorough assessment,
ications being taken should be re- medication abruptly, because this and initiation of interventions that
viewed. ACE inhibitors and ARBs are may inadvertently lead to an ad- include lifestyle behavioral changes.
contraindicated during pregnancy verse event such as stroke. Medica- Pharmacologic treatments if needed
because of known teratogenic and/ tions that can be taken daily instead may be prescribed or the patient
or fetotoxic effects.5 Women taking of 2 to 3 times a day will help the referred for management. Early di-
these medications should be coun- patient adhere to the protocol. Infor- agnosis and treatment can prevent
seled regarding the use of effective mation regarding local pharmacies serious TOD and CVD. The healthcare
contraception. with the lowest price for a medica- provider should remain up to date on
Estrogen-containing contraceptive tion should be provided to the pa- and follow evidence-based guidelines
methods (eg, pills, patches, vaginal tient. Several applications (apps) are for assessment and treatment of EBP
rings) are contraindicated for women available that can assist in finding and hypertension. Those providers
with uncontrolled hypertension or the lowest price of a medication. who focus on women’s reproductive
vascular disease due to the increased Both oral and written information healthcare have a specific role in
risk for stroke, myocardial infarction, provided should be appropriate to counseling women with hyperten-
and peripheral artery disease. Estro- the patient’s literacy level and lan- sion who could become pregnant
gen-containing contraceptive meth- guage. Medical interpreters should about the importance of optimizing
ods are not recommended even for be available as needed. The teach- blood pressure and evaluating the
women with adequately controlled back method can be used to assess need for any antihypertensive med-
hypertension unless no other method understanding. ication changes prior to pregnancy.
is available or acceptable. Long-acting Patients in many inner cities may Contraceptive counseling should in-
reversible contraceptive methods not have access to fresh fruits and clude attention to the use of the most
such as intrauterine devices and the vegetables or have money to pay for effective method of the patient’s
progestin implant as well as proges- them. Particularly vulnerable are the choice that is safe in regard to her
tin-only pills are options that are safe elderly and those who are socioeco- blood pressure status. =
and effective for women with hyper- nomically disadvantaged. Dieticians
tension. Unlike other progestin-only may be able to assist the patient Daria Napierkowski is Associate Pro-
methods, the use of depot medroxy- regarding healthy food choices that fessor and Adult Nurse Practitioner,
progesterone acetate by women with are available. Transportation assis- Counseling, Health & Wellness Cen-
uncontrolled hypertension is generally tance may be needed. ter, at William Paterson University in
not recommended because of the Accessibility to locales and ser- Wayne, New Jersey. Kimberly Buff
theoretical risk of unfavorable lipopro- vices that can provide the patient Prado is Assistant Professor at Rut-
tein changes that could contribute to with the opportunity for regular gers University, The State University
cardiovascular risk.18 physical activity should also be as- of New Jersey, and Adult Nurse Prac-
sessed. Neighborhoods with a high titioner at Summit Medical Group,
Adherence to treatment crime rate will discourage patients Cardiology, in Summit, New Jersey.
Adherence to treatment for hyper- to be physically active in simple The authors state that they do not
tension is critical but can be chal- ways like taking a walk. have a financial interest in or other
lenging both in terms of lifestyle Family members and caregivers relationship with any commercial
changes and medication regimens. who assist the patient with instrumen- product named in this article.
Assessment of and attention to so- tal activities of daily living required to
cioeconomic determinants such as prepare meals, shop for meals, and
A complete list of references
finances, health insurance, literacy, prepare medication should be in-
cited in this article is available
living environment, transportation, cluded in education by the healthcare
at npwomenshealthcare.
and access to healthy foods are crit- provider on the plan of care.
com/?p=8997
ical to develop a patient-centered,
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