Hypertension

Question 1

What conditions is hypertension a risk factor for?

Answer 1

Stroke
IHD (ischaemic heart disease)
Heart failure
Chronic kidney disease 
Cognitive decline
Premature death

Question 2

In what environment should BP be measured?

Answer 2

In a relaxed, temperate setting, with person quiet and seated and their arm outstretched and supported

Question 3

How is BP measured?

Answer 3

Measure blood pressure in both armsusingan appropriate cuff size

• If the difference in readings between arms is more than 15mmHg, repeat the measurements
• If the difference in readings between arms remains more than 15mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading

Palpate the radial or brachial pulse before measuring blood pressure
If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery

Question 4

What should you do if BP is between 140/90 and 180/120 mmHg?

Answer 4

Offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension
If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM)

Question 5

What is ambulatory BP monitoring?

Answer 5

Non-invasive method of monitoring BP over 24 hours in the patients usual environment therefore reflecting the patient’s true BP and mitigating against issues such as white coat hypertension

Question 6

What is home BP monitoring?

Answer 6

Home BP monitoring allows patients to measure their own BP at home
Often helpful in the in the ongoing monitoring of BP once treatment has been initiated and many patients value the role they have in monitoring and managing their own health

Question 7

What are the stages of hypertension?

Answer 7

Stage 1 - 135/85 to 149/94
Stage 2 - 150/95 to 179/119
Stage 3 - >180/120
- can result in malignant hypertension

Question 8

What is seen in hypertensive urgent?

Answer 8

NO target organ damage
Systolic > 180 mmHg or diastolic > 110 mmHg
Symptoms:
- Headache (severe), SOB, nose bleed, severe anxiety

Question 9

How is hypertensive urgency managed?

Answer 9

Oral anti-hypertensives

Treat as outpatient

Question 10

What is hypertensive emergency (aka malignant hypertension)?

Answer 10

High BP which causes target organ DAMAGE
- Can have severe/permanent effects on brain (e.g. encephalopathy), heart and kidneys
Systolic > 180 mmHg or diastolic > 120 mmHg

Question 11

What symptoms may be seen in hypertensive emergency?

Answer 11

Chest pain
SOB
Back pain
Numbness/weakness
Visions change
Difficulty speaking (dysphasia)

Question 12

How is hypertensive emergency managed?

Answer 12

Need IV medication for quicker effect

• vasodilators, CCB, ß-blocker (labetalol) -> to relax arteries
• GIVE IV NITROGLYCERINE on admission

Intensive care

• Sensible approach on reducing BP is to reduce 25% of BP over first few hours, then slowly over the next 24-48 hours to normal
• A rapid drop in BP should be avoided because it may precipitate cerebral or cardiac ischaemia

Question 13

What blood tests may be done for end organ damage?

Answer 13

U&Es, GFR - for renal function
HbA1c
Lipid profile

Question 14

How can damage to the eye be tested and what can be seen?

Answer 14

Fundoscopy

Findings in end organ damage (hypertensive retinopathy)

• Retinal haemorrhages
• Hard exudates
• Papilloedema

Question 15

How can damage to the kidneys be assessed and what would results show?

Answer 15

Tests:

• Urine dipstick
• Blood tests (U&Es and eGFR - decreased due to damage glomeruli)

Findings in end organ damage (hypertensive nephropathy)

• Haematuria, proteinuria (or both)
• Renal impairment

Question 16

How is damage to the heart assessed and what is seen?

Answer 16

Physical examination and ECG

Findings:

• Signs of congestive heart failure (increased JVP, S3 gallop rhythm, bibasal, peripheral oedema)
• ECG: left ventricular hypertrophy

Question 17

How is damage to the brain assessed and what is seen?

Answer 17

Examination

Findings (hypertensive cerebrovascular disease)

• Confusion (hypertensive encephalopathy)
• Cerebral haemorrhage

Question 18

What is QRISK?

Answer 18

An algorithm for predicting cardiovascular risk - estimates the risk of a person developing CVD over the next 10 years
- Applies to those aged between 35-74

NICE has determined that the treatment threshold for primary prevention of CVD is a CVD risk of 10% as assessed using QRISK

Question 19

What is seen on an ECG for LVH?

Answer 19

Deep S wave > 25mm in V1/2
Tall R wave > 25mm in V5 or 6 (or R+S > 35mm in V5/6)
T wave inversion V5/6 is a sign of LV ‘strain’ (another sign is ST depression)

Question 20

What lifestyle factors need to be controlled for hypertension?

Answer 20

• Healthy diet
• Salt – Reduce dietary sodium intake
• Coffee – Discourage excess caffeine
• Smoking – Offer smokers advice and help to stop smoking
• Alcohol intake –Reduce if in excess
• Regular Exercise

Question 21

Who should be given ACEi or ARB as first step in treatment of HTN?

Answer 21

People with T2DM
or
Age < 55 and NOT of black Afro-Caribbean origin

Question 22

Who should be given CCB as first step in treatment of HTN?

Answer 22

Age 55 or over

Black Afro-Carribean origin

Question 23

What medications are added in step 2 of HTN treatment?

Answer 23

Age <55 or not of black Afro-Carribean origin
Add: CCB or thiazide-like diuretic

Age 55 or over or Black Afro-Carribeaan origin
Add: ACEi or ARB or thiazide-like diuretic

Question 24

What medications are given in step 3 of HTN treatment?

Answer 24

ACEi or ARB + CCB + thiazide-like diuretic

Question 25

If resistant hypertension is confirmed with ABPM or HBPM what can be given?

Answer 25

Low-dose spironolactone (if blood K+ level is ≤ 4.5mmol/l) | Alpha-blocker or beta-blocker (if blood K+ level is ≥ 4.5mmol/l)

Question 26

What is primary hypertension?

Answer 26

Make up 90% of cases - NO underlying cause discovered

Question 27

What is secondary hypertension?

Answer 27

Make up 10% of cases - SPECIFIC underlying disease, which presents as hypertension

Question 28

What is seen in patients with renovascular disease as the cause of HTN?

Answer 28

* An acute elevation in serum creatinine of at least 30% after administration of angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) * Moderate to severe hypertension in a patient with diffuse atherosclerosis, a unilateral small kidney, or asymmetry in renal size of more than 1.5 cm that cannot be explained by another reason * Moderate to severe hypertension in patients with recurrent episodes of flash pulmonary oedema * Onset of stage II hypertension after age 55 years * Systolic or diastolic abdominal bruit (not very sensitive) Primary renal disease • Elevated serum creatinine concentration • Abnormal urinalysis

Question 29

What medications may cause secondary HTN?

Answer 29

Oral contraceptives, NSAIDs, Stimulants (e.g. cocaine, methylphenidate), Calcineurin inhibitors, Antidepressants - New elevation in BP temporarily related to use

Question 30

What causes related to the adrenal gland may cause HTN?

Answer 30

Pheochromocytoma - Paroxysmal elevations in blood pressure - Triad of headache (usually pounding), palpitations, and sweating Primary aldosteronism - Unexplained hypokalemia with urinary potassium wasting; however, more than one-half of patients are normokalemic - Excess aldosterone increase Na+ and H20 retention Cushing's syndrome - Cushingoid facies, central obesity, proximal muscle weakness, and ecchymoses - May have a history of glucocorticoid use - Increase in glucocorticoids increases Na+ and H20 retention

Question 31

How does sleep apnea cause HTN?

Answer 31

Primarily seen in obese men who snore loudly when sleeping | Breathing keeps stop starting -> decreased O2 inhaled -> heart pumps harder to compensate -> increases BP

Question 32

What condition of the heart may causes HTN

Answer 32

Coarctation of the aorta - birth defect in which a part of the aorta is narrower than usual * Hypertension in the arms with diminished or delayed femoral pulses and low or unobtainable blood pressures in the legs * Left brachial pulse is diminished and equal to the femoral pulse if origin of the left subclavian artery is distal to the coarct

Question 33

What causes related to the thyroid and parathyroid gland may cause HTN?

Answer 33

Hypothyroidism • Symptoms of hypothyroidism • Elevated serum thyroid stimulating hormone Primary hyperparathyroidism • Elevated serum calcium