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Test Bank for Primary Care The Art and Science of Advanced Practice Nursing chapter 35 Cardiac and Associated risk disorders

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Test Bank for Primary Care The Art and Science of Advanced Practice Nursing chapter 35 Cardiac and Associated risk disorders

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  • January 22, 2025
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, Chapter 35 HYPERTENSION
Hypertension (HTN) is one of the most common
chronic health problems seen in the primary-care setting,
with nearly one-half of all American adults affected. The
health implications of HTN are far reaching and widely
recognized as a public health concern. Healthy People
2020 includes 23 specific objectives for heart disease and
Cardiac and Associated stroke, six of which relate directly to HTN. The goals
Risk Disorders of these recommendations are improvement of cardiovas-
cular health and quality of life through the prevention,
detection, and treatment of risk factors, early identifica-
Kathryn B Keller PhD RN CNE tion and treatment of heart attacks and strokes, and the
Denese Sabatino MSN APRN NPC CCRN prevention of recurrent cardiovascular events.

Jill E WinlandBrown EdD APRN FNPBC
Brian Oscar Porter MD PhD MPH MBA EPIDEMIOLOGY AND CAUSES
HTN occurs in one of three Americans, or 34% of the
U.S. population (approximately 85.7 million persons). It
is projected that by 2030, 41.4% of the population will




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, 6 . C A R D I O VA S C U L A R P R O B L E M S
C h a p t e r 35 Cardiac and Associated Risk Disorders 459

have HTN. Historically, HTN has been more prevalent in including a growing elderly population; however, the role
men, particularly in African American men. As of 2017, of undetected and untreated or inadequately controlled
African American women surpassed African American HTN contributes significantly. Thus, primary-care prac-
men with a higher prevalence of HTN. However, this gen- titioners should be committed not only to the detection
der gap is narrowing and appears to be influenced by age. and treatment of HTN but also to its prevention.
For persons younger than 45 years, men are affected more
often than woman, whereas in persons 65 years of age and
older, more woman than men have HTN. African Ameri- PATHOPHYSIOLOGY
cans continue to experience HTN more often and at an
earlier age than European Americans or Latinos.
Essential Hypertension
The prevalence of HTN continues to increase with The term “essential hypertension” describes high BP that
age. HTN is a common disorder that occurs with aging has no identifiable etiology after a thorough clinical exami-
in industrialized societies. Data from the Framingham nation excludes possible secondary causes. The etiology
Heart Study suggest that even individuals who are nor- and pathophysiology of essential HTN are incompletely
motensive at 55 years of age still have a 90% lifetime risk understood. It is a complex, multifactorial disorder that
of developing HTN. There is a particular rise in systolic involves genetic and environmental factors, diet and life-
blood pressure (BP) that progresses throughout life, with style practices, imbalances in vasoactive substances, and
a difference of 20 to 30 mm Hg between early and late dysfunction of the arterial endothelium. Although the pre-
adulthood. cise cause is unknown, endothelial dysfunction is thought
More than 95% of patients with elevated BP have to be the key pathophysiological process involved in essen-
primary, or essential, HTN, with no single identifiable tial HTN. The arterial endothelium is an important regu-
cause. Primary HTN results from multiple genetic and lator of vascular tone, vascular structure, thrombosis, and
environmental factors, including lifestyle and behavioral inflammation. Endothelial dysfunction is central to many
influences. It is more common in individuals whose par- cardiovascular disorders, including HTN, atherosclerosis,
ents or other close family members have HTN, possibly and myocardial ischemia.
due to a diminished ability to excrete excess sodium cou- Vascular tone is maintained by endothelium-derived
pled with long-term high dietary sodium intake, which mediators such as nitric oxide, endothelin-1, and angio-
predisposes to increased peripheral vascular resistance tensin II. Nitric oxide, a major vasodilator, counteracts
and a rise in BP. the potent vasoconstrictors endothelin-1 and angioten-
Less than 5% of patients have secondary HTN due sin II, which regulate normal vascular tone. In essen-
to a specific and potentially reversible cause, such as an tial HTN, there is an imbalance in the vasodilator and
identifiable cardiac, renal, or endocrinological problem vasoconstrictive substances secreted by the endothelium.
or the use of vasoconstricting medications. The onset of Plasma levels of nitric oxide are diminished, whereas levels
diastolic HTN, with or without systolic elevation after of endothelin-1 and angiotensin II are elevated. Reasons
60 years of age is unusual, and a diagnosis of new-onset for this imbalance have not been elucidated, and it is not
secondary HTN should be considered in these individu- clear whether endothelial dysfunction precedes or is the
als. In particular, renovascular disease is a common cause result of HTN.
of new-onset diastolic HTN in this older age group. The role of altered sodium excretion by impaired epi-
HTN contributes to ischemic heart disease, heart fail- thelial cells in the kidney may also be a factor in the devel-
ure (HF), diabetic complications, chronic kidney disease, opment of HTN. Renin levels are markedly abnormal in
and cerebrovascular disease. While recent 2017 data from some hypertensive individuals, despite normal renal func-
the National Health and Nutrition Examination Survey tion. Individuals who secrete abnormally high levels of
(NHANES) demonstrated a 50% improvement in BP renin experience constant cycling of the renin-angiotensin-
control among Americans with HTN, 45.6% of persons aldosterone cascade, which raises blood volume and BP.
with HTN still had uncontrolled BP. Moreover, morbidity Low renin secretors, in general, are salt-sensitive hyperten-
is worsened in the setting of overweight and obesity, the sive individuals. Ingestion of sodium increases water reab-
prevalence of which has increased over the last 15 years, sorption into the bloodstream, which raises blood volume
with obesity rates growing from 30.5% to 37.7% in the and BP. The cause of renin imbalance in some persons with
United States. For example, a body mass index (BMI) of essential HTN is unknown, but measuring plasma renin
greater than 30 kg/m2 raises the risk of high BP and car- levels in patients with refractory HTN may assist in clini-
diovascular disease, while doubling the lifetime risk of HF cal diagnosis and treatment.
compared with persons with a BMI of less than 25 kg/m2. Other contributors include aging, sympathetic nervous
After decades of a steady reduction in rates of HTN- system overactivity, toxins, and low numbers of nephrons.
related diseases, researchers have reported a recent leveling An often-overlooked cause of essential HTN is sleep apnea
off of coronary heart disease rates, coupled with a slight with its associated activation of the sympathetic and renin-
increase in end-stage renal failure and age-adjusted stroke angiotensin systems. More commonly, metabolic syn-
rates. These changes are likely due to a number of factors, drome with its resultant insulin resistance and increased




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, 6 . C A R D I O VA S C U L A R P R O B L E M S


460 Unit II CARING-BASED NURSING: THE SCIENCE


insulin levels also leads to increased sympathetic activity that are damaged by HTN include the heart (LVH and
and hypertensive states (see Box 35.1). Worldwide epide- coronary artery disease (CAD) resulting in angina or acute
miological evidence demonstrates that age-related HTN is myocardial infarction [MI]), the kidneys (chronic renal
uncommon in societies where individuals maintain lower insufficiency), the brain (transient ischemic attacks [TIAs],
body weight, consume less sodium and more potassium, cerebrovascular accidents [CVAs], and increased risk of
and engage in greater levels of physical activity. These find- dementia), the eyes (retinal hemorrhages and hypertensive
ings indicate that high BP is influenced by environmen- retinopathy), and the peripheral arteries (peripheral vascu-
tal and modifiable lifestyle factors (e.g., smoking, obesity, lar disease).
stress) and is not an inevitable consequence of aging.
Genetic and ethnic influences also play a role in the
development of HTN. Persons with a family history of
Secondary Hypertension
HTN are four times more likely to have HTN than those Secondary HTN is elevated BP due to an identifiable,
with no family history of the condition. Studies show that underlying condition. Detection of secondary HTN is
the genetic contribution to essential HTN is complex, and critical to reverse the source of the pathological process
multiple genes are likely involved. Most genetic effects and prevent hypertensive target organ damage (TOD).
involve gene–gene interactions and gene–environment Much less common than essential HTN, secondary
interactions. Genes that encode components of the renin- HTN has an overall frequency of 5% to 10% in primary-
angiotensin-aldosterone system are being extensively stud- care practices. Secondary HTN is often distinguished
ied. Results of this line of investigation have implicated from essential HTN by certain assessment findings, such
mutations in the angiotensinogen gene and angiotensin- as an age of onset younger than 30 years or older than
converting enzyme gene. 50 years, BP higher than 180/110 mm Hg at diagnosis,
Studies of HTN in African Americans demonstrate significant TOD at diagnosis, hemorrhages and exudates
that ethnicity is related to HTN susceptibility and plays on funduscopic examination, renal insufficiency, LVH,
a role in the efficacy of specific types of drugs. Morbid- accelerated or malignant HTN, and a poor response
ity and mortality due to HTN and HTN-related disorders to therapy. Resistant HTN is often due to unexplored,
are more common in African Americans than in European reversible secondary causes.
Americans and non-Hispanic Americans. HTN also seems Reversible causes of secondary HTN include obesity,
to follow a more malignant course in African Americans. obstructive sleep apnea, renovascular disease, chronic
Compared with European Americans with HTN, African corticosteroid therapy, Cushing’s syndrome, primary hyper-
Americans have an increased risk of left ventricular hyper- aldosteronism, pheochromocytoma, coarctation of the
trophy (LVH), HF, and renal failure. aorta, hyperthyroid disease, parathyroid disease, and excess
HTN has localized and systemic adverse effects. Locally, alcohol intake. Secondary HTN can also be drug induced,
high BP creates a shearing force against the arterial walls, and a thorough history of the patient’s medications, includ-
which injures the endothelium and accelerates development ing herbal supplements, over-the-counter (OTC) agents,
of atherosclerosis. Endothelial injury initiates a detrimental and any illicit drug use is essential. Common drugs that can
localized reaction of vasoconstriction, inflammation, plate- cause HTN include NSAIDs, cyclooxygenase-2 (COX-2)
let aggregation, and fibrin and lipid deposition—the basis inhibitors, sympathomimetics such as decongestants and
of arteriosclerotic plaque formation. In turn, target organs anorectics (diet pills), oral contraceptives, erythropoietin,


Box 35.1 Lifestyle Modifications to Manage Hypertension
• Weight reduction: Maintain normal body weight (BMI, wine, or 3 oz of 80-proof whiskey) per day for most men and to
18.5–24.9 kg/m2) (lowers BP by 5–20 mm Hg). no more than one drink per day for women and lighter weight
• Adopt DASH (Dietary Approaches to Stop Hypertension) persons (lowers BP by 2–4 mm Hg).
eating plan: Consume a diet rich in fruits, vegetables, and • Stop smoking and/or use of other tobacco products.
low-fat dairy products, with a reduced content of saturated • Understand hot tub safety: When combined with heat,
and total fat (lowers BP by 14–18 mm Hg). antihypertensive drugs may cause vasodilation resulting in
• Dietary sodium reduction: Reduce dietary sodium intake to dizziness, light-headedness, fainting, and reduction of cerebral
no more than 100 mmol (2.4 g sodium) per day (lowers BP by blood flow, with the potential for falling and risk of injury.
2–8 mm Hg). • Maintain adherence to pharmacotherapeutic plan: When
• Physical activity: Engage in regular aerobic physical activity medication regimen is not followed, BP will rise.
such as brisk walking (at least 30 minutes/day on most days • Monitor for drug-induced HTN: Drugs that may induce HTN
of the week) (lowers BP by 4–9 mm Hg). include NSAIDs, antidepressants, glucocorticoids, oral contra-
• Moderation of alcohol: Limit consumption to no more than ceptives, hormone replacement therapy, and OTC medications
two drinks (1 oz or 30 mL of ethanol, e.g., 24 oz of beer, 10 oz of that contain decongestants.




6718_unit02_sec06_ch34-ch35_451-502.indd 460 14/12/18 5:45

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