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pre reg afsha CV > CV - hypertension > Flashcards

CV - hypertension Flashcards

1
Q

Define hypertension

A

Persistently raised arterial BP

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2
Q

Hypertension is a major risk factor for

A
  • Stroke
  • MI
  • Heart failure
  • CKD
  • Cognitive decline
  • Premature death
  • Premature morbidity and mortality
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3
Q

Hypertension is more common in

A
  • Advancing age
  • Woman 65-74
  • Black African or Afro-Caribbean origin
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4
Q

Risk factors for hypertension

A
  • Advancing age
  • Woman 65-74
  • Black African or Afro-Caribbean origin
  • Social deprivation
  • Lifestyle factors
  • Anxiety
  • Emotional stress
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5
Q

Aims of treatment

A
  • Reduce CV morbidity and mortality, including MI and stroke, by lowering BP
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6
Q

In patients with suspected or diagnosed hypertension, what investigations do you need to carry out

A

In patients with suspected or diagnosed hypertension, carry out investigations for target organ damage & assess CVD risk using a CV risk assessment tool and clinic BP measurements

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7
Q

Non drug treatment, in both suspected and diagnosed hypertension

A

○ Offer lifestyle advice and support to enable pt to make healthy lifestyle changes to reduce BP
- Give advice about benefits of
○ Regular exercise
○ Healthy diet
○ Low dietary sodium intake
○ Reduced alcohol intake (if excessive)
○ Discourage excessive consumption of coffee and other caffeine-rich products
○ Offer advice to help smokers to stop smoking

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8
Q

What to do if a patient presents with a BP of 140/90 or higher when measured in clinic

A

○ Offer ABPM or home BP monitoring if ABPM unsuitable
○ This is used to confirm the diagnosis and stage of hypertension

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9
Q

Stage 1 Hypertension

A

○ Clinic BP ranging from 140/90 to 159/99
○ Ambulatory daytime average or home BP average ranging from 135/85-149/94

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10
Q

Treatment of S1H in patients under 80

A

Discuss starting antihypertensive drug treatment with pt under 80 who have S1H if they have one or more of the following
- Target organ damage (e.g. left ventricular hypertrophy, CKD, hypertensive retinopathy)
- Established CVD
- Renal disease
- Diabetes
- 10 year CV risk ≥10%

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11
Q

When can you consider treatment of S1H in patients under 60

A

Consider antihypertensive drug treatment for under 60s with S1H and estimated 10 year CV risk below 10%

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12
Q

Treatment of patients with S1H who are over 80

A

Consider antihypertensives for over 80s with clinic BP over 150/90mmHg

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13
Q

Treatment of patients with S1H who are under 40

A

Consider seeking specialist advice for evaluation of secondary causes of hypertension

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14
Q

Stage 2 hypertension

A

Clinic BP of 160/100 or higher, but less than 180/120
Ambulatory daytime average or home BP average of 150/95 or higher

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15
Q

Treatment: S2H

A

Treat all patients regardless of age

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16
Q

Severe hypertension

A

○ Clinic systolic BP of 180 or higher, or a clinic diastolic BP of 120 or higher
○ Treat PROMPTLY
○ May require same day specialist referral

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17
Q

What is phaeochromocytoma

A

Small vascular tumour of the adrenal medulla, causing irregular secretion of adrenalin and noradrenaline leading to attacks of raised blood pressure, palpitations, and headache.

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18
Q

Referral for same day specialist assessment if patient has suspected phaechromocytoma - what are the signs?

A

○ Labile or postural hypotension
○ Headache
○ Palpitations
○ Pallor
○ Abdominal pain
○ Diaphoresis (sweating)

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19
Q

When does severe hypertension warrant referral for same day specialist assessment?

A

If clinic BP of 180/120 or higher with signs of
○ Retinal haemorrhage or papilloedema (accelerated hypertension)
○ Or life threatening symptoms e.g. new onset confusion, chest pain, signs of heart failure or AKI
○ Suspected phaeochromocytoma (for example labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis).

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20
Q

What to do if patients have severe hypertension

A

○ Clinic systolic BP of 180 or higher, or a clinic diastolic BP of 120 or higher
○ Treat PROMPTLY
○ If they have no symptoms or signs indicating the need for same day referral, carry out investigations of target organ damage ASAP
○ If identified, consider starting antihypertensive drug treatment immediately without waiting for results of ABPM or home BP monitoring
○ If no target organ damage identified, repeat clinic BP measurement within 7 days

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21
Q

Hypertension treatment targets for under 80s - clinic & at home/ABPM

A
  • Clinic BP should be reduced and maintained to below 140/90
  • For ambulatory or home BP monitoring (during the pt waking hours), average BP should be maintained at below 135/85 mmHg
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22
Q

Hypertension treatment targets for over 80s - clinic & at home/ABPM

A
  • Clinic BP should be reduced and maintained to below 150/90
  • For ambulatory or home BP monitoring (during the pt waking hours), average BP should be maintained at below 145/85
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23
Q

Is it true that response to drug treatment may be affected by age and ethnicity

A

Yes

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24
Q

Using an ACEi + ARB for treatment of hypertension

A

NOT recommended

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25
Q

If the patient is black African or Afro-Caribbean, consider an … instead of an ….

A

ARB instead of ACEi

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26
Q

If ACEi not tolerated, what should you offer instead

A

ARB

27
Q

If CCB not tolerated, what should you offer instead

A

Thiazide-like diuretic

28
Q

If starting or changing diuretic treatment for hypertension - TLD or thiazide?

A
  • Offer thiazide-like diuretics (e.g. indapamide) in preference to conventional thiazide diuretics (e.g. bendro or hydrochlorothiazide)
  • Continue current treatment in pt with hypertension who already have stable, well controlled BP whilst on bendro or hydrochlorothiazide
29
Q

What is isolated systolic hypertension and how would you treat it

A
  • When systolic (top number) BP is 160 or more
  • Offer pt the same treatments as you would with both raised systolic & diastolic BP
30
Q

Treatment pathway for hypertension with T2D in all patients, or hypertension w/o T2D in 55 or below and NOT black

A
  1. ACEi or ARB
    • CCB or thiazide like diuretic
    • Offer thiazide like diuretic if evidence of heart failure
  3. ACEi or ARB + CCB + thiazide-like diuretic
  4. Resistant hypertension treatment
31
Q
  1. ACEi or ARB
    • CCB or thiazide like diuretic
    • Offer thiazide like diuretic if evidence of heart failure
  3. ACEi or ARB + CCB + thiazide-like diuretic
  4. Resistant hypertension treatment
A

Treatment pathway for hypertension with T2D in all patients, or hypertension w/o T2D in 55 or below and NOT black

32
Q

Resistant hypertension - what do you need to do before considering treating, and how would you treat it

A
  • Before considering further treatment for a person with resistant hypertension, confirm elevated clinic BP measurements using ABPM or home BP recordings, assess for postural hypotension and discuss adherence
  • If further treatment required, consider seeking specialist advice or addition of low-dose spironolactone (unlicensed indication) if potassium is 4.5mmol/L or less; or an alpha blocker or beta blocker of potassium more than 4.5mmol/L
  • When using further diuretic therapy for step 3 treatment of resistant hypertension, monitor blood sodium potassium and renal function within 1 month of starting treatment and repeat as needed thereafter
  • Seek specialist advice if BP remains uncontrolled despite taking optimal tolerated doses of 4 drugs
33
Q

Hypertension treatment pathway for patients w/o T2D and 55 and over, or all black African or Afro Caribbean origin w/o T2D

A
  1. CCB
    • ACEi or ARB or thiazide like diuretic
  3. ACEi or ARB + CCB + thiazide like diuretic
  4. Resistant hypertension
34
Q
  1. CCB
    • ACEi or ARB or thiazide like diuretic
  3. ACEi or ARB + CCB + thiazide like diuretic
  4. Resistant hypertension
A

Hypertension treatment pathway for patients w/o T2D and 55 and over, or all black African or Afro Caribbean origin w/o T2D

35
Q

Hypertension in diabetes - how should it be treated, and why should it be treated?

A
  • Should be treated aggressively with lifestyle modification and drug treatment
  • Lowering BP in pt with diabetes reduces risk of macrovascular and microvascular complications
36
Q

Hypertension targets for under 80s with T1D

A
  • If urine ACR less than 70mg/mmol: target is below 140/90
  • If ACR is 70mg/mmol or more: target is below 130/80
37
Q

Hypertension targets for over 80s with T1D

A

Aim for clinic BP below 150/90 regardless of ACR

38
Q

Drug treatment for hypertension in pt with T1D

A
  • If drug treatment required, start a trial of renin-angiotensin system blocking drug as 1st line for hypertension in pt with T1D
  • Potential SE should not prevent use of a particular class of drug in order to control BP, unless SE become symptomatic or otherwise clinically significant
    • In particular
      • Selective beta-blockers should not be avoided where indicated for adults on insulin
      • Low dose thiazides may be used in combination with beta-blockers
      • Only long acting preparations of CCB should be used
39
Q

Hypertension thresholds in renal disease & drug treatment

A
  • Target clinic BP below 140/90 recommended in pt with renal disease (CKD) and an ACR less than 70mg/mmol
  • BP below 130/80 advised in pt with CKD and ACR or 70mg/mmol or more
  • If possible, offer treatment with drugs that only need to be taken OD
40
Q

% of pregnancies affected by hypertensive disorders

A

Hypertensive disorders during pregnancy affect ~8-10% of all pregnant females

41
Q

Why is hypertension during pregnancy bad

A

Complications can be associated with significant morbidity and mortality to the mother and baby

42
Q

Types of hypertension that may exist in pregnancy

A
  • Can exist before pregnancy
  • Can be diagnosed in the first 20 weeks of gestation (known as chronic hypertension)
  • Can occur as new-onset hypertension after 20 weeks gestation (gestational hypertension)
  • Can occur after 20 weeks gestation with features of multi-organ involvement (pre-eclampsia)
43
Q

Symptoms of pre eclampsia include

A
  • Severe headache
  • Problems with vision
  • Severe pain below ribs
  • Vomiting
  • Sudden swelling of hands, feet or face
  • Accompanies with significant proteinuria
  • BP more than 140/90
44
Q

You find that a pregnant woman has hypertension. What would you do?

A

Refer all pregnant women with hypertension to specialist

45
Q

You see a pregnant lady. She has her first episode of hypertension after 20 weeks gestation. What would you do?

A

Refer to secondary care to be seen within 24 hours

46
Q

What would you do if a pregnant lady had severe hypertension (160/110 or higher)

A

Urgent referral to secondary care for same day assessment - urgency should be determined by overall clinical assessment

47
Q

What is severe hypertension in pregnancy

A

160/110 or higher

48
Q

Risk factors for developing pre-eclampsia during pregnancy

A
  • CKD
  • Diabetes mellitus
  • Autoimmune disease
  • Chronic hypertension
  • Have had hypertension during previous pregnancy
49
Q

Why are some pregnant women advised to take aspirin

A
  • Women with risk factors for developing pre-eclampsia are advised to take aspirin (unlicensed indication) from week 12 of pregnancy until baby is born
  • Women with more than one moderate risk factors for developing pre-eclampsia are also advised to take aspirin
50
Q

Moderate risk factors for developing pre-eclampsia

A
  • First pregnancy
  • Older than 40
  • Pregnancy interval of more than 10 years
  • BMI above 35 at first visit
  • Multiple pregnancy
  • FHx pre-eclampsia
51
Q

What to do if there is a pregnant female with chronic hypertension who is already receiving antihypertensive treatment

A
  • Refer to specialist
  • Have drug therapy reviewed
  • Stop ACEI, ARB, thiazide or thiazide-like diuretics - increased risk of congenital abnormalities
52
Q

Who should be offered antihypertensive drug treatment? (pregnancy)

A

Females with pre-eclampsia, gestational or chronic hypertension who present with sustained BP of 140/90 or higher should be offered antihypertensives

53
Q

Name the drugs given to pregnant women for hypertension

A
  • 1st line oral labetalol to achieve target BP of less than 135/85
  • If labetalol unsuitable, consider nifedipine MR (unlicensed)
  • If both are unsuitable, consider methyldopa (unlicensed)
54
Q

Females with BP more than 160/110 who require critical care during pregnancy or after birth should receive immediate treatment of:

A

Either oral or IV labetolol HCl,
IV hydralazine HCl, or
oral nifedipine MR to achieve target BP of 135/85 or less

55
Q

Use of magnesium sulphate in pregnancy

A
  • Give IV magnesium sulfate to females in critical care setting with severe hypertension or severe pre-eclampsia or if they have or have previously had an eclamptic fit
  • Consider IV magnesium sulphate in severe pre-eclampsia if birth is planned within 24 hours
56
Q

Drug treatment to consider in females with pre-eclampsia where early birth is considered likely within 7 days..

A

Consider a course of antenatal CCs for fetal lung maturation

57
Q

Antihypertensives after birth & considerations for breast feeding

A
  • Appropriate antihypertensives should be continued if required after birth (dose adjustment according to BP)
  • Females who have been managed with methyldopa during pregnancy should discontinue treatment within 2 days of giving birth and switch to alternative antihypertensive
  • Post-birth, advise females with hypertension that the need to take antihypertensives does not prevent them from BF should they wish to do so
    - Although very low levels can pass into breast milk, and most medicines are not tested in pregnant or BF women
  • For women who decide to BF, 1st line to treat hypertension during postnatal period is ENALAPRIL MALEATE
  • Monitor maternal renal function and serum potassium
58
Q

1st line to treat hypertension during postnatal period if the mother is breast feeding

A

Enalapril maleate
Monitor renal function and serum potassium

59
Q

Drug treatment to treat hypertension during postnatal period in a patient who is of black African or Afro-Caribbean family origin who decided to breastfeed

A

Consider 1st line nifedipine or amlodipine

60
Q

Add on treatment if BP not controlled with single drug in the postnatal period to women who are breastfeeding

A
  • 1st line enalapril, or 1st line nifedipine or amlodipine if black
  • If not controlled, consider combination of nifedipine (or amlodipine) + enalapril
  • If this combination is not tolerated or ineffective consider either adding labetalol or atenolol to the combination treatment or swapping one of the medicines being used for labetalol or atenolol
61
Q

Females with hypertension in postnatal period who are not and do not plan to breastfeed

A

Treat in the same as patients who are not pregnant/breastfeeding - follow normal hypertension pathway

62
Q

When should BP monitoring be considered in babies

A
  • Born to mothers taking antihypertensives and are breastfeeding
  • Mothers to monitor their babies for any adverse reactions e.g. drowsiness, lethargy, pallor, cold peripheries, poor feeding
63
Q

Reviews of medications in females who have given birth/been treated for hypertension during pregnancy

A
  • Following birth, females remaining on antihypertensives should have their treatment reviewed 2 weeks after birth
  • Females treated for hypertension during pregnancy should have a medical review 6-8 weeks after birth with their GP or specialist

pre reg afsha CV (38 decks)

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