Clinical therapeutics + workshops Flashcards
What is primary hypertension?
90-95%; no apparent cause
What is secondary hypertension?
5%, secondary to another problem
- Endocrine gland disorders:
- Cushing’s syndrome
- Hyperaldosteronism (Conn’s syndrome)
- Kidney diseases:
- Polycystic kidney disease
- Kidney tumor
- Kidney failure
- Drugs induced:
- Anti-inflammatory corticosteroids
- NSAIDs
- Weight loss pills
- Birth control pills
How is hypertension diagnosed?
Measure in both arms:
If the difference is more than 15mmHg, repeat.
If the difference in readings between arms remains more than 15mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading.
If blood pressure measured in the clinic is 140/90mmHg or higher:
Take a second measurement during the consultation, If the second measurement is substantially different from the first, take a third measurement.Record the lower of the last two measurements as the clinic blood pressure.
If clinic blood pressure is between 140/90mmHg and 180/120mmHg, offer ambulatory blood pressure monitoring (ABPM) or HBPM to confirm the diagnosis of hypertension.
While waiting for confirmation of a diagnosis of hypertension, carry out investigations for target organ damage, followed by formal assessment of cardiovascular risk using a cardiovascular risk assessment tool
When using ABPM to confirm a diagnosis of hypertension, ensure that at least 2measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension.
When using HBPM to confirm a diagnosis of hypertension, ensure that:
for each blood pressure recording, 2 consecutive measurements are taken, at least 1minute apart and with the person seatedand blood pressure is recorded twice daily, ideally in the morning and eveningand blood pressure recording continues for at least 4days, ideally for 7days. Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension.
Confirm diagnosis of hypertension in people with a:
clinic blood pressure of 140/90 mmHg or higherand ABPM daytime average or HBPM average of 135/85 mmHg or higher.
What are the three stages of hypertension?
Stage 1 hypertension
Clinic - 140/90 to 159/99mmHg and ABPM from 135/85 to 149/94mmHg.
Stage 2 hypertension
Clinic - 160/100 to 179/119 mmHg and ABPM 150/95+
Stage 3 or severe hypertension
Clinic systolic 180mmHg or higher or clinic diastolic 120mmHg or higher.
What are the 5 lifestyle changes to reduce BP?
- Stopping smoking
- Reduce alcohol intake
- Reduce weight if obese (Target BMI of 20 – 25)
- Reduce salt intake
- Regular physical exercise > 30 mins 5 x week
Why are ACEi and ARBs used for hypertension?
- Either prevents formation or action of Angiotensin II (a vasoconstrictor)
- Arterial and venous dilatation
- Increase K+ by reducing aldosterone
- 1st choice for patients aged <55 years as high renin and therefore better response
- 1st choice in diabetic patients due to renoprotective effects
What are the 5 side effects of ACEIs?
- First dose hypotension - especially in those who are volume depleted i.e. elderly on high dose diuretics.
- Start low and increase slowly. Advise to start when not rushing out of the house (NB night is not always best!)
- Persistent dry cough (1 in 10 snd can occur after years)
- Problematic in renal artery stenosis; check U&Es within 14 days of dose increase.
- Hyperkalaemia in those also taking potassium sparing diuretics
Why are CCBs used for hypertension?
- Interfere with inward displacement of calcium ions through the channels into cell membranes. Relaxation of vascular smooth muscle causes vasodilatation.
- Three types of CCB
- Dihydropyridines (amlodipine) which cause vasodilation of coronary and peripheral blood arteries with little effect on heart rate
- Benzothiazipine (diltiazem) a rate limiting drug which reduces heart rate
- Phenylalkalamines (verapamil) a rate limiting drug which reduces heart rate
- 1st line for patients over 55 years or black African or African–Caribbean family origin and not diabetic.
- Contraindicated for those with evidence of or high risk of heart failure
What are the 5 side effects of CCBs?
- headaches
- abdominal pain
- flushing
- impotence
- ankle oedema.
Why are diuretics used for hypertension?
- Ineffective if eGFR less than 30.
- If starting or changing diuretic treatment for hypertension, offer a thiazide-like diuretic in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide.
- For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment.
What are the side effects of diuretics?
- gastro-intestinal side effects
- altered plasma lipid concentrations
- impotence
- hyponatraemia
- hyperglycaemia (caution diabetes esp. with beta blockers)
- hyperuricaemia
What is GRACE scoring?
6 month mortality from ACS (Lowest risk; <1.5%, highest risk >9%)
What are the most common symptoms of hypos?
- shaking
- sweating
- hunger
- tiredness
- blurred vision
- lack of concentration
- headaches
- Feeling tearful or moody
- going pale
What is diabetic ketoacidosis?
- Consistently high blood glucose levels can lead to diabetic ketoacidosis
- A severe lack of insulin means the body cannot use glucose for energy, and fat is used as an alternative energy source.
- Ketones are the by-product of this process and can build up and cause the body to become acidic
- DKA is life-threatening and requires admission to hospital for IV insulin and fluids
What are the order of treatments for T2DM?
- Metformin
- SGLT2 inhibitors
- DPP-4 inhibitors or Sulfonylureas or Pioglitazone
- Incretin mimetics (GLP-1 agonist)
- Insulin
