Betty, a 42-year-old African-American teacher, attended a health fair at her church and was told she has “borderline” hypertension. Now, as she visits her primary care office for an annual Pap smear, she asks you if anything should be done about it. You note that her blood pressure today is 142/90 mmHg. At 154 pounds and 64 inches high, Betty is overweight. She also has a past medical history of gastroesophageal reflux disease, two pregnancies with Cesarean deliveries, and an appendectomy. However, she denies any history of diabetes, heart disease, or kidney disease. She smokes about one pack of cigarettes per day, has never had her cholesterol checked, and has a family history of hypertension and premature coronary artery disease.

As nurses, we encounter patients with elevated blood pressure on a daily basis. We administer antihypertensive drugs, discuss low sodium diets, and take frequent blood pressure readings. But what about a patient like Betty? What should we tell her about her blood pressure, and what can we do for countless other people to help them prevent hypertension? It may seem like a losing battle, as we see more and more patients with inadequately controlled hypertension. But what can we do to win the war?

Hypertension has been called the silent killer because it causes no symptoms in most people until late stages when complications develop. The natural history of hypertension is that of insidious onset, a clinically asymptomatic course often for a decade or more, progression from mild hypertension to higher blood pressure elevation in 20% to 30% of people, and development of long-term complications in many.

The complications of hypertension are either the direct result of the presence of high blood pressure — hypertensive risks — or the result of the development of atherosclerosis over time — atherosclerotic risks. The major hypertensive risks are stroke, congestive heart failure, and renal failure. The major atherosclerotic risks are coronary artery disease, peripheral vascular disease, and retinopathy. In general, the higher the systolic blood pressure, the greater the risk of complications, but individual risk varies with age, race, gender, family history, comorbid illnesses, and other factors. Hypertension as a major cardiovascular risk factor is common worldwide, however it is largely undertreated and uncontrolled in many regions of the world, including the U.S.¹

More than 50 million Americans have hypertension. Of those people with hypertension, only 70% are aware of their diagnosis. While approximately 59% are receiving treatment, only 34% are under good control.² The risk of developing hypertension increases with age and is higher in blacks than in whites. The morbidity and mortality associated with hypertension increases with age. The systolic reading is a better indication of the risk of complications, especially in persons age 60 and older. Systolic readings of greater than 140 mmHg have been associated with significant increase in strokes and cardiovascular deaths.³

History of hypertension management

Researchers have known for more than 30 years that vigorous and early treatment of hypertension reduces morbidity and mortality, especially for those with moderate to severe hypertension.⁴ However, less convincing evidence supports the benefit of treating mild hypertension, which is how most Americans with hypertension are categorized. Past research studies showed a great risk reduction of stroke by treating hypertension, although the risk reduction for coronary events was much less. This made many experts suspicious that some antihypertensive agents might have side effects that contribute to coronary risk. It was also previously felt that isolated systolic hypertension in the elderly was not as worrisome as diastolic hypertension, and that mild elevations in systolic blood pressure were a natural consequence of aging. This information often left clinicians hesitant to treat patients with isolated systolic or mild hypertension. However, clinical trials have shown that antihypertensive therapy is associated with reductions of 35% to 40% in strokes, 20% to 25% in myocardial infarction, and 50% in cases of heart failure.⁵ In addition, sustained reduction in systolic blood pressure has been shown to reduce mortality.⁶

The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI)⁷ served as a wake-up call to all health care professionals to improve strategies of care for individuals with or at risk for hypertension. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) provides a new classification for high blood pressure and offers updated guidelines on management of hypertension, in order to reduce cardiovascular risk.²

Despite evidence of the risks of hypertension and the benefits of treatment, hypertension remains a major public health problem that will grow as the population ages. In addition, hypertension can be and often is identified in school-aged children and adolescents, based on age-related normotensive blood pressure tables.⁸ Despite increased public awareness about hypertension, access to blood pressure evaluation, and development of longer acting drugs with fewer adverse effects, many people who have hypertension are not doing what is necessary to bring blood pressure down to goal. Significant cost is expended for the treatment of hypertensive emergencies and urgencies due to nonadherence.⁹ Therefore, nurses must take the initiative to learn about hypertension management and motivate patients to participate in its control.

Classification of hypertension

In the past, mild elevation of blood pressure was often referred to as “borderline” hypertension, and therefore escaped aggressive lifestyle modification by the patient and treatment by the clinician. The term “borderline” was eliminated by the JNC V in 1992, and further changes in classification were made by the JNC VI and JNC VII. A new category known as prehypertension has been added with two categories listed for hypertension. Blood pressure ranges for prehypertension and stage 1 and 2 hypertension are listed in the “Classification of Blood Pressure” sidebar. When a patient’s systolic and diastolic blood pressures do not fall into the same stage, the higher stage should be chosen to represent the patient’s hypertension. Staging is used not only to classify the severity of disease, but also to determine the aggressiveness of management and frequency of follow-up.

Assessment of hypertension

Adult blood pressure screening should occur routinely at every medical encounter, ideally every one or two years. Elevated blood pressures are followed up more frequently. Blood pressure in children age 3 and over should be monitored periodically during office visits. The importance of screening cannot be overemphasized because hypertension is asymptomatic and treatment reduces morbidity and mortality. Accurate blood pressure readings can be obtained by controlling several patient variables, such as having the patient avoid tobacco, caffeine, or alcohol at least 30 minutes before measurement, having the patient seated for five minutes, and using the proper equipment and technique, such as using a well-calibrated blood pressure cuff that fits the patient’s arm and is not applied over clothing. If the bladder of the cuff does not encircle 80% of the arm circumference, it is too small.^2,10

Blood pressure is often found to be elevated at health encounters, but not followed up. Both health care workers and the patient may rationalize an elevation as due to “nerves” or just because the patient rushed to get to the examination. This often occurs when a seemingly healthy patient visits the hospital for outpatient surgery or diagnostic testing. It may also occur in a busy office or clinic setting when the patient is seen for some minor episodic illness or injury. Because hypertension and cardiovascular disease are not the focus of these health encounters, the obvious sign of elevated blood pressure is not taken seriously. Many patients believe the “white coat syndrome,” that is, that their blood pressure becomes elevated only in the presence of a clinician with a lab coat on and should be dismissed. The fact is blood pressure may rise during the day due to multiple stressors, and may not decrease during sleep in hypertensive individuals. Ambulatory blood pressure monitoring may be used to determine accurate average blood pressure.^2,8

Diagnosis of hypertension is based on at least two elevated readings done on two or more occasions. Additional assessment includes a comprehensive health history to evaluate other risk factors for stroke and CHD. These risks include age over 55 years for men or 65 for women, African-American race, male gender, family history of premature CHD, smoking, inactivity, obesity, diabetes, hyperlipidemia, and evidence of target organ disease, such as existing heart disease, stroke, transient ischemic attack, nephropathy, peripheral arterial disease, or retinopathy. The presence of diabetes or renal disease should always signal the need for more aggressive management.

Treatment of hypertension

Hypertension can be readily treated in most individuals, but not without cost. As a chronic disease, it cannot be cured, but it can be controlled. The primary treatment for established hypertension is medication, with lifestyle modifications playing a smaller, but still significant role. Control through medication may seem so simple that the seriousness of hypertension is downplayed. In fact, despite the multitude of antihypertensive agents to choose from, complete control of blood pressure through medications is often difficult to achieve. Medications are costly, especially angiotensin II receptor antagonists, also called angiotensin receptor blockers (ARB) and some calcium channel blockers (CCB), angiotensin-converting enzyme inhibitors (ACE), and alpha-1 blockers. Older, generic, and less expensive medications, such as the diuretics and beta-blockers, may be underutilized due to more frequent dosing requirements or concern about adverse effects. The greater the adverse effect profile of the medication, the less likely the patient is to adhere to the treatment regimen. Patient compliance is also compromised by multiple medications and dosing schedules. Once-daily dosing is the best approach with at least 50% of the peak effect at the later part of the day.¹¹

Individualization of therapy is important, taking into account the patient’s history of other illnesses, ability to pay for medication, preference on when and how often to take medicine, and response to therapy. The JNC VII report outlines a variety of drug classes that reduce the complications of hypertension. Thiazide diuretics are recommended as the initial drug choice for controlling uncomplicated hypertension, alone or in combination with other agents. ACE inhibitors are recommended for hypertensive patients with heart failure and diabetics with proteinuria. Beta-blockers are recommended following a myocardial infarction and calcium channel blockers have a favorable effect on those at high risk for coronary artery disease. Alpha-1 blockers may have a favorable effect for patients with benign prostatic hyperplasia or dyslipidemia. For those with hyperthyroidism or migraine headaches, beta-blockers may have a favorable effect.

Likewise, medications are outlined that may have an unfavorable effect on patients with certain comorbid conditions. Beta-blockers may have an unfavorable effect in hypertensive patients with bronchospastic disease, diabetes, dyslipidemia, peripheral vascular disease, and heart failure. Thiazide diuretics may have an unfavorable effect in those with gout. ACE inhibitors and ARBs are contraindicated in pregnancy. Potassium-sparing agents may have an unfavorable effect in those with renal insufficiency. A complete list of medications and conditions is listed in the JNC VI report.

Drug therapy should be initiated for most people who have a blood pressure of greater than 140/90 mmHg. With lifestyle modifications and drug therapy, their blood pressure should be maintained at a level below 140/90 mmHg or 130/80 mmHg for those with diabetes or renal failure.²

Close monitoring may be required to adjust dosage over a period of several months and long-term follow-up is necessary to ensure that therapy is effective and not producing adverse effects. Patients need to take medications daily even when feeling good, and to keep office appointments every couple of weeks to several times a year. Cost for drugs incurred by insurance companies or the patient can range from pennies a day for a generic drug such as hydrochlorothiazide to several dollars a day for a newer, once-a-day agent such as the angiotensin receptor blockers (ARBs). Additional cost can be incurred if a drug interaction or adverse reaction occurs that requires other therapy. However, cost of complications from inadequately controlled blood pressure is much higher. If blood pressure is >20/10 mm Hg above goal, initiation of drug therapy with a combination of two agents (usually including a thiazide diuretic) may be prudent.²

The role of lifestyle modification and prevention

Nurses should stress lifestyle modification and prevention for several reasons:

• Adults age 55 and older have a 90% chance of developing hypertension in their lifetime, and the risk of CHD doubles with each incremental BP increase of 20/10 mm Hg above 115/75.
• Lifestyle modifications can help get blood pressure to goal, reduce the need for medication, and reduce the cost of hypertension management.
• Lifestyle modifications not only reduce blood pressure, but also reduce the risk of diabetes, cardiovascular disease, cancer, osteoporosis, and other chronic illnesses.
• The prescription of lifestyle modifications to control and prevent hypertension is well within the scope of nursing practice.

Lifestyle modifications essential to both the prevention and treatment of hypertension include weight reduction, moderation of alcohol, increased physical activity, moderation of dietary sodium, and smoking cessation. A diet has been developed — the DASH diet — from the Dietary Approaches to Stop Hypertension clinical study.¹² This diet is rich in fruits, vegetables, and low-fat dairy products and low in sodium, total fat, saturated fat, and cholesterol. It is also high in fiber, potassium, calcium, and magnesium and moderately high in protein. Information on this diet and on high blood pressure for patients can be accessed at www.nhlbi.nih.gov/health/public/heart/hbp/dash. Sodium intake should be restricted to 2,400 mg per day and effective weight loss in the 3% to 9% range.^2,13,14 Nurses should become familiar with diet recommendations and discuss this and other topics with all patients, young and old, to prevent hypertension. In addition, the issue of smoking cessation should be approached at every health encounter. The patient’s personal risk for cardiovascular disease as well as stroke should be discussed. It should be stressed that two or more lifestyle modifications can achieve even better results.

While nurses in inpatient settings may be primarily dealing with sophisticated cardiovascular monitoring, multiple-drug administration, and the frequent reassessment of a patient’s condition related to the complications of hypertension, these nurses should not forget to teach the lifestyle modifications that may help improve the patient’s condition. Nurses in outpatient settings are in the ideal position for disseminating information to patients, family members, and the community. Adults should be encouraged to have blood pressure screening every one to two years.¹⁰

Nurses need to be aware of the vast burden that hypertension is casting on the entire population of Americans in terms of personal suffering and lost productivity of those with complications from hypertension, and cost in health care dollars. Specific populations, especially men, the elderly, African-Americans, and those who smoke, have diabetes, and other risk factors for cardiovascular disease, are even more heavily burdened by hypertension and its complications. Armed with blood pressure cuffs and stethoscopes, nurses are at the forefront of screening, but their involvement should not end there. They should assess blood pressure skillfully and be aware of risk stratification in order to advise patients if their blood pressures require intervention. In the case of Betty, it is time to tell her that she does not have borderline hypertension but has true stage 1 hypertension, and that full evaluation, lifestyle modification, and possible drug treatment are indicated. Whether you are a nurse practitioner, office nurse, home health nurse, specialty nurse, or staff nurse in an acute care facility, you could make an impact on this patient’s future health.

Nurses can advise lifestyle modification to all people despite blood pressure level in hopes of prevention, if not treatment of high blood pressure. Nurses also need to be role models for patients by having their own blood pressure monitored, carrying out lifestyle modifications, and following treatment recommendations. For those patients who have stage 1 or stage 2 hypertension, aggressive treatment should be considered. Treatment should be prescribed or the patient referred based on the nurse’s role and setting. Only then might we win the war.