CVS - Hypertension

Question 1

Diagnostic classification of clinic blood pressure levels

Answer 1

Optimal <120/80
Normal 120-129/80-84
High-Normal 130-139/85-89
Mild HTN 140-159/90-99
Moderate HTN 160-179/100-109 
Severe HTN >/180/110
Isolated systolic HTN >140/<90

Question 2

What patients are eligible for absolute CVD risk assessment

Answer 2

Adults >/ 45yoa or >35 in ATSI
No known history of CVD

Those with persistently elected BP >/180/110 or with target organ damage already have high absolute CVD

The risk assessment algorithm and treatment options are not appropriate for people with known CVD

• established vascular disease
• prior MI
• prior stroke or TIA
• PAD
• end stage kidney disease
• heart failure
• AF
• aortic disease

Question 3

What patients are ineligible for absolute CVD risk assessment

Answer 3

Adults <45yoa or <35 yoa in ATSI without known CVD (prior MI, prior stroke/TIA, peripheral artery disease, heart failure, AF, aortic disease, or end-stage kidney disease undergoing dialysis)

Question 4

What patients are already high risk (>15% chance of a cardiovascular event in the next 5 years)

Answer 4

Diabetics >60yoa or with microalbuminuria (urine albumin:creatinine 2.5-25mg/mmol Males, 3.5-35mg/mol Females)
Moderate or severe CKD with macroalbuminuria (urine albumin:creatinine >25 Mmg/mmol Males, >35 mg/mmol Females) or EGFR <45
Familial hypercholesterolaemia
Systolic BP >/180 OR diastolic bP >/110
Total cholesterol >7.5
ATSI >74

Question 5

Hypertensive urgencies

Answer 5

Are severe BP elevations >180/110 that are not immediately life threatening, but are associated with symptoms (severe headache) or moderate target organ damage

Treat with oral drugs and follow up within 24-72 hours

Question 6

Hypertensive emergencies

Answer 6

When BP is very high >220/140 and acute target organ damage or dysfunction is present (heart failure, acute pulmonary oedema, acute MI, aortic aneurysm, acute renal failure, major neurological changes, hypertensive encephalopathy, papilloedema, cerebral infarction, hemorrhagic stroke)

Hospitalise with close BP monitoring and parenteral antihypertensives

Question 7

Accelerated hypertension

Answer 7

Severe hypertension with the presence of retinal haemorrhages and exudates

Question 8

Malignant hypertension

Answer 8

Severe hypertensions with retinal haemorrhages and exudates plus papilloedema

Question 9

How to measure BP in clinic

With either a mercury sphygmomanometer or an automated digital device

Answer 9

Cuff with bladder length of >/80% and width >/40% of mid-upper arm circumference.

Palpate pulse prior to measuring BP and if irregular pulse then measure BP manually over the brachial artery

Quiet room
Appropriate temperature
Patient seated (legs not crossed) and relaxed for several minutes before measurements
Patient free of caffeine and smoking for at least 2 hours

Selected arm free from constricted clothing, wrap cuff snugly and place cuff at heart level by supporting the arm

Start the first measurement after 5 minutes of rest

Take 3 readings, at 1-2 minute intervals and average the last 2 readings. If the readings vary more than 10mmHg systolic or 6mmHg diastolic, have the patient rest quietly for 5 minutes and then re-measure

For first BP, measure both arms and if variation of >5mmHg use the higher reading arm for all subsequent measures

Where there is suspected postural HTN do both sitting and standing BP after 2 minutes

Question 10

HTN diagnosis on clinic BPM

Answer 10

Should be based on multiple measurements, taken on several separate occasions. That is at least twice, one or more weeks apart, or sooner if HTN is severe

Question 11

Clinical indications for out-of-clinic BPM

Answer 11

Suspicion of which-coat HTN
Suspicion of masked HTN
Identification of white-coat HTN
Marked variability of clinic and home BPM
Autonomic, postural, post-prandial and drug-induced hypotension
Identification of true resistant HTN
Suspicion of nocturnal HTN or absence of nocturnal dipping (e.g. sleep apnoea, CKD or diabetes)

Question 12

Criteria for the diagnosis of HTN using different methods of BP measurements

Answer 12

Clinic >/140 systolic and/or >/90 diastolic
ABPM daytime >/135 systolic and/or >/85 diastolic
ABPM night >/120 systolic and/or >/70 diastolic
ABPM over 24hrs >/130 systolic and/or >/80 diastolic
HBPM >/135 systolic and/or >85 diastolic

Question 13

Medical history to take

Answer 13

BLOOD PRESSURE
New onset HTN
Duration of raised BP and previous levels
ABPM and HBPM if known
Current antihypertensives
Previous antihypertensives, efficacy and adverse effects
Medications that influence BP

RISK FACTORS
Family and personal history of CKD, HTN, diabetes, dyslipidaemia, stroke, early onset coronary artery disease (before 55 in men and 65 in women), low birth weight

Modifiable lifestyle factors including smoking, diet, weight control, obesity, exercise, recreational drug use, alcohol intake

Personal, psychosocial and environmental factors including education, family situation, work environment, financial concerns, psychological stress

Depression, social isolation, quality of social support

END ORGAN DAMAGE
Past of current symptoms of IHD, heart failure, cerebrovascular disease or peripheral arterial disease
Past or current symptoms that suggest CKD

SECONDARY HTN
Phaeochromocytoma (headaches, sweating, palpitations)
Sleep apnoea (obesity, snoring, daytime sleepiness)
Complementary or recreational drug use
Hypokalaemia (muscle weakness, hypotonia, muscle tetany, cramps, cardiac arrhythmias)
Thyroid disease

Question 14

Substances that may influence BP

Answer 14

NSAIDS 
Sympathomimetics (decongestants, diet pills, cocaine) 
Stimulants (AHDHD meds) 
Excessive alcohol intake 
Oral oestrogen contraceptives 
HRR 
Corticosteroids 
Clozapine 
SNRIs 
MAOis 
Haemopoietic drugs
Withdrawal of bromocriptine, clonidine 
Bupropion 

Bitter orange, ginseng, guarana 
Caffiene pills 
Natural liquorice 
St John's wort 
Energy drinks

Question 15

Recommendations on methods of BP measurement

Answer 15

If clinic BP is >/140/90, or HTN is suspected, ABPM or HBPM should be offered to confirm the BP level

Clinic BP measures are used in absolute CVD risk calculators NOT home/ambulator BPs

Procedures for home BPM or ABPM should be adequately explained to patients

Finger/wrist BP measuring devices are not recommended

Question 16

When reviewing ABPM data

Answer 16

2 measurements per hour when waking and >/14 measurements
Compare the profile with standard values
The normal range differs to clinic BP
HTN diagnosis is supported if a patient’s average ABPM reading exceeds standard values for daytime OR nighttime, or if ambulatory BP load is reported and exceeds the reference range by 20%
Mean night time systolic ABPM should be 10% lower than the daytime level. Those who are non dippers are at increased CVD risk

Question 17

Physical Examination for HTN

Answer 17

SIGNS OF SECONDARY HTN or ORGAN DAMAGE
Pulse rate, rhythm, and character
JVP
Evidence of cardiac enlargement (displaced apex, extra heart sounds)
Evidence of cardiac failure (basal crackles, peripheral oedema, pulsatile liver)
Evidence of arterial disease (carotid, renal, abdominal or femoral bruits; AAA; absent femoral pulses, R-F delay)
Palpation of enlarged kidneys
Abnormal of the optic funds (retinal haemorrhages, papilloedema, tortuosity, thickening of AV nipping of retinal arteries, exudates or diabetic retinopathy)
Evidence of abnormality of the endocrine system (Cushing’s, thyroid)

EVIDENCE OF OBESITY
Waist circumference
BMI

Question 18

Initial laboratory investigations for ALL patients

Answer 18

Urine dipstick for blood - if abnormal send for microscopy

Albuminuria and proteinuria status

• Mandatory for diabetes, highly recommended in all
• Urine albumin:creatinine in first void (or spot is also acceptable)
• If in macroalbuminuria range, then a 24 hour protein level
• If proteinuria then urine PCR can be used for quantification and monitoring

Bloods
- fasting glucose
- fasting serum total cholesterol, LDL, HDL and TG
- serum urea, electrolytes and creatinine (with eGFR)
Hb

12 lead ECG
- to detect AF, LVH and evidence of previous ischaemic heart disease

Question 19

What is microalbuminuria on tests

Answer 19

ACR mg/mmol Males 2.5-25; Females 3.5-35
Albumin excretion mg/day 30-300 
PCR mg/mmol Males 4-40, Females 6-60 
Protein excretion mg/day 50-500 
Protein reagent strip trace to +1

Question 20

What is macroalbuminuria on tests

Answer 20

ACR mg/mmol Males >25; Females >35
Albumin excretion mg/day >300
PCR mg/mmol Males >40, Females >60
Protein excretion mg/day >500
Protein reagent strip >/ +1

Question 21

What additional tests are required for patients with cardiovascular disease

Answer 21

Echocardiography - To diagnose LVH

Carotid USS - To rule out asymptomatic atherosclerosis

Question 22

What additional tests are required for patients with chronic kidney disease

Answer 22

Renal artery imaging

Renal artery duplex USS, renal nuc med and/or CT angiogram

Question 23

What additional tests are required for patients with peripheral arterial disease

Answer 23

Ankle-Brachial index (ABI) in those with risk factors for PAD including hypertensive patients with:

• diabetes
• vascular bruit
• old age
• smokers

An index <0.9 is diagnostic for PAD

Question 24

Other additional tests that may be required

Answer 24

Plasma aldosterone/renin ratio to rule in/out primary aldosteronism
This occurs in 5-10% of patients with HTN and is not excluded by a normal serum potassium

Consider in patients with HTN, moderate-severe, or treatment resistant HTN, and those with hypokalaemia

Metanephrine and normetanephrine excretion (with creatinine) and/or plasma catecholamine, metanephrine and normetanephrine concentration, 24 hour urinary catecholamine - IF symptoms of episodic catecholamine excess and/or episodic HTN suggestive of phaeochromocytoma

Question 25

Recommendations for lifestyle advice

Answer 25

PHYSICAL ACTIVITY 150-300 minutes of moderate intensity OR 75-150 minutes of vigour activity each week For >65 yoa aim to accumulate at least 30 minutes of moderate-intensity activity preferably all days Start low and go slow as sudden vigorous activity has been associated with increased risk of cardiovascular events Patients with chronic disease can be referred to an exercise physiologist or physiotherapist Muscle strengthening activities on at least 2 days of each week WEIGHT CONTROL Waist circles <94 in males or <90 in Asian males <80 in females BMI<25 1kg weight reduction = ~1mmHg diastolic BP lowering DIET Total fat account for 20-35% of energy intake Salt to 6g/day for primary prevention and 4g/day for secondary prevention Choose labeled foods with <400mg/100g of salt. LOW SALT foods are those with less than 120mg/100g of salt 5 serves of veg and 2 serves of fruit/day Can use the DASH diet - Dietary Approaches to Stop Hypertension SMOKING Cease ALCOHOL No more than 2 standard drinks on any one day No more than 4 on any occasion No more than 10/week

Question 26

Which patients will require medical review prior to physical activity and supervised physical activity

Answer 26

``` Unstable angina BP >/180 systolic OR >/110 diastolic Uncontrolled HF or cardiomyopathy MI within the last 3 months Severe aortic stenosis Resting tachycardia or arrythmias Chest discomfort or SOB at rest of low activity Diabetes with poor glycaemic control ```

Question 27

BMI classifications

Answer 27

``` 18.5-24.9 Healthy 25 - 29.9 Overweight 30 - 34.9 Obesity I 35 - 39.9 Obesity II 40 + Obesity III ```

Question 28

When to initiate antihypertensives

Answer 28

Consider a patient's absolute CVD risk with accurate BP readings those with mild HTN who are stratified as moderate to high absolute CVD risk those with low absolute CV risk, but persistent BP >/16-/100 should be commenced Patients with uncomplicated HTN should be targeted to treat to <140/90 or lower if tolerated In selected high CV risk populations aim for target of <120 systolic BP and monitor for hypotension, syncope, electrolyte abnormalities and acute kidney injury

Question 29

Choice of antihypertensive drug

Answer 29

In patients with uncomplicated HTN can use either ACE I, ARB, Ca C blockers or a thiazide diuretic as either monotherapy or combination therapy unless contraindicated

Question 30

MOA ACE inhibitors

Answer 30

Reduces the synthesis of angiotensin-2 by inhibiting the action of ACE Can precent the onset of nephropathy and reduced mortality in early diabetes. Are more effective in preventing coronary heart disease with patients with HTN

Question 31

MOA ARBs

Answer 31

Bind directly to the angiogenesis 1 reception, preventing its activation by angiotensin 2 Can better prevent kidney failure in people with advanced diabetic nephropthy

Question 32

Superior combination therapy

Answer 32

ACE inhibitor and Calcium channel blockers superior Then ACE inhibitors and diuretics Then beta blockers and diuretics

Question 33

Drug treatment strategy to reach BP target

Answer 33

Lifestyle advice for everyone Manage associated conditions for everyone Start a low-moderate recommended dose of a first line drug, if not tolerated change to a different class and start again at a low-moderate dose ``` IF TARGET NOT REACHED AFTER 3 MONTHS Add a second drug from a different class at a low-moderate dose ``` IF TARGET NOT REACHED AFTER 3 MONTHS Increase the dose of 1 drug (excluding thiazides) incrementally to the maximum recommended dose ``` IF TARGET NOT REACHED AFTER 3 MONTHS Despite maximal doses of at least 2 drugs, a third drug class can be started at a low-moderate dose ``` IF BP REMAINS ELEVATED Consider seeking specialist advice

Question 34

ACE/ARB plus calcium channel blocker

Answer 34

Effective combination Useful in presence of diabetes and/or lipid abnormalities

Question 35

ACE/ARB plus thiazide diuretic

Answer 35

Effective combination Useful in presence of heart failure or post stroke

Question 36

ACE/ARB plus beta blocker

Answer 36

Effective combination Recommended post MI or in patients with heart failure (carvedilol, bisoprolol, metoprolol XR or nebivolol)

Question 37

Beta blocker plus dihydropyridine calcium channel blocker

Answer 37

Effective combination Useful in presence of symptomatic coronary heart disease

Question 38

Thiazide diuretic plus calcium channel blocker

Answer 38

Effective combination

Question 39

Thiazide diuretic plus beta blocker

Answer 39

Effect combination Not recommended in presence of glucose intolerance, metabolic syndrome or established diabetes

Question 40

Combinations antihypertensives to use with care

Answer 40

Diltiazem plus beta blocker - Risk of heart block | ACE/ARB plus potassium sparking diuretic - Risk of hyperkalaemia

Question 41

Combinations to avoid

Answer 41

ACE and ARB - increased risk of renal dysfunction | Verapamil + Beta blocker - Risk of heart block

Question 42

Contraindications ACE/ARBS

Answer 42

Pregnancy Angioedema Hyperkalaemia Bilateral renal artery stenosis Possible - women with childbearing potential

Question 43

Contraindications calcium channel blocker

Answer 43

Possible - heart failure

Question 44

Contraindications low-dose thiazides

Answer 44

``` Gout Young age (as increased risk of developing diabetes) ``` Possible - Diabetes, metabolic syndrome, glucose tolerance, hypercalcemia, hypokalaemia

Question 45

Contraindications beta blocker (NO LONGER FIRST LINE IN UNCOMPLICATED HTN |)

Answer 45

Asthma Bradycardia AV block Uncontrolled HR Possible - diabetes, metabolic syndrome, glucose intolerance, athletes, active patients, COPD, depression

Question 46

Common side effects of ACE inhibitors "prils"

Answer 46

Cough Hyperkalaemia (risk increased by renal impairment) renal impairment (risk increased by hypovolaemia or NSAIDS) Angioedema

Question 47

Common side effects of ARBs "sartans"

Answer 47

``` Hyperkalaemia (risk increased by renal impairment) Renal impairment (risk increased by hypovolaemia or NSAIDS) ``` Rare - cough and angioedema

Question 48

Common side effects of Dihydropyridine calcium channel blockers Amlodipine Felodipine Lercanidipine Nifidipine

Answer 48

Peripheral vasodilation - peripheral oedema - flushing - headache - dizziness ``` Postural hypotension Tachycardia Palpitations Chest pain Gingival hyperplasia ```

Question 49

Common side effects of Non-dihydropyridine calcium channel blockers Diltiazem Verapamil

Answer 49

Bradycardia Constipation AV block Heart failure

Question 50

Common side effects of Thiazide-like diuretics Chlorthalidone Hydrochlorothiazide Indapamide

Answer 50

``` Postural hypotension Dizziness Hypokalaemia Hyponatraemia Hyperuricaemia Hyperglycaemia ```

Question 51

Common side effects of Beta blockers | "olols"

Answer 51

``` Bradycardia Postural hypotension Worsening of heart failure Bronchospasm Cold extremities ```

Question 52

Common side effects of Potassium sparing diuretic - Amiloride

Answer 52

Can be used in patients with hyperaldosteronism who do not tolerate spironolactone Hyperkalaemia

Question 53

Common side effects of Clinidine

Answer 53

``` Postural hypotension Constipation Bradycardia Dry moth CNS effects - sedation, dizziness ```

Question 54

Common side effects of Hydralazine

Answer 54

Used for refractory HTN usually with a beta blocker and diuretic ``` Palpitations Flushing Headache Oedema Tachycardia May exacerbate angina Lupus like syndrome ```

Question 55

Common side effects of Methyldopa

Answer 55

Predominately used for HTN in pregnancy ``` CNS effects - sedation, dizziness Hepatitis Hepatic necrosis Positive Coombs test Haemolytic anaemia ```

Question 56

Common side effects of Moxonidine

Answer 56

Dry mouth CNS effects (somnolence, dizziness) Bradycardia Vasodilation

Question 57

Common side effects of Prazosin

Answer 57

Hypotension may be profound

Question 58

Common side effects of Spironolactone

Answer 58

Hyperkalaemia Hyponatremia Anti-androgenic effects (mastalgia, gynaecomastia, sexual dysfunction)

Question 59

Recommendations for patients with HTN and prior stroke/TIA

Answer 59

For patients with a history of TIA or stroke, antihypertensive therapy is recommended to reduce overall cardiovascular risk Any of the first line antihypertensive drugs that effectively reduce BP are recommended BP target <140/90

Question 60

Recommendations for patients with HTN and CKD

Answer 60

Any of the first line antihypertensives that effectively reduce BP are recommended in patients with HTn and CKD When treating HTN with CKD in the presence of micro or macro albuminuria an ARB or ACEI should be first line In patients with CKD, antihypertensive therapy should be started in those with BPs consistency >140/90 and to a target of <140/90 Dual renin-angiotensin blockage is not recommended Aim towards a target of <120 systolic where tolerated with close follow up for adverse effects including hypotension, syncope, electrolyte abnormalities and AKI

Question 61

Recommendations for patients with HTN and diabetes

Answer 61

Antihypertensives is strongly recommended in patients with diabetes and systolic BP >/140 Any of the first-line antihypertensives that effectively lower BP are recommended A target of <140/90 is recommended A systolic BP of <120 may be considered in patients with diabetes in whom prevention of stroke is prioritised, with close follow up of side effects including hypotension, syncope, electrolyte abnormalities and AKI

Question 62

Recommendations for patients with HTN and a previous MI

Answer 62

ACE inhibitors and beta blockers are recommended For patients with symptomatic angina beta blockers or calcium channel blockers are recommended

Question 63

Recommendations for patients with HTN and chronic heart failure

Answer 63

ACE inhibitors and selected beta blockers (carvedilol, bisoprolol, metoprolol XR and nebivolol) ARBs are recommended inpatients who do not tolerate ACE inhibitors

Question 64

In patients with HTN and peripheral arterial disease

Answer 64

In patients with PAD, treating HTN is recommended to reduce CVD risk Any of the first line antihypertensives that effectively reduce BP are recommended Treat to a target of <140/90

Question 65

Define white coat HTN

Answer 65

Applies to untreated individuals and is a condition in which BP measured in a clinical setting is usually at hypertensive levels, but in non-medical setting is usually normal Then ABPM or HBPM is required for diagnosis Patients need more frequent follow ups Patients have been shown to have a comparable risk of stroke to patients with sustained HTN

Question 66

Define masked HTN

Answer 66

Clinic BP measurements are usually normal, but in non medical settings is hypertensive Suspect in clinically normotensive patients with evidence of end organ disease, regular heavy drinkers, smokers and patients with diabetes Screen in ABPM

Question 67

Recommendations of HTN in older persons

Answer 67

Any of the first line antihypertensives can be used Commence at the lowest dose and titrate slowly For patients >75 you, aim towards a systolic of <120 with close follow up of side effects of hypotension, syncope, electrolyte abnormalities and AKI

Question 68

Recommendations for patients with HTN and suspected BP variability

Answer 68

For high risk patients with suspected high variability in sysBP, focus on lifestyle advice and consistent adherence to medications

Question 69

Antiplatelet therapy for patients with HTN

Answer 69

Low dose aspirin recommended in patients with HTN and previous CVD events, unless bleeding risk is increased

Question 70

Lipid lowering therapy

Answer 70

Lipid lowering therapy is recommended in patients without prior cardiovascular events stratified at moderate to high absolute CVD, treating to an LDL target of <2

Question 71

When to follow up patients with HTN

Answer 71

Electrolytes and creatinine measured at baseline then at 2 weeks after commencing therapy in people high risk of changes in kidney function After starting therapy, at 4-5 week intervals For patients with significantly elevated baseline BP, shorter reviews may be considered Once BP is stabilised, review in 3-6 months

Question 72

How common is secondary HTN

Answer 72

5-10% adults | 70-85% children

Question 73

When to consider secondary HTN

Answer 73

Treatment resistant HTN (elevated BP despite adherence to optimal dosage of 3 antihypertensives, including a diuretic) Early or late onset HTN A severe or accelerated course Specific drug intolerances

Question 74

Medications that may elevate BP

Answer 74

Estrogen - OCP Herbal - ephedra, ginseng, ma huang Illicit - amphetamines, cocaines NSAIDS - Ibuprofen, naproxen, naprosyn Psychiatric - Buspirone, carbamazepine, clozapine, fluoxetine, lithium, TCAs Steroids - Methlyprednisolone, prednisone Sympathomimetic - decongestants, diet pills

Question 75

Coarctation of the aorta

Answer 75

Arm to leg systolic BP difference >22mmHg Delayed or absent femoral pulses urmur MRI adults to Dx TTE in children to Dx

Question 76

Renal artery stenosis

Answer 76

Increase in serum creatinine concentration >.0.5-1mg per dL after starting ACE inhibitor or ARB Renal bruit to Dx CT angiogram Doppler USS of renal arteries MRI with gadolinium

Question 77

Thyroid disorders

Answer 77

Brady/tachycardia Cold/heat intolerance Constipation/diarrhoea Irregular, heavy or absent menstrual cycle To Dx TSH

Question 78

Aldosteronism

Answer 78

Hypokalaemia To Dx Renin and aldosterone levels to calculate ratio

Question 79

Obstructive sleep apnoea

Answer 79

Apneic events during sleep Daytime sleepiness Snoring To Dx Polysomnography (sleep study_ Sleep Apnea Clinical Score with nighttime pulse oximetry

Question 80

Pheochromocytoma

Answer 80

``` Flushing Headaches Labile BP Orthostatic hypotension Palpitations Sweating Syncope ``` To Dx Plasma free metanephrines 24hr urinary fractioned metanephrines

Question 81

Cushings

Answer 81

Buffalo hump Central obesity Moon facies Striae To Dx 24hr urinary cortisol Late-night salivary cortisol Low dose dexamethasone suppression

Question 82

Most common cause of secondary HTN in children 0-12yoa

Answer 82

Renal parenchymal disease (Glomerulonephritis) Coarctation of the aorta Do a blood urea nitrogen and creatinine levels, urinalysis, urine culture and a renal USS

Question 83

Most common cause of secondary HTN in adolescents 12-18 yoa

Answer 83

Renal parenchymal disease | Coarctation of the aorta

Question 84

Most common cause of secondary HTN in young adults 19-39yoa

Answer 84

``` Thyroid dysfunction Fibromuscular dysplasia (causing renal artery stenosis) which is a vascular disorder of unknown ethology that causes narrowing of the renal arteries which leads to decreased renal perfusion Renal parenchymal disease ``` Do an MRI with gadolinium contrast media and CT angiogram to visualise the stenosis. However if contrast contraindicated can to a MRI instead If MRI and CT are both contraindicated can do a renal doppler USS Check TSH

Question 85

Most common cause of secondary HTN in middle aged adults 40-64yoa

Answer 85

Aldosteronism ~6% of patients with HTN and 10-20% of those with resistant HTN have primary aldosteronism as the cause - Test with aldosterone/renin ratio measured in the morning at least 2 hours after waking an in an upright position and IF above 20ng/dL:ng/mL AND aldosterone level >15ng/dL refer to endocrinologist for confirmation Thyroid dysfunction - test TSH OSA - Refer for sleep study, do Epworth Sleepiness Scale, Sleep Apnoea Clinical score, consider ABPM to evaluate circadian pressures Cushings - Test only if symptomatic with 24-hr urinary free cortisol, low dose-dexamethasone suppression, ornate night salivary cortisol levels and refer to endocrinologist Pheochromocytoma in 0.5% of secondary HTN, if symptomatic test with plasma free metanephrines

Question 86

Most common cause of secondary HTN in older adults 65 years and older

Answer 86

Atherosclerotic renal artery stenosis, suspect in patients who develop HTN after 50 yoa who have known atherosclerosis elsewhere, have unexplained renal insufficiency, or have a rapid deterioration in kidney function what started on an ACE or ARB Renal failure - Do a GFR and urinalysis to assess albuminuria, renal USS may help to detainee cause and chronicity Hypothyroidism - TSH

Question 87

SPRINT

Answer 87

Systolic BP Intervention Trial People with high CV risk, but without diabetes, randomised to BP targets <120 or <140 Stopped early as a clear reduction of CV events in the intense treatment arm as well as reduced all-cause mortality

Question 88

ACCORD

Answer 88

Action to Control Cardiovascular Risk in Diabetes trial People randomised to more or less intensive blood sugar control and then 1/2 participants when into BP trial of <120 or <140 No statistically significant difference Intensive glucose control increased the risk of CV and total mortality

Question 89

SPS3

Answer 89

The 3rd Stroke Prevention Study Compared BP targets 130-140 VS <130 in people with recent lacunar stroke No statistically significant effect on stroke or CV death BUT intracerebral haemorrhage was significantly reduced with intensive BP lowering