CVS: hypertension Flashcards
What is stage 1 hypertension (values)?
clinic and HBPM
- clinic: 140/90- 159/99
- AND subsequent HBPM 135/85 - 149/94
What is stage 2 hypertension (values)?
- clinic: 160/100 - 180/120
- AND subsequent HBPM average 150/95 or higher
What is stage 3 or severe hypertension? (values)
clinic SBP >=180 or clinic DBP >=120
does not require HBPM/ABPM
What is accelerated (or malignant) HTN?
- severe increase in BP to >=180/120 with signs of retinal haemorrhage and/or papilloedema (new or progressive target organ damage)
What is ‘white coat’ HTN?
- occurs in 15-30% population. High BP in clinic, but normal in non threatening situations.
- discrepancy of >20/10 between clinic and average HBPM
Which renal disorders can cause secondary HTN?
- CKD (most common identifiable cause of HTN)
- chronic pyelonephritis
- diabetic nephropathy
- glomerulonephritis
- PKD
- obstructive uropathy
- renal cell carcinoma
What are other causes of secondary HTN (except renal)?
suspect in age <40, worsens suddenly, accelerated HTN
- vascular: coarctation of aorta, renal artery stenosis
- endocrine: primary hyperaldosteronism- adrenal adenoma (most common curable cause of HTN) - present with hypokalaemia, alkalosis, high sodium. (laparoscopic adrenalectomy)
- phaechromocytoma - intermittently high or labile BP, postural drop, headaches, sweating, palps, abdo pains (fatal if malignant transformation or catastrophic haemorrhage from tumour)
- Cushing’s
- Acromegaly
- Hypothyroidism (increased DBP)
- Hyperthyroidism (increased SBP)
- Drugs: alcohol, stimulant drugs, COCP, steroids, EPO, NSAIDS, HRT, venlafaxine.
- pregnancy, connective tissue disorders, OSA.
HTN increases risk of which conditions?
- Heart failure.
- Coronary artery disease.
- Stroke.
- Chronic kidney disease.
- Peripheral arterial disease.
- Vascular dementia.
How should BP be measured in clinic?
- relaxed, quiet, seated, arm supported
- check for pulse irregularity - manual BP if pulse irregular
- Both arms with right cuff size
- If difference between arms >15, use arm with higher reading.
- If falls/postural dizziness - check BP again with person standing for 1 min - if SBP falls by >=20, measure future BPs standing
- If >140/90, take 3 readings, record the lower of the last 2 measurements as the clinic BP.
If the persons clinic BP is 140/90 - 180/120, how should HTN be confirmed?
- ABPM
- HBPM if unsuitable/intolerable
How many readings are needed for ABPM?
- at least two measurements per hour are taken during the person’s usual waking hours
- Use average value of at least 14 measurements to confirm a diagnosis of hypertension.
How many readings are needed for HBPM?
- For each BP recording, two consecutive measurements are taken, at least 1 minute apart, with the person seated
*Blood pressure recorded twice daily, morning and evening. - for at least 4 days, ideally 7 days
- discard the first day
- use the average value of all the remaining measurements to confirm the diagnosis of HTN
If BP is 180/120 , how should pt be managed?
- Refer for same-day specialist assessment if there are:
- Signs of retinal haemorrhage and/or papilloedema (accelerated hypertension).
- Life-threatening symptoms: confusion, chest pain, heart failure, AKI.
- suspected pheochromocytoma (significant hypertension with symptoms such as abdominal pain, pallor, diaphoresis or headache)
- Consider if ‘extreme hypertension’ e.g. >220/120 mmHg
- If none of the above: treat in the community:
- investigate for target organ damage ASAP.
- consider Starting antihypertensive immediately- especially if damage identified (without waiting for HBPM)
- repeat BP <1 week to check response
What ABPM or HBPM reading confirms diagnosis of HTN?
- Clinic BP >=140/90 AND ABPM daytime average/HBPM average >= 135/85
Whilst waiting for confirmation of HTN diagnosis, perform investigations for target organ damage and formal Ax of CV Risk. Which investigations should be done?
Target organ damage:
* urine dip - haematuria
* Urine Albumin:Creatinine Ratio (ACR)
* HbA1C
* U&E
* Fundoscopy
* ECG (for LVH)
CVS risk:
* Lipids
How should CV risk be assessed?
- Measure serum total cholesterol and HDL cholesterol
- Use QRISK tool to estimate 10-year risk of developing CVD (use clinic BP measurements)
What lifestyle advice should be given for HTN?
- diet and exercise
- caffeine
- low dietary sodium
- smoking cessation
- reduce alcohol
offer info leaflets e.g patient decision aid for Rx
What is the management for stage 1 HTN?
- For age >80 with clinic BP >150/90
- Age <80 with: target organ damage, CVD, renal disease, diabetes, or QRISK >=10%
- Age <60 with QRISK <10%
- Age <40
- Offer lifestyle advice and consider drug treatment
- Offer lifestyle advice and start drug treatment
- Offer lifestyle advice and consider drug treatment
- Specialist referral ?secondary cause. consider renin:aldosterone ratio ?primary hyperaldosteronism before starting Rx, Check TFTs, consider renal US.
For all:
* discuss Qrisk
* preferences including no treatment
* Give NICE decision aid
* Offer annual R/V
What is the management for stage 2 HTN?
- Offer lifestyle advice and drug treatment regardless of age.
- If aged <40 - refer to specialist ?secondary cause.
What is the BP target for age <80?
Clinic and HBPM
- clinic: <140/90
- HBPM/ABPM: <135/85
Use the same blood pressure targets for people with and without cardiovascular disease.
Which is the antihypertensive of choice for those with T2DM?
ACEI or ARB
(irrespective of age)
(If ACEI not tolerated due to cough, offer ARB)
(if black african or african-caribbean family origin - use ARB in preference)
What is the BP target for age >=80?
Clinic and HBPM
- Clinic: <150/90
- ABPM/HBPM: <145/85
Use the same blood pressure targets for people with and without cardiovascular disease.
Which is the antihypertensive of choice for those without T2DM?
age <55
age>=55
Black african/caribbean origin
- age <55: ACEI or ARB
- age >=55: CCB
- Black african/caribbean family origin of any age: CCB
If CCB not tolerated (e.g ankle oedema) - offer thiazide-like diuretic Indapamide.
What is step 2 of treatment if HTN not controlled with ACEI/ARB?
- offer choice of adding in either CCB OR thiazide-like diuretic
What is step 2 of treatment if HTN not controlled with CCB?
- offer the choice of adding in either a ACEI/ARB OR thiazide-like diuretic
ARB preferable to ACEI in african caribbean
What is step 3 of treatment if HTN not controlled with step 2 (two drugs)?
- offer a combination of all 3 drugs: ACEI/ARB + CCB + thiazide-like diuretic
ARB preferable in black african caribbean
What is step 4 of treatment if HTN not controlled with step 3 (3 drugs) ?
- ensure optimal tolerated doses
- check adherence
- check for postural Hypotension
- confirm clinic readings with ABPM/HBPM
- If confirmed resistant HTN: refer to specialist or add a 4th drug:
- if potassium <=4.5 use low dose spironolactone (caution if reduced eGFR - increased risk of hyperkalaemia). Monitor U&E within 1 month and repeat as needed.
- if potassium >4.5 consider alpha blocker or beta blocker.
If BP remains uncontrolled when taking optimal doses of 4 drugs - refer to specialist
What should be included in a HTN annual review?
- lifestyle advice
- adherence to meds
- check BP
- U&E, urine ACR
- Reassess Qrisk
Which 3 groups of patients should have standing BP according to NICE?
- symptoms of postural hypotension
- Aged over 80
- Type 2 diabetes (autonomic dysfn)
What standing BP is significant for postural drop?
- drop in SBP of 20 mmHg or more, taken after the person has been standing for 1 minute.
Treatment should be targeted at the standing blood pressure,
What is a significant BP difference between arms?
- A difference of 15 mmHg or more in systolic blood pressures
?peripheral vascular disease
treat the higher arm and use this arm going forwards
Medication is now recommended for people aged under 80 with stage 1 hypertension who have either:
- Qrisk score >=10
- target organ damage
- renal disease
- CVS disease
- diabetes
People with stage 1 hypertension not eligible for medication should be offered relevant lifestyle advice:
- Smoking cessation
- Increased exercise
- Weight reduction
- Reduction of excess caffeine or alcohol intake
- Reduction of dietary salt, fat and saturated fat
What are the common side effects of alpha blockers?
e.g doxazosin
Dizziness, headaches, swollen feet, ankles or
fingers
caution:postural hypotension
What are the common side effects of ACEI?
e.g ramipril
- Dry cough, dizziness
- monitor U&E
Avoid during pregnancy, tolerate 30% rise in creatinine afterstarting
What are the common side effects of ARBs?
e.g. losartan
- Dizziness, headaches
- monitor U&E
What are the common side effects of aldosterone antagonists?
e.g spironolactone
- Nausea, fatigue,
gynaecomastia - monitor U&E & potassium levels
What are the common side effects of beta blockers?
e.g bisoprolol
- Sleep disturbance, exercise limitation, cold
intolerance
What are the common side effects for CCBs?
- Ankle oedema,
constipation, headaches - avoid in HF (except amlodipine)
What are the common side effects of thiazide-like diuretics?
e.g. indapamide
- Urinary frequency,
postural dizziness, rash - monitor U&E
What is the target BP for patients with T1DM, and an ACR <70?
clinic BP <140/90
What is the target BP for patients with T1DM, and an ACR >=70?
clinic BP <130/80
What is the target BP for patients with T1Dm aged >80?
no matter what the ACR is, aim BP <150/90
In a patient with CKD, without diabetes, and urine ACR of <30, how should their HTN be managed?
Manage as per the HTN guidlines, same as adults without CKD
If a patient has CKD, and urine ACR of >=30, with HTN, what is the first line antihypertensive?
What are the BP targets?
ACEI/ARB
If urine ACR <70 - target <140/90
If urine ACR >=70 - target <130/80
What is the secondary prevention BP target for patients who had a stroke/TIA?
- same targets as adult HTN guidline.
- except if severe bilateral carotid artery stenosis : systolic BP should be 140-150
