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Cardiology core conditions > Essential Hypertension > Flashcards

Essential Hypertension Flashcards

1
Q

What is hypertension?

A

Hypertension is defined by persistent elevation of BP in the systemic arterial circulation. It is a disease of ageing => due to age related stiffening (due to atherosclerosis) in large arteries.
Hypertension is the most important risk factor for premature death

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2
Q

What is essential hypertension?

A

Essential hypertension (aka primary hypertension) has no known cause.

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3
Q

Raised BP is a leading risk factor for which conditions?

A

Atrial fibrillation
Stroke
Myocardial infarction
End-stage kidney disease

Leading risk factor for death worldwide

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4
Q

What is considered to be a protective factor in women against hypertension?

A

Oestrogen - as women have lower BP than men until menopause.

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5
Q

Hypertension is most commonly seen in which ethnic group?

A

Black, African, African-Caribbean

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6
Q

What are the risk factors of hypertension?

A
  1. Weight
  2. Alcohol
  3. Recreational drugs
  4. Tobacco
  5. Exercise
  6. Stressors (work/personal)
  7. Family hx
  8. Pregnancy
  9. Adherence to anti-hypertensives
  10. Secondary causes e.g. renal artery stenosis, chronic kidney disease, primary hyperaldosteronism, acromegaly, thyroid disease, obstructive sleep apnoea etc

(see pg 1139 Kumar & Clarks for more)

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7
Q

What clinical examination are carried out in hypertension?

What are the aims of the clinical exam?

A
  1. Out of office BP level
  2. Asymptomatic organ damage : fundoscopy, palpations and auscultation
  3. Estimation of total cardiovascular risk

=> Look for signs of end organ damage i.e. retinal disease, heart failure, stroke and chronic kidney disease

=> Assess assoc. cardiovascular risk factor i.e. blood glucose, stigmata of hyperlipidaemia

=>Younger patients look for rarer secondary causes e.g. cushingoid features, acromegaly, renal masses

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8
Q

Which investigations are carried out for suspected BP?

A

To assess target organ disease:

  • Urine reagent strip testing and ACR
  • eGFR
  • ECG
  • CV risk i.e. lipids, HbA1c
  • Secondary causes
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9
Q

What is the meaning of in office / out of office BP measurement?

A

In office BP : BP measured at by a healthcare professional in a GP surgery (primary care) or hospital out-patient department ; correct technique (seated position after 5mins of uninterrupted rest).

Out of office : Ambulatory (portable) measurement ; BP at home

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10
Q

What is the threshold BP values for hypertension in under 80 year olds (in office and home measurements)
and
over 80 year olds (in office and home measurements)?

A

Under 80 years : >140/90 (office) ; >135/85 (home)

Over 80 years : >160/90 (office) ; >150/85 (home)

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11
Q

What is the target BP values in the UK?

A

Under 80 years : <140/90mmHg

Over 80 years : <150/90mmHg

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12
Q

What is the correct way to measure blood pressure?

A
  1. Legs uncrossed, back supported and uninterrupted rest for 5 min
  2. Palpate pulse to ensure in sinus rhythm (in case of AF use auscultatory method).
  3. Record at least two readings at each sitting
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13
Q

What is the cause of isolated systolic hypertension?

What is the risk of subsequent widening pulse pressure (big difference between systolic and diastolic)?

A
  1. Age-Related arterial stiffening = systolic BP continues to rise in patients over 50 years whilst diastolic BP declines
  2. Aortic valve dysfunction can also result in isolated systolic hypertension (but usually found on auscultation or echo)

=> Widening pulse pressure leads to increased vascular damage.

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14
Q

What are the causes of a raised BP?

A
  1. Primary (essential) hypertension - 90% patients with no singular identifiable cause
  2. Polygenetics - each single gene only contributes a small amount to high BP levels but combined can attribute to 60% of high BP level.
  3. Environment - 40% effect on BP
DIET: 
High salt intake; 
low veggie & fruit intake; 
high saturated fat intake; 
high simple carbohydrates intake;
excessive liquorice (inhibits enzyme that normally prevents cortisol from activating the mineralocorticoid receptor)

EXERCISE:
Lack of exercise increases risk of high BP ; cardio and strength training assoc. with low BP

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15
Q

Which drugs may raise BP?

A
  1. Alcohol
  2. Recreational drugs
  3. Oral contraceptive pill
  4. NSAID
  5. Corticosteroid
  6. Calcineurin inhibitors
  7. Vascular endothelial growth factor inhibitors
  8. Venlafaxine
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16
Q

What is the formula for BP?

A

BP = CO x SVR

CO = cardiac output
SVR = systemic vascular resistance
17
Q

What factors result in raised CO and SVR, thus raised BP?

A

Cardiac output:
Sympathetic nervous system activation (through renin); aldosterone; ADH => sodium/water retention

=> raised intravascular volume => raised preload (dependent on venous tone SNS via alpha 1 receptors)

=> raised Stroke volume (dependent on contractility SNS, catecholamines) => increased CO (SNS, catecholamines)

Systemic vascular resistance:
Direct innervation SNS via alpha 1 receptors

Circulating factors i.e. angiotensin II and catecholamines

Local factors i.e. angiotensin II, endothelin, Nitric oxide

18
Q

What is resistant hypertension?

A

Uncontrolled BP despite 3 separate guideline recommended anti-hypertensives.

*Check adherence or causes of secondary hypertension

19
Q

What are the most common causes of secondary hypertension?

A

Secondary hypertension = singular, identifiable cause which can be removed or reversed to normalise BP.

Common causes:

  1. Primary hyperaldosteronism (increased water/sodium retention)
  2. Obstructive sleep apnoea
  3. Obesity

*Last two causes due to sympathetic overdrive

20
Q

What is the physiological response to circulating volumes in pregnancy?

How does pregnancy result in hypertension?

A

Physiological response to pregnancy: There is an increase in circulating volume => leading to significant vasodilation => low BP esp in 2nd trimester

However, sometimes there is a defect in placental formation or vascularity leading to hypertension or pre-eclampsia

21
Q

What is the grading system and thresholds for hypertension?

A

Normal office BP: <130/80mmHg

High-normal office BP: 130-139 systolic ; 80-89 diastolic

Grade 1 hypertension:
Office BP: 140-149 systolic ; 90-99 diastolic
Daytime ambulatory/home BP: 135-149 systolic ; 85-94 diastolic

Grade 2 hypertension:
Office BP: 160-179 systolic ; 100-109 diastolic
Daytime ambulatory/home BP: 150-169 systolic ; 95-104 diastolic

Severe hypertension:
Office BP: >180/110mmHg
Daytime ambulatory/home BP: >170/105mmHg

Isolated systolic hypertension:
Office BP: >140 systolic ; <90 diastolic
Daytime ambulatory/home BP: >135 systolic ; <85 diastolic

22
Q

Uncontrolled hypertension can lead to target organ damage.

The retina (retinopathy) is one example of hypertensive target organ damage. This is investigated using direct ophthalmoscope (fundpscopy) to see any hypertensive vascular changes.

What are the 3 grades of retinopathy?
*Images of fundoscopy on pg 1141 Kumar & Clark’s

A
  1. Mild: generalised arteriolar narrowing focal arteriolar narrowing, arteriovenous nicking => modest assoc. with cardiovascular & cerebral events
  2. Moderate: Haemorrhage (blot, dot or flame shaped haemorrhage), micro-aneurysm, cotton-wool spot, hard exudates => strong assoc. with cardiovascular & cerebral events
  3. Severe: signs of moderate retinopathy mentioned above + papilloedema (swelling of optic head) => strong assoc. with cardiovascular events, stroke and death
23
Q

Uncontrolled hypertension can lead to target organ damage.

The heart is another example of hypertensive target organ damage.

What change is seen in the heart as a result of hypertension?

Which modalities help detect this change?

A

Hypertension leads to increase workload on the heart.
=> Initially, this leads to left ventricular remodelling (compensation) to reduce wall stress.
=> But eventually, this leads to a pathogenic left ventricular hypertrophy (LVH).

LVH = usually asymptomatic but sometimes ECG may detect changes (T-wave abnormalities).

  1. ECG recommended in all hypertensive patients (cheap & easy to use). ECG have low sensitivity but high specificity.
  2. Transthoracic echocardiography and cardiac MRI more sensitive and specific than ECG (more expensive, not easy access/training)
24
Q

Uncontrolled hypertension can lead to target organ damage.

Kidney disease is both a cause and consequence of hypertension.

Early hypertensive kidney damage detectable through an increase is microalbuminuria on urine test strips or as an increased lab albumin:creatinine ratio.

Most anti-hypertensive drugs = nephrotoxic so GFR reduction by 10% okay in anti-hypertensive therapy. Follow up to ensure this doesn’t result in renal decline

A

Information card.

25
Q 
10/5mmHg reduction in BP is assoc. with 
=> 15% reduction in all causes mortality
=> 35% reduction in strokes
=> 40% reduction in heart failures
=> 20% reduction in myocardial infarction

CVS risk scores i.e. Q-risk useful in integrating all risk factors to judge benefit in treating hypertension.

Treatment of hypertension reduces major cvs and renal events.

A

Information card.

26
Q

What life-style changes can patients with high BP undertake?

A
  1. Reduce salt intake (5mmHg drop)
  2. Reduce body weight/BMI
  3. Exercise 30 mins daily (5mmHg drop)
  4. Reduce high saturated fat intake + Increase veggie/fruit intake (10mmHg drop)
  5. Alcohol (<2 units daily) (3mmHg drop)
  6. Stop smoking
  7. Check drugs which may increase BP
27
Q

Single anti-hypertensives therapies are used in mild hypertension, whilst combined hypertensive therapies are used in moderate to severe hypertension.

UK NICE guidelines use age and ethnicity as surrogate for plasma renin activity.

Older (>55yrs) and black African ethnicity is assoc with low renin, therefore have reduced responsiveness to ACEi and ARBs as monotherapy.

  1. Which monotherapy is first choice of treatment in >55yrs old black patient?
  2. Which monotherapy is first choice of treatment in<55yrs old patient?
A
  1. Calcium channel blocker

2. ARB (or ACEi if ARB is not tolerated)

28
Q

Most guidelines recommend choosing one of the three classes of drugs as initial therapy. Name the 3 CLASSES of drugs (not individual drugs).

A
  1. Angiotensin-converitng enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs)
  2. Calcium channel blockers
  3. Thiazide-like diuretics
29
Q
  1. Explain the mechanism of action for ACEi.
  2. What are its adverse effects?
  3. What are the contraindications?
  4. Examples?
A
  1. ACEi reduces angiotensin II vasoconstriction
  2. Adverse effects: cough, angio-oedema, hyperkalaemia
  3. Contraindications: Angio-oedema ; bilateral renal artery stenosis
  4. Ramipril (2.5-10mg daily) ; Lisinopril
30
Q
  1. Explain the mechanism of action for ARB.
  2. What are its adverse effects?
  3. What are the contraindications?
  4. Examples?
A
  1. Reduces angiotensin II vasoconstriction
  2. Adverse effect: hyperkalaemia
  3. Contraindication: Bilateral renal artery stenosis
  4. Losartan 25-100mg ; candesartan ; irbesyrtan etc
31
Q

There are two types of calcium channel blockers (CCB): dihydropyridine and non-dihydropyridine.

  1. Explain the mechanism of action for dihydropyridine CCB.
  2. What are its adverse effects?
  3. Examples?
A
  1. Peripheral vasodilation
  2. Adverse effects: constipation, headache, oedema
  3. Amlodipine (5-10mg) ; Nifedepine
32
Q

There are two types of calcium channel blockers (CCB): dihydropyridine and non-dihydropyridine.

  1. Explain the mechanism of action for non-dihydropyridine CCB.
  2. What are its adverse effects?
  3. What are the contraindications?
  4. Examples?
A
  1. Peripheral vasodialtion
  2. Constipation ; Bradycardia
  3. High grade atrioventricular block ; bradycardia
  4. Verapamil (120-480mg daily) ; Diltiazem
33
Q
  1. Explain the mechanism of action for thiazide-like diuretic.
  2. What are its adverse effects?
  3. What are the contraindications?
  4. Examples?
A
  1. Vasodilation ; salt/water loss
  2. Adverse effects: hyponatraemia, hypokalaemia, hyperuricaemia, hyperglycaemia
  3. Contraindications: Gout
  4. Indapamide (1.5-2.5mg daily) ; used particularly in heart failure
34
Q
  1. Explain the mechanism of action for potassium-sparing diuretic.
  2. What are its adverse effects?
  3. What are the contraindications?
  4. Examples?
A
  1. Salt/water loss
  2. Adverse effects: hyponatraemia; hyperkalaemia; gynaecomastia
  3. Contraindication: Potassium >5mmol/L
  4. Spironolactone (25-50mg daily) esp given in primary hyperaldosteronism ; resistant hypertension
35
Q
  1. Explain the mechanism of action for beta-blocker.
  2. What are its adverse effects?
  3. What are the contraindications?
  4. Examples?
A
  1. Vasodilation through renin inhibitor, sympatholysis
  2. Adverse effects: Bradycardia, sleep disturbance, bronchospasm
  3. Contraindication: Asthma, high-grade atrioventricular block; bradycardia
  4. Bisoprolol (2.5-10mg) daily ; atenolol ; carvedilol
    => used particularly in heart failure with reduced ejection fraction, ischaemic heart disease

Consider in younger people esp if ACEi/ARB intolerated ; women of child bearing age

36
Q
  1. Explain the mechanism of action for alpha-blocker.
  2. What are its adverse effects?
  3. What are the contraindications?
  4. Examples?
A
  1. Venodilation
  2. Adverse effects: Postural hypotension, urine incontinence, oedema
  3. Contraindications: Urinary incontinence ; postural hypotension ; heart failure
  4. Doxazosin ; particularly used in BPH and pheochromocytoma
37
Q

How do you confirm diagnosis of hypertension?

A
  1. Ambulatory blood pressure

or

  1. Home BP monitoring
38
Q

How do you quantify overall risk?

How do you look for end organ damage?

A
  1. Fasting blood glucose ; cholesterol

2. ECG ; Echo ; urine analysis

Cardiology core conditions (8 decks)

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