Hypertension - booklet

Question 1

Stages of hypertension

Answer 1

1
2
Severe

Question 2

Stage 1 hypertension

Answer 2

• Clinic BP 140/90 or higher
• Ambulatory or home average 135/85 or higher

Question 3

Stage 2 hypertension

Answer 3

• Clinic BP 160/100 or higher
• Ambulatory or home average 150/95 or higher

Question 4

Severe hypertension

Answer 4

• Clinic systolic 180 or higher
• Or Clinic diastolic 120 or higher
• Treatment should be considered immediately without the need for ambulatory/home readings

Question 5

When should ambulatory monitoring be offered?

Answer 5

If BP is higher than 140/90
Alternative is home monitoring

Question 6

Symptoms of high blood pressure

Answer 6

• None/headache
• Sweating, headache, palpitations and anxiety could point to phaechromocytoma
• Muscle weakness or tetany could point to hyperaldosteronism

Question 7

CVS risk factors

Answer 7

• TIA
• Stroke
• Diabetes
• Previous renal disease
• Smoking
• Cholesterol
• NSAID excess
• PMH of angina, CCF, palpitations, syncope/valvular heart disease

Question 8

CVS risk factors - FH

Answer 8

• Hypertension
• Premature coronary disease
• PCKD

Question 9

CVS risk factors - drugs

Answer 9

• All
• Inc any prior antihypertensives
• Drug intolerances/allergies
• Ask about compliance

Question 10

Investigations for hypertension

Answer 10

• UACR
• Urine dip for haematuria
• Glucose
• U&Es
• Lipid profile
• Examine fundi - hypertensive retinopathy?
• ECG - 12 lead
• Consider echo if suggestion of LVH, valve disease or LVSD or diastolic dysfunction

Question 11

CVS risk assessement

Answer 11

QRISK3 tool

Question 12

When should treatment be offered?

Answer 12

• Stage 1 hypertension under 80 - treatment offered in those with evidence of organ damage, established CV disease, renal impairement, diabetes and 10yr QRISK of 10% or more
• Stage 2 - any age treatment should be offered

Question 13

Blood pressure targets when on medication

Answer 13

• Clinic - If under 80 - target is less than 140/90
• If over 80 - target is 150/90

-

• Ambulatory under 80 is 135/85
• Over 80 is 145/85

Question 14

Non-pharmacological treatment hypertension

Answer 14

• Weight reduction if BMI greater than 25kg/m2 - each kg weight loss = 3/2 mmHg reduction in BP
• Reduce salt intake
• Minimise alcohol intake
• Aerobic exercise
• Smoking cessation

Question 15

Guidance for pharmacological management of BP

Answer 15

Question 16

When to measure sitting and standing BP?

Answer 16

• Type 2 diabetes
• Postural hypotension symptoms
• Aged 80 and older

Question 17

What is a hypertensive crisis?

Answer 17

• Increase in blood pressure, which if sustained over the next few hours, will lead to irreversible end organ damage (eg encephalopathy, LV failure, aortic dissection, unstable angina, renal failire)

Question 18

How can people in hypertensive crisis present?

Answer 18

Emergency presentation:
* High BP with critical event eg encephalopathy, pulmonary oedema, AKI, MI)

Urgency presentation:
* High BP without critical illness but may include malignant hypertension associated with grade 3/4 hypertensive retinopathy

Question 19

Aim of treatment in hypertensive emergencies

Answer 19

• Reduce diastolic BP to 110mmHg in 3-12hrs in emergency, 24hrs in urgency
• BMJ says: 25% within minutes-1hr
• If patient stable reduce BP to 160 systolic and 100-110 diastolic within next 2-6hrs

Question 20

Treatment for hypertensive crisis emergency options

Answer 20

IV:
* Sodium nitroprusside
* Labetalol
* Glyceryl trinitrate
* Nicardipine

Question 21

What is hypertensive urgency?

Answer 21

• Blood pressure that will damage organs within days
• Diastolic usually greater than 130mmHg, retinal changes present

Question 22

Aim treatment in hypertensive urgency

Answer 22

• Reduce BP to diastolic of 100mmHg over 48-72hrs using oral regime

Question 23

Options for oral treatment of hypertensive crisis

Answer 23

• Amlodipine
• Diltiazem
• Lisinopril
• ACEi and CCB icombo s effective and well tolerated
• Majority pts nifedipine + amlodipine is best

Question 24

Classic triad of symptoms phaeochromocytoma

Answer 24

Episodic
* Headache
* Sweating
* Tachycardia

Most patients will not have all three

Question 25

Classic sign of phaechromocytoma

Answer 25

• Sustained or paroxysmal hypertension

Question 26

Diagnosing phaeochromocytoma

Answer 26

• Urinary and plasma metanephrines and catecholamines
• 24hr urine test main test
• CT and MRI scan abdo pelvis for adrenal tumours
• MIBG scan can detect if not showing on CT/MRI if diagnosis is likely

Question 27

How is BP controlled in phaechromocytoma pending surgery?

Answer 27

• Alpha and beta blockade
• Alpha - Phenoxybenzamine
• Alpha ALWAYS before beta

Question 28

When to suspect Cushings as cause of HTN?

Answer 28

• Physical appearance characteristics
• Hyperglycaemia bloods
• 24hr urine cortisol elevated
• Confirm with low dose dexamethasone supression test

Question 29

When to suspect primary aldosteronism as cause of HTN?

Answer 29

• Low serum potassium
• High/normal sodium
• Resistant hypertenson
• FH of premature HTN

Question 30

Investigations for primary aldosteronism

Answer 30

• Aldosterone:renin ratio in morning
• Plasma renin low in primary
• Adrenal CT