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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
If the patient is black African or Afro-Caribbean, consider an ... instead of an ....
ARB instead of ACEi
26
If ACEi not tolerated, what should you offer instead
ARB
27
If CCB not tolerated, what should you offer instead
Thiazide-like diuretic
28
If starting or changing diuretic treatment for hypertension - TLD or thiazide?
- 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
What is isolated systolic hypertension and how would you treat it
- When systolic (top number) BP is 160 or more - Offer pt the same treatments as you would with both raised systolic & diastolic BP
30
Treatment pathway for hypertension with T2D in all patients, or hypertension w/o T2D in 55 or below and NOT black
1. ACEi or ARB 2. + 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
1. ACEi or ARB 2. + 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
Treatment pathway for hypertension with T2D in all patients, or hypertension w/o T2D in 55 or below and NOT black
32
Resistant hypertension - what do you need to do before considering treating, and how would you treat it
- 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
Hypertension treatment pathway for patients w/o T2D and 55 and over, or all black African or Afro Caribbean origin w/o T2D
1. CCB 2. + ACEi or ARB or thiazide like diuretic 3. ACEi or ARB + CCB + thiazide like diuretic 4. Resistant hypertension
34
1. CCB 2. + ACEi or ARB or thiazide like diuretic 3. ACEi or ARB + CCB + thiazide like diuretic 4. Resistant hypertension
Hypertension treatment pathway for patients w/o T2D and 55 and over, or all black African or Afro Caribbean origin w/o T2D
35
Hypertension in diabetes - how should it be treated, and why should it be treated?
- Should be treated aggressively with lifestyle modification and drug treatment - Lowering BP in pt with diabetes reduces risk of macrovascular and microvascular complications
36
Hypertension targets for under 80s with T1D
- 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
Hypertension targets for over 80s with T1D
Aim for clinic BP below 150/90 regardless of ACR
38
Drug treatment for hypertension in pt with T1D
- 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
Hypertension thresholds in renal disease & drug treatment
- 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
% of pregnancies affected by hypertensive disorders
Hypertensive disorders during pregnancy affect ~8-10% of all pregnant females
41
Why is hypertension during pregnancy bad
Complications can be associated with significant morbidity and mortality to the mother and baby
42
Types of hypertension that may exist in pregnancy
- 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
Symptoms of pre eclampsia include
- 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
You find that a pregnant woman has hypertension. What would you do?
Refer all pregnant women with hypertension to specialist
45
You see a pregnant lady. She has her first episode of hypertension after 20 weeks gestation. What would you do?
Refer to secondary care to be seen within 24 hours
46
What would you do if a pregnant lady had severe hypertension (160/110 or higher)
Urgent referral to secondary care for same day assessment - urgency should be determined by overall clinical assessment
47
What is severe hypertension in pregnancy
160/110 or higher
48
Risk factors for developing pre-eclampsia during pregnancy
- CKD - Diabetes mellitus - Autoimmune disease - Chronic hypertension - Have had hypertension during previous pregnancy
49
Why are some pregnant women advised to take aspirin
- 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
Moderate risk factors for developing pre-eclampsia
- First pregnancy - Older than 40 - Pregnancy interval of more than 10 years - BMI above 35 at first visit - Multiple pregnancy - FHx pre-eclampsia
51
What to do if there is a pregnant female with chronic hypertension who is already receiving antihypertensive treatment
- Refer to specialist - Have drug therapy reviewed - Stop ACEI, ARB, thiazide or thiazide-like diuretics - increased risk of congenital abnormalities
52
Who should be offered antihypertensive drug treatment? (pregnancy)
Females with pre-eclampsia, gestational or chronic hypertension who present with sustained BP of 140/90 or higher should be offered antihypertensives
53
Name the drugs given to pregnant women for hypertension
- 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
Females with BP more than 160/110 who require critical care during pregnancy or after birth should receive immediate treatment of:
Either oral or IV labetolol HCl, IV hydralazine HCl, or oral nifedipine MR to achieve target BP of 135/85 or less
55
Use of magnesium sulphate in pregnancy
- 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
Drug treatment to consider in females with pre-eclampsia where early birth is considered likely within 7 days..
Consider a course of antenatal CCs for fetal lung maturation
57
Antihypertensives after birth & considerations for breast feeding
- 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
1st line to treat hypertension during postnatal period if the mother is breast feeding
Enalapril maleate Monitor renal function and serum potassium
59
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
Consider 1st line nifedipine or amlodipine
60
Add on treatment if BP not controlled with single drug in the postnatal period to women who are breastfeeding
- 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
Females with hypertension in postnatal period who are not and do not plan to breastfeed
Treat in the same as patients who are not pregnant/breastfeeding - follow normal hypertension pathway
62
When should BP monitoring be considered in babies
- 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
Reviews of medications in females who have given birth/been treated for hypertension during pregnancy
- 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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