Condition- Hypertension Flashcards
What is hypertension
Systolic > 140 mm Hg and/or diastolic > 90 mm Hg measured on three separate occasions with no secondary cause identified
What are the two main classifications of hypertension (according to aetiology) which type of HT is more common?
- Primary (essential) hypertension
- idiopathic so no know cause
- Most COMMON (90%)
- Secondary
- Isolated systolic Hypertension- stiffening of large arteries
- Malignant hypertension- rapid rise in BP causing vasuclar damage
Give some examples of causes of secondary hypertension (go through systems)
RENAL:
- renal artery stenosis
- chronic glomerulonephritis
- chornic pyelonephritis
- Chronic renal failure
- Renovascular disease
ENDO:
- DM
- Hyperthyroidism
- Cushings
- Conns
- HPT
- Phaeochromocytoma
- Congenital adrenal hyperplasia
- Acromegaly
CVS:
- aortic coarction
- Increase intravascular volume
What is isolated systolic hypertension?
Caused by stiffening of the large arteries (arteriosclerosis)
Most common form in the UK – affects >50% of the over 60s
Which syndrome in pregnant women can cause HT?
Pre-eclampsia
List some drugs that could cause HT
Sympathomimetics
Corticosteroids
COCP
List some symptoms that hypertensive patients may present with.
Usually ASYMPTOMATIC
- Symptoms of complications: retinopathy, nephropathy, IHD, HF, PVD
- Symptoms of cause
- Scotomas: visual field loss
- Blurred vision
- Headaches
- Seizures
- SOB- if congestive HF
- Chest pain
What are the three objectives when managing a patient with Hypertension?
- Look for risk factors
- Identify cause of HT
- Target organ damage
What is the criteria for concluding that a patient has hypertension?
- Blood pressure measured if >140/90mmHg measure a further two times and take lower of last two
- If BP>140/90mmHg offer ABPM or HBPM
- If BP > 180/110mmHg start immediately on Tx, check for end organ damage and refer to phaeo specialist if suspected (6Ps)
What signs on physical examintion of a patient could give you an idea about the cause of the hypertension…
- CVS: Radiofemoral delay = coarctation of the aorta distal to the left subclavian artery
- RENAL: Renal artery bruit = renal artery stenosis,Palpable kidneys
- ENDO: Signs of phaeochromocytoma or Cushing’s
List how you would asses target organ damage?
- CVS: ECG to see signs of LV hypertrophy, might hear S4
- RENAL: urine dip (proteinuria, haematouria), U&Es and eGFR
- EYES: Retinal fundoscopy
HARDER: What grading system is used to grade the extent of hypertensive retinopathy. And go through the characteristics of each grade…
Keith Wagner Classification
- Grade I: Silver wiring (silver line down the middle of arterioles)
- Grade II: Silver wiring + AV nipping (artery crosses the vein and nips it as it crosses, causing vein to become narrow due to high pressure in artery)
- Grade III: Flame haemorrhage, sometimes cotton wool spots too
- Grade IV: papilloedema (cannot see optic disc) – these can be either due to chronic hypertension or intracranial hypertension (caused by a brain tumour), requires admission
Which investigations would you order for someone with hypertension?
Aims: Assess risk factors, aetiology and target organ damage
- Bloods: U+Es, glucose, lipid profile, renin, aldosterone, catecholamines, K+ (low in Conn’s), Ca2+ (High in HPT)
- Urine Dipstick: protein and blood
- ECG: LV hypertrophy or ischaemia
- ABPM: to exclude white coat hypertension
What advice could you give to a patient with hypertension?
- smoking cessation
- Lose weight
- reduce alcohol intake
- reduce dietary sodium
When would you give ACEi or ARB as first line treatment for hypertension?
- If SBP>160 or DBP > 100 or evidence of end-organ damage. Medical treatment is recommended
- ACEi or ARB if:
- <55yrs
- Diabetic
- HF
- LV dysfunction
Which drug is prescribed as first line treatment for hypertension for people >55yrs and Afro-carribeans (not T2DM) and why?
- CCBs (amlodipine) or Thiazide-like diuretics
- Because these patients have low renin production anyways and they are salt sensitive.
What’s second and third treatment for hypertension?
- 2nd: ACEi + CCB/ thiazide-like diuretic. ARB is preferred over ACEi in >55s and Afro-carribean
- 3rd: ACEi + CCB + thiazide-like diuretic
If a patient’s hypertension is not controlled by triple therapy what is it classifed as and which medications could you prescribe…?
RESISTENT HYPERTENSION:
- If K+ < 4.5 mmol
- Low dose spironolactone
- if K+>4.5 mmol
- Alpha-blocker (can be used in patients with prostate disease)
- or Beta-blocker- can cause diabetes, contraindicated in asthmatics and HF patients
List the complications of hypertension…
- Heart Failure
- Coronary artery disease
- Cerebrovascular disease
- Peripheral vascular disease
- Emboli
- Hypertensive retinopathy
- Renal Failure
Describe the features of Grade I hypertensive retinopathy from the Keith-Wagner Classification
Grade I: Silver wiring (silver line down the middle of arterioles)
Describe the features of Grade II hypertensive retinopathy from the Keith-Wagner Classification
Grade II: Silver wiring + AV nipping (artery crosses the vein and nips it as it crosses, causing vein to become narrow due to high pressure in artery)
Describe the features of Grade III hypertensive retinopathy from the Keith-Wagner Classification
Grade III: Flame haemorrhage, sometimes cotton wool spots too
Describe the features of Grade IV hypertensive retinopathy from the Keith-Wagner Classification
Grade IV: papilloedema (cannot see optic disc) – these can be either due to chronic hypertension or intracranial hypertension (caused by a brain tumour), requires admission
What is Stage 1 Hypertension according to NICE?
- Clinic SBP >140/90mmHg
- ABPM/ HBPM > 135/85mmHg
What is Stage 2 Hypertension according to NICE?
- Clinic BP > 160/ 100mmHg
- ABPM/ HBPM > 150/95mmHg
What is severe Hypetension / Stage 3 according to NICE?
- Clinic SBP > 180mmHg
- or DBP > 110 mmHg
