CV: Hypertension

Question 1

Stage 1 hypertension threshold in clinic and at home

Answer 1

140/90 clinic, 135/85 at home

Question 2

Stage 2 hypertension threshold clinic and at home

Answer 2

160/100mmHg clinic, 150/90mmHg home.

Treat all people with stage 2 regardless of age, review people under 40 yrs with stage 1 for specialist review.

Question 3

what is the definition for severe hypertension?

Answer 3

> 180 systolic or 110 diastolic

Question 4

Under 80 target blood pressure

Answer 4

<140 clinic, <135 at home.

Question 5

Over 80 target blood pressure

Answer 5

<150/90, at home <145/85`

Question 6

What is the 4 step treatment pathway for hypertension in non-special patient group under 55 year old patient?

Answer 6

1. ACEi or ARB if not toelrated. If ACEi or ARB not tolerated, consider a BB.
2. ACE or ARB + CCB. If a CCB is not tolerated of if there is evidence of, or high risk of heart failure, give a thiazide-related diuretic.

(If a BB was given at step 1, add a CCB in preference to a thiazide-related diuretic).

3. ACEi or ARB + CCB + thiazide-like diuretic.
4. Resistant hypertension requires specialist advice: low-dose spironolactone if K <4.5 or high-dose thiazide related diuretic if K >4.5.

Monitor renal function and electrolytes, if additional diuretic therapy is contra-indicated, ineffective or not tolerated, consider an alpha-blocker or a beta-blocker.

Question 7

What is the hypertension treatment pathway in those over 55 or those of any age who are of African or Caribbean family origin?

Answer 7

Step 1

Calcium-channel blocker; if not tolerated or if there is evidence of, or a high risk of, heart failure, give a thiazide-related diuretic (e.g. chlortalidone or indapamide)
Step 2

Calcium-channel blocker or thiazide-related diuretic in combination with an ACE inhibitor or angiotensin-II receptor antagonist (an angiotensin-II receptor antagonist in combination with a calcium-channel blocker is preferred in patients of African or Caribbean family origin)
Steps 3 and 4

Treat as for patients under 55 years

Question 8

Unless contra-indicated, what OTC drug is recommended for all patients with established cardiovascular disease?

Answer 8

Aspirin: uncontrolled hypertension needs to be controlled before addition to therapy due to risk of GI bleeds.

Question 9

Diabetic target clinic blood pressure when no signs of target organ damage are present

Answer 9

<140/80

Below 130/80 is advised if kidney, eye, or cerebrovascular disease are also present.

Question 10

In type 1 diabetes, hypertension usually indicates what?

Answer 10

The presence of diabetic nephropathy.

ACEi or ARB may have a specific role in the management of diabetic nephropathy

Question 11

Renal disease target clinic blood pressure (not chronic disease or diabetes)

Answer 11

<140/90, <130/80 if chronic kidney disease and diabetes, or if proteinuria exceeds 1g in 24 hours)

Question 12

Three drugs used (not necessarily licensed) for treating hypertension in pregnancy.

Answer 12

1. Labetelol
2. Methyldopa
3. MR nifedipine [unlicensed].

Question 13

In uncomplicated chronic hypertenson, a target blood pressure of what is recommended in pregnancy?

Answer 13

<150/100mmhg

Question 14

In women with target-organ damage as a result of chronic hypertension, and in women with chronic hypertension who have given birth, a target blood pressure of what is advised?

Answer 14

<140/80mmHg

Question 15

Women managed with methyldopa during pregnancy should discontinue treatment and restart their original antihypertensive medication within how many days of birth?

Answer 15

2 days

Question 16

Pregnant women are at a high risk of developing pre-eclampsia if they have chronic kidney disease, diabetes mellitus or what else? (3)

Answer 16

1. An autoimmune disease
2. Chronic hypertension
3. Hypertension during a previous pregnancy.

Question 17

Women at risk of developing pre-eclampsia are advised to take what once daily from week 12 of pregnancy until the baby is born?

Answer 17

Aspirin once daily

Question 18

Intravenous what can be used in women with a blood pressure of >160/110mmHg who require critical care during pregnancy or after birth?

Answer 18

Women with a blood pressure of ≥160/110 mmHg who require critical care during pregnancy or after birth should receive immediate treatment with either oral or intravenous labetalol hydrochloride, intravenous hydralazine hydrochloride, or oral modified-release nifedipine to achieve a target blood pressure of <150 mmHg systolic, and diastolic 80–100 mmHg.

Question 19

In women with pre-eclampsia where birth is considered likely within 7 days, intramuscular what is recommended for fetal lung maturation?

Answer 19

Intramuscular betamethasone is recommended for fetal lung maturation.

Question 20

What are the risk involved with a too rapid reduction in blood pressure during the management of a hypertensive crisis?

Answer 20

If blood pressure is reduced too quickly in the management of hypertensive crises, there is a risk of reduced organ perfusion leading to cerebral infarction, blindness, deterioration in renal function, and myocardial ischaemia.

Question 21

In the management of acute hyperensive crisis, the aim is to reduce blood pressure by what % over the first few minutes or within 2 hours?

Answer 21

20-25%.

Question 22

When IV therapy for hypertensive crisis is indicated treatment with nicardipine, labetalol or esmolol or hydralazine is possible. What other options are there? (3)

Answer 22

1. GTN
2. Sodium nitroprusside
3. Phentolamine

Question 23

A hypertensive emergency is when what conditions are met?

Answer 23

1. > 180/110
   AND
2. Acute damage to the target organs:

Papilloedema: optic disc swelling that is caused by increased intracranial pressure.

Retinal haemorrhage, ACS, acute aortic dissection, acute pulmonary oedema, hypertensive encephalopathy etc.

Question 24

Severe hypertension (blood pressure >180/110mmHg) without acute target-organ damage is defined as a hypertensive urgency; blood pressure should be reduced using what agents over what period?

Answer 24

Severe hypertension (blood pressure ≥ 180/110 mmHg) without acute target-organ damage is defined as a hypertensive urgency; blood pressure should be reduced gradually over 24–48 hours with oral antihypertensive therapy, such as labetalol hydrochloride, or the calcium-channel blockers amlodipine or felodipine. Use of sublingual nifedipine is not recommended.

Question 25

What is phaeochromocytoma?

Answer 25

A neuroendocrine tumour of the medulla of the adrenal glands (originating in the chromaffin cells), or extra-adrenal chromaffin tissue that failed to invoute after birth, that secretes high smounts of catecholineamines, mostly noradrenaline plus adrenaline to a lesser extent.

This causes elevated blood pressure.

Question 26

How is phaeochromocytoma managed?

Answer 26

Phaeochromocytoma is managed using surgery, however, surgery should not take place untl there is adequate blockade of both alpha and beta-adrenoreceptors.

Alpha blockade with alpha blockers then beta blockade with beta blockers.