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Year 3 - CR > Hypertension > Flashcards

Hypertension Flashcards

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1
Q

what signs and symptoms of hypertension

A

end organ damage

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2
Q

What are the three stages of hypertension

A

Stage 1
- 140/90 and ABPM 135/85

Stage 2
- 160/100 and ABPM 150/95

Stage 3
- Systolic> 180 or diastolic >110

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3
Q

ABPM what does it stand for

A

ambulatory blood pressure mean - get a day time mean and and a night time mean - the figure is for the day time mean

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4
Q

How do you measure postural hypotension

A
  • Measure BP seated or supine
  • Stand the patient for 1 minute
  • Systolic drops by more than 20mm
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5
Q

What is the definition of postural hypotension

A
  • this is when systolic drops by more than 20mm
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6
Q

What is the definition of malignant hypertension

A
  • BP > 180/110 AND signs of papilloedema or retinal haemorrages
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7
Q

Describe how a ABPM work

A
  • 24 hr monitoring

Machine size of half a BNF

  • Take BP 3 times an hour during the day and hourly at night
  • BP should dip at night; if not worse prognosis
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8
Q

in ABPM what should drop at night

A

BP should dip at night; if not worse prognosis

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9
Q

guidelines suggests that all patients should have a

A

ABPM before treatment

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10
Q

What is the alternative to ABPM

A
  • Week of home blood pressure monitoring and then ask them to average it out
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11
Q

How should you take a history

A

CO

HPC

  • Ask about pregnancy and the pill
  • Ever had a BP check at work or for work eg HGV

PMH

  • Diabetes
  • CVA
  • MI
  • Renal disease

FH

  • Cause and age of death
  • Specifically ask about MI and CVA
  • Parents and siblings

SH

  • Smoking
  • Alcohol
  • Salt
  • Dairy
  • 5 a day
  • Exercise
  • Caffeine
  • snoring
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12
Q

What should you look for in systems review for hypertension

A
  • Cardiovascular
  • Angina
  • Claudication
  • Exercise tolerance
  • Erectile function

Females
- Pregnancy plans /contraception

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13
Q

How do you examine a patient with blood pressure

A
  • Measure BP in both arms
  • APBM before starting treatment

Look for end organ damage

  • eyes
  • urine - proteinuria

Look for secondary causes

  • cushings
  • coarctation
  • renal artery stenosis
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14
Q

What does coarctation look like

A

Between the two arms

radial delay

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15
Q

What investigations can you use

A
  • ABPM
  • Urinalysis - for protein, albumin:creatine ratio and haematuira

U&E

  • Conns
  • hyperparathyroidism

Blood tests

  • glucose
  • electrolytes
  • creatine
  • eGFR
  • total and HDL cholesterol
  • Fundoscopy - check for retinopathy
  • ECG - check for left ventricular hypertrophy

Secondary care

  • ECHO
  • Urinary Metanephrines
  • Renin/aldo ratio (Conns)
  • Renal/liver ultrasound
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16
Q

What are the two things can can effect measurement of blood pressure not due to hypertension

A
  • Wrong cuff size - lead to wrong measurement
  • White coat - doctors make patients anxious - picked up on ABPM
  • masked hypertension - relaxed when they see the doctor but BP is high the other time - picked up on ABPM
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17
Q

What can cause essential hypertension

A

Genetic

Environmental

  • City living
  • Alcohol
  • Obesity
  • Salt
  • Lack of exercise
  • OSA - obstructive sleep apnea
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18
Q

What causes secondary hypertension

A
  • Phaeochromocytoma
  • Cushings
  • OSA
  • Obesity
  • Conns
  • Renal disease
  • Renal artery stenosis

Drugs

  • OC
  • Steroids
  • Recreational drugs e.g. cocaine
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19
Q

What type of end organ damage presents in hypertension

A

Heart

  • MI
  • CCF

Brain
- CVA

Kidney

  • Nephrosclerosis
  • Accelerates other forms of kidney disease

Depends on ethnicity

Legs

Erectile function

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20
Q

How do you manage stage 1 hypertension

A

Assess cardiovascular risk

  • If target organ damage or 10% over 10 yrs risk give drugs
  • Younger adults; consider drug treatment at a lower risk
  • Life style intervention
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21
Q

How do you manage stage 2 hypertension

A
  • Check with ABPM

- Drugs and lifestyle

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22
Q

How do you manage stage 3 hypertension

A
  • Treat now with drugs
  • then do an ABPM
  • then recommend lifestyle
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23
Q

Describe what medications to give to what patients

A 
Younger than 55 
Step 1
- ACE 1st 
Step 2
- ACE + CCB or ACE + Thiazide type diruetics 
Step 3
- ACE + CCB + Thiazide like diuretics 
step 4 
- add a further direutics 
or
- alpha blocker 
or 
- beta blocker 
and consult specialist advice 
Older than 55 or afro-carrabean or black patients of any age 
Step 1 
- CCB or Thiazide 
Step 2 
- ACE + CCB or ACE + thiazide 
Step 3 
- ACE + CCB + Thiazide 
Step 4 
- add a further direutics 
or
- alpha blocker 
or 
- beta blocker 
and consult specialist advice
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24
Q

Why do black and Afro-Caribbean patients not respond to ACE inhibitors

Study These Flashcards
A
  • They have lower plasmin renin therefore something that acts on the RAAS it is less effective
  • but if you stimulate the RAAS you raise the renin aldosterone levels and they become sensitive to the ACE
25
Describe what you should check before you prescribe an ACE
- Check pregnancy plans (can be tetrogenic) - Under 55 - Not as monotherapy in Africans or Caribbean
26
Who should you give CCBs to
- over 55 | - African or Caribbeans
27
What can be contradicted in calcium channel blockers
- Can cause ankle swelling - therefore caution if worried about heart failure or oedema
28
Name the types of calcium channel blockers
- Verapamil - Dilitiazem Dihydropyridines - Amlodipine (common) - nifedepine (in pregnancy and breast feeding) - lacidipine (less ankle oedema)
29
Name a side effect of calcium channel blockers
- All cause gum hyperplasia - good dental hygiene is needed | - can cause ankle oedema
30
Name some examples of a loop diuretics
- Bumetanide | - Furosemide
31
Name some examples of a potassium sparing diuretics
Amilioride
32
Name some examples aldosterone antagonist
- Spironolactone | - eplenerone
33
What are the side effects of ACE inhibitors
- Angioedema - dry cough - causes high potassium
34
Name some examples of ACE inhibitors
- Ramipril - perindopril - lisinopril
35
What is the mechanism of action of ARBs
Block the A2 angiotensin receptor
36
What are the side effects of ARBs
- Increase potassium
37
Name some examples of ARBs
- Irbesarten - losarten - valsarten - candarsarten
38
How does spironlactone work
- Aldosterone antagonist | - Affects renin angiotensin system
39
What are the side effects of aldosterone antagonists
- Spironolactone = Gynacomastia due to oestrogen effects | - Eplenerone less oestrogen effects so no gynacomastia
40
What blood pressure drugs can be used in pregnancy
- Labetolol - Methyl Dopa - Nifedipine
41
What are the targets for hypertension
- Reduce clinic BP to below 140/90 | - ABPM or home monitoring 135/85
42
what would a U and E show if conns was the cause of hypertension
- decrease in potassium
43
What would a U and E show if hyperparathyroidism was a cause of hypertension
- increase in calcium
44
What are examples of end organ damage
- LVH - Previous medical history of MI or angina - previous medical history of stroke/TIA - peripheral vascular disease - renal failure
45
How does conns disease present in the clinical history and physical examination
- Muscle weakness - family history of early onset hypertension - cerebrovascular events aged before 40 Physical examination - arrhythmias if severe hypokalaemia
46
What are the laboratory investigations for primary aldosteronism confirmation
- Hypokalaemia in U and E - aldosterone:renin ratio under standardised conditions - fludrocortisone suppression test - adrenal CT scan - adrenal vein sampling
47
what are the clinical presentation and physical examination on pheochromocytoma
- Paroxysmal hypertension - headache - sweating - palpitations - pallor - family history Physical examination - skin stigmata of neurofibromatosis - cafe-au-lait spots
48
What investigations do you use to diagnose pheochromocytoma
- incidental discovery of adrenal mass - measurement of urinary fractionated metanephrines or plasma free metaneprhines - CT or MRI of abdomen and pelvis - genetic screening
49
What are the clinical history of cushings syndrome
- weight gain - polyuria - polydipsia - psychological disturbances Physical examination - central obesity - moon face - buffalo hump - red striae - hirsutism
50
What tests can you do to confirm Cushings syndrome
- hyperglycaemia - 24 hour urinary cortisol excretion - dexamethasone suppression tests
51
What is the clinical history of renal artery stenosis and what would you find on a physical examination
Fibromuscular dysplasia - early onset hypertension Atherosclerotic stenosis - abrupt onset hypertension - worsening or difficult to treat - flash pulmonary oedema physical examination - abdominal bruit
52
What is the clinical history of renal parenchymal disease and what would you find on a physical examination
Clinical history - history of urinary tract infection or obstruction - haematuria - family history of polycystic kidney disease physical examination - abdominal mass
53
Define accelerated hypertension
Accelerated hypertension is defined as a recent significant increase over baseline BP that leads to target organ damage
54
when is same day referral given with accelerated hypertension
- with palpilloedema and retinal haemorrhages - with new onset confusion, chest pain, signs of heart failure or acute renal failure - with suspected phaeochromocytoma
55
Describe the mechanism of action of atherosclerosis
1. Endothelial wall damage - shear stress - hypertension - toxic damage - e.g. cigarette smoke - exposure to high levels of LDL 2. Uptake and modification of LDL - Following endothelial damage, LDL and monocytes infiltrate subendotheilal space Once taken up LDL is modified - oxidation - in the presence of reactive oxygen specific - glycation in the presence of increased glucose 3. Infiltration of macrophages into subendothelial space - Oxidised LDL stimulates endothelial cells to produce inflammatory mediators required for uptake of monocytes - Monocytes taken up and transform into macrophages 4. Formation of fatty streaks - Macrophages take up excess LDL van scavenger receptors and transform into foam cells 5. Smooth muscle proliferation and fibrous cap formation - Endothelial cells and macrophages release growth factors, inducing smooth muscle proliferation and collagen deposition (can form fibrous cap) - Ca2+ deposits onto plaque, hardening it - Smooth muscle cells can also take up LDL and become foam cells - Fibrous cap is very fragile and can break off: collagen exposed to blood 🡪 thrombus formation (can break off and embolise)
56
What are the signs of accelerated phase HTN
- Severe hypertension (SBP>200, DBP >130) - bilateral retinal haemorrhages - exudates +/- papilloedema
57
What are the symptoms of accelerated phase hypertension
Headache +/- visual disturbance
58
What is the treatment for accelerated phase hypertension
- oral therapy unless there is encephalopathy or CCF - aim is controlled reduction in blood pressure over days not hours - avoid sudden drops in blood pressure as cerebral auto regulation is poor - bed rest and hypotensive drug - atenolol or long acting CCBs
59
What are the grades of hypertensive retinopathy
1. Tortuous arteries with thick shiny walls (silver or copper wiring) 2. AV nipping 3. Flame haemorrhages and cotton wool spots 4. Papilloedmea

Year 3 - CR (44 decks)

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