Hypertension Flashcards
(33 cards)
What is hypertension? What are the 2 different classifications?
Persistently raised arterial blood pressure
=>140/90 in clinic
=>135/85 ambulatory BP
Primary/essential HTN= no single identifiable cause but associated with multiple risk factors
Secondary HTN= known underlying cause
What are the common risk factors for essential hypertension?
Male Increased age Smoking Dyslipidaemia Raised fasting glucose (5.6-6.9) Obesity (especially central obesity) FH of CVD Diabetes CKD
What are the causes of secondary hypertension? Which is the most common?
Most common- primary hyperaldosteronism (Conn’s disease) i.e. Na+ retention leads to water retention = expansion of BV
ROPE ++
Renal disease
Obesity
Pregnancy/Pre-eclampsia
Endocrine disorders i.e. Cushings/phaeochromocytoma/hyperparathyroidism/acromegaly/pregnancy/hyperthyroidism
Aortic coarctation= narrowing of portion of aorta
-presents with delayed femoral pulse
Alcohol
Caffeine
What are the possible complications of high blood pressure?
CHD (MI) LVH HF Stroke Peripheral vascular disease Retinopathy Aortic aneurysm Chronic kidney disease
I.e. increased risk of mortality with increase in systolic BP
What neurological signs should you be looking for in patient with history of hypertension and why?
UMN signs
- hypertonia
- hyperreflexia
- Positive babinski sign
- pyramidal weakeness= weakness in LL flexors and UL extensors
- cerebellar signs
- visual defects= heminopia
Indication there has been stroke
What are signs of peripheral vascular disease?
Increased CRT
Problems with palpating peripheral pulse or change to character/volume
Bruits
Cold shiny pale skin
If patient has secondary hypertension not responding to treatment, what should you suspect?
Renal artery stenosis
What investigations should be done for HTN patient to determine if causes renal disease?
Urinalysis- proteinuria
U+Es= raised creatinine
What signs might patient with CVS end organ damage related to HTN present with?
Signs of HF:
- raised JVP
- Displaced apex= hypertrophy
- S3= due to large amount of blood hitting compliant LV (i.e. HF associated with “flabby” heart)
- pitting oedema
- SOB + crepitations in lung bases= pulmonary oedema
What are important fundoscopic signs to note which may indicate hypertensive retinopathy? Which sign is particularly important to look for and why?
Arteriolar narrowing Flame haemorrhage Hard exudate Cotton wool spot= due to nerve damage Retinal oedema= sign of malignancy
What are the 3 different types of blood pressure measurement?
Clinic
-manual BP done if patient has irregular pulse
Ambulatory blood pressure (ABPM)
-24 hr BP which records multiple measurements of systolic and diastolic BP
Home blood pressure monitoring (HBPM)
-patients check BP 2x a day for 4 days
When is ABPM or HBPM indicated?
Confirmation of diagnosis of HTN
White-coat syndrome
Masked hypertension
Variability in clinic BP over visits
Hypotensive episodes
Suspected pre-eclampsia or hypertension in pregnancy
Resistant hypertension i.e. when hypertension resistant to 3+ antihypertensive drugs
When is anti-hypertensive treatment started regardless of ABPM?
When >=180 systolic
What is the definition of white coat hypertension?
Clinic blood pressure <149/90
Daytime ambulatory pressure <135/85
What would you want to assess in clinical examination of someone with hypertension?
Fundi with fundoscope
Abdomen for AAA/kidney/bruits
CVS for HF/pulses/peripheral vasc
L-R arm difference and diminished femoral pulse= aortic coarctation
What investigations/ examinations are done to assess for end organ damage?
Fundus examination= hypertensive retinopathy
Bloods= HbA1c/U+E/ eGFR
Urine albumin:creatinine ratio= proteinuria
ECG= cardiac abnormalities
If you suspected secondary hypertension, what investigations would you need to do?
Renin/aldosterone tests
Thyroid function test
U+Es
What is the target clinical blood pressure? How is this different for people over 80?
BP<140/90
80+= <150/90
A patient presents with a blood pressure of 150/100 to GP. What stage of hypertension are they? How is this patient likely to be managed?
May be asked to do ABPM or HBPM to determine their average BP outside of clinical environment to determine if this is one-off event due to white coat syndrome or if patient needs to be diagnosed with hypertension
Stage 1 i.e. >140/90
Stage 2 = 160/100
Stage 3= 180
Life style changes recommended 1st before medical intervention
- ensure moderate alcohol consumption
- moderate consumption of caffeine
- decrease salt intake
- smoking cessation
- regular exercise
- physical activity
- weight reduction
- dietary advice i.e. increase fruit and veg consumption
- regular sleep pattern
- relaxation therapies i.e. stress management advice
When is anti-hypertensive medication started immediately? When else is medical managment offered?
Stage 3 hypertension (>180 systolic)
Stage 2
What are the 4 main forms of anti-hypertensive therapy? What add ons can be used for additional control?
ACEi/ARBs i.e. ramipril Beta blockers i.e. bisoprolol Calcium channel blockers amlodipine Diuretics -thiazide-like i.e. indapamide (diuretic of choice) -spironolactone -amiloride
Add ons:
- alpha blockers i.e. doxazosin
- vasodilators (in emergencies) i.e. nitrates
- centrally acting antihypertensives i.e. moxonidine
Why would a patient be put on ARB rather than ACEi?
When ACEi not well tolerated due to causing dry cough due to accumulation of bradykinin in airways
What is the mechanism of centrally acting antihypertensives?
Act on alpha2 adrenoreceptor in brain stem to induce fall in BP
A 35 yo white patient with stage 2 hypertension requires anti-hypertensive medication. Which drug should they be given first and what is the step-wise progression if this does not control their hypertension?
A= mono therapy
ACEi i.e. ramipril 1.25mg to 10mg per day
A+C or A+D= dual therapy
Add calcium channel blocker (amlodipine) or diuretic (Indapamide)
A+C+D= triple therapy
Addition
Extra diuretic i.e. spironolactone
Beta-blocker i.e. bisoprolol
