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Hypertension Flashcards

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1
Q

When to use a large BP cuff?

A

If the mid upper arm.circumference is >=33

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2
Q

When taking blood pressure for diagnosing hypertension how many readings should be done?

A

Take two readings 1-2 minutes apart and use the lowest BP reading or the average of the two

Repeat blood pressure measure on 2 further occasions at least 2 days apart(within 2 weeks if BP>=160/110)

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3
Q

When do you measure three BP readings for the diagnosis of hypertension?

A

1.If this is the first time BP measurements
2. If the first two readings differ by > 5 mmHg
3. If BP >= 180/110

REMEMBER: THE LOWEST BP READING SHOULD BE USE OR THE AVERAGE BETWEEN THE READINGS

AVOID DIAGNOSING HYPERTENSION ON ONE READING

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4
Q

Outline how the patient should be positioned when measuring BP?

A

Should be sat with the back against the chair, the arm supported at the level.of the heart and the legs on the floor

No talking should be allowed during the reading

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5
Q

Define hypertensive urgency and list four of its clinical presentation

A

Urgency is when the BP reading is >=180/110 and there are symptoms with/without target organ damage

Clinical features include: Severe headaches, visual disturbances, dizziness and confusion

Others: Chest pain, oedema and orthopnea indicate TOD.

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6
Q

What is the initial treatment if a patient comes in with a BP of >=180/130?

A

Considered hypertensive emergency: Give amlodipine 10 mg orally

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7
Q

State why short acting nifedipine is not preferred over amlodipine for treatment of hypertensive emergencies?

A

Nifedipine can drop the blood pressure too quickly leading to stroke

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8
Q

What should you do if the patient is dizzy after the treatment of hypertensives emergency?

A

Lie him/her down

If BP<160/100 : Raise the legs

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9
Q

What do you do if the BP measurements fall into different categories of hypertension?

A

Use the highest reading

AVOID DIAGNOSING HYPERTENSION ON ONE READING

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10
Q

The patient comes in for the first to your office and you find the BP of 135/85, what is your next step?

A

Assess for cardiovascular risk factors and the decide on frequency of follow up

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11
Q

When should blood pressure be re-measured if the BP is <120/80 and the CVD risk is <10% and there are not CVD risk factors?

A

After 5 years

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12
Q

When should blood pressure be re-measured if the BP is 120/80-139/89 and the CVD risk is >=10% or there is any CVD risk factor?

A

Check BP after 1 year

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13
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A
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14
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15
Q
A
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16
Q

Should Hypertension be diagnosed on the day of measurement for the first time?

A

Nope, repeat BP measurements on 2 further occasions at least 2 days apart (within 2 weeks if BP is >=160/110)

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17
Q

What is considered mild hypertension?

A

BP 140/90-159/99

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18
Q

What is considered moderate hypertension?

A

BP of 150/100-179/109

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19
Q

When should you consider excluding secondary hypertension after the diagnosis of hypertension?

A

If the patient is younger than 30 years old

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20
Q

List 6 commonest cardiovascular disease risk factors

A
  1. Smoking
  2. Waist circumference of >80 cm in females and >94 cm in males(BMI>25)
  3. Diabetes which is the most dangerous risk factor
  4. Hypertension which is the most common risk factor
  5. First degree relatives had hypertension (Men before 55 and females before 65)
  6. Total cholesterol>5.2
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21
Q

What should you do immediately after realising the patients BP measurement is >=180/110 without symptoms at their first visit?[3]

A
  1. Check the BP size if the person is obese
  2. Repeat BP readings after the patient rested for 1 hour
  3. Take at least 3 readings
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22
Q

Define severe hypertension

A

BP >=180/110 without any symptoms

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23
Q

List 7 things that should be assessed immediately after the diagnosis of hypertension is made.

A
  1. Creatinine and eGFR (if eGFR is less than 30 then check potassium as well)
  2. Depression (In the past month)
  3. Alcohol/drug use
  4. BMI and waist circumference
  5. Urine dipstick
  6. Cardiovascular disease risk
  7. Total cholesterol

SCREEN FOR SYMPTOMS AS WELL

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24
Q

List 4 things that should be assessed at every visit on someone suffering from hypertension.

A
  1. Symptoms: Any symptoms of heart failure, stroke or ischemic heart disease
  2. BP control (Check two readings)
  3. Adherence
  4. Pregnancy in all child-bearing age group
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25
When should the diabetes risk be assessed on a hypertensive?
Yearly and if there is glucose on urine dipsticks
26
When should a urine dipstick be repeated on a hypertension patient?
Repeat yearly (Remember the first one is done at diagnosis)
27
When your BMI and waist circumference be repeated after hypertension has been diagnosed?
Yearly or 3 monthly if trying to lose weight (Remember the first one was done at diagnosis?
28
When should eGFR and creatinine be repeated on a hypertensive?
Yearly or at 4 weeks if using enalapril
29
When should potassium be rechecked on a hypertensive?
If on enalapril: At diagnosis, at 4 weeks and then yearly If on Spironolactone/eGFR<30: At diagnosis then 6 monthly
30
When do you repeat potassium levels measurement at 2 weeks on a hypertensive?
If eGFR<60 and the patient is on enalapril
31
What is the treatment of chronic hypertension pregnancy?
Methyldopa 250 mg
32
Give three questions used to assess for alcohol/drug use?
1. Drunk >=4 drinks per session 2. Used illegal drugs 3. Misused prescription or over the counter medications One is 1 tot of spirits, 1 small glass of wine(125 ml) or 1 can/bottle(330 ml) of beer
33
A 45 year old female with hypertension and no other comorbidities.comes in for a follow up visit, at the first you found her blood pressure is 135/85. What is your next step?
Continue the current treatment and review 6 monthly
34
A 52 year old man comes to your clinic for a follow up visit. He has hypertension with no other comorbidities. At the visit his blood pressure was 145/92 and he reported adherence to his medications. What is your next step? Also include if he was not adherent
Step up the treatment Not adherent: Support and review in 1 month
35
What do you do if the systolic blood pressure is consistently<=110 at every visit on a hypertensive on treatment?
Decrease the dose or medications
36
What is the ideal BMI and waist circumference?
BMI <25 Waist circumference of <80 in females and 94 in males
37
What should be done if the urine dipstix shows 1+protein in a routine visit of a hypertensive?
Check creatinine and eGFR.
38
What should be done if a patient suffering from hypertension have glucose in the urine dipstix on a routine visit?
Screen for diabetes
39
What should you do if eGFR is <30 at diagnosis or routine follow up for hypertension?
Refer
40
41
What should you do if eGFR is <60 at diagnosis or routine follow up for hypertension?
Urine albumin/creatinine ratio: If ratio>3 refer
42
A 52 year old man who has hypertension and no known comorbidities presents to your office for routine follow up. He is on hydrochlorothiazide and enalapril. At this visit, his creatinine has increased by 26% since the last visit. What is your next step?
Stop enalapril What if he was on enalapril only: Stop it and replace with another drug
43
Mr Samuels is a 65 year old man known with hypertension and diabetes. He is using Metformin, hydrochlorothiazide, enalapril and Spironolactone. He now presents for his routine follow up visit. At this visit, his potassium was measured to be 5.2 mmol/L but asymptomatic. What is your next step?
Stop offending drugs including Spironolactone and enalapril
44
When should TSH be measured in a hypertension patient?
1. If total cholesterol is >=7.5 2. If the patient has symptoms of thyroid diseases
45
Does BP stay the same during the day?
Nope it changes
46
What is the recommended salt intake and exercise for a hypertensive?
Salt<=1 teaspoon per day Moderate aerobic exercise of at least 150 minutes per week
47
Should NSAIDs and combined oral contraceptives be used by a hypertensive?
Should be avoided.
48
List 4 common target organ damage resulting from hypertension
1. Stroke 2. Ischemic heart disease 3. Chronic kidney disease 4. Retinopathy
49
What should all patients on hydrochlorothiazide be advised?
Limit sun exposure and use sunscreen when exposed to sunlight
50
Should someone suffering from hypertension receive an influenza vaccine?
Yep yearly
51
Name three commonest contraindication for simvastatin.
Liver disease and pregnancy and being on protease inhibitors
52
What is the first line drug of choice for someone who is known with CVD.
Simvastatin and aspirin
53
Should simvastatin be stopped if someone is on amlodipine?
Nope half the dose
54
When do you replace simvastatin with another statin?
If a patient is using protease inhibitors
55
List 4 commonest contraindications for aspirin
1. Peptic Ulcer diseases 2. Liver disease 3. Kidney disease 4. Dyspepsia
56
What are cardiovascular diseases.
Ischemic heart disease, stroke/Transient ischemic attack and peripheral vascular disease
57
What is the drug of choice if a patient is not known with cardiovascular disease but have a CVD risk of >=20?
Simvastatin 10 mg without aspirin
58
What is the treatment of mild hypertension in a patient without cardiovascular risk factors and comorbidities?
Lifestyle modification
59
What is the treatment of mild hypertension in a patient with a history of ischemic heart disease or at least one cardiovascular risk factor?
Lifestyle modification and hydrochlorothiazide
60
List 5 contraindications of hydrochlorothiazide.
1. Pregnancy 2. Personal/family history of skin cancer 3. Gout 4. Severe liver disease 5. eGFR<30
61
What is the first line treatment of mild hypertension in someone with both diabetes and hypertension?
Enalapril plus lifestyle modifications
62
List three commonest contraindications of enalapril?
1. Pregnancy 2. eGFR<30 3. Potassium>=5
63
When is the patient usually advised to stop enalapril immediately?
If angioedema occurred (Swelling of the lips, tongue, face and airways)
64
What is the treatment of choice for moderate hypertension for the first time?
Lifestyle modification and hydrochlorothiazide (if diabetic enalapril over hydrochlorothiazide)
65
What is the first line treatment of severe hypertension if the patient is not on any hypertension medication?
Lifestyle modification,. hydrochlorothiazide and enalapril Review the client in 1 week
66
What are the steps of hypertension treatment
1. Lifestyle modification 2. Hydrochlorothiazide 12.5 mg 3. Enalapril 10 mg 4. Increase enalapril to 20 mg 5. Amlodipine 5 mg 6. Increase amlodipine to 10 mg 7. Spironolactone 25 mg and increase hydrochlorothiazide to 25 mg All are daily meds
67
When should Spironolactone be avoided?(3)
Pregnancy and eGFR<30 Only use it if potassium can be monitored if not do not use
68
When to avoid amlodipine as treatment of hypertension?
If the patient has untreated heart failure
69
What should you do if a hypertension patient is not adherent to medications?
1. Check if the client is using the medications correctly 2. Discuss side effects 3. Refer to community health care workers 4. Review in 1 month
70
If a patient with hypertension is not adherent to medications, when should they be seen again?
Review in 1 month
71
When should a poorly controlled hypertension and a controlled hypertension be reviewed?
Poor control: in a month God control
72
In every visit which two things should be measured in hypertension?
1. Weight 2. Blood pressure
73
What should be checked 6 monthly in a hypertension patient?
Serum potassium if on Spironolactone or eGFR<30 Note: If BP is controlled the patient is seen every 6 months so this are the visit that you check potassium
74
What baselines should be established at diagnosis of hypertension?
» Urine protein by dipstix. - If dipstix positive send blood for serum creatinine concentration (and eGFR) » BMI for cardiovascular risk assessment » Abdominal circumference. » Serum potassium concentration, if on ACE-inhibitor or eGFR < 30 mL/min
75
What should be checked on the annual follow up visit for hypertension?
» Fingerprick blood glucose » Urine protein by dipstix » Serum creatinine concentration (and eGFR) in patients
76
Who should get their serum creatinine and eGFR measured at the annual visit for hypertension?
1. Proteinuria 1+ 2. Existing cardiovascular disease 3. Hypertension for at least 10 years(if uncontrolled) 4. Chronic kidney disease with eGFR <60
77
What is the recommended drinking for hypertension?
Reduce alcohol intake to no more than 2 standard drinks per day for males and 1 for females
78
What is considered healthy diet?
low fat, high fibre and unrefined carbohydrates, with adequate fresh fruit and vegetables
79
When should a new diagnosed hypertension patient be seen again if their treatment is lifestyle modification?
At 3 months. Poor control=Step up
80
When do you need to confirm a diagnosis of severe hypertension?
Within an hour
81
How long should it wait before confirmation of moderate hypertension?
Confirm within 2 weeks
82
Is aortic stenosis and bilateral renal stenosis contraindications for ACE inhibitors?
Yip
83
In which instances is enalapril considered first before hydrochlorothiazide or any antihypertensive?(4)
1. Diabetes 2. Chronic kidney disease 3. Heart failure 4. Left ventricular hypertrophy confirmed by ecg
84
State how isolated systolic hypertension is treated.
Hydrochlorothiazide or amlodipine
85
What is the treatment of hypertension in a patient with prior MI?
Beta blockers and Ace inhibitors
86
What is the treatment of hypertension in angina
Beta blocker or amlodipine
87
Name two instances where amlodipine can be the first line hypertension drug.
1. Stable angina 2. Isolated systolic hypertension
88
What is the treatment of hypertension in heart failure?
ACE inhibitors and carvedilol or Spironolactone If volume overloads significantly: furosemide
89
What is the treatment of hypertension for secondary prevention of stroke?
Hydrochlorothiazide and ACE inhibitors
90
When to refer a patient with hypertension?(7)
» Young adults (< 30 years of age). » BP not controlled by 4 medicines and where there is no doctor available. » Pregnancy. » Signs of target organ damage e.g. oedema, dyspnoea, proteinuria, angina etc. » If severe adverse drug reactions develop. » Hypertensive urgency and hypertensive emergency. » Severe renal impairment (eGFR < 30 mL/min).
91
After starting Spironolactone when should the potassium be checked?
In 1 month then 6 monthly Elderly, people on ACE inhibitors/other potassium sparring agents
92
Which routine tests should be done for symptomatic hypertension?
Urinalysis EKG Eye exam for retinopathy Cardiac exam for murmur and S4 gallop
93
What is the target BP for normal and Diabetic patients?
Normal: BP<140/90 DM: BP<130/80
94

Ambulatory Care (10 decks)

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