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Hypertension Flashcards

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1
Q

What is hypertension?

A

This is the persistent elevation of BP in the systemic arterial circulation to a level higher than expected for the age, sex and race of the individual, such that treatment does more good than harm

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2
Q

What is blood pressure?

A

This is the outwards hydrostatic pressure exerted on the blood vessel walls, by the blood

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3
Q

What are the 2 different blood pressures?

A

Systolic - during ventricular contraction
Diastolic - during ventricular relaxation

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4
Q

What is meant by mean arterial pressure (MAP)?

A

This is the average pressure over one whole cardiac cycle

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5
Q

What is the calculation for MAP?

A

. (2 x Diastolic) + Systolic
. MAP = ———————————-
. 3

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6
Q

What is the normal value of MAP?

A

70-105mmHg

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7
Q

What is the normal range of systolic blood pressure?

A

90 - 120 mmHg

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8
Q

What is the normal range of diastolic blood pressure?

A

60 - 80 mmHg

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9
Q

What is pulse pressure?

A

This is the difference between systolic and diastolic blood pressure

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10
Q

What is the normal range of pulse pressure?

A

30 - 50 mmHg

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11
Q

What receptors detect changes in blood pressure?

A

Baroreceptors

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12
Q

Where are the baroreceptors located in the body?

A

Aortic baroreceptors
Carotid baroreceptors

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13
Q

What is the site of first synapse in the medulla to baroreceptor signals?

A

Nuceus tractus solitarius (NTS)

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14
Q

How does increased blood pressure affect the firing rate of baroreceptors?

A

It increases the firing rate of baroreceptors

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15
Q

Via which nerve do impulses from the aortic baroreceptors reach the medulla?

A

Vagus nerve

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16
Q

Via which nerve do impulses from the carotid baroreceptors reach the medulla?

A

Hering’s branch of Glossopharyngeal nerve

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17
Q

What is released by the heart in response to cardiac distension?

A

Natriuretic peptides

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18
Q

What are the 2 types of natriuretic peptide?

A

ANP - Atrial distension
BNP - Ventricular distension

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19
Q

What is the effect of natriuretic peptide release?

A

They cause the secretion of water and Na+ from the kidneys, as well as decreasing renin release and therefore causing vasodilation to decrease blood pressure

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20
Q

How are most cases of hypertension found?

A

Incidentally during regular health checks

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21
Q

What are some symptoms of acute malignant hypertension?

A

Headache
Blurred vision
Nausea
Vomiting
Chest pain
Altered mental status

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22
Q

What are some clinical signs of hypertension?

A

Pulses bruits
Hypertensive retinopathy

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23
Q

What are some ways in which hypertension can be classified?

A

Primary / secondary
Stage 1 / Stage 2 / Severe
Benign / Malignant / White coat

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24
Q

What is meant by primary hypertension?

A

This is hypertension with no singular identifiable cause

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25
What are some risk factors for primary hypertension?
Age Smoking Family history Obesity High alcohol intake High salt intake
26
How do effervescent tablets increase risk of mortality from hypertension?
They have a high sodium level and so increase risk of mortality 2 fold
27
What is meant by secondary hypertension?
This is hypertension caused by an identifiable singular cause, removal or reversal of which will lead to normalisation of blood pressure
28
What are some common causes of secondary hypertension?
Renal disease Obstructive sleep apnoea Aldosteronism Reno-vascular disease Drugs e.g. corticosteroids, NSAIDs, contraceptive pill Pregnancy e.g. pre-eclampsia
29
What is aldosteronism?
This is the autonomous excretion of aldosterone, without the need of the RAAS pathway
30
What are some less common causes of secondary hypertension?
Cushing's syndrome Liddel's syndrome Phaeochromocytoma Aortic coarction Hyperparathyroidism Inter-cranial tumour Polycystic kidney disease Fibromuscular dysplasia
31
What is meant by benign hypertension?
This is the stable elevation of blood pressure over many years
32
What are some possible consequences of benign hypertension?
Left ventricular hypertrophy Congestive heart failure Atheroma formation Thickening of tunica media Aneurysm rupture Renal disease
33
What is the more common name for malignant hypertension?
Accelerated phase hypertension
34
What is malignant hypertension?
This is an acute, severe elevation of BP, with a diastolic pressure >130-140 mmHg
35
What are some complications of malignant hypertension that make it an emergency?
Cerebral oedema Acute renal failure Acute heart failure Haemorrhage (Haemorrhagic stroke)
36
What is white coat hypertension?
This is an increased blood pressure during medical consultations, often due to increased stress or anxiety
37
How is white coat hypertension clinically classified?
A discrepancy of more than 20/10 mmHg between clinical and daytime average ABPM
38
What blood pressure is defined as stage 1 hypertension?
Clinic BP > 140/90 mmHg AMBP > 135/85 mmHg
39
What blood pressure is defined as stage 2 hypertension?
Clinic BP > 160/100 mmHg AMBP > 150/95 mmHg
40
What blood pressure is defined as severe hypertension?
Clinical BP > 180/110 mmHg
41
What is resistant hypertension?
Hypertension that does not respond to treatment using ACEis, ARBs or diuretics
42
What are some possible causes of resistant hypertension?
Non-concordance White coat effect Pseudo-hypertension Lifestyle factors (e.g. cocaine use) Drug interactions 2º hypertension True resistance
43
What are the 2 methods of hypertension diagnosis?
Ambulatory blood pressure monitoring (AMBP) Home blood pressure monitoring
44
What does diagnosis via ambulatory pressure monitoring require?
At least 2 measurements per hour during the patients usual waking hours (14 / day)
45
What does diagnosis via home blood pressure monitoring require?
2 consecutive seated measurements, 1 minute apart BP is recorded twice a day for at least 4 days, but preferably 7 Measurements on the 1st day are discarded and the average of the remaining days is used
46
What are some tests that can be performed in hypertension?
Urine sampling - Proteinuria - albuminurea Blood testing - Glucose, Electrolytes, raised Creatine, eGFR, cholesterol 12-lead ECG Fundoscopy
47
What are the 4 grades of hypertensive retinopathy in fundoscopy?
I - Slight narrowing of retinal arterioles (≥1:2 arteriovenous ratio) II - Severe narrowing of retinal arterioles (<1:2 arteriovenous ratio) III - Bilateral soft exudates or flame haemorrhages IV - Bilateral optic nerve oedema
48
What are some ECG findings that may suggest hypertension?
ST depression on leads V4-6 due to LV hypertrophy
49
What are some lifestyle management strategies in hypertension?
Exercise Smoking cessation Decrease salt, caffeine and alcohol intake
50
How will stage I hypertension often by managed?
Through lifestyle factors alone
51
How much does 1kg of weight loss decrease blood pressure by on average?
1mmHg
52
How does exercise affect mortality in hypertension?
15 minutes of daily physical activity decreases mortality by 14%, with every extra 15 minutes reducing mortality by 4%
53
What part of the kidneys controls the RAAS pathway?
Juxtaglomerular apparatus
54
What are the 3 components of the juxtaglomerular apparatus?
Macula cells Granular cells Mesangial cells
55
Describe the role of the juxtaglomerular apparatus in the RAAS pathway and blood pressure control
Macula dense cells are found in the renal tubule and detect low Na+ levels Extra-glomerular granola cells detect renal artery hypotension These stimulate the release of renin
56
Describe the RAAS pathway
Renin coverts angiotensinogen to angiotensin I ACE converts angiotensin I to II Angiotensin II stimulates aldosterone release Aldosterone stimulates ADH release
57
Where is angiotensinogen synthesise?
The liver
58
Where is angiotensin converting enzyme (ACE) found?
In the lung endothelium
59
What is the action of angiotensin II?
This causes vasoconstriction and stimulates thirst
60
What is the function of aldosterone?
This causes Na+ and thus water retention
61
How do ACE inhibitors work?
They block the conversion of angiotensin I to angiotensin II, which prevents vasoconstriction and decreases Na+ and water retention, therefore decreasing blood pressure
62
What are some examples of ACE inhibitors?
Lisinopril Ramipril Enalopril Perindopril
63
What are some side effects of ACE inhibitors?
Dry cough Renal dysfunction Angioneurotic oedema
64
What form of hypertension are ACE inhibitors contraindicated in?
Pregnancy induced hypertension
65
How do ARBs work?
They are angiotensin receptor blockers, so prevent the effects of angiotensin II on the body, preventing vasoconstriction and Na+ and water retention
66
What are some examples of ARBs?
Losartan Irbesartan Candesartan Valsartan
67
What is a possible side effect of ARB use?
Renal dysfunction
68
What type of hypertension are ARBs contraindicated in?
Pregnancy induced hypertension
69
How do diuretics work?
They block the reabsorption of Na+ in the kidneys, thus increasing the levels of excreted water
70
What are the 2 types of diuretic?
Thiazide diuretics - Mild Loop diuretics - Stronger
71
In what conditions are thiazide diuretics most indicated in?
Hypertension
72
In what conditions are loop diuretics most indicated in?
Congestive heart failure Oedema
73
What are some examples of loop diuretics?
Furosemide Bumetanide
74
What are some examples of thiazide diuretics?
Bendroflumethiazide Indapamide
75
What are some side effects of diuretics?
Hypokalaemia -> Tiredness Hyperglycaemia -> Diabetes Hyperuricaemia -> Gout Impotence Arrhythmia
76
How do calcium channel blockers work?
They block calcium channels in the heart, therefore slowing action potential triggering by the SA node and decreasing muscle contraction, therefore decreasing SVR and workload of the heart
77
What are the 2 types of Ca2+ channel blockers?
Dihydropyridine Rate-limiting
78
Where do dihydropyridine Ca2+ work?
On vascular smooth muscle, not in the heart
79
Where do rate-limiting calcium channel blockers usually work?
Mostly on the heart, decreasing heart rate
80
What are some examples of dihydropyridine Ca2+ channel blockers?
Amplodipine Nicardipine
81
What are some examples of rate-limiting Ca2+ channel blockers?
Verapamil Diltiazem
82
In what conditions are rate limiting Ca2+ channel blockers indicated?
Hypertension Heart failure Angina Supraventricular tachycardias
83
What are some examples of potent vasodilator drugs?
Hydralazine Minoxidil
84
What is a common side effect of minoxidil?
Hypertrichosis (Excessive hair growth)
85
What are some examples of alpha 2 agonists used as anti-hypertensives?
Methyldopa Clonidine
86
What are some examples of alpha 1 antagonists used as anti-hypertensives?
Prazosin Terazosin Doxazosin
87
What type of drug is dobutamine?
A ß-adrenoceptor agonist
88
What type of drug is digoxin?
A cardiac glycoside
89
How do cardiac glycosides (Digoxin) work?
They are synthesised from foxgloves (Digitalis purpurea) It blocks the sodium potassium pump This prevents the building of a concentration gradient for the Na+/Ca2+ exchanger This increases intracellular Ca2+ levels, leading to an increased force of contraction They also increase vagal activity, slowing AV conduction and slowing heart rate
90
What is the progression of treatment in patients with hypertension, who are under 55 and caucasian, or have diabetes?
1 - ACEi or ARB (Or ß-Blocker in young female) 2 - Add calcium channel blocker 3 - Add thiazide-like diuretic 4 - Add spironolactone
91
What is the progression of treatment in patients over 55, or patients who are black afro-carribean?
1 - Calcium channel blocker 2 - Add ACEi or ARB (or ß-blocker in young female) 3 - Add thiazide-like diuretic 4 - Add spironolactone
92
What are the treatment aims for blood pressure in people under 80 years old?
< 140/90 mmHg
93
What are the treatment aims for blood pressure in people over 80 years old?
< 150/90 mmHg
94
What are the treatment aims for blood pressure in patients with diabetes?
< 130/80 mmHg

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