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CVS > CVS 5 Control Of Blood Pressure+ Hypertension > Flashcards

CVS 5 Control Of Blood Pressure+ Hypertension Flashcards

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1
Q

Normal range of blood pressure

A

Systolic - 90-120
Diastolic - 60-80

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2
Q

BP in stage 1 hypertension

A

Clinical: >140/90 mmHg
Home: >135/85 mmHg

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3
Q

BP in stage 2 hypertension

A

Clinical: >160/100 mmHg
Home: >150/95

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4
Q

BP in severe hypertension

A

> 180 systolic or > 110 diastolic

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5
Q

Difference in the changes of the stages of hypertension

A

+ 20 systolic: - normal 90-120
- stage 1 140
- stage 2 160
- severe 180

+ 10 diastolic: - normal 60-80
- stage 1 90
- stage 2 100
- severe 110

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6
Q

diagnosis of hypertension

A

pt with clinical BP >140/90 should have 24 hour ambulatory blood pressure or home readings

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7
Q

What should you do if clinical blood pressure reading in >180/120?

A
  • assess for target organ damage
  • if there is damage, start drug treatment without ABPM
  • if no damage, confirm diagnosis: repeated clinical BP in 7 days OR ABPM + clinical review in 7 days
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8
Q

Blood pressure screening

A
  • every 5 years
  • more often in borderline cases
  • every year in pts with type 2 diabetes
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9
Q

What should all patients with a new diagnosis of hypertension have?

A
  • urine albumin:creatiine ratio
  • urine dipstick
  • bloods HbA1c, U&Es, lipids
  • fundus exam
  • ECG
  • QRISK score
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10
Q

Modifiable risk factors of hypertension

A
  • excess weight
  • excess dietary salt intake
  • lack of physical activity
  • excessive alcohol intake
  • stress
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11
Q

Non-modifiable risk factors of hypertension

A
  • increasing age
  • family history
  • ethnicity
  • gender: BP higher in men up to age 65, then women higher >65
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12
Q

Causes of primary hypertension

A

Idiopathic - Unknown

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13
Q

Causes of secondary hypertension

A

ROPED
- Renal disease e.g. renal artery stenosis
- Obesity
- Pregnancy induced or Pre-eclampsia
- Endocrine e.g. Cushing’s syndrome, hyperaldosteronism
- Drugs e.g. alcohol, steroids, NSAIDS, oestrogen

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14
Q

what is the most common cause of secondary hypertension?

A

renal disease e.g. renal artery stenosis

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15
Q

diagnosis of renal artery stenosis

A

duplex USS
MR or CT angiogram

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16
Q

What is the most common endocrine condition that can cause hypertension?

A

hyperaldosteronism
(Conn’s syndrome)

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17
Q

What organs should be assessed by clinical history + physical exam in relation to hypertension?

A

Brain
Eyes
Heart
Kidneys
Arteries

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18
Q

Life style management of hypertension

A
  • regular exercise
  • healthy diet
  • reduce salt + caffeine intake
  • reduce alcohol
  • smoking cessation
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19
Q

Hypertension management for:
- type 2 diabetics (regardless of age)
- under 55

A
  • step 1: ACEi or ARB
  • **step 2 **: add CCB or thiazide like diuretic
  • step 3: add the other one (ACEi/ARB + CCB + thiazide like diuretic)
  • step 4 if K+ <4.5mmol/L: spironolactone
  • step 4 if K+ >4.5mmol/L: alpha blocker or beta blocker
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20
Q

Hypertension management for:
- over 55 years old
- black African or African-Caribbean family origin (regardless of age)

A
  • step 1: CCB
  • step 2: add ACEi/ARB or thiazide like diuretic
  • step 3: add the other one (CCB + ACEi/ARB + thiazide like diuretic
  • step 4 if K+ is <4.5mmol/L: spironolactone
  • step 4 if K+ is >4.5mmol/L: alpha blocker or beta blocker
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21
Q

What controls short term regulation of blood pressure?

A

Baroreceptors reflexes

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22
Q

Why can baroreceptors only work in short term regulation of BP?

A

Threshold for baroreceptor firing resets
So not long term

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23
Q

Where are baroreceptors located?

A

Carotid sinus
Aortic arch

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24
Q

What are the neurohumoral pathways that control blood pressure?

A

1- renin-angiotensin-aldosterone-system
2- sympathetic nervous system
3- anti diuretic hormone
4- atrial natriuretic peptide

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25
Where is renin released from?
Granular cells of juxaglomerular apparatus (JGA) in kidney
26
What is renin release stimulated by?
- decreased NaCl delivery to distal convoluted tubule - decreased kidney perfusion - sympathetic stimulation of JGA
27
What is kidney perfusion detected by?
Baroreceptors in afferent arteriole to kidney
28
What can a decrease in kidney perfusion be due to?
Renal artery stenosis Decrease circulating volume
29
What is the pathway in RAAS?
Angiotensinogen > angiotensin I > angiotensin II *renin*. *ACE*
30
What is angiotensinogen produced by?
Liver
31
What type of receptor is angiotensin receptor 1/2?
G protein coupled receptor
32
Action of angiotensin II
- **increases BP** - **vasoconstriction** of arterioles - **increased Na+ reabsorption** at kidney - stimulates sympathetic NS to **release more NA** - acts on hypothalamus to **increase thirst** + **increase ADH release** - **aldosterone release** from adrenal cortex
33
Where is aldosterone released from?
Adrenal cortex Zona glomerulosa
34
Action of aldosterone on kidney
- increased expression of Na/K ATPase > increased Na reabsorption > H2O follows - H2O reabsorption - activates apical Na+ and K+ channels
35
ACE action on bradykinin
**Breaks down bradykinin** into peptide fragments
36
Function of bradykinin
Vasodilator
37
Why do ACE inhibitors cause dry coughs?
Prevent breakdown of bradykinin Build up bradykinin cause cough
38
What is the sympathetic nervous system stimulated by for regulating BP?
RAAS directly (AngII) A decrease in BP
39
What do high levels of sympathetic stimulation cause?
- **Decreased renal blood flow** by vasoconstriction of afferent arterioles - **stimulates renin release from JGA** - ^ AngII levels > ^ aldosterone - **activates apical NHE + basolateral Na/K ATPase** All cause increased Na + fluid reabsorption > ^ BP
40
Where is ADH released from?
Posterior pituitary
41
What stimulates ADH release?
Severe hypovalaemia Increase in plasma osmolarity
42
What does ADH do?
- **increase water reabsorption** - **increase Na+ reabsorption** - **vasoconstiction** Increased BP
43
How does ADH cause increase water reabsorption?
- insertion of aquaporins into collecting duct of kidney nephron - forms concentrated urine
44
What do atrial natriuretic peptides do?
**Promotes Na+ excretion** > water follows > decreased BP
45
How does ANP promote Na+ excretion?
Inhibits Na+ reabsorption Stimulates vasodilation of afferent arterioles
46
Where are atrial natriuretic peptides synthesised + stored?
Atrial myocytes
47
Where are atrial natriuretic peptides released from? In response to what?
Atrial cells In response to stretch (increased BP)
48
What inhibits atrial natriuretic peptides?
Decreased filling of heart due to low BP > less stretching > ANP release inhibited > increased BP
49
What is dopamine made from?
L-DOPA
50
Effects of dopamine
Vasodilatation Increased renal blood flow Decreased reabsorption of NaCl
51
What do prostaglandin act as?
Vasodilators Buffers to excessive vasoconstriction by SNS + RAAS
52
Examples of a1 receptor blockers
*Doxazosin*
53
Examples of L-type Ca2+ channel blockers
*Verapamil Nifedipine*
54
Adrenal causes of secondary hypertension
- conn’s syndrome - cushing’s syndrome - phaeochromocytoma
55
What is Conn’s syndrome
Aldosterone secreting adenoma
56
What is Cushing’s syndrome? How does it cause secondary hypertension?
- Excess secretion of cortisol from Zona fasiculata - at high levels, acts on aldosterone receptors > Na+ and H2O retention
57
What is a phaeochromocytoma?
Tumour of adrenal medulla Secretes catecholamines (NA + adrenaline)
58
Triad of symptoms for phaeochromocytoma
- episodic headache - sweating - tachycardia (Patients often do not have all three)
59
what is the most common symptoms of phaeochromocytoma?
Sustained or paroxysmal hypertension
60
Treatment of phaeochromocytoma
- resection - before surgery a + B blockers are needed *phenoxybenzamine* 10mg od/bd
61
Diagnosis of phaeochromocytoma
- 24 hour urine collection - Abdominal CT or MRI to detect tumours . - confirmed by measuring urinary + plasma fractionated metanephrines
62
What drug is most commonly used during treatment of phaeochromocytoma?
*Phenoxybenzamine* (alpha blocker)
63
What is the target blood pressure for those <80 on treatment?
<140 systolic <90 diastolic
64
What is the target blood pressure for those >80 on treatment?
<150 systolic <90 diastolic
65
What is accelerated/malignant hypertension?
BP >180/120 with retinal haemorrhages or papilloedema
66
IV options in hypertensive emergency
- *sodium nitroprusside* - vasodilator - *labetalol* - B blocker - *glyceryl trinitrate* - vasodilator - *nicardipine* - CCB - *esmolol* - B blocker
67
What are the two ways patients can present in hypertensive crisis?
- **emergency**: high BP associated with a critical event *e.g. encephalopathy, pulmonary oedema, MI, AKI* - **urgency**: high BP without critical illness but may include malignant hypertension
68
What is the aim of therapy for hypertensive crisis: - emergency - urgency
To reduce diastolic BP to 110mmHg: - in 3-12 hours for **emergency** - in 24 hours for **urgency** then to 100mg in 48-72 hours
69
What is the safest treatment for most patientsof hypertensive urgency?
- *nifedipine* 20mg MR BD + *amlodipine*10mg OD for three days - continue *amlodipine* 10mg OD after
70
What is a hypertensive emergency?
High BP with assocaited critical event *e.g. MI, AKI, pulmonary oedema, encephalopathy*
71
What is hypertensive urgency?
High BP without critical event But may include malignant hypertension

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