CARDIO: HTN Flashcards
What is stage 1 HTN?
Clinical BP is 140/90 mmHg or higher.
Ambulatory BP monitor or home BP monitor averages out at 135/85 mmHg
What is stage 2 HTN?
Clinical BP is 160/100 mmHg or higher
ABPM or HBPM average is 150/95 mmHg or higher
What is severe HTN?
Clinical systolic BP is 180 mmHg or higher.
Clinical diastolic Bp is 120 mmHg or higher.
When should ambulatory BP readings be offered?
If BP is >140/90.
How to manage pt with severe HTN (S=>180mmHg or= 120mmHg)?
- Consider treatment immediately.
- For patients < 40 years consider specialist referral to exclude secondary causes.
No need to do ABPM or HBPM
Signs and symptoms of pt with HTN?
Asymptomatic
If severe:
* headaches
* on fundoscopy: retinal haemorrhages and papillodema
* dizzy
* nausea and vomiting
* chest pain
Main ddx of pt with HTN, sweating, headache, palpatations, anxiety?
Phaeochromocytoma
could also be MI, hyperthyroid
Main ddx of pt with HTN, muscle weakness and tetany?
Hyperaldosteronism
Hyperaldosterone leads to hypercalciuria and hypocalcemia which cause secondary hyperparathyroidism.(tetany)
CVS RF that may lead to HTN?
TIA, stroke, DM, previous renal disease, smoking, cholesterol, NSAID excess
Pt has HTN. What may be present in PMH?
Angina, CCF, palpatations, syncope, valvular heart disease
Pt has HTN. What should you cover in FHx?
FHx of HTN?
FHx of premature coronary disease
FHx of polycystic kidney disease
FHx of cardiac related death before 40 ?
What are secondary causes of HTN?
Cushing's syndrome Polycystic kidney disease Renal bruits Radio-femoral delay (coarctation) Phaechromocytoma Hyperaldosteronism
What investigations would you fo for pt with HTN?
Urinanalysis - albumin:creatinine ratio
Urinanalysis - haematuria
Blood glucose, U+Es = creatinine and eGFR
Lipid profile - serum total cholesterol, HDL cholesterol
U+Es for secondary cause too - low potassium and high sodium = hyperaldosteronism
12 lead ECG
ECHO - if LVH, valve disease, LVSD, diastolic dysfunction
How to do a CVS risk assessment?
Use Q risk calculator
When should pts with stage 1 HTN (under age of 80) be offered treatment?
- if they have evidence of: target organ damage
- if they have evidence of: established CVD
- have renal impairment
- have DM
- have 10 year risk >20%
Your pt has HTN (worked out by ABPM). Now you need to work out QRISK2 score and Investigate for end-organ damage…
What investigations to assess for end organ damage…?
- Urine dip and albumin:creatinine level
- Blood glucose, lipids and renal function
- Fundoscopy for evidence of hypertensive retinopathy
- ECG: look for evidence of LV hypertrophy
When should pts with stage 2 HTN be offered treatment?
Always offer if have stage 2 HTN
What is target BP in low-moderate risk pts with HTN?
<140 mmHg systolic
What is target BP in pts who have HTN with a background of either DM, stroke, TIA, IHD, CKD?
<130/80 mmHg
Elderly pt with systolic >160mmHg should have target BP of ??
(a) if under 80
(b) if over 80
(a) 140-150mmHg if under 80, ideally <140mmHg
(b) 140-150mmHg
What is target diastolic BP in:
1) all pts with HTN?
2) diabetics specifically?
1) <90 mmHG
2) <85mmHg
What is target systolic BP in pt with CKD and overt proteinuria?
<130mmHg
Non-pharmacological treatment for HTN?
- lose weight if BMI >25 kg/m2. (for every kg lost = reduce BP by 3/2 mmHg)
- reduce salt intake (can reduce BP by 8/5mmHg)
- minimise alcohol intake
- exercise
- smoking cessation
Initial pharmacological treatment for HTN in pt under 55?
ACEi or ARB
Initial pharmacological treatment for HTN in pt 55+, or black person of African or Carribean family origin of any age?
CCB
Pt is already on ACEi for HTN. It isn’t reducing BP. What to add next ?
ACEi + CCB
Pt is already on CCB for HTN. It isn’t reducing BP. What to add next ?
CCB + ACEi
Pt is already on ACEi and CCB for HTN which is not helping. What to consider adding next?
Thiazide like diuretic e.g. Indapamide
Bendroflumethiazide - not preference thiazide type diuretic. Indapamide better at reducing stroke / CVS events
Pharmacological treatment for resistant HTN?
ACEi, CCB, Thiazide like diuretic + one of the following:
- spironolactone
- higher dose of thiazide like diuretic
- alpha or beta blocker if the above 2 do not work.
What is a hypertensive crisis?
An increase in BP which if sustained over the next few hours, will lead to irreversible end-organ damage
E.g. encephalopathy, LV failure, aortic dissection, unstable angina, renal failure.
Distinguish between a hypertensive emergency and a hypertensive urgency
Hypertensive emergency:
= high BP associated with a critical event (e.g. encephalopathy, pulm oedema, AKI, MI)
Hypertensive urgency:
= high BP without a critical illness but may include malignant hypertension.
What is main target BP aim of treating a HTN emergency?
Reduce diastolic BP to 110mmHg in 3-12hrs
What is main target BP aim of treating a HTN urgency?
Reduce diastolic BP to 110mmHg in 24hrs.
What IV drugs should be started in hypertensive emergency?
- Sodium nitroprusside
- Labetalol
- GTN (1-10mg/hr)
- Esmolol
Oral treatment options for hypertensive urgency?
Amlodipine - 5-10mg OD
Diltiazem - 120-300mg daily
Lisinopril - 5mg OD
Note: ACEi and CCB is effective and well tolerated
What is the safest and most effective oral treatment for hypertensive urgency (according to CVS booklet)?
Nifedipine 20mg BD + Amlodipine 10mg OD for 3 days.
After 3 days, continue with amlodipine 10mg OD.
Triad of symptoms in pheochromocytoma?
Most common sign?
The triad:
Episodic headache
sweating
tachycardia
most common sign: sustained or paroxysmal HTN
Investigation for phaeochromocytoma?
24hr urine collection.
Measure urinary metanephrines and catecholamines.
Measure plasma fractionated metanephrines and catecholamines.
CT scan or MRI of abdomen and pelvis - detect adrenal tumours. If these do not show, can do MIBG scan.
Management of phaeochromocytoma?
Resection
How to manage phaeochromocytoma before surgery?
Alpha adrenergic blockade and beta adrenergic blockade.
Name of commonly used alpha adrenergic blockage used for phaeochromocytoma?
Phenoxybenzamine
Which order are alpha adrenergic blockade and beta adrenergic blockades given to pt for phaeochromocytoma?
Describe dosage.
Alpha first - ALWAYS. Phenoxybenzamine is used. Initial dose is 10mg OD/BD. Dose is increased every 2-3days to control BP. Final dose is 20-100mg daily.
After use of alpha adrenergic blockade is achieved, can start beta-adrenergic blockade - usually 2-3 days pre-operatively.
Investigations and findings for Cushing’s syndrome with HTN?
Blood glucose = hyperglycaemia
24hr urine cortisol excretion = elevated by 3x
Adrenal CT
Low dose - dexamethasone suppression test. = Show high cortisol.
Investigations for primary aldosteronism with HTN?
Aldosterone:renin - plasma renin will be low, aldosterone will be high
Adrenal CT
Complications of HTN?
- Increased risk of morbidity and mortality from all causes
- Coronary artery disease
- Heart failure
- Renal failure
- Stroke
- Peripheral vascular disease
What is HTN a risk factor for?
- cardiovascular disease
- cerebrovascular disease
- chronic kidney disease
- peripheral vascular disease.
