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Chemical Pathology > BCH Investigation OF HYPERTENSION > Flashcards

BCH Investigation OF HYPERTENSION Flashcards

1
Q

Hypertension is defined as?

A

a persistently elevated blood pressure ≥140/90mmHg

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2
Q

How many percent of people aged over 25yrs have hypertension?

A
  • 40%
  • Affects 1/4 of the global population
  • Leading modifiable risk factor for CVD
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3
Q

What’s the role of psychosocial stress on hypertension?

A
  • Remains uncertain.
  • Acute stress raises blood pressure acutely
  • Chronic stress has less clear cut effects.
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4
Q

Causes of hypertension ? PRIMARY

A

Essential (primary) hypertension: Found in 95% of cases. cause unknown
- related to
- familial tendency
- obesity
- high alcohol intake
- high salt diet

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5
Q

Secondary causes of hypertension include?

A

1) Renovascular hypertension
2) Renal disease
3) Drug induced hypertension
4) Diabetes mellitus Insulin dependent and non-insulin dependent
5) Other endocrine diseases
6) Adrenal disease
7) Arterial disease

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6
Q

Causes of Reno-vascular hypertension include?

A
  • Atheromatous formations
  • Fibro-muscular hyperplasia
  • Extrinsic renal artery compression.
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7
Q

Intrinsic renal disease causing hypertension include ?

A
  • glomerulonephritis
  • Pyelonephritis
  • Polycystic renal disease
  • Renin secreting tumours
  • chronic renal failure.
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8
Q

Drugs that can induce hypertension include??

A
  • Oral contraceptives
  • Hormone replacement therapy
  • Liquorice and carbenoxolone,
  • Non steriodal anti-inflammatory drugs, - Sympathomimetic amines
  • Corticosteroid and ACTH therapy
  • Nephrotoxic drugs.
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9
Q

Endocrine Diseases that can cause Hypertension ?

A

Acromegaly
Primary hyperparathyroidism, Myxedema
Thyrotoxicosis

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10
Q

Adrenal disease that can cause hypertension include

A

Catecholamine excess
- pheochromocytoma
Aldosterone excess
- aldosterone secreting adenoma
- adrenocortical hyperplasia
- adrenal carcinoma
- cushing’s disease.

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11
Q

Arterial disease that can cause hypertension include?

A
  • co-arctation of the aorta
  • polyarteritis nodosa
  • systemic lupus erythematosus
  • pulseless disease
  • Takayasu’s disease
  • progressive systemic sclerosis
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12
Q

The aim of laboratory investigation of hypertensive patients ?

A
  • it is used to exclude the rare identifiable renal or adrenal causes of hypertension
  • it may help to detect evidence of ‘target organ damage’ for example, renal impairment
    c)identification of hypertensive patients who are at higher risk
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13
Q

Identification of hypertensive pateients who are at higher risk, what are the factors the makes a person at “higher risk”

A
  • Hyperlipidemia (elevated serum cholesterol, LDL-c and TG concentrations and a low HDL cholesterol level)
  • Renal impairment
  • Glucose intolerance

These conditions substantially
- increase the risk of death for a given level of blood pressure
- influence the choice of antihypertensive drugs

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14
Q

All patients with sustained hypertension should have blood samples taken for ?

A
  • measurement of creatinine and calculate the estimated Glomerular Filtration Rate (eGFR)
  • glucose- glycated haemoglobin A1c (HbA1c),
  • urea, electrolytes (sodium, potassium),
  • lipid profile (total cholesterol, triglycerides, high density lipoprotein cholesterol (HDL cholesterol), low density lipoprotein cholesterol (LDL cholesterol),
  • thyroid function tests (free thyroxine (FT4) and thyroxine stimulating hormone (TSH),
  • urate and liver function tests (LFTs: total protein (TProt), albumin, total bilirubin (TBili), alkaline phosphatase (ALP), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma glutamyl transpept
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15
Q

What type of urine sample is required for urinalysis ?

A

24 hour or spot urine collection should be done

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16
Q

Other tests that can be done apart form ones previously listed?

A
  • Plasma aldosterone concentration
  • Plasma renin activity
  • Plasma renin concentration
  • Plasma cortisol

Can be measured in a non-fasting state

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17
Q

What’s the purpose of all these blood work while evaluating hypertension?

A

measurement of these analytes
permits evaluation
- kidney
- thyroid
- liver function
the identification of
- dyslipidaemia
- glucose intolerance
- metabolic syndrome
- cardiovascular risk stratification.

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18
Q

Dip stick urinalysis findings?

A

Dipstick urinalysis can detect
- significant proteinuria
- haematuria
- glycosuria.

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19
Q

Proteinuria In an hypertensive patient may be due to what ?

A
  • proteinuria may be due to arteriolar fibrinoid necrosis: due to the malignant phase of either essential or secondary hypertension.
  • Proteinuria may also be due to hypertensive nephrosclerosis (a consequence of hypertension)
  • intrinsic renal disease which may be a cause of the hypertension.
20
Q

Arteriolar fibrinoid necrosis is characterized by ?

A
  • retinal haemorrhages and exudates
  • If left untreated, has a 2-year mortality rate of 80 %.
21
Q

hypertensive patients the presence of proteinuria indicates?

A

a substantially worse prognosis for both renal and non-renal disease.

  • May be due to UTI (nitrite and L.esterase would be positive then)
22
Q

Diabetes and hypertension

A
  • Glycosuria suggests diagnosis of Diabetes mellitus (may be negative, this doesn’t rule it out)
  • The presence of diabetes will affect the choice of treatment for hypertensions as (thiazide diuretics are mildly diabetogenic**’ and are best avoided.)
  • Glycosuria and hypertension may be secondary to an endocrine disorder Cushing’s syndrome, pheochromocytoma, acromegaly etc
23
Q

Sodium

A
  • Serum sodium levels may be normal or raised in primary hyperaldosteronism (140-150 mmol/L)24
  • low or low-normal (l25-135mmoljL) in conditions with secondary hyperaldosteronism such as malignant hypertension and renal or renovascular disease, with or without renal failure.
  • Sodium may be lowered by thiazide or loop diuretics
24
Q

Potassium

A

Primary hyperaldosteronism (conns syndrome) and it’s non-tumorous variants are almost always associated with marked hypokalaemia ( 2·0 mmol/L.)
- In secondary hyperaldosteronism hypokalaemia is usually less severe and serum potassium may be normal.

25
Q

The comments cause of hypokalemia is ?

A
  • Diuretics
  • Must be stopped one month before serum potassium measurement
26
Q

Hypokalemia is usually associated with ?

A
  • Metabolic alkalosis
  • High serum bicarbonate concentration
  • treatment with carbenoxolone for peptic ulcer
  • intestinal postasisum loss with purgative or laxative abuse
27
Q

The most useful screening test for conns syndrome (surgical remidiable)?

A

Serum postassium measurement

28
Q

Hyperkalemia can be seen where?

A
  • In acute renal failure (when potassium sparing diuretics or potassium supplements are used) spirinolactone, amiloride, triamterene
  • together with ACEI - captopril, enalapril, lisinopril
29
Q

RFT should be done how frequently in hypertensives?

A
  • Assessed on presentation and annually in all hypertensives.
  • By serial serum creatinine determinations.

Notes
- Routine estimation of creatinine clearance is not necessary in the vast majority of hypertensive patients.
- This test may be a more sensitive indicator of loss of renal function, but it is not easily organized in general practice and is inconvenient.

30
Q

Why is blood pressure control necessary in HYP secondary to CKD?

A
  • Those patients with hypertension secondary to chronic renal failure need careful control of their blood pressure as this may slow the otherwise inevitable decline in renal function.
31
Q

When is taking serial estimation of Creatinine clearance necessary?

A

When renal impairment is severe and the need for chronic dialysis is considered to be likely in the future, it is helpful to plot serial measurements of the reciprocal of the serum creatinine against time.
- This provides an indication of whether renal function is deteriorating and gives some indication of whether or when chronic dialysis may be necessary.

32
Q

Calcium

A
  • Serum calcium concentrations are raised in primary hyperparathyroidism and serum phosphate is usually low.
  • Hypertension is found in about 50 % of these patients.

Notes
- The mechanism of the association is uncertain.
- It is not explained by hypercalcemia-induced renal damage or by the levels of the serum calcium or parathyroidhormone concentrations.
- Surgical cure of hyperparathyroidism rarely results in any improvement in blood pressure.

33
Q

Extra notes about calcium concentrations and hypertension?

A
  • Hypertension in a hyperparathyroid patient is not an indication for parathyroidectomy unless there is concurrent renal failure.
34
Q

Relationship between thiazides and Hypercalcemia?

A
  • Thiazide diuretics may rarely cause hypercalcemia and these drugs should be stopped for a few weeks before rechecking to exclude hyperparathyroidism.
  • If hypercalcemia persists, then a serum parathyroid hormone assay should be performed.
35
Q

Urate in evaluating hypertension?

A
  • Serum uric acid is raised in about 40 % of hypertensives with essential hypertension
  • more common in those with renal failure.
  • Urate nephropathy may occasionally be the cause of the hypertension.
36
Q

Possible causes of hyperuricemia ?

A
  • Hyperuricemia may be caused or aggravated by diuretic therapy although only a small proportion of patients develop clinical gout.
  • Excessive intake of alcohol - unexplained hyperuricemia
37
Q

Notes about Uric acid?

A
  • It is uncertain whether a raised serum uric acid level is itself an independent cardiovascular risk factor
    after allowing for the relationship between uric acid and hyperlipidemia, obesity, alcohol abuse, drug therapy and the height of the blood pressure
38
Q

Relationship between Diabetes and hypertension?

A
  • About 50 % of both insulin dependent and non-insulin dependent diabetics also have hypertension
  • Up to 10% of hypertensives are also diabetic.
39
Q

Prognosis and RF for the development of both Hypertension and diabetes ?

A
  • The combination of these two conditions becomes increasingly common with advancing age and with increasing levels of obesity
  • The prognosis is correspondingly bad.
40
Q

Notes about diabetes coexisting with hypertension ?

A
  • Thiazide diuretics are best avoided.
  • Calcium channel blockers and angiotensin converting enzyme inhibitors have no deleterious effects
  • ACEI may have major benefits by delaying the onset of renal damage
41
Q

cholesterol and triglycerides

What substantially worsens the prognosis in a hypertensive patient? .

A
  • The presence of hyperlipidemia
  • Beta blockers, thiazide diuretics should be avoided in patients with overt hyperlipidemia.
42
Q

Effects of BB, thiazide, CCB, ACEI on plasma lipids

A
  • Both beta blockers and thiazide diuretics (usually the first line drugs for hypertension) may adversely affect plasma lipid profiles and it is possible that their use has been responsible for the disappointing impact of antihypertensive therapy on coronary heart disease’.
  • The calcium channel blockers and angiotensin converting enzyme inhibitors have no such effects on plasma lipids, and the newer alpha receptor blockers terazocin and doxazocin may even modestly reduce lipid levels
43
Q

Gamma glutamyl transpeptidase Assay

A
  • High alcohol intake is a relatively recently recognized cause of a raised blood pressure
  • Hypertension appears to be readily reversible with reduction or abstinence.

• It has been estimated that 10-20 % of hypertension may be related to a high alcohol intake but unless the clinician is alert to this point it may pass unnoticed.

44
Q

Importance of estimating serum gamma glutamyl transferase activity?

A
  • helps to identify the commonest known cause of hypertension.
  • Serum aspartate transaminase levels may also be raised
  • hematological indices may show evidence of macrocytosis with a normal or even a slightly raised hemoglobin level
45
Q

Plasma aldosterone concentration (PAC) and Plasma renin activity (PRA) or plasma renin concentration (PRC):

A
  • Plasma renin levels in peripheral blood may be high or normal in renovascular hypertension
  • However in primary hyperaldosteronism, the plasma renin levels would be low and plasma aldosterone concentration would be high.
46
Q

What may indicate the presence of secondary hypertension ?

A
  • There is a higher chance of there being an underlying cause of hypertension in younger patients (less than 45 years old)
  • those with severe (diastolic blood pressure > 120mm Hg)
  • Those with difficult-to-control hypertension.

Thus, such patients should undergo further investigations to find the cause of hypertension.

47
Q

Importance of biochemical investigations of hypertension

A

The results from biochemical investigations of hypertension
- may influence the choice of drugs used to control the blood pressure
- suggest that the hypertension is secondary to renal or endocrine disease.

Chemical Pathology (8 decks)

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