Clinical Aspects of Hypertension Flashcards
Why is out-of-office blood pressure testing recommended?
o confirm the diagnosis, titrate BP-lowering medication, and monitor BP control, often alongside telehealth or clinical interventions.
What does NICE recommend for blood pressure monitoring?
NICE recommends out-of-office (OOO) measurements as the preferred method for monitoring blood pressure.
What is hypertension?
Hypertension is when there is an increase in peripheral vascular resistance with normal cardiac output, defined as blood pressure >140/90 mmHg.
What percentage of hypertension cases are primary vs. secondary?
98% of hypertension cases are primary, and 2% are secondary.
When should patients under 40 be investigated for hypertension?
NICE recommends investigating all hypertensives under age 40, as they are more likely to have secondary causes.
What medical conditions can cause secondary hypertension?
Chronic kidney disease, primary hyperaldosteronism, renovascular disease, Cushing’s syndrome, pheochromocytoma, aortic coarctation, thyroid disease, parathyroid disease, and sleep apnea.
How does blood pressure in a clinical setting compare to home readings?
Home blood pressure readings are generally 10 mmHg lower than office readings.
Which medications can cause secondary hypertension?
NSAIDs, oral contraceptives, adrenal steroids, sympathomimetics, cyclosporine, tacrolimus, erythropoietin, ephedra, cocaine, amphetamines, and excessive alcohol.
What is primary hyperaldosteronism?
A rare cause of secondary hypertension, responsible for 1-2% of unselected hypertensives, caused by adrenal adenoma (30%) or hyperplasia (70%).
What organs are commonly damaged by hypertension?
Kidneys, heart (leading to thickening and myocardial infarction), and brain (leading to cerebral hemorrhage and neurological damage).
What type of hypertrorphy increase risk of cardiovascular disease?
Left ventricular hypertrophy
What is left ventricular hypertrophy?
Increased mass in left ventricular mass, either due to thickness of ventricle or left ventricular cavity enlargement
What physical signs suggest secondary hypertension or organ damage?
Features of Cushing syndrome, enlarged kidneys, abdominal murmurs (renal hypertension), precordial murmurs, diminished femoral pulses, and delayed femoral blood pressure.
What are the different examinations for hypertension?
Skin stigmata of neurofibromatosis (because increased phaeochromocytoma)
Palpation of enlarged kidneys (autosomal dominant polycystic kidneys associated with hypertension)
Auscultation of abdominal murmurs (renovascular hypertension) - suggests stenosis
Ascultation of precordial or chest murmurs (aortic coarctioation or aortic disease)
Fundoscopy: check retinas
What is diminished/delayed during end organ damage from hypertension?
Diminishes and delayed femoral and reduced femoral blood pressure (aortic coartation, aortic disease)
What are signs of organ damage from hypertension?
Brain: murmurs over neck arteries, motor sensory defects
Retina: funduscopic abnormalities
Heart: location and characteristics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales, dependent oedema
Peripheral arteries: absence, reduction or asymmetry of pulses, cold extremities, ischemic lesions
Auscultation of cardiovascular vein: atherosclerosis
What are current blood pressure targets for treating hypertension?
BHS 2019: <140/90 mmHg
ESH/ESC 2023: <140/90 mmHg, or <130/80 if tolerated with medication
USA 2017: <130/80 mmHg.
What is the importance of blood pressure control, according to recent trials?
Intensive monitoring and lowering of blood pressure reduces the risk of cardiovascular diseases.
What lifestyle changes can help manage hypertension?
Smoking cessation, weight reduction, reducing alcohol intake, physical exercise, reducing salt, and increasing fruit/vegetable intake while decreasing saturated and total fats.
Describe the path of antihypertensive drug treatment of a patient aged under 55 years.
1) ACE (A)
2) ACE + Calcium Channel Blocker (A + C^2)
3) ACE + Calcium Channel Blocker + Thiazide-like diuretic (A + C + D)
4) A + C + D + consider further diuretic 3/4, or alpha-or beta-blocker
Describe the path of antihypertensive drug treatment of a patient aged over 55 years or from African or Caribbean family origin of any age.
1) Calcium Channel Blocker (C^2)
2) ACE + Calcium Channel Blocker (A + C^2)
3) ACE + Calcium Channel Blocker + Thiazide-like diuretic (A + C + D)
4) A + C + D + consider further diuretic 3/4, or alpha-or beta-blocker
What is another system that can be adopted (dual combination)?
A + C or D (1pill)
What is another system that can be adopted (triple combination)?
A + C + D (1pill)
What is another system that can be adopted (triple combination)?
Resistant hypertension, add spironolactone or further diuretic (2 pills)
