8. Hypertension Flashcards
Before taking a patients blood pressure, what should you make sure?
- They don’t have an AV fistula or any arm that they have been told not to use
- In the last 15 minutes, they have not drunk alcohol, smoked or had a caffeinated drink
What are the types of hypertension? Which is most common?
Primary hypertension / essential hypertension is when it has developed on its own without a known cause. It accounts for 95% of hypertension.
Secondary hypertension is when hypertension has developed because of a known cause (ie. secondary to a condition)
What are the main causes of secondary hypertension?
Remember it using ROPE
R- Renal Disease (ie. renal artery stenosis)
O - Obesity
P - Pregnancy-Induced hypertension / pre-eclampsia
E - Endocrine (most endocrine conditions cause hypertension, but especially consider hyperaldosteronism)
When should you perform specialist investigations on someone with hypertension?
- If they are under 40 years of age
- If they have a potential secondary cause
What are some risk factors for essential hypertension?
STRONG
- Obesity
- Aerobic exercise <3 times/week
- Moderate/high alcohol intake
- Metabolic syndrome
- Diabetes mellitus
- Black ancestry
- Age >60 years
- Family history of hypertension or coronary artery disease
- Sleep apnoea
WEAK
- Sodium intake >1.5 g/day
- Low fruit and vegetable intake
- Dyslipidemia
What is Dyslipidemia?
An abnormal amount of lipids (ie. triglycerides, cholesterol and/or fat phospholipids) in the blood
Which arm should you measure blood pressure on?
Ideally you should measure on both arms
What happens if there is a difference in blood pressure between arms?
If the difference is below 15 mmHg, take an average.
If its more than 15mmHg, repeat the measurements. If it remains, then use the arm with the higher reading
When can automated blood pressure devices become unreliable? How do you predict this?
When the patient has pulse irregularity (for ex. due to atrial fibrilation) then it can be unreliable.
Before putting the automated device on, palpate the radial or brachial pulse to assess for regularity.
How should you measure blood pressure in someone with symptoms of postural hypertension?
- Measure blood pressure whilst sat down
- Get them to stand up for atleast a minute
- Measure blood pressure whilst they are stood up
- If systolic BP falls by more than 20mmHg, measure subsequent BP whilst they are standing
How do you record a ‘clinic BP’?
- Record BP
- If BP is greater than 140/90, take a second recording
- If second reading is substantially different, then do a 3rd measurement
- Record the lower of the last 2 measurements as the clinically blood pressure
What do you do next if you diagnose someone with a clinical blood pressure of 141/90
As this is between 140/90 and 180/120, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. if ABPM is unsuitable, then offer home blood pressure monitoring (HBPM)
How is ambulatory blood pressure monitoring set up so that it can diagnose hypertension?
It records the patients blood pressure atleast twice per hour during the patients usual waking hours (eg. from 8am to 10pm). The average value of all these results is used to diagnose hypertension
How is home blood pressure monitoring set up so that it can diagnose hypertension?
- For each BP reading, it is recorded twice, atleast 1 min apart. if the results are significantly different, do a 3rd measurement.
- Record it in the morning (6am-12pm) and afternoon (6pm-12am) each day
- This should be repeated for atleast 4 days, but ideally 7
- ignoring the first days results, average the rest of them to find an average blood pressure value
What should you do whilst you wait for either ABPM or HBPM to confirm a diagnosis of hypertension?
Carry out investigations for target organ failure
What investigations can you do to check for target organ damage?
- U&E
- GFR
- HbA1C
- Lipid Profile
- Urine albumin:creatinine ratio
- ECG
- Form a Qrisk3 score
If someone has a blood pressure of greater than 180/120, what factor decides how to manage this patient?
Whether or not there are signs and symptoms of end-organ failure
When should you send someone with hypertension for a same-day specialist assessment?
When they have a Bp over 180/120 and 1 or 2 of;
- Signs of retinal haemorrhage and papilloedema
- Life-threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
How should you manage a patient with a BP of greater than 180/120, but whose not reporting any symptoms or signs?
- Carry out investigations for target organ damage as soon as possible
- If target organ damage is found, consider starting them on anti-hypertensives immediately without waiting for the results of ABPM or HBPM
How should you manage a patient with a BP of greater than 180/120, but whose not got any signs of target organ failure?
Repeat blood pressure measurement within 7 days
What is required to diagnose hypertension?
Clinic blood pressure of 140/90 mmHg or higher PLUS ABPM / HBPM average of 135/85 or higher
If there is a difference of greter than 20/10 between clinic BP and home BP, what should you be suspecting?
White coat syndrome`
What is masked hypertension and when would you suspect it?
When clinic BP is normal but home BP are higher
How often should you get your blood pressure measured?
Atleast every 5 years, and consider doing it more frequently if the persons clinic blood pressure is close to 140/90 mmHg
What is a Qrisk3 score?
The Qrisk3 algorithm calculates a person’s risk of developing a heart attack or stroke over the next 10 years.
It can be calculated by putting their risk factors into a online calculator.
What are the stages of hypertension?
Stage 1 - 135/85 to 149/94
Stage 2 - 150/95 to 179/119
Stage 3 - 180/20 and above
What are the 2 types of hypertensive crisis?
- Hypertension Urgency
- Hypertension Emergency
What is a hypertension urgency crisis?
This is when systolic BP is greeater than 180 mmHg, or diastolic BP is greater than 110 mmHg.
There is no acute damage to any of the target organs
What symptoms would someone in a hypertensive urgency report?
They may report any of the following symptoms;
- Headache
- Shortness of breath
- Nose bleed (epistaxis)
- Severe anxiety
How is a hypertensive urgency managed?
Oral anti-hypertensive medication
Typically done in an outpatient or same-day observational setting
What is a hypertensive emergency crisis? What can it also be called?
This is when blood pressure is so high that it has reached levels that damage target organs. Sometimes this is also referred to as malignant hypertension.
How high is BP in a hypertensive emergency?
Systolic blood pressure can be over 180 mmHg, and diastolic blood pressure can be greater than 120 mmHg.
However, a hypertension emergency can also occur at lower blood pressures, in patients whose bodies aren’t as used to high blood pressures.
What symptoms would someone in a hypertensive emergency report?
- Chest pain
- Shortness of breath
- Back pain
- Numbness/weakness
- Vision change
- Difficulty speaking
How can a hypertensive emergency result in encephalopathy?
Due to high blood pressure, blood is forced out of cerebral capillaries, which is both toxic to the neural tissue, and also causes increased intracranial pressure, which if untreated it leads to permanent brain dysfunction
How and where is a hypertensive emergency treated?
As its complications are severe, treatment needs to be speedy. It is managed in ICU
- IV medications instead of oral
- IV Vasodilator, calcium channel blocker or beta blocker can be given
Having hypertension puts you at increased risk for which conditions?
- Stroke
- Ischaemic Heart Disease
- Heart Failure
- Chronic Kidney Disease
- Cognitive Decline
- Premature Death
For every 2 mmHg rise in blood pressure, what happens?
- The risk of IHD increases by 7%
- The risk of stroke increases by 10%
If you get newly diagnosed with hypertension, what follow up tests should you get?
- Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
- Bloods for HbA1c, renal function and lipids
- Fundus examination for hypertensive retinopathy
- ECG for cardiac abnormalities
What is involved in the initial management of someone with hypertension?
- Establish a diagnosis
- Investigate for possible causes and end organ damage
- Advice on lifestyle. This includes recommending a healthy diet, stopping smoking, reducing alcohol, caffeine and salt intake and taking regular exercise.
What is involved in conservative management of hypertension?
- Recommend a healthy diet
- Stop smoking
- Reducing alcohol intake
- Reducing caffeine intake
- Reducing salt intake
- Regular exercise
What is involved in the medical management of hypertension?
Hint: just a broad overview of drugs used
Remember it with ABCD ARB
A - Ace Inhibitors B - Beta Blockers C- Calcium Channel Blockers D- Thiazide-like Diuretics ARB - Angiotensin II receptor blocker
When are angiotensin II blockers used for hypertension?
Angiotensin receptor blockers are used in place of an ACE inhibitor if the person does not tolerate ACE inhibitors (commonly due to a dry cough) or the patient is black of African or African-Caribbean descent.
Which 2 anti-hypertensive drugs should not be used toghether?
ACE inhibitors and Angiotensin II receptor blockers
Who is medical management offered to for hypertension?
- All patients with stage 2 or 3 hypertension
- All patients under 80 with stage 1 hypertension that also have a Q-risk score of 10% or more, diabetes, renal disease, cardiovascular disease or end organ damage.
Who is medical management not offered to for hypertension?
Anyone with stage 1 hypertension either
- over the age of 80
- under 80, but with a Qrisk3 score less than 10% and no evidence of diabetes, renal disease, cardiovascular disease or end organ damage
What is involved in step 1 in the pathway of prescribing anti-hypertensive medications?
- If aged less than 55 and non-black, use an Ace Inhibitor
- If aged over 55, or black of African or African-Caribbean descent, use a Calcium channel blocker
What is involved in step 2 in the pathway of prescribing anti-hypertensive medications?
- If aged less than 55 and non-black, use ‘A’ + ‘C or D’
- If aged over 55, or black of African or African-Caribbean descent, use ‘ARB’ + ‘C or D’
What is involved in step 3 in the pathway of prescribing anti-hypertensive medications?
- If aged less than 55 and non-black, use ‘A’ + ‘C’ + ‘D’
- If aged over 55, or black of African or African-Caribbean descent, use ‘ARB’ + ‘C’ + ‘D’
What is involved in step 4 in the pathway of prescribing anti-hypertensive medications?
A/ARB + C + D then a final drug depending on serum potassium levels.
- If equal to 4.5mmol/L or less, use potassium sparring diuetic such as sporonolactone
- If its more than 4.5mmol/L, use an alpha or beta blocker
What should you do if BP remains unctronlled even after treatment at stage 4?
Seek specialist advice
How does Spironolactone work? Why are they helpful?
Spironolactone is a “potassium-sparing diuretic” that works by blocking the action of aldosterone in the kidneys, resulting in sodium excretion and potassium reabsorption. This can be helpful when thiazide diuretics are causing hypokalemia.
Which anti-hypertensive drugs do you need regular U&Es monitoring for? Why?
ACE Inhibitors and all diuretics (thiazide-like + spirinolactone).
- Spirinolactone can cause hyperkalaemia
- ACE inhibitors can cause hyperkalaemia
- Thiazide-like diuretics can cause electroyle disturbances
If treating someone over the age of 80 on antihypertensives, what BP are you aiming for?
Systolic under 150
Diastolic under 90
If treating someone under the age of 80 on antihypertensives, what BP are you aiming for?
Systolic under 140
Diastolic under 90
