Managing Hypertension in Primary Care Flashcards
(35 cards)
1
Q
What is pre-hypertension
A
- systolic blood pressure 120-139 mmHg
- diastolic blood pressure 80-89 mmHg
2
Q
Define stage 1 hypertension
A
clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average ranging from 135/85 mmHg to 149/94 mmHg
3
Q
define stage 2 hypertension
A
clinic blood pressure ranging from 160/100 mmHg to 179/119 mmHg and subsequent ABPM daytime average or HBPM average is 150/95 mmHg or higher
4
Q
define stage 3 hypertension
A
clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 120 mmHg or higher
5
Q
Who gets hypertension
A
- ethnic origin - highest in african-caribbean people and from the Indian subcontinent
6
Q
hypertension is usually…
A
asymptomatic
7
Q
When is hypertension detected
A
- opportunistic screening
- routine consultations
- medical examinations for insurance, travel or occupational purposes
- may present with complications of hypertension
8
Q
what devices can be used to measure blood pressure
A
- The traditional mercury sphygmomanometer: although reliable, this is becoming less widespread, partly due to environmental concerns about disposal of mercury
- Aneroid sphygmomanometers
- Automated sphygmomanometers: these are becoming more popular in primary care but may not measure accurately if there is pulse irregularity.
9
Q
what happens if the cuff size is too small or too large
A
- too small= overestimation of blood pressure
- Too large = underestimation of blood pressure
10
Q
what does it mean if you have lower blood pressure in the legs compared with the arms
A
- if you have lower blood pressure in the legs compared with the arms it indicates peripheral vascular disease and is associated with increased mortality
11
Q
what patients should you look for in postural hypotension
A
- elderly
- have diabetes
- have dizziness or falls
12
Q
when should you admit patients as a medical emergency
A
- Symptoms or signs of a cardiovascular event
- Clinic blood pressure 180/120 mmHg or higher with signs of papilloedema or retinal haemorrhages (accelerated hypertension), or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney failure
- Signs or symptoms of phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor, abdominal pain or and diaphoresis).
13
Q
what should you do if a patient has severe hypertension of 180/120mmHg or higher but no symptoms or signs indicating same day referral for specialist care
A
- investigate for target organ damage as soon as possible
- if target organ damage is found consider starting antihypertensive treatment immediately
- advise about lifestyle changes
- request ambulatory or home blood pressure monitoring but do not wait for the results before treating
- if no target organ damage is identified you should repeat the clinic blood pressure measurement within 7 days
14
Q
what should you do if blood pressure is greater than 140/90
A
- take a second confirmatory reading at the same consultation
- if the second blood pressure is different from the first take a third measurement
- record the lower of the last two measurements as the clinic blood pressure
- if the blood pressure remains between 140/90 and 180/120 at the first consultation then you shoulder offer the patient a 24 hour ABPM
15
Q
How often should patients with an ABPM lower than 135/95 have there blood pressure checked
A
- every 5 years
16
Q
What are the risk factors for cardiovascular disease
A
- Age
- Sex
- Socioeconomic group
- Smoking habits throughout the patient’s lifetime
- Family history of cardiovascular disease (particularly a history of a proven cardiovascular event in a first degree relative when they were younger than 60)
- Personal history of diabetes, kidney disease, or elevated cholesterol.
17
Q
What are the symptoms of cardiovascular disease
A
- chest pain
- breathlessness
- ankle swelling
- palpitations
18
Q
name causes of secondary hypertension
A
- Chronic renal disease
- Cushing’s syndrome
- Primary aldosteronism
- Thyrotoxicosis
- Phaeochromocytoma.
19
Q
What are common clinical features of secondary hypertension
A
- age younger than 30
- sudden worsening of hypertension
- poor response to treatment
20
Q
What are common findings of secondary hypertension
A
- elevated serum creatine on initial assessment (suggesting renal disease)
- hypokalaemia (may suggest renovascular hypertension or hyperaldosteronism)
- a large rise in serum creatinine after starting an angiotensin converting enzyme inhibitor
21
Q
What should you find in a clinical examination of someone with hypertension
A
- Fundoscopy for evidence of papilloedema or retinal haemorrhage
- Observation of neck veins. If these are distended it could indicate a raised jugular venous pulse, which is a sign of congestive cardiac failure
- Assessment of the apex beat to look for left ventricular hypertrophy
- Auscultation of the heart for murmurs (indicating valve disease or cardiac failure)
- Auscultation of the lungs for basal crepitations (suggesting congestive cardiac failure)
- Palpation of the radial, popliteal, and foot pulses. Weak or absent pulses in the lower limbs may indicate peripheral vascular disease
- Assessment of the ankles and sacrum for any evidence of oedema
- Auscultation of the carotid arteries for bruits (may indicate carotid stenosis, which carries an increased risk of a stroke).
22
Q
What clinical investigations should you do to look for secondary hypertension or signs of target organ damage
A
- urinalysis with a dipstick to detect protein and blood as possible markers for kidney disease and send a sample for urinary albumin:creatine ratio
- ECG - look for evidence of left ventricular hypertrophy, myocardial ischaemia, old myocardial infarctions or arrhythmias
Serum biochemistry
- electrolytes and creatine
- glycated haemoglobin
- serum lipid profile
- estimated glomerular filtration rate (eGFR)
23
Q
How do you establish the total risk of cardiovascular disease
A
- NICE guidelines currently recommend that the QRISK2 tool is used to assess the 10 year risk of developing cardiovascular disease in those aged between 25 and 84 years who do not have type 1 diabetes and have no pre-exisiting cardiovascular disease
24
Q
When should you refer a patient with hypertension
A
- suspected secondary hypertension
- drop in systolic blood pressure of over 20mmHg when standing and persistent symptoms of a postural hypotension
- poor response to antihypertensive drug treatment
25
What is isolate diastolic hypertension thought to be due to
The mechanism for it is thought to be increased arteriolar resistance, in the presence of low or normal arterial stiffness, reflecting a healthy arterial vasculature with minimal atherosclerosis.
- should be followed up in the long term though to check that systolic hypertension does not happen
26
What lifestyle changes should you recommend for people with hypertension
- Weight reduction - even moderate weight loss has a beneficial effect on blood pressure - 10kg of weight loss leads to a mean reduction in systolic blood pressure of 5-10mmHg
- Physical activity - encourage sedentary patients to increased aerobic activity
- Alcohol intake
- dietary changes - reduce salt
27
What are the measures that do not impact on blood pressure directly but reduce the risk of cardiovascular disease
- stop smoking
- increasing consumption of oily fish
- replace saturated fats with monounsaturated fats
28
which stage of hypertension should you introduce antihypertensive drug treatment to
- persistent stage 2 hypertension
29
in what stage 1 patients should you introduce antihypertensive drug treatment
Adults aged less than 80 years who have persistent stage 1 hypertension and one of the following:
- target organ damage
- established cardiovascular disease
- renal disease
- diabetes
- estimated 10 year risk of cardiovascular disease of 10% or more
30
Name the 5 classes of antihypertensive drugs
- Thiazide diuretics
- ACE inhibitors
- Angiotensin II receptor blockers
- Calcium channel blockers
- Beta blockers (preferably cardioselective beta blockers)
31
What is step 1 hypertension treatment
Offer an ACE inhibitor or an ARB to adults who:
- Have type 2 diabetes (any age or family origin) or
- Are aged less than 55 years old and are not of African or Caribbean origin
- Offer an ARB if ACE inhibitor is not tolerated. Do not combine ACE inhibitor and ARB to treat hypertension
Offer a calcium-channel blocker (CCB) to adults who:
- Are aged 55 years or older and do not have type 2 diabetes or
- Are of African or Caribbean origin and do not have type 2 diabetes
Offer a thiazide-like diuretic if CCB is not tolerated or if there is evidence of heart failure
- A thiazide-like diuretic (such as indapamide) is preferred over a conventional thiazide diuretic (such as bendroflumethiazide or hydrochlorothiazide) if starting or changing diuretic treatment for hypertension.
- If the patient is already receiving conventional thiazide diuretic and has stable, well-controlled blood pressure, continue with current treatment.
32
what is step 2 hypertensive treatment
- You should first review your patient to check they are taking medication as prescribed in step one.
- For adults whose blood pressure is not controlled with step one treatment of an ACE inhibitor or ARB, offer a CCB or a thiazide-like diuretic in addition to the step one regimen
- For adults whose blood pressure is not controlled with step one treatment of a CCB, offer an ACE inhibitor, or an ARB, or a thiazide-like diuretic in addition to the step one regimen
- For adults whose blood pressure is not controlled with step one treatment of a thiazide-like diuretic, offer an ACE inhibitor or an ARB in addition to the step one regimen
- For adults of African or Caribbean origin who do not have type 2 diabetes, offer an ARB in preference to an ACE inhibitor in addition to step one treatment
33
What is step 3 hypertensive treatment
- Review your patient’s medication to ensure they are being taken at optimal tolerated doses.
- For adults whose blood pressure is not controlled with step two treatment, offer a combination of three drugs: an ACE inhibitor or ARB, a CCB, and a thiazide-like diuretic.
34
What is step 4 hypertensive treatment
- Adults whose blood pressure is not controlled with optimal tolerated doses of a combination of an ACE inhibitor or ARB, a CCB, and a thiazide-like diuretic are considered to have resistant hypertension
- You should confirm blood pressure measurements using ABPM or HBPM, assess your patient for postural hypertension, and review their adherence to medication before considering additional treatment.
- If resistant hypertension is confirmed, consider adding a fourth drug:
- Low-dose spironolactone for adults who have blood potassium level 4.5 mmol/L or less (monitor blood sodium and potassium and renal function within one month of starting treatment)
- Alpha-blocker or beta-blocker for adults who have blood potassium level more than 4.5 mmol/L
- Seek specialist advice or refer the patient if blood pressure remains uncontrolled in those taking optimal tolerated doses of four drugs.
35
what are the recommended targets for optimal blood pressure control
- For patients aged under 80 years: clinic blood pressure lower than 140/90 mmHg. This equates to a daytime average blood pressure of lower than 135/85 mmHg on ABPM or HBPM during waking hours.
- For patients aged over 80 years: clinic blood pressure lower than 150/90 mmHg This equates to a daytime average blood pressure of lower than 145/85mmHg on ABPM or on HBPM during waking hours.
- It is recommended that you use clinical judgement for people with frailty or multimorbidity.
