Hypertension Flashcards
(73 cards)
1
Q
What is the definition of hypertension?
A
Based on JNC8 Guidelines
- SBP ≥ 140 and/or DBP ≥ 90 in general patients
- SBP ≥ 150 systolic and/or DBP ≥ 90mmHg in pts >80YO
- SBP ≥ 130 and/or DBP ≥ 80 in patients with proteinuria w/ or w/o DM
- SBP ≥ 140 and/or DBP ≥ 90 in DM w/o proteinuria
2
Q
What is the grading of hypertension (for adults 18 years or older?
A
- Normal: <130/85
- Pre-hypertension: 130-139/ 85-89
- Grade 1 Hypertension: 140-159/ 90-99
- Grade 2 Hypertension: 160- 179 / 100- 109
- Grade 3 Hypertension: > 180/ >110
- Isolated systolic hypertension: >140/ <90
3
Q
How is hypertension diagnosed?
A
- Based on 2 Readings in 2 healthcare professional setting
- Can Dx in a single reading if there are signs of target organ damage
4
Q
How do you r/o white coat hypertension?
A
Home BP monitoring
1) HTN if SBP ≥135/85
>135/85; averaging across 2 weeks, 2x a day w/ 2 readings each time, discarding the very first reading
- Not Reliable due to iffy compliance 🡪 can consider 24Hr ABP
- This is not used for Dx in hospital – only used in GP Setting!
2) 24 hrs ABP monitoring: HTN if
- Average daytime SBP ≥135/85
- Average night time SBP ≥120/70
- Average 24 hour SBP ≥130/80
5
Q
What are the different types of HTN?
A
- Primary/Essential hypertension: suspect in middle aged man, w/ metabolic syndrome, smoker
- Secondary hypertension:: High BP due to a specific, potentially curable disorder.
- Refractory, Resistant hypertension: BP ≥ 140/90mmHg despite an optimal 3-drug regimen that includes a diuretic for at least 1 month to take effect.
6
Q
When to screen for secondary causes of HTN?
A
- Resistant hypertension
- An acute rise in blood pressure developing in a patient with previous stable values
- Age less than 30 years especially with a negative family history of hypertension
- hypertensive crisis
- proven age of onset before puberty
7
Q
What are the endocrine causes of HTN?
A
- Acromegaly
- Cushing’s
- Conn’s
- Phaeochromocytoma- TRO MEN
- Hyperthyroid: increased SBP
- Hypothyroid: Increased DBP
- OSA (STOP BANG)
- PCOS
8
Q
What are the neuro causes of HTN?
A
- Raised ICP
- Stroke
- Autonomic dysfunction e.g. GBS, SDS
9
Q
What are the iatrogenic causes of HTN?
A
- OCPS
- NSAIDs (uncommon unless chronic intake)
- Sympathomimetics
- Glucocorticoids
- TCM/ JAMU
- TCAs
- Cocaine
10
Q
What are the renal causes of HTN?
A
RAS activation due to renal artery stenosis
- Young female: fibromuscular dysplasia
- elderly: atherosclerosis
Parenchymal damage/ CKD
- DM
- APKD; ask for fam hx
- SLE & other AI diseases
- Calculi
- ESRF & CLD
- Acute/ chronic glomerulonephritis (haematuria)
11
Q
What are the cardio causes of HTN?
A
Coarctation of aorta (check signs of HF, ESM)
12
Q
What are the risk factors for primary hypertension?
A
Non-modifiable
- Advanced age
- Family history
- Male if <45 years old
- Female if >64 years old
- Chronic conditions eg DM, hyperlipidemia
Modifiable
- High salt diet
- Sedentary lifestyle
- Smoking
- Alcohol consumption
- Obesity
- Stress
13
Q
What symptoms do you need to ask TRO intracranial hypertension as a cause of 2’ hypertension?
A
Headache, worse in morning; N&V, Changes in Vision, Focal neuro deficits
14
Q
What symptoms do you need to ask TRO stroke as a cause of 2’ hypertension?
A
Neurological deficits
15
Q
What symptoms do you need to ask TRO OSA as a cause of 2’ hypertension?
A
Sleep symptoms, STOP-BANG screening
16
Q
What symptoms do you need to ask TRO acromegaly as a cause of 2’ hypertension?
A
Compare IC photo, ring size, shoe size
17
Q
What symptoms do you need to ask TRO Cushing’s as a cause of 2’ hypertension?
A
Weight gain, Cushingoid habitus, bruising, proximal myopathy (combing hair, hanging clothes, standing from squat, climbing stairs
18
Q
What symptoms do you need to ask TRO Conn’s as a cause of 2’ hypertension?
A
Difficult from history; muscle weakness from hypo K?
19
Q
What symptoms do you need to ask TRO Pheochromocytoma as a cause of 2’ hypertension?
A
EPIDOSDIC S&S: Palpitations, sweating, flushing, headaches
20
Q
What symptoms do you need to ask TRO thyroid (hyperthyroid, thyroid storm) as a cause of 2’ hypertension?
A
LOW, palpitations, flushing, tremors, heat intolerance, diarrhea, amenorrhea
21
Q
What symptoms do you need to ask TRO PCOS as a cause of 2’ hypertension?
A
Amenorrhea, signs of hirsutism, acne, weight gain
22
Q
What symptoms do you need to ask TRO CKD as a cause of 2’ hypertension?
A
Difficult to screen in history – look below for physical exam finding
23
Q
What symptoms do you need to ask TRO RAS as a cause of 2’ hypertension?
A
Frothy urine, Haematuria, oliguria, history of kidney problems
24
Q
What symptoms do you need to ask TRO drugs as a cause of 2’ hypertension?
A
Drug history, TCM, supplements
Any missed anti-hypertensives and last dose served?
25
What are the symptoms of complications of HTN and how would you assess it?
Heart: Hx of AF, CAD/IHD/AMI
- Symptoms: exertional dyspnoea, SOB, orthopnoea, PND, pedal edema
Neuro: Hx of CVA/TIA, SAH
- Symptoms: neurological deficits, seizures, headache, giddiness
- To check for power, reflexes, facial features, swallowing, sensation for neurological deficits in assessing Hx of stroke
Renal: HTN Nephrosclerosis
- Symptoms: oliguria, pedal edema, hematuria, frothy urine
Eye: Hypertensive Retinopathy - Visual loss
PVD: Claudication
26
What is the hx approach towards hypertension
Age: Young or old
Lifestyle: Obesity, Salt, Smoking, Alcohol, Exercise, Stress, Occupation
Any headache
- Acute or chronic?
- Stress-related?
- Migraine: unilateral, aura
- Tension headaches: all around tense, throbbing
- Cluster headaches: lacrimation, rhinorrhoea
- Associated symptoms: dizziness, giddiness, sensory motor disturbances, meningism (neck stiffness, photophobia, fever? -> fever + headache, always TRO meningism), mass: (seizures), papilloedema (blurring of vision),
- Severity
Any urinary symptoms
- Nephrotic syndrome: frothy urine, blood in urine (dark coloured urine)
- RAS
- UTI: history of stones
- Uraemia: nausea/vomiting, pruritus
- Fluid overload: progressively increasing exertional dyspnoea, SOB
Medication history: OCP, NSAIDs, Recreational drugs (amphetamines, cocaine), compliance to any anti-hypertensives
Thyroid
- Neck swelling
- Hyperthyroid: Heat intolerance, Sweatiness , LOA/LOW, Palpitations (tap the beat out), Emotional eg irritable agitation
- Hypothyroid: Cold intolerance, Lethargy, Weight gain, Constipation
Phaeochromocytoma – paroxysmal!: Episodic headaches, Palpitations, Diaphoresis, Flushing, Drenching night sweats, Postural hypotension
Cushing’s
- Any medications?
- Central obesity, dorsocervical/supraclavicular fatty deposits
- Thin skin, abdominal striae
- Bruising
- Proximal weakness (climbing stairs)
Obstructive Sleep Apnoea (suspect if pt is obese and large neck circumference)
- OSA episodes produce surges in systolic and diastolic pressure that keep mean blood pressure levels elevated at night. In many patients, blood pressure remains elevated during the daytime, when breathing is normal.
- Snoring – very loud, can be heard outside the room
- Tiredness – day time somnolence (do you fall asleep when driving / reading papers? Morning headaches)
- Observed – has anyone seen you stop breathing when you sleep?
- Pressure – do you have high BP
- BMI; Age; Neck Circumference; Gender
27
What is the PE required to be performed in a patient with HTN?
Blood pressure
- If upper limb BP is extremely high, consider taking lower limb BP (in clinical setting) to rule out Coarctation of Aorta
- Patient seated in a chair with back supported and arms bared and supported.
- BP cuff should be at the level of the patient’s heart.
- Good night’s rest with no smoking or caffeine 30mins before measurement
- Measurement begin 5 mins after rest in a quiet room.
Appropriate cuff size (Bladder encircles at least 80% of arm)
- Take the lower of 2 or more readings (confirmed on the contralateral arm) at least 2 mins apart.
- Standing BP levels should be check during initial evaluation and after drug titrations to exclude significant orthostasis
Body mass index (BMI)
Eyes
- Fundoscopy: Features of hypertensive retinopathy leading to arteriosclerosis
- Grade 1 - Silver-wiring / Copper wiring
- Grade 2 - AV-nicking (Gunn sign)
- Grade 3 - Hemorrhages and exudates
- Grade 4 – Papilloedema
- Thyroid eye signs
Neck: Goitre, Carotid bruit,
Raised JVP
Heart and Lungs
- Cardiomegaly and CCF (S3, - Rales, Crepitations)
- Valvular heart disease
- Clicks (prosthetic valve) and murmurs (ESM in Coarctation of aorta)
- Radio-femoral delay OR radial-radial delay (coarctation of aorta)
- Apex beat displacement
- Pulse
- Arm to leg SBP difference >20mm Hg (coarctation of aorta)
Abdomen
- Renal bruits (RAS)
- Ballotable kidneys: PCOS/APKD
- Ascites
- Aortic aneurysm
- Truncal obesity with abdominal striae (Cushing’s)
- Enlarged uterus?
Lower limbs
- Peripheral pulses
- Features of Peripheral vascular disease
Neurological assessment
- Neurological deficits
- Pronator drift
- Facial weakness
28
What are the investigations TRO Intracranial hypertension as a cause of HTN?
- LP to measure opening pressure
- Fundoscopy: to check for papilloedema
- CT scan to assess elevated ICP
29
What are the investigations TRO OSA as a cause of HTN?
Sleep study – polysomnography 🡪 only if u suspect (eg: obese)
30
What are the investigations TRO Cushing's as a cause of HTN?
24hr urine cortisol OR LD dexamethasone suppression test
- If either is +ve must repeat a second time to confirm
- We do not check ACTH due to possibility of non ACTH dependent Cushings
Late night salivary cortisol
31
What are the investigations TRO Conn's as a cause of HTN?
Uncontrolled HTN w HypoK is Conn’s until proven otherwise
Serum K levels
- Serum Aldosterone: Renin
Aldosterone > 417
- AND Aldosterone/renin ratio >20
Saline infusion challenge test
- If above tests are +ve – CT Abdomen
32
What are the investigations TRO Pheochromocytoma as a cause of HTN?
24hr urine catecholamine AND Serum free Metanephrine
33
What are the investigations TRO Hyperthyroidism as a cause of HTN?
TFT
34
What are the investigations TRO RAS as a cause of HTN?
US Doppler renal artery
35
What are the investigations TRO CKD as a cause of HTN?
Renal Panel
36
What are the investigations TRO Coarctation of aorta as a cause of HTN?
- CXR – rib notching, MRI
- Check for ESM, thrills, radiation of murmur to intrascapular space due to formation of collaterals, hypoplastic lower limbs (due to decreased flow)
- Only if above signs highly point to presence of coarctation then we will do 2D Echo (due to cost)
37
What are the investigations TRO cardiomegaly as a cause of HTN?
CXR
38
What are the investigations TRO pregnancy as a cause of HTN?
UPT
39
What are the investigations TRO acromegaly as a cause of HTN?
Serum IGF1 🡪 only do this if you suspect
40
What are the cardiovascular risk factor screen?
- DM: fasting glucose, OGTT
- Hyperlipidemia: lipids
- BMI
41
What are the goals of management in patients with hypertension?
- Age >80 years old: <150/90
- Moderate to severe albuminuria (urine ACR > 3mg/mmol; PCR > 15mg/ mmol): <130/80
- DM: <140/80
- All other patients: <140/90
42
What is the non pharmacological therapy for hypertension?
Note: Recommend lifestyle changes to all hypertensive patients, and in patients with high normal BP. However, drug treatment should not be delayed without reason beyond 3 to 6 months if indicated.
Unless contraindicated, advise patients to reduce weight to a BMI below 23 kg/m2 and to a waist circumference below 90cm in men, and below 80cm in women (for Asians).
Salt intake reduction (<2g of sodium/day 🡪 aka <6g of NACL table salt/day)
Exercise
- Advise patients to do at least 30 minutes of moderate dynamic exercise 5 to 7 days per week.
- Any physical exercise above the basal level, up to about 150 minutes a week, confers incremental cardiovascular and metabolic benefits, including BP reduction.
Increase the consumption of vegetables, fruits, low-fat dairy products, and decrease the intake of saturated and total fats.
Alcohol in moderation (≤ 2 drinks for men; ≤ 1 drink for women)
Smoking Cessation
43
What is the pharmacological therapy for hypertension?
Begin first-line antihypertensive treatment with any one, or an appropriate combination, of the five major drug classes available in Singapore, namely:
1. Angiotensin-converting enzyme inhibitor (ACE inhibitor)
2. Angiotensin II receptor blocker (ARB)
3. Calcium-channel blocker (CCB)
4. Diuretic (thiazide, thiazide-like, or loop)
5. Beta-blocker
Other classes of antihypertensive drugs, such as methyldopa, hydralazine, and alpha-adrenergic receptor blockers (peripheral alpha-1 blockers such as terazosin; central alpha-2 blockers like clonidine) may be used in combination treatment as third or fourth-line agents
44
What needs to be monitored when starting on a ACE inhibitor?
serum creatinine and potassium levels after 1- 2 weeks
45
What needs to be monitored when starting on diuretics?
serum potassium and sodium levels
46
What should be used in a patient with DM with + HTN?
Recommended
- Grade A level 1: ACE-I/ ARB
- Grade B level 2: dihydropyridine calcium channel
- Supplementary treatment: diuretic or calcium channel blocker
47
What should be used in a patient with CKD stage 5 (ESRF) + HTN?
- Recommended: ACE-I/ ARB
| - Contraindicated: Aldosterone antagonist
48
What should be used in a patient with Heart Failure + HTN?
- Recommended: diuretic, ACE inhibitor, ARB, aldosterone antagonist (spironolactone, eplerenone) or beta blocker (bisoprolol, carvedilol)
- Supplementary treatment: Dihydropyridine calcium channel blocker (amlodipine, felodipine)
- Contraindicated: Non- dihydropyridine calcium channel blocker (verapamil, diltiazem)
49
What should be used in a patient with Isolated systolic hypertension in older people?
- Diuretics
| - Dihydroyridine CCB
50
What should be used in a patient with previous MI + HTN?
- ACE-I/ ARB
| - beta blocker
51
What should not be used in a patient with asthma/ bronchospasm + HTN?
beta blocker
52
What should not be used in a patient with 2'/3' heart block + HTN?
- beta blocker
| - non dihydropyridine calcium channel blocker
53
What should not be used in a patient with gout + HTN?
diuretics
54
What should not be used in a patient with bilateral renal artery stenosis + HTN?
ACE-I/ ARB
55
What should not be used in a patient with pregnancy + HTN?
ACE-I/ ARB
56
What is the common ADR of beta blockers?
- postural hypotension
- tiredness/ fatigue
- cold extremities
- Bradycardia
- Heart block
- Giddiness
57
What are the C/Is to beta blockers
- asthma
- sinus node dysfunction
- pregnancy
- uncompensated heart failure
- heart block greater than 1st degree
- COPD
58
What is the ADR of Ca Channel blockers ?
- peripheral edema
- dizziness
- headache/ flushing
- LL swelling
- constipation
59
What is the C/I of Ca Channel blockers (dihydropyridines)?
caution use in patients with heart failure
if to use, amlodipine or felodipine are the preferred choice
60
What is the C/I of Ca Channel blockers (diltiazem)?
- sick sinus syndrome
- second or third degree AV block
- acute MI
- pulmonary congestion
- caution use in HF
61
What are the s/e of thiazides?
- postural hypotension
| - electrolyte disturbances (hypoK, hypoNa, HyperCa)
62
What are the c/i of thiazides?
- pregnancy
- renal decompensation
- anuria
- sulphonamides allergy
- may precipitate gout
- avoid in severe renal disease (ineffective)
- anuria
- electrolyte imbalance
63
What are the s/e s of ACE-I?
- postural hypotension
- dizziness
- abnormal taste
- dry cough
- angioedema
- hyperkalemia
- teratogenic
- AoCKD
64
What are the C/I of ACE-I?
- bilateral renal artery stenosis
- pregnancy (2nd/ 3rd trimester)
- idiopathic or hereditary angioedema
- AKI
65
What are the common ADR of ARBs?
- postural hypotension
- dizziness
- fatigue
- teratogenic
- hyperkalemia
- AKI
- AoCKD
66
What are the C/I of ARBs?
- bilateral renal artery stenosis
- pregnancy (2nd/ 3rd trimester)
- AKI
67
What is the first line hypertensive medications in pregnant patients?
```
First Line:
- Labetalol
- Methyldopa
- Ca Channel Blocker eg: Nifedipine
- Hydralazine (esp in Pre-Eclampsia)
Absolute C/I: ACEi and ARB
```
68
What is the number of drugs to be prescribed?
Approach 1 (preferred): Start on 1 drug 🡪 review every 2-3 months, increasing dose until max 🡪 before starting on 2nd drug
Approach 2: Start on 1 drug 🡪 upon review, start on 2nd drug for synergistic effect even before 1st drug has been maxed
Approach 3 (for Stage III HTN): Start on 2 drugs from the beginning
69
What is hypertensive crisis?
Large elevations in blood pressure (systolic blood pressure > 180 mmHg or diastolic blood pressure > 110 mmHg) associated with impending or progressive organ damage
• Brain (hypertensive encephalopathy, PRES, cerebral infarction, ICH)
• Heart (MI, acute LV failure, APO, aortic dissection)
• Kidney (renal failure)
• Eye (retinopathy)
• Pregnancy (eclampsia)
70
What are the end organ damage in hypertensive crisis and what ix needs to be done?
Heart
- AMI, CCF, aortic dissection
- CV exam, ECG, Trops, CKMB, CXR (for HF, widened mediastinum)
Lung
- Pulmonary edema
- CXR (ABCDE)
Brain
- Hypertensive encephalopathy
- Stroke: Ischemic, Haemorrhagic
- Neuro Examination, CT brain
Kidneys
- AKI (due to Hypertensive Nephrosclerosis)
- Renal panel
- Urine Dipstick – for Haematuria
Eyes
- Hypertensive Retinopathy causing Papilloedema
- Fundoscopy
71
What is the management of a hypertensive crisis
Target: bring down BP <160 or 25% within 2hours
Urgency
- bring down BP within a few days
- Usually PO meds
Emergency
- 10-20% in 1st hour and a further 5 to 15% in the next 23 hours – 25% in 24 hours
- Usually IV meds: Sodium nitroprusside, labetalol, nicardipine (dihydropyridine)
However – specifics for which we should Mx Blood Pressure + medication depends on Cx!
- Ischemic stroke: Permissive HTN for perfusion 🡪 only ↓ BP if SBP >220; Diastolic >120
- Acute aortic dissection: rapidly lower HR to 60-80 (via labetalol), then lower BP to 100-120mmHg (via Nitroprusside)
- Preeclampsia/Eclampsia: IV magnesium sulfate and labetalol
Management for STEMI
- Morphine
- Oxygen therapy
- Aspirin 300mg STAT
- Ticagrelor 180mg loading dose, 90mg TDS
- PCI: percutaneous coronary intervention
Management of APO (acute pulmonary oedema)
- IV furosemide (Lasix) for definitive management
- IV GTN (Nitroglycerin) for acute relief
- Remove drip
- Strict I/O
- Fluid restriction
- Insert IDC
72
What is the definition of resistant hypertension?
Resistant hypertension is defined as BP that remains above the goal despite concurrent use of 3 antihypertensive agents of different classes, at adequate doses, one of which should be a diuretic.
73
What are the causes of resistant hypertension?
Spurious causes
- non-compliance to medication
- white coat effect
- wrong cuff size
- arterial stiffening (due to calcification) in the elderly
True causes
- lifestyle factors (eg. obesity, excessive alcohol or sodium intake)
- chronic intake of vasopressor/Na-retaining substances (eg. sympathomimetics, nasal decongestants, OCPs, NSAIDs)
- exclude OSA, chronic pain and other causes of secondary HTN
- advanced end-organ damage
