Hypertension Flashcards
(32 cards)
What are the different types of Hypertension?
- Primary or Essential
Cause is usually unidentifiable - Secondary
Identifiable cause - Whitecoat
Elevated clinical BP but normal AMBP - Malignant
Rapid rise in BP
What is AMBP?
Ambulatory Monitoring BP over a period of time - Non invasive test
What are the risk factors of hypertension?
- Age
- Family History
- Ethnicity
- Smoking
- High salt diet
- Too little K+ in diet
- Obesity
What is the differential diagnosis of hypertension?
- Essential hypertension
- Renal Artery Stenosis
- Chronic Kidney Disease
- Obstructive uropathy => structural or functional hinderance of normal urine flow
What are the environmental and genetic factors leading to essential hypertension?
=> Environmental factors:
- Stress
- Diet
- Intrauterine life
=> Genetic factors:
- Candidate genes fro angiotensinogen, renin, ANP
What are the causes of secondary hypertension?
- Chronic kidney Disease
- Coarctation of aorta
- Endocrine Disease
- Drugs
- Pregnancy
What is the most common presentation of Malignant hypertension?
Malignant Hypertension is marked by increased diastolic BP and end organ damage
Headache and visual disturbances
What are the effects of hypertension on blood vessels?
- Accelerates atherosclerosis and arteriosclerosis
- Arteriosclerosis is the hardening if an artery or arteriole (arteriolosclerosis)
Arteriolosclerosis can be divided into:
- Hyaline arteriosclerosis
- Hyperplastic arteriosclerosis
What is hyaline arteriosclerosis?
- Smooth muscle cells of media are replaced by collagen
- Increased rigidity and lower compliance, further contributing to hypertension
- Autoregulation curve shifts to the right, making hypotension more dangerous
What is hyperplastic arteriosclerosis?
- Very high systolic BP causes fibrinoid necrosis of vessel wall
- Gives vessel ‘onion like’ appearance
- significant reduction of blood flow leading to tissue ischaemia
What is the main difference between atherosclerosis and arteriosclerosis?
Arteriosclerosis differs from atherosclerosis as there is no lipid deposition
What are the effects of hypertension on the heart?
- Hypertension accelerates coronary artery atherosclerosis
- Left ventricular hypertrophy
Left ventricular hypertrophy is a compensatory mechanism to overcome the increased pressure against the heart. Eventually the heart decompensates, leading to LV Heart Failure
=> Hypertensive Heart Disease presents as:
- MI
- Arrhythmias
- Progressive Left Heart Failure
Why is Atrial Fibrillation dangerous?
- Blood stasis in atria may result in thrombus, which may embolise
- Decrease in CO
What are the effects of hypertension on the kidney?
- Hyaline arteriosclerosis in renal arterioles may cause progressive renal ischaemia => Specific results: - Tubular atrophy - Interstitial fibrosis - Progressive glomerular sclerosis
What are the effects of hypertension on the eyes?
- Flame haemorrhage
- Papilloedema
- Hard exudates
What are the effects of hypertension on the brain?
=> Hypertension + Atherosclerosis:
Berry Aneurysm
=> Rupture of Berry Aneurysm:
Subarachnoid Haemorrhage
=> Rupture of Charcot Bouchards Aneurysm:
Intracerebral Haemorrhage
What are the clinical consequences of maliginant hypertension?
- Hypertensive encephalopathy
- Blurred vision
- Acute LV Failure
- Stroke
- Haemolytic Anaemia + disseminated intravascular coagulation
- Acute Renal Failure
- Proteinuria
- Haematuria
What are the investigations do in someone with suspected hypertension?
=> AMBP
=> Fasting glucose and cholesterol levels
To quantify risk
=> ECG + Echo
To determine any end organ damage
=> U&E, Ca levels
Used to determine secondary causes
U&E - low K and high Na in Conn’s
Ca - high in hyperparathyroidism
=> Ultrasound
Small kidneys
What is the management of hypertension?
Clinical BP is measured first
If BP ≥ 140/90 mmHg:
- Offer AMBP. Calculate CVS risk and look for end organ damage
If BP ≥ 180/110 mmHg (severe hypertension):
- Consider referral and starting anti-hypertensive medication
- Then offer AMBP. Calculate CVS risk and look for end organ damage
=> AMBP < 135/85 mmHg = NORMOTENSIVE
=> AMBP ≥ 135/85 mmHg
- Stage 1 hypertension. Treat if < 80 years and ONE of the following (if not then give lifestyle advice + statins):
- End organ damage
- CVD
- Diabetes
- Renal disease
- CVS risk ≥ 10%
=> AMBP ≥ 150/95 mmH
Stage 2 Hypertension, treat regardless of age
Role of anti-hypertensive medication
Must be determined if patient requires mono-therapy or combination therapy
=> Mono-therapy:
- > 55 year old OR Afro ethnicity: Ca antagonists or Thiazides
- < 55 year old OR Diabetes: ACE Inhibitors
B Blockers less effective not usually first choice
=> Combination therapy:
- (ACE inhibitors + Ca antagonists) or (ACEi + Thiazide Diuretic) if 2 drug combo
- (ACE inhibitors + Ca antagonists + Thiazide) if 3 drug combo
If K ≤ 4.5 add low dose spirolactone
If K > 4.5 add alpha blocker or B blocker
IF ACE-i NOT TOLERATED, USE ARBs (eg if patient experiences cough)
ACEi used as first line treatment for diabetics regardless of age
For patients of Afro-Caribbean decent on dual therapy already on Ca antagonist, consider Ang II blocker over ACEi
What are the 5 types of anti-hypertensive drugs
=> THIAZIDES
Chloratidone
=> Ca ANTAGONISTS
Nifedipine
=> B BLOCKERS
Bisoprolol
=> ARB
Candesartan
=> ACE-i
Lisinopril
What is the management of orthostatic hypotension?
- Adequate hydration and salt intake
- Discontinuation of vasoactive drugs
=> IF symptoms still persist, then:
- Compression garments
- Fludrocortisone
- Midodrine
- Counter pressure manouvres
- Head up tilt sleeping
Why should Verapamil and a B blocker not be taken together?
Risk of complete heart block
What are the BP targets for type 2 diabetes?
If end organ damage present: < 130/80 mmHg
Otherwise < 140/80
