HYPERTENSION Flashcards
(121 cards)
1
Q
What happens if the bladder of the cuff is too small?
A
overestimation of blood pressure (BP).
2
Q
What effect does a cuff with a bladder that is too large have on BP measurement?
A
underestimation of blood pressure (BP).
3
Q
How should the arm be positioned during a blood pressure measurement?
A
The arm should be horizontal at the level of the heart.
4
Q
What happens if the arm is positioned lower than heart level during a blood pressure measurement?
A
It leads to an overestimation of blood pressure
5
Q
What happens if the arm is elevated above heart level during a blood pressure measurement?
A
It leads to an underestimation of blood pressure.
6
Q
What posture is considered standard for routine blood pressure measurement?
A
The sitting position.
7
Q
Why is arm support important during a blood pressure measurement?
A
Lack of arm support can raise diastolic blood pressure due to isometric exercise of the arm.
8
Q
What does NICE recommend when considering a diagnosis of hypertension?
A
measuring blood pressure in both arms.
9
Q
What should be done if the difference in blood pressure readings between arms is more than 20 mmHg?
A
The measurements should be repeated.
10
Q
What should be done if the difference in blood pressure readings between arms remains greater than 20 mmHg after repeating the measurement?
A
Subsequent blood pressures should be recorded from the arm with the higher reading.
11
Q
What techniques help confirm the diagnosis of hypertension?
A
Ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM) help provide a more accurate assessment.
12
Q
Why is ABPM considered superior to clinic readings?
A
ABPM is a more accurate predictor of cardiovascular events and prevents overdiagnosis of hypertension.
13
Q
Stage 1 hypertension
A
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
14
Q
Stage 2 hypertension
A
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
15
Q
Severe hypertension
A
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg
16
Q
What should be done if there is a significant difference in blood pressure readings between arms?
A
Listen to heart sounds and consider further investigation if the difference is large.
17
Q
What does NICE recommend if the first blood pressure reading is > 140/90 mmHg?
A
Take a second reading during the consultation; the lower of the two readings should guide further management.
18
Q
What should be offered to patients with a blood pressure of >= 140/90 mmHg?
A
Offer ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM).
18
Q
What is the recommended action if no target organ damage is identified with a BP of >= 180/120 mmHg?
A
Repeat clinic blood pressure measurement within 7 days.
18
Q
What should be done if the blood pressure is >= 180/120 mmHg?
A
Admit for specialist assessment if there are signs of retinal haemorrhage, papilloedema, or life-threatening symptoms like chest pain or new-onset confusion, signs of heart failure or AKI.
18
Q
What should be done if target organ damage is suspected in a patient with high blood pressure?
A
blood tests, urine ACR, and ECG.
19
Q
When should a referral be made if a phaeochromocytoma is suspected?
A
Referral should be made if the patient has symptoms such as labile or postural hypotension, headache, palpitations, pallor, and diaphoresis.
20
Q
What should be done if target organ damage is identified in a hypertensive patient?
A
Consider starting antihypertensive drug treatment immediately, without waiting for the results of ABPM or HBPM.
21
Q
How is Ambulatory Blood Pressure Monitoring (ABPM) done?
A
At least 2 measurements per hour during the person’s usual waking hours (e.g., 08:00–22:00).
use the average value of at least 14 measurements
21
Home blood pressure monitoring (HBPM)
For each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
BP should be recorded twice daily, ideally in the morning and evening
BP should be recorded for at least 4 days, ideally for 7 days
discard the measurements taken on the first day and use the average value of all the remaining measurements
21
When should treatment be considered for stage 1 hypertension in patients under 80 years old?
if the patient has:
target organ damage,
established cardiovascular disease,
renal disease,
diabetes, or a 10-year cardiovascular risk of 10% or greater.
22
What ABPM/HBPM reading indicates stage 1 hypertension?
ABPM/HBPM >= 135/85 mmHg.
22
What additional recommendation did NICE make in 2019 for stage 1 hypertension in adults under 60 years old?
NICE suggested considering antihypertensive drug treatment in addition to lifestyle advice for adults under 60 with stage 1 hypertension and an estimated 10-year risk below 10%, due to evidence that QRISK may underestimate lifetime cardiovascular disease risk.
23
What ABPM/HBPM reading indicates stage 2 hypertension?
ABPM/HBPM >= 150/95 mmHg.
24
What should be done for patients with stage 2 hypertension?
Offer drug treatment regardless of age.
25
What is the recommended daily salt intake to help manage hypertension?
A low salt diet is recommended, aiming for less than 6g/day, ideally 3g/day.
26
What are some other general lifestyle advice tips for managing hypertension?
Reduce caffiene
Stop smoking
Drink less alcohol
Eat a balanced diet rich in fruit and vegetables
Exercise more
Lose weigh
27
What should be considered for patients under 40 years with hypertension?
Consider specialist referral to exclude secondary causes of hypertension.
28
What is the first-line treatment for patients under 55 years old or those with type 2 diabetes mellitus?
ACE inhibitors (ACE-i) or Angiotensin Receptor Blockers (ARB).
29
When should an Angiotensin Receptor Blocker (ARB) be used instead of an ACE inhibitor?
ARBs should be used when ACE inhibitors are not tolerated (e.g., due to a cough).
30
What is the first-line treatment for patients aged 55 years or older or those of black African or African-Caribbean origin?
Calcium channel blockers (CCBs).
31
Why are ACE inhibitors not used as first-line treatment in patients of black African or African-Caribbean origin?
ACE inhibitors have reduced efficacy in these patients.
32
What should be added if a patient is already on an ACE-i or ARB?
A Calcium channel blocker (CCB) or a thiazide-like diuretic.
33
What should be added if a patient is already on a Calcium channel blocker (CCB)?
An ACE-i, ARB, or a thiazide-like diuretic.
34
What treatment should be considered for patients of black African or African-Caribbean origin taking a calcium channel blocker?
If a second agent is needed, consider an Angiotensin Receptor Blocker (ARB) in preference to an ACE inhibitor.
35
What is the recommended third step in hypertension treatment?
Add a third drug, for example:
If on (A + C), add a diuretic (D).
If on (A + D), add a calcium channel blocker (C).
The combination should be (A + C + D).
36
What defines step 4 treatment in hypertension management?
Step 4 is defined as resistant hypertension, and it involves either adding a fourth drug or seeking specialist advice
37
What should be checked before adding a fourth drug in step 4 treatment?
Confirm elevated clinic BP with ABPM or HBPM
Assess for postural hypotension
Discuss medication adherence
38
What should be added if potassium levels are < 4.5 mmol/L in step 4 of HTN treatment?
Add low-dose spironolactone.
39
What should be added if potassium levels are > 4.5 mmol/L in step 4 treatment?
Add an alpha-blocker or beta-blocker.
40
What should be done if a patient fails to respond to step 4 treatment?
Refer the patient to a specialist.
41
Age < 80 years BP Targets
Clinic BP 140/90
ABPM / HBPM 135/85
42
Age > 80 years BP Targets
Clinic BP 150/90
ABPM / HBPM 145/85
43
What is the most common cause of secondary hypertension?
Primary hyperaldosteronism, including Conn's syndrome.
44
What percentage of hypertension cases are thought to be caused by primary hyperaldosteronism?
Between 5-10%
45
What renal diseases can lead to secondary hypertension?
Glomerulonephritis
Pyelonephritis
Adult polycystic kidney disease
Renal artery stenosis
46
What endocrine disorders (other than primary hyperaldosteronism) can cause secondary hypertension?
Phaeochromocytoma
Cushing's syndrome
Liddle's syndrome
Congenital adrenal hyperplasia (11-beta hydroxylase deficiency)
Acromegaly
47
What are some drug causes of secondary hypertension?
Steroids
Monoamine oxidase inhibitors (MAOIs)
Combined oral contraceptive pill
NSAIDs
Leflunomide
48
What are some other causes of secondary hypertension?
Pregnancy
Coarctation of the aorta
49
What is the prevalence of isolated systolic hypertension (ISH) in people older than 70 years?
Around 50% of people over 70 years old are affected by ISH.
50
How do the 2011 NICE guidelines approach the treatment of isolated systolic hypertension (ISH)?
The 2011 NICE guidelines recommend treating ISH in the same stepwise fashion as standard hypertension, contradicting the SHEP study's approach of using thiazide diuretics.
51
What are ACE inhibitors commonly used to treat?
Hypertension in younger patients
Heart failure
Diabetic nephropathy
Secondary prevention of ischaemic heart disease
52
Why are ACE inhibitors less effective in hypertensive Afro-Caribbean patients?
ACE inhibitors are less effective in these patients, though the exact reason for this is not entirely clear.
53
: What is the mechanism of action of ACE inhibitors?
ACE inhibitors are activated by phase 1 metabolism in the liver
Inhibit the conversion of angiotensin I to angiotensin II,
Reduced angiotensin II levels lead to vasodilation and reduced blood pressure and also reduced aldosterone release this decreases sodium and water retention by the kidneys, thus leads to low blood pressure .
Renoprotective effect, especially in diabetic nephropathy
54
How do ACE inhibitors protect the kidneys in diabetic nephropathy?
ACE inhibitors cause dilation of the efferent glomerular arterioles, reducing glomerular capillary pressure and decreasing mechanical stress on the filtration barriers of the glomeruli.
55
What are some common side effects of ACE inhibitors?
Cough (in around 15% of patients)
Angioedema
Hyperkalaemia
First-dose hypotension (more common in patients on diuretics)
56
In which all conditions should ACE inhibitors be avoided ?
Pregnancy and breastfeeding
Renovascular disease (risk of renal impairment)
Aortic stenosis (risk of hypotension)
Hereditary or idiopathic angioedema
Specialist advice should be sought before starting ACE inhibitors in patients with a potassium >= 5.0 mmol/L
57
What drug interaction increases the risk of hypotension when using ACE inhibitors?
High-dose diuretic therapy e.g., >80 mg of furosemide daily
58
What monitoring is required when taking ACE inhibitors?
Check urea and electrolytes before starting and after increasing the dose.
A rise in creatinine (up to 30%) and potassium (up to 5.5 mmol/L) may be expected.
Renal impairment can occur in patients with undiagnosed bilateral renal artery stenosis.
59
What are some common ACE inhibitors?
Ramipril
Enalapril
Lisinopril
60
When are Angiotensin II receptor blockers (ARBs) typically used?
ARBs are used when patients cannot tolerate ACE inhibitors, often due to the development of a cough
61
What are some common examples of Angiotensin II receptor blockers (ARBs)?
Candesartan
Losartan
Irbesartan
62
What is the mechanism of action of Angiotensin II receptor blockers (ARBs)?
ARBs block the effects of angiotensin II at the AT1 receptor
63
What evidence supports the use of Angiotensin II receptor blockers (ARBs)?
ARBs reduce the progression of renal disease in patients with diabetic nephropathy.
Losartan has evidence showing it reduces mortality from cerebrovascular accidents (CVA) and ischaemic heart disease (IHD) in hypertensive patients.
63
What are some common side effects of Angiotensin II receptor blockers (ARBs)?
Hypotension
Hyperkalaemia
64
In which patients should Angiotensin II receptor blockers (ARBs) be used with caution?
ARBs should be used with caution in patients with renovascular disease
65
What are examples of loop diuretics?
Furosemide
Bumetanide
66
What is the mechanism of action of loop diuretics?
Loop diuretics inhibit the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle, reducing the absorption of NaCl.
67
Which variant of NKCC do loop diuretics act on?
Loop diuretics act on NKCC2, which is more prevalent in the kidneys.
68
why do patients with poor renal function require escalating doses of loop diuretics for it to show effect?
Loop diuretics must be filtered into the tubules by the glomerulus before they can have an effect, so patients with poor renal function may require escalating doses.
69
What are the main indications for loop diuretics?
Heart failure (both acute (iv) and chronic (oral) )
Resistant hypertension, particularly in patients with renal impairment
70
What are some common adverse effects of loop diuretics?
Hypotension
Hyponatremia
Hypokalemia
Hypomagnesaemia
Hypochloremia alkalosis
Ototoxicity
Hypocalcemia
Renal impairment (from dehydration and direct toxic effect)
Hyperglycemia (less common than with thiazides)
Gout
71
What is the primary role of thiazide diuretics in treating heart failure?
Thiazide diuretics are used in the treatment of mild heart failure, though loop diuretics are preferred for reducing fluid overload.
71
What is the mechanism of action of thiazide diuretics?
Thiazide diuretics inhibit sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Cl- symporter, leading to increased sodium delivery to the collecting ducts and causing potassium loss.
72
What are the common adverse effects of thiazide diuretics?
Dehydration
Postural hypotension
Hypokalaemia (due to increased sodium delivery to the distal tubule, causing potassium and hydrogen ion exchange)
Hyponatraemia
Hypercalcaemia (and hypocalciuria, which may reduce renal stone risk)
Gout
Impaired glucose tolerance
Impotence
72
Which thiazide-like diuretics are recommended by recent NICE guidelines for managing hypertension?
Recent NICE guidelines recommend thiazide-like diuretics such as indapamide and chlortalidone for managing hypertension, rather than bendroflumethiazide
73
What rare adverse effects are associated with thiazide diuretics?
Thrombocytopaenia
Agranulocytosis
Photosensitivity rash
Pancreatitis
74
What are some examples of beta-blockers?
Atenolol
Propranolol (one of the first beta-blockers, lipid-soluble, crosses the blood-brain barrier)
74
What are the contraindications for using beta-blockers?
Uncontrolled heart failure
Asthma
Sick sinus syndrome
Concurrent verapamil use (may precipitate severe bradycardia)
74
What are common side effects of beta-blockers?
Bronchospasm
Cold peripheries
Fatigue
Sleep disturbances (including nightmares)
Erectile dysfunction
74
What are the primary indications for using beta-blockers?
Angina
Post-myocardial infarction
Heart failure (certain beta-blockers improve symptoms and mortality)
Arrhythmias (especially in atrial fibrillation for rate control)
Hypertension (though their role has diminished)
Thyrotoxicosis
Migraine prophylaxis
Anxiety
75
What are examples of centrally acting antihypertensives?
- Methyldopa
- Moxonidine
- Clonidine
76
What is the primary use of methyldopa in managing hypertension?
Methyldopa is commonly used in the management of hypertension during pregnancy.
77
When is moxonidine used in treating hypertension?
Moxonidine is used in managing essential hypertension when conventional antihypertensives have failed to control blood pressure.
78
How does clonidine work as an antihypertensive?
Clonidine lowers blood pressure by stimulating alpha-2 adrenoceptors in the vasomotor center of the brain.
78
How does blood pressure typically change during a normal pregnancy?
Blood pressure usually falls during the first trimester (especially diastolic).
It continues to decrease until 20-24 weeks.
After this time, blood pressure typically increases to pre-pregnancy levels by term.
79
How is hypertension defined in pregnancy?
Systolic blood pressure > 140 mmHg or diastolic > 90 mmHg
Or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic
79
What does NICE recommend for women at high risk of developing pre-eclampsia?
75mg of aspirin daily from 12 weeks of pregnancy until the birth of the baby.
80
What is defined as pre-existing hypertension in pregnancy?
Pre-existing hypertension is defined as:
- A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation.
- There is no proteinuria or oedema present.
81
What should be done if a pregnant woman with pre-existing hypertension is taking an ACE inhibitor or ARB?
It should be stopped immediately, and alternative antihypertensives (e.g., labetalol) should be started while awaiting specialist review.
81
How common is pre-existing hypertension in pregnancy, and who is more likely to have it?
occurs in 3-5% of pregnancies and is more common in older women.
82
What defines pregnancy-induced hypertension (PIH)?
Hypertension (systolic > 140 mmHg or diastolic > 90 mmHg) occurring in the second half of pregnancy (after 20 weeks), without proteinuria or oedema.
83
How common is pregnancy-induced hypertension (PIH)?
Pregnancy-induced hypertension occurs in around 5-7% of pregnancies.
84
What happens to pregnancy-induced hypertension after birth?
typically resolves after birth, usually within one month.
85
What long-term risk do women with pregnancy-induced hypertension (PIH) face?
increased risk of developing future pre-eclampsia or hypertension later in life.
86
What defines pre-eclampsia?
Pre-eclampsia is defined as pregnancy-induced hypertension in association with proteinuria (> 0.3g/24 hours).
86
Is oedema a necessary criterion for diagnosing pre-eclampsia?
Oedema may occur in pre-eclampsia, but it is now less commonly used as a diagnostic criterion.
87
How common is pre-eclampsia in pregnancies?
Pre-eclampsia occurs in around 5% of pregnancies.
88
What is the first-line treatment for pre-eclampsia according to the 2010 NICE guidelines?
Oral labetalol
89
What are alternative antihypertensive options for managing pre-eclampsia?
Oral nifedipine (especially if the patient is asthmatic)
Hydralazine
90
What is pre-eclampsia?
Pre-eclampsia is the emergence of high blood pressure during pregnancy that may lead to complications like eclampsia. It is classically defined by a triad of:
New-onset hypertension
Proteinuria
Oedema
91
What is the formal definition of pre-eclampsia?
New-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND
One or more of the following:
Proteinuria
Other organ involvement (e.g., renal insufficiency with creatinine ≥ 90 umol/L, liver, neurological, haematological, or uteroplacental dysfunction)
92
Q: What defines eclampsia?
development of seizures in association with pre-eclampsia
93
What are the guidelines for administering magnesium sulphate in eclampsia?
- Administer once a decision to deliver has been made
- In eclampsia, an IV bolus of 4g over 5-10 minutes should be given, followed by an infusion of 1g/hour
- Monitor urine output, reflexes, respiratory rate, and oxygen saturations during treatment
93
How is magnesium sulphate used in the management of eclampsia?
- Prevent seizures in patients with severe pre-eclampsia
- Treat seizures once they develop
94
How long should magnesium sulphate treatment continue after a seizure or delivery?
Magnesium sulphate treatment should continue for 24 hours after the last seizure or delivery .
Around 40% of seizures occur post-partum.
94
What other aspect is important in treating severe pre-eclampsia/eclampsia?
Fluid restriction is important to avoid the potentially serious consequences of fluid overload.
95
What are potential consequences of pre-eclampsia?
Eclampsia
Neurological complications (altered mental status, blindness, stroke, clonus, severe headaches, or persistent visual scotomata)
Fetal complications (intrauterine growth retardation, prematurity)
Liver involvement (elevated transaminases)
Haemorrhage (placental abruption, intra-abdominal, intra-cerebral)
Cardiac failure
96
What are the features of severe pre-eclampsia?
Hypertension: typically > 160/110 mmHg
Proteinuria: dipstick ++/+++
Headache
Visual disturbance
Papilloedema
RUQ/epigastric pain
Hyperreflexia
Platelet count < 100 * 10^6/l
Abnormal liver enzymes or HELLP syndrome
97
High risk factors for preeclampsia
hypertensive disease in a previous pregnancy
chronic kidney disease
autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension
98
Moderate risk factors for preeclampsia
first pregnancy
age 40 years or older
pregnancy interval of more than 10 years
body mass index (BMI) of 35 kg/m² or more at first visit
family history of pre-eclampsia
multiple pregnancy
99
When should women take aspirin to reduce the risk of hypertensive disorders in pregnancy?
Women should take aspirin 75-150mg daily from 12 weeks gestation until the birth if they have:
≥ 1 high-risk factor
≥ 2 moderate-risk factors
99
What is the recommended initial management when pre-eclampsia is suspected?
NICE recommends arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected. Women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed.
100
What is the first-line treatment for managing pre-eclampsia according to the 2010 NICE guidelines?
According to the 2010 NICE guidelines, oral labetalol is the first-line treatment for managing pre-eclampsia.
100
What alternative antihypertensives may be used in the management of pre-eclampsia?
Nifedipine (especially if the woman is asthmatic)
Hydralazine
101
What is the most important and definitive management step in pre-eclampsia?
The most important and definitive management step is the delivery of the baby. The timing of delivery depends on the individual clinical scenario.
