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AKT - Lizzie Bain > CVS: hypertension > Flashcards

CVS: hypertension Flashcards

1
Q

What is stage 1 hypertension (values)?

clinic and HBPM

A
  • clinic: 140/90- 159/99
  • AND subsequent HBPM 135/85 - 149/94
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2
Q

What is stage 2 hypertension (values)?

A
  • clinic: 160/100 - 180/120
  • AND subsequent HBPM average 150/95 or higher
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3
Q

What is stage 3 or severe hypertension? (values)

A

clinic SBP >=180 or clinic DBP >=120

does not require HBPM/ABPM

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4
Q

What is accelerated (or malignant) HTN?

A
  • severe increase in BP to >=180/120 with signs of retinal haemorrhage and/or papilloedema (new or progressive target organ damage)
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5
Q

What is ‘white coat’ HTN?

A
  • occurs in 15-30% population. High BP in clinic, but normal in non threatening situations.
  • discrepancy of >20/10 between clinic and average HBPM
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6
Q

Which renal disorders can cause secondary HTN?

A
  • CKD (most common identifiable cause of HTN)
  • chronic pyelonephritis
  • diabetic nephropathy
  • glomerulonephritis
  • PKD
  • obstructive uropathy
  • renal cell carcinoma
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7
Q

What are other causes of secondary HTN (except renal)?

suspect in age <40, worsens suddenly, accelerated HTN

A
  • 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.
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8
Q

HTN increases risk of which conditions?

A
  • Heart failure.
  • Coronary artery disease.
  • Stroke.
  • Chronic kidney disease.
  • Peripheral arterial disease.
  • Vascular dementia.
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9
Q

How should BP be measured in clinic?

A
  • 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.
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10
Q

If the persons clinic BP is 140/90 - 180/120, how should HTN be confirmed?

A
  • ABPM
  • HBPM if unsuitable/intolerable
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11
Q

How many readings are needed for ABPM?

A
  • 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.
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12
Q

How many readings are needed for HBPM?

A
  • 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
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13
Q

If BP is 180/120 , how should pt be managed?

A
  • 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
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14
Q

What ABPM or HBPM reading confirms diagnosis of HTN?

A
  • Clinic BP >=140/90 AND ABPM daytime average/HBPM average >= 135/85
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15
Q

Whilst waiting for confirmation of HTN diagnosis, perform investigations for target organ damage and formal Ax of CV Risk. Which investigations should be done?

A

Target organ damage:
* urine dip - haematuria
* Urine Albumin:Creatinine Ratio (ACR)
* HbA1C
* U&E
* Fundoscopy
* ECG (for LVH)

CVS risk:
* Lipids

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16
Q

How should CV risk be assessed?

A
  • Measure serum total cholesterol and HDL cholesterol
  • Use QRISK tool to estimate 10-year risk of developing CVD (use clinic BP measurements)
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17
Q

What lifestyle advice should be given for HTN?

A
  • diet and exercise
  • caffeine
  • low dietary sodium
  • smoking cessation
  • reduce alcohol

offer info leaflets e.g patient decision aid for Rx

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18
Q

What is the management for stage 1 HTN?

  1. For age >80 with clinic BP >150/90
  2. Age <80 with: target organ damage, CVD, renal disease, diabetes, or QRISK >=10%
  3. Age <60 with QRISK <10%
  4. Age <40
A
  1. Offer lifestyle advice and consider drug treatment
  2. Offer lifestyle advice and start drug treatment
  3. Offer lifestyle advice and consider drug treatment
  4. 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

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19
Q

What is the management for stage 2 HTN?

A
  • Offer lifestyle advice and drug treatment regardless of age.
  • If aged <40 - refer to specialist ?secondary cause.
20
Q

What is the BP target for age <80?

Clinic and HBPM

A
  • clinic: <140/90
  • HBPM/ABPM: <135/85

Use the same blood pressure targets for people with and without cardiovascular disease.

21
Q

Which is the antihypertensive of choice for those with T2DM?

A

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)

22
Q

What is the BP target for age >=80?

Clinic and HBPM

A
  • Clinic: <150/90
  • ABPM/HBPM: <145/85

Use the same blood pressure targets for people with and without cardiovascular disease.

23
Q

Which is the antihypertensive of choice for those without T2DM?

age <55
age>=55
Black african/caribbean origin

A
  • 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.

24
Q

What is step 2 of treatment if HTN not controlled with ACEI/ARB?

A
  • offer choice of adding in either CCB OR thiazide-like diuretic
25
Q

What is step 2 of treatment if HTN not controlled with CCB?

A
  • offer the choice of adding in either a ACEI/ARB OR thiazide-like diuretic

ARB preferable to ACEI in african caribbean

26
Q

What is step 3 of treatment if HTN not controlled with step 2 (two drugs)?

A
  • offer a combination of all 3 drugs: ACEI/ARB + CCB + thiazide-like diuretic

ARB preferable in black african caribbean

27
Q

What is step 4 of treatment if HTN not controlled with step 3 (3 drugs) ?

A
  • 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

28
Q

What should be included in a HTN annual review?

A
  • lifestyle advice
  • adherence to meds
  • check BP
  • U&E, urine ACR
  • Reassess Qrisk
29
Q

Which 3 groups of patients should have standing BP according to NICE?

A
  • symptoms of postural hypotension
  • Aged over 80
  • Type 2 diabetes (autonomic dysfn)
30
Q

What standing BP is significant for postural drop?

A
  • 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,

31
Q

What is a significant BP difference between arms?

A
  • A difference of 15 mmHg or more in systolic blood pressures

?peripheral vascular disease
treat the higher arm and use this arm going forwards

32
Q

Medication is now recommended for people aged under 80 with stage 1 hypertension who have either:

A
  • Qrisk score >=10
  • target organ damage
  • renal disease
  • CVS disease
  • diabetes
33
Q

People with stage 1 hypertension not eligible for medication should be offered relevant lifestyle advice:

A
  • Smoking cessation
  • Increased exercise
  • Weight reduction
  • Reduction of excess caffeine or alcohol intake
  • Reduction of dietary salt, fat and saturated fat
34
Q

What are the common side effects of alpha blockers?

e.g doxazosin

A

Dizziness, headaches, swollen feet, ankles or
fingers

caution:postural hypotension

35
Q

What are the common side effects of ACEI?

e.g ramipril

A
  • Dry cough, dizziness
  • monitor U&E

Avoid during pregnancy, tolerate 30% rise in creatinine afterstarting

36
Q

What are the common side effects of ARBs?

e.g. losartan

A
  • Dizziness, headaches
  • monitor U&E
37
Q

What are the common side effects of aldosterone antagonists?

e.g spironolactone

A
  • Nausea, fatigue,
    gynaecomastia
  • monitor U&E & potassium levels
38
Q

What are the common side effects of beta blockers?

e.g bisoprolol

A
  • Sleep disturbance, exercise limitation, cold
    intolerance
39
Q

What are the common side effects for CCBs?

A
  • Ankle oedema,
    constipation, headaches
  • avoid in HF (except amlodipine)
39
Q

What are the common side effects of thiazide-like diuretics?

e.g. indapamide

A
  • Urinary frequency,
    postural dizziness, rash
  • monitor U&E
40
Q

What is the target BP for patients with T1DM, and an ACR <70?

A

clinic BP <140/90

41
Q

What is the target BP for patients with T1DM, and an ACR >=70?

A

clinic BP <130/80

42
Q

What is the target BP for patients with T1Dm aged >80?

A

no matter what the ACR is, aim BP <150/90

43
Q

In a patient with CKD, without diabetes, and urine ACR of <30, how should their HTN be managed?

A

Manage as per the HTN guidlines, same as adults without CKD

44
Q

If a patient has CKD, and urine ACR of >=30, with HTN, what is the first line antihypertensive?
What are the BP targets?

A

ACEI/ARB

If urine ACR <70 - target <140/90
If urine ACR >=70 - target <130/80

45
Q

What is the secondary prevention BP target for patients who had a stroke/TIA?

A
  • same targets as adult HTN guidline.
  • except if severe bilateral carotid artery stenosis : systolic BP should be 140-150

AKT - Lizzie Bain (55 decks)

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