Essential or secondary hypertension (CV) Flashcards

1
Q

What is hypertension?

A
  • blood pressure that is persistently >/=140/90 mmHg
  • AND
  • 24 hour blood pressure average reading (ABPM/HBPM) >/=135/85 mmHg
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is essential/primary hypertension?

A

Persistently raised BP with no identifiable/secondary cause identified

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is secondary hypertension?

A

Hypertension caused by an identifiable underlying cause

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the most common cause of secondary hypertension?

A

Conn’s syndrome - primary hyperaldosteronism

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are some other causes causes of secondary hypertension? (9)

A
  • (Conn’s syndrome = most common)
  • renal stenosis
  • chronic renal failure
  • Cushing’s syndrome
  • phaeochromocytoma
  • acromegaly
  • hyperthyroidism
  • coarctation of the aorta
  • combined OCP
  • pre-eclampsia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are some causes of essential hypertension?

A
  • disturbance of auto-regulation (reflex and persistently increasing vascular resistance to match an increased cardiac output)
  • excess sodium intake
  • renal sodium retention
  • RAAS dysregulation (increased plasma renin –> increased angiotensinogen, AT1, AT2 –> vasoconstriction)
  • increased sympathetic drive
  • increased peripheral resistance
  • endothelial dysfunction
  • cell membrane transporter perturbations
  • insulin resistance/hyperinsulinaemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How does hypertension usually present?

A

Often asymptomatic (incidental finding) - unless BP is very high

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are some non-specific symptoms of hypertension? (6)

A
  • headache
  • visual changes (blurred vision)
  • dyspnoea
  • chest pain
  • motor/sensory deficit
  • dizziness
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What might you see on examination of hypertension?

A
  • systolic BP>140 mmHg and/or diastolic BP>90 mmHg measured on three separate occasions
  • hypertensive retinopathy
  • radiofemoral delay = coarctation of the aorta distal to the left subclavian artery
  • renal artery bruit = renal artery stenosis
  • palpable kidneys
  • signs of phaeochromocytoma or Cushing’s
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How is hypertensive retinopathy classified?

A

Keith-Wagner Classification:

  • grade I: silver wiring (line down middle of arterioles)
  • grade II: silver wiring + AV nipping (artery crosses vein and nips it, causing vein to narrow)
  • grade III: flame haemorrhage, sometimes cotton wool spots too
  • grade IV: papilloedema (cannot see optic disc) - either due to chronic hypertension or intracranial hypertension (from brain tumour), needs admission
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

When can orthostatic hypertension be diagnosed?

A

When there is a drop in SBP >/=20 mmHg and/or a drop in DBP >/=10 mmHg after 3 minutes of standing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are some risk factors for hypertension? (9)

A
  • obesity
  • aerobic exercise <3 times/week
  • alcohol intake
  • metabolic syndrome
  • diabetes mellitus
  • black ancestry
  • age >60 years
  • Fx of hypertension or chronic coronary disease
  • sleep apnoea
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is the 1st line investigation for hypertension?

A

Ambulatory blood pressure monitoring (ABPM) - measures BP at fixed intervals over 12-24 hours allowing average to be taken

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

If ABPM is declined for hypertension, what is the next step?

A

Home BP monitoring, measured by individual at periodic intervals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What other investigations can be done alongside ABPM to investigate hypertension? (6)

A
  • ECG - check for left ventricular hypertrophy or old infarction
  • fasting metabolic panel with eGFR - renal insufficiency, hyperglycaemia, hypokalaemia, hyperuricaemia, hypercalcaemia
  • lipid panel
  • urinalysis - may show proteinuria/haematuria
  • Hb - anaemia/polycythaemia suggest secondary cause or complication
  • TSH - high or low if thyroid dysfunction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

If new BP is >180/120 mmHg, what is this indicative of and what investigations can we do to assess this?

A

End organ damage

  • fundoscopy - retinopathy
  • urine dipstick - renal disease
  • ECG - LVH
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are some differential diagnoses for hypertension?

A
  • drug-induced
  • CKD
  • renal artery stenosis (renal duplex US/magnetic resonance angiogram, treated with renal balloon)
  • aortic coarctation
  • OSA
  • hyperaldosteronism
  • hypo/hyperthyroidism
  • hyperparathyroidism
  • Cushing’s syndrome
  • phaeochromocytoma
  • acromegaly
  • collagen vascular disease
  • gestational hypertension
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What do we offer to patients with BP between 140/90 and 180/120?

A
  • offer ABPM
  • offer to test urine ACR, haematuria, HbA1c, electrolytes, creatinine, eGFR, cholesterol, fundoscopy, ECG
  • estimate Q-risk
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What do we do if a patient presents with BP>180/120?

A
  • same day referral if retinopathy, confusion, chest pain, heart failure, AKI
  • start antihypertensive drug
  • if no target organ damage: repeat reading in 7 days
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are the stages of hypertension?

A
  • stage 1 HTN: clinic >140/90, ABPM >135/85
  • stage 2 HTN: clinic >160/100, ABPM >150/95
  • stage 3 HTN: clinic >180/120
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What do you do if a patient under 40 presents with hypertension?

A

Seek specialist evaluation for secondary causes

22
Q

How do you treat secondary hypertension?

A

Treat underlying cause FIRST

23
Q

What lifestyle modification advice can you give to patients with hypertension? (5)

A
  • smoking cessation
  • weight loss
  • exercise
  • reduce alcohol intake
  • reduce dietary sodium
24
Q

What are some examples of ACE inhibitors?

A

Ramipril, lisinopril

25
What are some examples of ARBs?
Losartan, candesartan
26
What are some examples of calcium channel blockers (CCBs)?
Amlodipine, felodipine
27
What are some examples of beta blockers?
Propranolol, atenolol, metoprolol
28
What is an example of an alpha blocker?
Doxazosin
29
What are some examples of diuretics (4 types)?
- loop: furosemide - thiazide: chlorothiazide, bendroflumethiazide - thiazide-like: indapamide - potassium sparing: spironolactone, eplerenone
30
What is the 1st line management for a hypertensive patient without chronic renal disease/CVD-related comorbidity: stage 1 hypertension and lower CVD risk and without diabetes?
Lifestyle modification and monitoring
31
What is the 1st line management for a hypertensive patient <55 years or diabetic?
ACEi (or ARB)
32
In what case should a patient with CKD be started on ACEi?
If ACR>30 or 3.0 (regardless of age)
33
What are some side effects of ACEi? (3)
- angioedema - cough - elevated K+
34
What is ACEi the most common cause of?
Drug-induced angioedema
35
When is ACEi contraindicated and why?
- renal artery stenosis - starting ACEi may cause significant renal impairment (deranged U&Es) - considered for a patient with risk factors and evidence of atherosclerotic vascular disease
36
What is the preferred anti-hypertensive medication for black patients?
ARB (Losartan)
37
What is the 1st line management for a hypertensive patient >55 years old (and not diabetic) or black ethnicity?
CCB e.g. amlodipine/nifedipine
38
What are some side effects of CCBs e.g. amlodipine? (3)
- ankle swelling (peripheral oedema) - headache - flushing
39
What is offered if a hypertensive patient has a Q-risk score of >10%?
Statin e.g. atorvastatin
40
What thiazide-like diuretics could we give for hypertension? (3)
- indapamide - hydrochlorothiazide - chlorthalidone
41
In what condition are thiazide-like diuretics contraindicated?
Gout
42
What are some side effects of thiazide-like diuretics? (5)
- hypercalcaemia - hyponatraemia - hypokalaemia (T-wave flattening, U-waves, long QT, prolonged PR interval, ST depression) - impaired glucose tolerance - erectile dysfunction
43
What can you add on if a patient has poorly controlled hypertension, already taking ACEi, CCB and standard dose thiazide-like diuretic?
- if K+ <4.5mmol/L - add low dose spironolactone (K+ sparing diuretic) - if K+ >4.5mmol/L - add alpha blocker (-zosin) or beta blocker (-olol)
44
Summarise the treatment ladder for hypertension.
- step 1: - diabetic/<55: ACEi or ARB - black/>55: CCB or thiazide-like diuretic - step 2: ACEi & CCB or ACEi & thiazide-like diuretic (or CCB & thiazide-like diuretic) - step 3: ACEi & CCB & thiazide-like diuretic - step 4: low dose spironolactone (K+<4.5)or alpha/beta blocker
45
What are the target BPs for different types of hypertensive patients?
- <80: aim for 135/85 - >80: aim for 145/85 - diabetes: 140/90
46
What is the 1st line management for a hypertensive patient with CHD?
Beta blocker & CCB
47
What is the 1st line management for a hypertensive patient with HFrEF?
ACEi or ARB + beta blocker
48
What is the 1st line management for a hypertensive patient with left ventricular hypertrophy/renal disease/diabetes?
ACEi or ARB
49
What is the 1st line management for a hypertensive patient with atrial fibrillation?
Beta blocker 1st line (CCB 2nd line)
50
What are some complications of hypertension?
- heart failure - coronary artery disease (turbulent flow --> thrombosis and embolism) - cerebrovascular accidents (stroke) - peripheral vascular disease - hypertensive retinopathy - renal failure - hypertensive encephalopathy - posterior reversible encephalopathy syndrome (PRES) - malignant hypertension - CCBs --> leg swelling
51
Describe the prognosis of hypertension.
Even modest reductions in BP decrease morbidity and mortality due to complications