8. Hypertension Flashcards
What is the main cause of hypertension and what is it more commonly known as
Primary/essential hypertension (95%)
This means that hypertension has developed on its own and does not have a secondary cause
What are the main causes of secondary hypertension
mnemonic ROPE
Renal disease (most common)
Obesity
Pregnancy induced hypertension/ pre-eclampsia
Endocrine- most do but primarily consider hyperaldoesteronism (Conns syndrome)
If patients develop hypertension below the age of _____ , this is when specialist investigations should be considered in patients with a potential secondary cause
40
what are the complications of hypertension
ischemic heart disease cerebrovascular accident (stroke or haemorrhage) hypertensive retinopathy Hypertensive nephropathy heart failure premature death
NICE recommend measuring blood pressure every _____ years to screen for hypertensive but more often in which patients
5 years
more often in those with borderline for diagnosis (140/90) and every year in patients with type 2 diabetes
patients with clinic blood pressure of between what range should have 24 hour ambulatory blood pressure or home readings to confirm the diagnosis
between 140/90 and 180/120 mmHg
When you measure the blood pressure in both arms, if the difference is more than ______ then you should repeat the readings
15mmHg
Explain to the patient how they should carry out home blood pressure monitoring
o Need to make sure that you don’t smoke, have a drinking containing caffeine or exercise for 30 minutes before you take reading
o Make sure to use the same arm and rest for 5 mins before taking the reading
o For each measurement, 2 measurements are taken at least 1 minute apart and with the person seated
o BP recorded twice a day, ideally in the morning and evening
o Blood pressure recording should be taken for about 4-7 days (discard the first days readings and take an average of the rest)
What is the clinic reading and ambulatory reading for stage 1 hypertension
Clinic of above 140/90
ambulatory of above 135/85
what is the clinic reading and ambulatory reading for stage 2 hypertension
clinic of above 160/100
ambulatory of above 150/95
what is the reading for stage 3 hypertension
above 180/120
What are the red flags for hypertension
- accelerated hypertension (BP usually higher than 180/110 with signs of papilloedema and/or retinal haemorrhage)
- Suspected phaeochromocytoma (tumour of the adrenal glands) –> postural hypertension, headache, palpitations, pallor and diaphoresis ie sweating
- consider specialist investigations in people with signs and suggesting of a secondary cause of hypertension
Describe what hypertensive urgency is and what are the symptoms
this is where there is uno target organ damage
BP 180 mmHg systolic OR 110mmHg diastolic
Symptoms
- headahce
- SOB
-nosebleed
- severe anxiety
describe what hypertensive emergency is aka malignant hypertension
this is where there is target organ damage systolic of above 180 mmHg OR diastolic of above 120 mmHg but note these could be lower symptoms - chest pain - SOB -back pain -numbness/weakness -vision changes - difficulty speaking
Whilst waiting for a diagnosis of hypertension what tests would you carry out to test for end organ damage
- Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
- Bloods for HbA1c, renal function and lipids
- fundus exam for hypertensive retinopathy
- ECG for cardiac abnormalities
What does the Qrisk3 score calculate
a persons risk of developing a heart attack or stroke over the next 10 years
NICE determine that the treatment threshold for primary prevention of CVD is above what percentage Qrisk3 score
10% or more
What is the formula for cardiac output and what is the definition
The amount of blood the heart pumps through the circulatory system in a minute
CO = HR x SV
if a patient has a HR of 70 BPM and a stroke volume of 70L what is the cardiac output
CO= HR x SV 70x70 = 4.9 L
What is the formulae for blood pressure
Cardiac output x peripheral resistance
Why does hypertension cause reduced blood flow to the kidneys and hence what does the kidneys release I response to reduced blood flow
High blood pressure can constrict and narrow the blood vessels, which eventually damages and weakens them throughout the body, including in the kidneys. The narrowing reduces blood flow.
- the kidney releases renin
Renin causes the release of aldosterone, how does this affect the blood pressure
- aldosterone increases reabsorption of Na+and therefore water which increases the blood volume
- Increasing the blood volume increases the cardiac output
How does renin release interact with angiotensinogen
- angiotensin I –> Angiotensin II by ACE enzyme from the lungs
- angiotensin II is a potent vasoconstrictor which increases the peripheral resistance
to raise the arterial pressure what does NA act on
alpha adrenergic receptors on vascular smooth muscle cells which cause them to contrict
note that there are beta-adrenergic receptors in the heart which cause increased contractility
what are baroreceptors and chemoreceptors sensitive to
baroreceptor sensitive to stretch
chemoreceptor sensitive to low O2, high CO2 and acidosis (note chemoreceptors have their own blood supply)
What is the role of aldosterone
causes increased absorption of Na+ (and therefore water) as well as secretion of K+ and H+
what happens in primary hyperaldoesteronism (aka Conns syndrome)
there is high levels of aldosterone therefore low K+ and low H+ which leads to hypokalaemia
What is the problem in Addisons disease
the adrenal glands done produce enough cortisol, aldosterone and adrenaline
what is the result of Addisons disease on blood pressure
as there isn’t enough aldosterone produced it can lead to postural hypotension and dehydration
What can cause an addisonian crisis
sepsis or surgery which causes an exacerbation of chronic insufficiency
adrenal haemorrhage
steroid withdrawal
What end organ damage can occur in the eye and the kidney
hypertensive retinopathy and nephropathy
what end organ damage can occur in the Brian
hypertensive cerebrovascular disease
what end organ damage can occur in the heart
Left ventricular hypertrophy, ischaemic heart disease with or without heart failure
Name a common ACEi
ramipril
name a common CCB
amlodopine
name a common thiazide like diuretic
indapamide
give an example of a K+ sparing diuretic
spironolactone
Secondary hypertension; what renal diseases are there and why does it occur
the Kidneys don’t regulate water and sodium correctly which leads to increase in fluid and pressure
- polycystic kidney disease
- glomerular disease
- narrowing of the renal artery
Why does cushings syndrome cause secondary hypertension
increases in glucocorticoids by the adrenal gland –> increases sodium and water retention
Why does sleep apnoea cause secondary hypertension
Breathing starts and stops which decreases oxygen that is enhaled
heart pumps harder to compensate
and so you will see an increase in blood pressure at night
Name some other things which can lead to secondary hypertension
Oral contraceptive NSIADs Stimulatants (eg cocaine, methylphenidate ) calciineurin inhibitors antidepressants pheochromocytoma coarctation of the aorta hypothyroidism primary hyperparathyroidism (increase serum calcium leading to calcification of arterial walls) liquorice
what is the triad for pheochromocytoma
pounding headache, palpitations and sweating
What is the initial management of hypertension
establish a diagnosis
investigate for possible causes and end organ damage
advise on lifestyle
Name the lifestyle factors that you can give to the patient for management of hypertension
healthy diet reduce salt intake discourage excess caffeine offer smoking advice reduce alcohol intake regular exercise relaxation therapies (not available on the NHS)
what can high blood pressure be caused by
being overweight being stressed eating too much salt excessive alcohol too much caffeine smoking cigarettes not having enough fruit and veg not enough exercise family history carribean or Africans descent
True or false
you should offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension
true
Discuss antihypertensive drug treatment, as well as lifestyle advice, with adults aged 80 with persistent type 1 hypertension as well as 1 or more of what things
target organ damage established cardiovascular disease renal disease diabetes an estimated 10 year risk of CVD of 10% or more
What is step 1 antihypertensive treatment for someone with type 2 diabetes
ACEi or ARB (such as ramipril )
What is step 1 antihypertensive treatment for someone without type 2 diabetes who is younger than 55 and not of black African or African-caribbean origin
ACEI or ARB (such as ramipril)
What is step 1 antihypertensive treatment for someone who is aged 55 or over
CCB (such as amlodipine)
What is step 1 antihypertensive treatment for someone whoo is of black African or african-carribean family origin of any age
CCB (such as amlodipine )
What is step 2 antihypertensive treatment
add ACEi/ CCB or thiazide-like diuretic
what is step 3 antihypertensive treatment
ACEi (or ARB) + CCB + thiazide like diuretic
In step 4 of antihypertensive treatment, if there is confirmation of resistant hypertension (using ABPM or HBPM) then you would do what
check for adherence
consider seeking specialist advice
adding the following drugs
- low dose spironolactone if blood potassium is less than 4.5 mmol/l
- alpha or beta block is blood potassium is greater than 4.5mmol/l
in step 4 of antihypertensive treatment, what drug would you add if the blood potassium was below 4.5 mmol/l
spironolactone
in step 4 of antihypertensive treatment, what drug would you add if the blood potassium was above 4.5 mmol/l
alpha blocker or beta blocker
In relation to the stages of hypertension, medical management is offered to which classes of patients
all Patients with stage 2 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
name a common alpha blocker
doxazosin
name a common beta blocker in relation to hypertension
atenolol
What class of antihypertensive can increase the risk of hyperkalaemia
ACE inhibitors and spironolactone
note that thiazide like diuretics can also cause electrolyte disturbances
howdoes spironolactone work
it is a potassium sparing diuretic that works by blocking the action of aldosterone in the kidneys, causing sodium excretion and potassium reabsorption
- this is helpful when thiazide diuretics are causing hypokalaemia
what is the treatment targets in someone over the age of 80 compared to under the age of 80
over the age of 80 it is <140/<90
under the age of 80 it is <150/<90
What class of antihypertensive is amlodipine and what is the main side effect
CCB ankle swelling (and flushing headaches initially)
What class of antihypertensive is ramipril and what is the main side effect
ACEi and dry tickle cough
What class of antihypertensive is bisoprolol and what is the main side effect
Beta blocker and bradycardia
what class of antihypertensive is indapamide and bendroflumethiazide and what is the main side effect
thiazide diuretic and hyponatraemia (it reduces the reabsorption of NaCl in the DCT
What class of antihypertensive is furosemide and what are the main side effects
loop diuretic and gout attack (as there is increased risk will develop crystals)
What class of antihypertensive is spironolactone and what are the main side effects
aldosterone antagonist and hyperkalaemia ( as it is a potassium sparing diuretic
What class of antihypertensive is candesartin
angiotensin receptor blocker (ARB)
what 2 antihypertensive drugs can you not use together
ACEi and ARB
someone needs same day assessment if they have blood pressure above 180/120 and what other symptoms
signs of retinal haemorrhage or papilloedema (accelerated hypertension) or
life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury. [2019]
