Chronic - Hypertension Flashcards
When considering a diagnosis of hypertension, how should blood pressure be taken?
- Blood pressure should be measured in both arms. If the difference in the readings between arms is more than 20mmHg, repeat the measurements. If the difference in readings between arms remains more than 20mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading
- Automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation). Palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually
- If blood pressure in the clinic is 140/90 or higher, take a second measurement during the consultation. If the second measurement is substantially different from the fist, take a third. Record the lower of the last two measurements as the clinic blood pressure
When should hypertension be suspected?
Clinic blood pressure is 140/90 or higher
Diagnosis should be confirmed with ABPM or HBMP if ABPM is not tolerated. What should be considered when interpreting these?
ABPM –
- ensure at least two measurements per hour are taken during the person’s usual waking hours and use the average of at least 14 measurements
HBPM –
- Ensure that for each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart with the person seated
- Blood pressure is recorded twice daily, ideally in the morning and evening
- Blood pressure recording continues for at least 4 days, ideally 7 days. Discard measurements taken on the first day and use the average value of all the remaining measurements
When should white coat hypertension be suspected?
Raised clinic blood pressure readings with HBPM or ABPM lower with a discrepancy of more than 20/10mmHg – may also exhibit signs in clinic such as tachycardia, sweating or palpitations
Emergencies – who would you refer for same-day specialist care?
- Accelerated hypertension - BP >180/110 with signs of papilloedema/retinal haemorrhage
- Suspected phaeochromocytoma – labile or postural hypotension, headache, palpitations, pallor, diaphoresis
What should be done if stage 1 hypertension is found in an individual under 40 years of age?
- Consider seeking specialist evaluation of secondary causes of hypertension
- Conduct a more detailed assessment of potential organ damage
For what stage of hypertension is drug treatment offered straight away without lifestyle management trialled first?
Stage 2 or above
When should drug treatment be offered without first attempting lifestyle intervention to individuals with stage 1 hypertension?
Target organ damage
Established CVS disease
Renal disease
Diabetes
10-year CVS risk calculated by QRISK2 to be >20%
How should patients with hypertension be monitored?
- Lifestyle measures - follow up every 3 or 4 months until blood pressure is well controlled or antihypertensive drug treatment is started
- Starting drug treatment – follow up after at least 4 weeks for treatment effects to stabilise
Once blood pressure is well-controlled, how often should they be reviewed?
annually
What is done in the annual hypertension review?
- Discuss lifestyle, symptoms, medication and adverse effects
- Check clinic blood pressure
- Check renal function –
- U&Es, eGFR
- Urine dipstick to check for proteinuria
- QRISK3 for those not on antiplatelet or statin
- Offer details of where they can get more information about hypertension
What are the different stages of hypertension?
- Stage 1 hypertension
- Clinic reading >140/90
- Ambulatory/home readings >135/85
- Stage 2 hypertension
- Clinic reading >160/100
- Ambulatory/home readings >150/95
- Severe hypertension
- Clinic systolic blood pressure >180 or clinic diastolic pressure at least 110
- Accelerated hypertension
- Clinic blood pressure usually higher than 180/110 with signs of papilloedema and/or retinal haemorrhage
List some causes of secondary hypertension.
- Renal disorders –
- LITERALLY ANY - apckd, diabetic nephropathy
- Vascular disorders –
- coarctation of aorta
- renal artery stenosis - particularly if not responding to medical treatment
- Endocrine
- primary hyperaldosteronism (conns)
- phaeochromocytoma
- Cushing’s syndrome
- Acromegaly
- Hypothyroidism
- Hyperthyroidism
What questions can you ask to screen for end-organ damage and complications of hypertension?
- Hypertensive retinopathy - Any problems with vision?
- Hypertensive nephropathy - Decreased urinary frequency? Fatigue? Pruritus?
- CVD - Previous MI? Previous stroke?
- Heart failure - Peripheral oedema? SOB?
How do you decide which anti-hypertensive to prescribe?
What are the signs of hypertensive retinopathy?
Keith-Wagener Classification
Stage 1: Mild narrowing of the arterioles
Stage 2: Focal constriction of blood vessels and AV nicking
Stage 3: Cotton-wool patches, exudates and haemorrhages
Stage 4: Papilloedema
