Cardiovascular Disease - Hypertension

Question 1

What BP is classified as hypertension in clinic and at home/ambulatory readings?

Answer 1

Above 140/90 in a clinic or 135/85 with ambulatory or home readings

Question 2

What percentage of hypertension are essential?

Answer 2

95%

Question 3

What are possible secondary causes of hypertension? ROPE

Answer 3

R – Renal disease. This is the most common cause of secondary hypertension. If the blood pressure is very high or does not respond to treatment consider renal artery stenosis.

O – Obesity
P – Pregnancy induced
hypertension / pre-eclampsia

E – Endocrine. Most endocrine conditions can cause hypertension but primarily consider hyperaldosteronism(“Conns syndrome”) as this may represent 2.5% of new hypertension. A simple test for this is a renin:aldosterone ratio blood test.

Question 4

Due to ‘white coat hypertension’ what is mainly used to diagnose hypertension?

Answer 4

This has led to the use of both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM)

Question 5

What drugs may cause hypertension?

Answer 5

NSAIDs, Herbal remedies, oral contraceptive pill

Question 6

What are hypertension risk factors as past medical history or family history ?

Answer 6

CVD, kidney disease, BP in pregnancy

Endocrine disease

Question 7

What examination do you perform if you think someone has hypertension?

Answer 7

Pulse, rhythm, symmetry, radio-femoral delay, BP (both arms + standing), heart, chest, abdomen and fundoscopy

Question 8

If BP is greater than 20mmHg in one arm compared to another, what do you do?

Answer 8

Repeated, if continued use higher value

Keep in mind other diseases which may cause this so listen to the heart

Question 9

Do you take BP from both arms when diagnosing?

Answer 9

Yes

Question 10

After you have taking a reading of both harms, do you take it again during consultation?

Answer 10

Yes, lower reading determines management if >140/90 mmHg

Then suggest ABPM or HBPM

Question 11

If a person is going to take their BP at home what do you tell them?

Answer 11

Ideally in the morning or evening, twice daily you should take it when seating down 2 readings at leats a minute apart

Question 12

Which BP readings do you use?

Answer 12

At least 4 to 7 days, discard day one and use the average of the other values

Question 13

If an ABPM, what happens?

Answer 13

2 reading in waking hours, an average of at least 14

Question 14

What is stage one hypertension in clinic vs home?

Answer 14

> 140 and >135 at home

Question 15

What is a stage 2 hypertension?

Answer 15

> 160 or > or equal 150 at home

Question 16

What is stage 3 hypertension?

Answer 16

> or equal 180

Question 17

If a patient has 180/120 mmHg what do you do?

Answer 17

Admit speciality assessment if signs of accelerated hypertension or life threatening symptoms or pheochromocytoma

Question 18

If no signs of an emergency, accelerated hypertension or pheochromocytoma, what do you do if your patient has BP of 180/120mmHg?

Answer 18

Check for organ damage if present give medication immediately without ABPM or HBPM if not then repeat BP within 7 days

Question 19

How do you check of kidney damage?

Answer 19

Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess fo

Question 20

What other tests can you do to check for organ damage?

Answer 20

Bloods for HbA1c, renal function and lipids
Fundus examination for hypertensive retinopathy
ECG for cardiac abnormalities

Question 21

What lifestyle advise should you give someone with hypertension?

Answer 21

reduce salt intake to <6g/day, ideally 3g/day

Reduce caffeine intake

stop smoking, drink less alcohol, eat a balanced diet rich in fruit and vegetables, exercise more, lose weight

Question 22

When should medical management be offered for hypertension?

Answer 22

All patients with stage 2 hypertension

All patients under 80 years old with stage 1 hypertension that also have a Q-risk score of 10% or more, diabetes, renal disease, cardiovascular disease or end organ damage.

Question 23

What is step 1 treatment for hypertension management for under 55 or T2DM?

Answer 23

ACE or ARB

Question 24

What is step 1 treatment for hypertension management for >55 or black African?

Answer 24

CCB

Question 25

If hypertension is not controlled in STEP 1 is not working?

Answer 25

Give CCB or thiazide if given ACE/ARB

If given CCB, then ARB over ACE or thiazide

Question 26

What is STEP 3 treatment?

Answer 26

one of each

Either Ace/ARB
+
CCB
+
Thiazide

Question 27

If none of medication work for hypertension, what is the 4th Step?

Answer 27

Seek specialist advice or 4th drug

Question 28

Before checking with a specialist about persistent hypertension what should you do?

Answer 28

first, check for:

confirm elevated clinic BP with ABPM or HBPM

assess for postural hypotension.

discuss adherence

Question 29

What is the 4th drug you would give a hypertensive patient if potassium is >4.5mmol/l?

Answer 29

Alpha or beta-blocker

Question 30

If potassium is <4.5mm/l, what drug would you give to a resistant hypertensive patient?

Answer 30

Spironolactone

Question 31

What is target BP for those <80 years old

Answer 31

140 or 135 at home

Question 32

What is target BP for those >80?

Answer 32

150 or 145 at home