High blood pressure, also known as hypertension, affects millions — including children, teens and elderly. There is debate over how aggressively hypertension should be treated in older patients; the definition of a healthy blood pressure does not change with age for the general population. The causes of elevated Blood Pressure are diverse. Prolonged elevation of BP can lead to a diversity of changes in the myocardial structure, coronary vasculature, and conduction system of the heart. These changes in turn can lead to the development of left ventricular hypertrophy, coronary artery disease ,and systolic and diastolic dysfunction of the myocardium, complications that manifest clinically as angina or myocardial infarction, cardiac arrhythmias (especially atrial fibrillation), and congestive heart failure (CHF). No one can deny that congestive heart failure is very dangerous. CHF incidence and prevalence increases with age. It may cause serious complication to salim condition.
Hypertension
High blood pressure is a common condition. Blood pressure is the force of blood pressing against the walls of the arteries. When it's too high, your heart has to work harder. This can cause serious damage to the arteries. Over time, uncontrolled hypertension makes patient more likely to get heart disease, stroke, and kidney disease. Hypertension is two types: first, essential (primary) hypertension which results from unknown pathological etiology. Secondly, secondary hypertension which associated with, or secondary to, a disease. (Feltner et al., 2017)
Measuring of hypertension appears as two numbers. The first, the higher of the two, is your systolic pressure. That's the force in the arteries when the heat beats. The second number is your diastolic pressure or the pressure in the arteries when the heart rests between beats. Normal blood pressure is a reading below 140/90. The top number, 140, is systolic pressure, when the heart beats and is pumping blood. The bottom number, 90, is diastolic pressure, when the heart is at rest between beats. A healthy blood pressure would be below both these numbers, indicating a low risk of heart attacks and stroke .Symptoms of hypertension is a largely symptomless ‘silent killer. (Feltner et al., 2017)
Hypertension can be either, Hypertensive urgency occurs when blood pressure spikes — blood pressure readings are 180/110 or higher — but there is no damage to the body's organs. Blood pressure can be brought down safely within a few hours with blood pressure medication, OR Hypertensive emergency means blood pressure is so high that organ damage can occur. Blood pressure must be reduced immediately to prevent organ damage. (Cold et al., 2017)
Non pharmacological management of hypertension is too often overlooked in the elderly. Lifestyle modifications may be the only treatment necessary for preventing or even treating milder forms of hypertension in the elderly: Weight reduction (results in a 5-20 mmHg decrease in systolic blood pressure per 10kg less),dietary sodium reduction (2-8 mmHg decrease in SBP), physical activity (4-9 mmHg decrease in SBP), moderate alcohol consumption (2-4 mmHg decrease in SBP).
When lifestyle measures fail to lower BP to goal, pharmacotherapy should be initiated. There are several drug option to manage hypertension: 1-Thiazide diuretics for example (Hydrochlorothiazide).
2-an angiotensin converting enzyme inhibitor (ACEIs) for instance (captopril). 3-angiotension receptor blocker (ARBs) such as (losartan). 4- Calcium channel blocker (CCBs) for example (verapamil) is preferred agent in nonblack population; whereas CCBs or thiazide diuretics are favored in black patients. There are alternative drug classes that may be used in selected patients after primary agents such as Alfa-Blocker, center alfa2 agonist, adrenergic inhibitors, and vasodilators. Sensitivity of the elderly to sodium and to diuretics enhances rather than reduces the value of a thiazide diuretic as the first-line choice in mainstream treatment. The second-line option is either an angiotensin inhibitor (ACE inhibitor/angiotensin II receptor blocker) or a calcium antagonist, depending upon the clinical setting. Often, elderly patient requires several antihypertensive agents to achieve adequate blood pressure control. In elderly patient, the safety and efficacy to use of multiple medication classes. Also, Clonidine patch can be useful in elderly patient with labile blood pressure.
Congestive heart failure
Heart failure does not mean the heart has stopped working. Rather, it means that the heart's pumping power is weaker than normal. With heart failure, blood moves through the heart and body at a slower rate, and pressure in the heart increases. As a result, the heart cannot pump enough oxygen and nutrients to meet the body's needs. The chambers of the heart may respond by stretching to hold more blood to pump through the body or by becoming stiff and thickened. This helps to keep the blood moving, but the heart muscle walls may eventually weaken and become unable to pump as efficiently. As a result, the kidneys may respond by causing the body to retain fluid (water) and salt. If fluid builds up in the arms, legs, ankles, feet, lungs, or other organs, the body becomes congested, and congestive heart failure is the term used to describe the condition. Heart failure symptoms may include: Shortness of breath when you exert yourself or when you lie down, Fatigue and weakness, Swelling in your legs, ankles and feet, Rapid or irregular heartbeat, Reduced ability to exercise, Persistent cough with white or pink blood-tinged phlegm, Increased need to urinate at night, Swelling of your abdomen (ascites), Sudden weight gain from fluid retention. (Anon, 2017)
CHF is a syndrome that can be brought about by several causes. CHF is a weakening of the heart caused by an underlying heart or blood vessel problem, or a combination of several different problems, including: cardiomyopathy, Blocked blood vessels supplying the heart muscle, Toxic exposures, Infections, commonly viruses and hypertension that results in thickening of the heart muscle (left ventricular hypertrophy). There are four different stages of heart failure: A, B, C, and D. (Daniel Lee Kulick, 2017)
Stage A: High risk of developing HF due to having other conditions strongly associated with HF developing. Examples of these conditions include chronic hypertension, diabetes, and coronary artery disease. Stage B: People at this stage will have developed structural heart disease that is strongly linked with the development of HF. Stage C: People at this stage will be showing or will have shown symptoms of HF linked to an underlying structural heart disease. Stage D: People at this stage will have advanced structural heart disease, and will display significant symptoms of HF even when at rest.
Classification of congestive heart failure: Class I – Patients without limitation of physical activity. Class II – Patients with slight limitation of physical capacity, in which marked increase in physical activity leads to fatigue, dyspnea, or angina pain; they are comfortable at rest. Class III – Patients with marked limitation of physical activity in which minimal ordinary activity results in fatigue, palpitation, dyspnea, or angina pain; they are comfortable at rest. Class IV – Patients who are not only unable to carry on any physical activity without discomfort but who also have symptoms of heart failure or the angina syndrome even at rest; the patient's discomfort increases if any physical activity is undertaken.
Non-pharmacological measures for the management of heart failure: Weight reduction, avoid high salt content foods and not to add salt, moderate alcohol consumption, avoid smoking, regular exercise should be encouraged. (Ecrjournal.com, 2017)
Different medications can help symptoms of CHF. These include: Angiotensin-Converting Enzyme (ACE) inhibitors to widen blood vessels, making it easier for the heart to pump blood around the body such as Captopril. Anti-platelet drugs used to stop blood clots by preventing platelets in the blood from sticking together. Angiotensin II Receptor Blockers such as Candesartan, Losartan, Valsartan. Beta-blockers, which lower the heart rate and reduce the force with which the heart must pump such as Bisoprolol. Calcium channel blockers (CCBs), prescribed to help the heart pump less forcefully. They can also control irregular heart rhythms. Diuretics to help the body excrete more fluid in the urine and prevent it from overwhelming the heart and lungs. Vasodilators reduce the amount of oxygen the heart needs to dilate such as Nitrates or hydralazine. Cardiotonic as added therapy to improve myocardial contractility and increase cardiac output such as Digoxin. (Anon, 2017)
Summary
A patient with CHF and hypertension must make major changes in his life. Patient will need to eat differently, take medications consistently and according to instruction, keep as active as possible, stop smoking and reduce stress. Calling the doctor immediately if patient observe any of symptoms such as sudden weight gain, Shortness of breath while at rest. Although patient should ask the doctor for specific dietary guidelines. (Becker and Maiman, 2017)
Steps in the pharmaceutical care process of hypertension:
‘ Patients should understand the concept of hypertension.
‘ Collecting patient specific medical information.
‘ Develops an individualized patient-centered care plan.
‘ Explain the role lifestyle changes such as a healthy diet, exercise, salt reduction, and smoking cessation can play in reducing hypertension.
‘ Encourage patients to keep an up-to-date record of their blood pressure numbers
Steps in the pharmaceutical care process of congestive heart failure:
‘ Taking clinically appropriate medication to reduce symptom and to limit of the severity of CHF.
‘ Because of most patients may take multi drug in case of CHF so pharmacist should identifying drug-drug related problems.
‘ Educate patient to reduce weight, avoid high salt content foods, moderate alcohol consumption, and avoid smoking and regular exercise.
‘ Using such techniques to communicate with patient to follow up his condition.