Blood pressure

Question 1

NICE definition of hypertension

Answer 1

a clinic reading persistently above >= 140/90 mmHg, or:

a 24 hour blood pressure average reading >= 135/85 mmHg

Question 2

What is primary/essential hypertension

Answer 2

No single disease is causing the rise in bp but rather a series of complex physiological changes which occur with age

Question 3

Secondary causes of hypertension linked to renal disease

Answer 3

Glomerulonephritis
Chronic pyelonephritis
Adult polycystic kidney disease
Renal artery stenosis

Question 4

Secondary causes of hypertension linked to endocrine disorders

Answer 4

Primary hyperaldosteronism
Phaeochromocytoma
Cushing's syndrome
Liddle's syndrome
Congenital adrenal hyperplasia (11-beta hydroxylase deficiency)
Acromegaly

Question 5

IX to check for end-organ damage from hypertension

Answer 5

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

Question 6

Definition of stage 1 hypertension

Answer 6

Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

Question 7

Definition of stage 2 hypertension

Answer 7

Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg

Question 8

Definition of severe hypertension

Answer 8

Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg

Question 9

BP measurement in the event of different readings from each arm

Answer 9

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.

Question 10

Pathological causes of unequal blood pressure readings from arms

Answer 10

Supravalvular aortic stenosis

Question 11

What do NICE recommend offering to any patient with a blood pressure >= 14090

Answer 11

ABPM or HBPM

Question 12

When should patients with hypertension be admitted for specialist assessment

Answer 12

> = 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

Question 13

What should be started if target organ damage is identified

Answer 13

Immediate antihypertensive treatment without waiting for results of ABPM or HBPM

If no target organ damage, repeat BP within 7 days

Question 14

Features of ABPM

Answer 14

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

Question 15

Features of HBPM

Answer 15

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

Question 16

Mx of stage 1 hypertension

Answer 16

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

Question 17

Mx of stage 2 hypertension

Answer 17

Offer drug treatment regardless of age

Question 18

Lifestyle advice for hypertension

Answer 18

Low salt diet(less than 6g/day) 
Reduce caffeine intake 
Less alcohol 
Stop smoking 
Balanced diet 
Exercise 
Weight loss

Question 19

Step 1 anti-hypertensive treatment - patients <55 or type 2 DM

Answer 19

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)

Question 20

Step 1 anti-hypertensive treatment - patients >= 55 or black Africa or african-caribbean origin

Answer 20

Calcium channel blocker (C)
ACE inhibitors have reduced efficacy in patients of black African or African–Caribbean origin are therefore not used first-line

Question 21

Step 2 anti-hypertensive treatment if already taking an ACE-i or ARB

Answer 21

CCB or thiazide-like diuretic

Question 22

Step 2 anti-hypertensive treatment if already taking CCB

Answer 22

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

Question 23

What do NICE define as resistant hypertension

Answer 23

If step 4 and uncontrolled with 3 anti-hypertensive medication

Question 24

Mx of resistant hypertension

Answer 24

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

Question 25

BP target - Age<80

Answer 25

Clinic BP
140/90 mmHg

ABPM / HBPM
135/85 mmHg

Question 26

BP target - Age>80

Answer 26

Clinic BP - 150/90mmHg

ABPM/HBPM - 145/85mmHg

Question 27

BP target for type 2 diabetics

Answer 27

< 140/90 mmHg, the same as for patients without diabetes

Question 28

NICE advice for BP control in type 1 diabetics

Answer 28

Intervention levels for recommending blood pressure management should be 135/85 mmHg unless the adult with type 1 diabetes has albuminuria or 2 or more features of metabolic syndrome, in which case it should be 130/80 mmHg