Blood pressure Flashcards
NICE definition of hypertension
a clinic reading persistently above >= 140/90 mmHg, or:
a 24 hour blood pressure average reading >= 135/85 mmHg
What is primary/essential hypertension
No single disease is causing the rise in bp but rather a series of complex physiological changes which occur with age
Secondary causes of hypertension linked to renal disease
Glomerulonephritis
Chronic pyelonephritis
Adult polycystic kidney disease
Renal artery stenosis
Secondary causes of hypertension linked to endocrine disorders
Primary hyperaldosteronism Phaeochromocytoma Cushing's syndrome Liddle's syndrome Congenital adrenal hyperplasia (11-beta hydroxylase deficiency) Acromegaly
IX to check for end-organ damage from hypertension
fundoscopy: to check for hypertensive retinopathy
urine dipstick: to check for renal disease, either as a cause or consequence of hypertension
ECG: to check for left ventricular hypertrophy or ischaemic heart disease
Definition of stage 1 hypertension
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
Definition of stage 2 hypertension
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
Definition of severe hypertension
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg
BP measurement in the event of different readings from each arm
If the difference in readings between arms is more than 20 mmHg then the measurements should be repeated.
If the difference remains > 20 mmHg then subsequent blood pressures should be recorded from the arm with the higher reading.
Pathological causes of unequal blood pressure readings from arms
Supravalvular aortic stenosis
What do NICE recommend offering to any patient with a blood pressure >= 14090
ABPM or HBPM
When should patients with hypertension be admitted for specialist assessment
> = 180/120 mmHg if signs of retinal haemorrhage or papilloedema
Life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure or acute kidney injury
Suspected phaeochromocytoma
What should be started if target organ damage is identified
Immediate antihypertensive treatment without waiting for results of ABPM or HBPM
If no target organ damage, repeat BP within 7 days
Features of ABPM
at least 2 measurements per hour during the person’s usual waking hours (for example, between 08:00 and 22:00)
use the average value of at least 14 measurements
Features of HBPM
for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
BP should be recorded twice daily, ideally in the morning and evening
BP should be recorded for at least 4 days, ideally for 7 days
discard the measurements taken on the first day and use the average value of all the remaining measurements
Mx of stage 1 hypertension
treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater
Lifestyle advice
Mx of stage 2 hypertension
Offer drug treatment regardless of age
Lifestyle advice for hypertension
Low salt diet(less than 6g/day) Reduce caffeine intake Less alcohol Stop smoking Balanced diet Exercise Weight loss
Step 1 anti-hypertensive treatment - patients <55 or type 2 DM
ACE inhibitor or a Angiotensin receptor blocker (ACE-i or ARB): (A)
angiotensin receptor blockers should be used where ACE inhibitors are not tolerated (e.g. due to a cough)
Step 1 anti-hypertensive treatment - patients >= 55 or black Africa or african-caribbean origin
Calcium channel blocker (C)
ACE inhibitors have reduced efficacy in patients of black African or African–Caribbean origin are therefore not used first-line
Step 2 anti-hypertensive treatment if already taking an ACE-i or ARB
CCB or thiazide-like diuretic
Step 2 anti-hypertensive treatment if already taking CCB
add an ACE-i or ARB or a thiazide-like Diuretic
For patients of black African or African–Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an angiotensin receptor blocker in preference to an ACE inhibitor
What do NICE define as resistant hypertension
If step 4 and uncontrolled with 3 anti-hypertensive medication
Mx of resistant hypertension
first, check for:
confirm elevated clinic BP with ABPM or HBPM
assess for postural hypotension.
discuss adherence
if potassium < 4.5 mmol/l add low-dose spironolactone
if potassium > 4.5 mmol/l add an alpha- or beta-blocker
Seek specialist support
