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Year 3 - TCD > Case 8 - Hypertension > Flashcards

Case 8 - Hypertension Flashcards

1
Q

What is classified as hypertension?

A

Blood pressure >140/90 mmHg

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2
Q

What are the different types of hypertension?

A
  • Primary (essential): no detectable cause

- Secondary: due to underlying disease

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3
Q

What are the causes of primary hypertension?

A
  • Non modifiable risk factors: positive family history, ethnicity, older age
  • Modifiable risk factors: obesity, diabetes, smoking, high salt diet, low potassium diet, inactivity, stress, excess alcohol and caffeine
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4
Q

What are the causes of secondary hypertension?

A
  • Primary aldosteronism (most common)
  • Renovascular disease (fibromuscular dysplasia)
  • Oral contraceptive
  • NSAIDs
  • Stimulants (cocaine)
  • Antidepressants
  • Pheochromocytoma
  • Cushing’s syndrome
  • Coarctation of the aorta
  • Hyper/hypothyroidism
  • Primary hyperparathyroidism
  • Brain tumours
  • Encephalitis
  • Pregnancy
  • Methamphetamines
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5
Q

How can brain tumours and encephalitis lead to hypertension?

A

Decreased blood flow to brain ->

CNS vasopressor response

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6
Q

How can obesity lead to hypertension?

A

Increased body weight -> Increased plasma volume -> Increased cardiac output

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7
Q

How does medial fibromuscular dysplasia cause hypertension?

A
  • This causes abnormal growth within the renal artery leading to renal artery stenosis.
  • It has a string ob beads appearance due to the alternating aneurysms that cause the stenosis.
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8
Q

What are the symptoms of hypertension?

A
  • Often asymptomatic
  • Headaches (waking headaches)
  • Epistaxis
  • Fatigue, sleep disturbance due to nocturnal hypertension
  • Chest discomfort, palpitations
  • End organ damage symptoms
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9
Q

What are the different ways to diagnose hypertension?

A
  • Measure in the clinic
  • Ambulatory home blood pressure
  • Home blood pressure monitoring
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10
Q

How is hypertension in the clinic diagnosed?

A
  • Measure in both arms
  • Should be 140/90 mmHg or higher
  • Take 2 readings
  • Record lower of the 2 measurements.
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11
Q

How is ambulatory hypertension interpreted?

A
  • Used to confirm hypertension
  • 2 measurements taken every hour during waking hours
  • Average of last 14 results
  • Requires an average of >135/85 mmHg
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12
Q

Why and how is home blood pressure monitoring used?

A
  • Used if can’t tolerate ABPM
  • Seated with 2 consecutive readings taken with at least 1 min apart.
  • Recorded 2x daily
  • At least 4 days, ideally 7 days
  • Requires an average of >135/85 mmHg
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13
Q

How is postural hypotension measured?

A

1) Measure when supine

2) Measure when standing for at least 1 min prior measurement

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14
Q

What is stage 1 hypertension?

A

Systolic: 140-159
Diastolic: 90-99

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15
Q

What is stage 2 hypertension?

A

Systolic: 160-179
Diastolic: 100-109

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16
Q

What is stage 3 hypertension?

A

Systolic: ≥180
Diastolic: ≥110

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17
Q

What is isolated systolic hypertension?

A

Systolic: ≥140
Diastolic: ≤90

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18
Q

How to treat isolated systolic hypertension?

A
  • Thiazide diuretic or

- Dihydropyridine calcium antagonists

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19
Q

What investigations are done for hypertension?

A
  • ECG - left ventricular hypertrophy or concomitant heart disease (e.g., coronary artery disease, arrhythmias)
  • FBC count
  • Renal function – urea, creatinine and eGFR
  • Random blood sugar
  • Total cholesterol and HDL cholesterol
  • Urine – To detect microalbuminuria and/or haematuria, estimation of albumin: creatinine ratio, hypokalaemia
  • TSH – high or low if thyroid dysfunction
  • CXR - may show LVH
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20
Q

What is the QRISK2 score?

A

Calculates % risk of having heart attack or stroke in next 10 years.

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21
Q

When is QRISK2 score valid?

A

If patient does NOT have a diagnosis of previous coronary heart disease/stroke/TIA

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22
Q

How to conservatively treat hypertension?

A
  • Healthy diet
  • Reducing sodium, caffeine
  • Increasing potassium intake
  • Weight loss
  • Regular exercise
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23
Q

What is the step 1 drug treatment for hypertension?

A

If <55y - ACEi OR ARB

If >55y/Asian/Afro-Caribbean - CCB. (thiazide if not CCB)

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24
Q

What is the step 2 drug treatment for hypertension?

A

ACEi/ARB + CCB (thiazide if not CCB)

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25
Q

What is the step 3 drug treatment for hypertension?

A

ACEi/ARB + CCB + Thiazide

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26
Q

What is the step 4 drug treatment for resistant hypertension?

A

ACEi/ARB + CCB + Thiazide + Further diuretic or Alpha/Beta blocker

27
Q

What is the drug treatment in pregnancy?

A

1st - Methyldopa (alpha 2 agonists), labetatol, nifedipine (CCB), hydralazine (vasodilator)

28
Q

What drugs are contraindicated in pregnancy?

A

Furosemide, ACEi, ARB, Renin inhibitors

29
Q

What is white coat hypertension?

A

Hypertension only in clinical settings due to anxiety

30
Q

What is hypertensive crisis?

A

Increase in BP >180/120 mmHg with/without symptoms and with/without signs of organ damage

31
Q

What is hypertensive emergency?

A

Acute increase in BP >180/110 mmHg with symptoms and with signs of organ damage

32
Q

What is hypertensive urgency?

A

Acute increase in BP >180/110 mmHg without symptoms and with no signs of organ damage.

33
Q

What cardiovascular end organ damage does a hypertensive emergency patient present with?

A

PE, MI, CHF, Aortic dissection

34
Q

What neuroloigcal end organ damage does a hypertensive emergency patient present with?

A

Hypertensive encephalopathy, stroke, malignant hypertension (hypertension with retinopathy)

35
Q

What renal end organ damage does a hypertensive emergency patient present with?

A

Azotaemia - increased nitrogen in urine

Oliguria - due to acute renal failure

36
Q

What is the treatment for hypertensive urgency?

A

Start anti-hypertensive drugs OR increase dosage of oral drugs

37
Q

What is the main cause of hypertensive urgency?

A

Non-compliance with anti-hypertensive therapy

38
Q

What is the treatment for hypertensive emergency?

A

ICU + IV antihypertensives (nitro-glycerine or labetalol)

39
Q

IV nitro-glycerine drug profile

A

Onset: 2- 5 mins
Duration: 10 mins
SE: Headaches, flushing, vomiting
Comments: Better control of BP

40
Q

IV labetalol drug profile

A

Onset: 5-10 mins
Duration: 2-6 hours
SE: Heart block, hypotension, bronchoconstriction
Comments: Better control of BP

41
Q

Cardiovascular end organ damage

A
  • LV hypertrophy
  • CHF
  • CAD + MI
  • Aortic dissection
  • Ischaemic heart disease
42
Q

Neurological end organ damage

A
  • Stroke (ischaemic or hemorrhagic)

- Cognitive changes

43
Q

Renal end organ damage

A
  • Chronic hypertension leding to glomerulus fibrosis
44
Q

Eyes end organ damage

A
  • Vasoconstriction leading to breakdown of retinal barrier
45
Q

What tests and findings to check for cardiac end organ damage?

A
  • ECG + cardiac exam
  • Signs of cardiac failure
  • ECG: LV hypertrophy
46
Q

What tests and findings to check for renal end organ damage?

A
  • Haematuria and/or proteinuria

- Renal impairment

47
Q

What tests and findings to check for retinal end organ damage?

A
  • Fundoscopy

- Cotton wool spots, retinal haemorrhage, papilledema and hard exudates

48
Q

What is blood pressure?

A

Cardiac output x total peripheral resistance

49
Q

What is cardiac output?

A

Heart rate x stroke volume

50
Q

What is the RAAS system?

A
  • Kidneys release renin
  • Renin causes angiotensinogen to be converted into angiotensinogen I.
  • ACE converts angiotensinogen I to angiotensinogen II.
  • Angiotensinogen II causes vasoconstriciton.
51
Q

What are the side effects of calcium channel blockers?

A
  • Flushes/headache
  • Ankle oedema
  • Fatigue
52
Q

What are the side effects of ACE inhibitors?

A
  • Dry cough
  • High K+
  • Angioedema/rash
  • Renal failure
53
Q

What are the side effects of ARBs?

A
  • Dizziness/headache
  • Urticaria/pruritus
  • High K+
  • Cough
54
Q

What are the side effects of beta blockers?

A
  • Dry mouth/skin/eyes
  • Cold peripheries
  • Dizziness
  • GI upset
55
Q

What are the CI of ACEi?

A
  • Bilateral renal artery stenosis

- Aortic valve stenosis

56
Q

What are the CI of ARBs?

A
  • Caution in valve disease
  • Cardiomyopathy
  • Monitor K
57
Q

What are the CI of Beta blockers?

A
  • Asthma

- Caution in heart failure.

58
Q

What are the side effects of thiazide diuretic?

A
  • Hyponatraemia
  • Hypokalaemia
  • Impotence
59
Q

What are the CI of thiazide diuretics?

A

Gout

60
Q

What are the side effects of loop diuretic?

A

Gout

Hyponatreamia

61
Q

Where does thiazide diuretic work?

A

DCT, blocks Na and Cl

62
Q

What does loop diuretic work?

A

Inhibiting NKCC in thick ascending limb

63
Q

Where does potassium sparing diuretic work.

A

Blocks action of aldosterone, resulting in sodium excretion and K+ reabsorption.

Year 3 - TCD (17 decks)

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