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Year 3 > Hypertension > Flashcards

Hypertension Flashcards

1
Q

Define HTN

A

Blood pressure >=140/90 mmHg

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2
Q

HTN causes

A

> 90% cases = PRIMARY – essential/idiopathic

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3
Q

How do you correctly measure BP in clinic?

A

Offer to measure in both arms.

If difference between both arms >15mmHg –> repeat + measure from arm with higher BP

If BP >140/90 –> 2nd measurement –> 3rd measurement + record lower of last 2 measurements

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4
Q

Define white coat effect

A

Discrepancy of more than 20/10mmHg between clinic and average daytime ABPM

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5
Q

Secondary renal causes of HTN

A 
Renal artery stenosis
Chronic glomerulonephritis
Pyelonephritis
Polycystic kidney disease
Renal failure
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6
Q

Secondary endocrine causes of HTN

A 
Diabetes
Hyperthyroidism
Cushing’s
Conn’s
Hyperparathyroidism
Phaeochromocytoma
Congenital Adrenal Hyperplasia
Acromegaly
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7
Q

Secondary non-renal/endocrine causes of HTN

A

pre-eclampsia
CARDIO: coarctation of the aorta,increased intravascular volume
DRUGS: sympathomimetics, corticosteroids, oral contraceptives

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8
Q

What is stage 1 HTN?

A

Clinic BP >=140/90 mmHg

ABPM daytime/HBPM BP >=135/85 mmHg

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9
Q

What is stage 2 HTN?

A

Clinic BP >=160/100 mmHg

ABPM daytime average/HBPM average BP >=150/95 mmHg

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10
Q

What is stage 3 HTN?

A

Clinic systolic BP >= 180 mmHg OR

Clinic diastolic BP >= 110 mmHg

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11
Q

What do you do if someone comes into the clinic with BP >140/90?

A

Offer ABPM or HBPM

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12
Q

If a PT has BP >135/85 (stage 1 HTN) on A/H BPM what is the criteria for management?

(CORD10)

A

Treat if <80 years AND any of the following:

  • Established CVD
  • Target Organ damage
  • Renal disease
  • Diabetes
  • 10 year CV risk equivalent to 10% or greater
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13
Q

If a PT has BP >150/95 (stage 2 HTN) on A/H BPM what is the criteria for management?

A

Treat all patients regardless of age

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14
Q

Management of HTN step 1 (give example)

A

If <55yr / T2DM:

  • ACE-i - ends with ‘-pril’ -eg ramipril
  • or ARB if not tolerated- ends with ‘-sartan’

If >55yrs / Afro-caribbean/black African:
- CCB- ends with ‘dipine’- eg amlodipine

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15
Q

Management of HTN step 2

A

If <55yr / T2DM:
- ACEi/ARB + CCB
OR
- ACEi/ARB + thiazide-like diuretic (‎bendroflumethiazide)

If >55yrs / Afro-caribbean/black African:
- CCB + ACEi/ARB
OR
- CCB + thiazide-like diuretic (‎bendroflumethiazide)

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16
Q

Management of HTN step 3

A

ACEi/ARB + CCB + thiazide-like diuretic

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17
Q

Management of HTN step 4

A

If K+ <= 4.5 mmol/L: add low-dose spironolactone
If K+ > 4.5 mmol/L: add an alpha- or beta-blocker

If BP not controlled on 4 drugs then specialist review

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18
Q

What lifestyle advice would you offer for hypertension?

A

Low salt (<6/day, ideally 3g), fruit + veg rich, reduce caffeine intake
Stop smoking
Drink less alcohol
Exercise, lose weight

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19
Q

ACE inhibitor MOA

A

Inhibit the conversion angiotensin I to angiotensin II

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20
Q

ACE inhibitor side effects

A

Cough
Angioedema
Hyperkalaemia
Renal failure (RAS)

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21
Q

ACE inhibitor contraindications/warnings

A

Must be avoided in pregnant women

Check renal function 2-3 weeks after starting (risk of worsening renal function in PTs with renovascular disease)

22
Q

Name a common ACE inhibitor

A

Ramipril

23
Q

Angiotensin II receptor blocker MOA

A

Block effects of angiotensin II at the AT1 receptor

24
Q

Angiotensin II receptor blocker side effect

A

Hyperkalaemia

25
Q

Angiotensin II receptor blocker indications

A

Generally used where patients have not tolerated an ACE inhibitor, usually due to the development of a cough

26
Q

Name a common ARB

A

Losartan

27
Q

MOA of CCBs

A

Block voltage-gated calcium channels relaxing vascular smooth muscle and force of myocardial contraction

28
Q

CCB side effects

A

Flushing
Ankle oedema
Headache
Gum hyperplasia

29
Q

Name a common CCB

A

amlodipine

30
Q

MOA of thiazide like diuretics

A

Inhibit sodium absorption at the beginning of the distal convoluted tubule

31
Q

Side effects of thiazide like diuretics

A 
Hyponatraemia
Hypokalaemia
Dehydration
ECG changes/ arrythmia
Metabolic alkalosis
Hypercalcemia. 
Hyperglycemia
Hyperuricemia.
Hyperlipidemia.
32
Q

Side effects of spironolactone

A

Hyperkalaemia

Gynaecosmastia- decreases testosterone production, increasing peripheral conversion of testosterone to estradiol

33
Q

BB side effects

A

Bronchospasm
Heart failure
Lethargy

34
Q

When are BB contraindicated?

A

Asthma
Uncontrolled HF
Hypotension/marked bradycardia

35
Q

When in spironolactone contraindicated?

A

Addison’s disease
Anuria
Hyperkalaemia

36
Q

BP targets in HTN (once started on treatment)

A

Age < 80 years

  • clinic 140/90 mmHg
  • home 135/85 mmHg

Age > 80 years

  • clinic 150/90 mmHg
  • home 145/85 mmHg
37
Q

What is malignant hypertension?

A

Severe increase in BP to >180/120 mmHg & signs of new or progressive target organ damage

e.g. retinal haemorrhage and/or papilloedema

(NOTE: urgency = high but no target organ damage)

38
Q

RFs for malignant hypertension

A 
uncontrolled HTN
CKD
RAS
renal transplant
phaeochromocytoms
pregnancy
39
Q

1st line Tx for malignant hypertension

A

Specialist referral + IV labetalol

Reduce MAP by max 25% in 1st hour
then 160/100 or less within the next 2-6 hours
avoid organ ischaemia

40
Q

Signs of target organ damage in HTN

A

Congestive heart failure

Encephalopathy: headache, CNS signs, seizures, coma

41
Q

management of hypertensive urgency

A

if no target organ damage is identified, repeat clinic blood pressure measurement within 7 days

42
Q

Grade 1 of hypertensive retinopathy

A 
Tortuosity (twisting) of retinal arteries 
Increased reflectiveness (SILVER WIRING)
43
Q

Grade 2 of hypertensive retinopathy

A

Grade 1 + ARTERIOVENOUS NIPPING (thickened retinal arteries pass over retinal veins)

44
Q

Grade 3 of hypertensive retinopathy

A

Grade 2 + FLAME HAEMORRHAGE and COTTON WHOOL exudates (due to small infarct)

45
Q

Grade 4 of hypertensive retinopathy

A

Grade 3 + PAPILLOEDEMA (blurry margin of the optic disc)

46
Q

A 58-year-old man is reviewed in a hypertension clinic, where it is found that his blood pressure is 165/105 mmHg. He is currently on ramipril, amlodipine and Bendroflumethiazide.

What would be your next stage in his management?

A

Measure serum potassium level

47
Q

A 57-year-old man is reviewed in a hypertension clinic, where it is found that his blood pressure is 165/105 mmHg despite standard doses of amlodipine, perindopril, doxazosin and bendroflumethiazide. Electrolytes and physical examination have been, and remain, normal.

What would be your next stage in his management?

A

Arrange for his medication to be given under direct observation

One of the biggest issues is compliance- before specialist review you’d want to do this

48
Q

A 43 year old patient is started on some medication to control his high blood pressure. He now presents to you complaining of ankle swell. O/E you find bilateral ankle oedema.

What is the most likely culprit?

A

Calcium Channel Blocker

49
Q

A 45 year old gentleman with difficult to control hypertension presents to your practice for an annual review of his medication. On examination you notice gynaecomastia.

What is the most likely culprit?

A

Spironolactone

50
Q

A 65-year-old man present to his GP complaining of headaches and problems with his vision. O/E the GP finds his BP to be 190/130 and on fundoscopy see the edges of the optic disc are blurred.

Which of the following would be your next stage in his management?

A

Send the patient to A&E for specialist review

this patient has malignant hypertension- before doing anything need to review in A+E (not done in GP setting)

Year 3 (38 decks)

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