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Year 3 > Essential or secondary hypertension (CV) > Flashcards

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
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2
Q

What is essential/primary hypertension?

A

Persistently raised BP with no identifiable/secondary cause identified

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3
Q

What is secondary hypertension?

A

Hypertension caused by an identifiable underlying cause

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4
Q

What is the most common cause of secondary hypertension?

A

Conn’s syndrome - primary hyperaldosteronism

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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
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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
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7
Q

How does hypertension usually present?

A

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

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8
Q

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

A
  • headache
  • visual changes (blurred vision)
  • dyspnoea
  • chest pain
  • motor/sensory deficit
  • dizziness
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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
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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
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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

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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
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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

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14
Q

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

A

Home BP monitoring, measured by individual at periodic intervals

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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
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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
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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
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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
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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
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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
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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
Q

What are some examples of ARBs?

A

Losartan, candesartan

26
Q

What are some examples of calcium channel blockers (CCBs)?

A

Amlodipine, felodipine

27
Q

What are some examples of beta blockers?

A

Propranolol, atenolol, metoprolol

28
Q

What is an example of an alpha blocker?

A

Doxazosin

29
Q

What are some examples of diuretics (4 types)?

A
  • loop: furosemide
  • thiazide: chlorothiazide
  • thiazide-like: indapamide
  • potassium sparing: spironolactone, eplerenone
30
Q

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?

A

Lifestyle modification and monitoring

31
Q

What is the 1st line management for a hypertensive patient <55 years or diabetic?

A

ACEi (or ARB)

32
Q

In what case should a patient with CKD be started on ACEi?

A

If ACR>30 or 3.0 (regardless of age)

33
Q

What are some side effects of ACEi? (3)

A
  • angioedema
  • cough
  • elevated K+
34
Q

What is ACEi the most common cause of?

A

Drug-induced angioedema

35
Q

When is ACEi contraindicated and why?

A
  • 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
Q

What is the preferred anti-hypertensive medication for black patients?

A

ARB (Losartan)

37
Q

What is the 1st line management for a hypertensive patient >55 years old (and not diabetic) or black ethnicity?

A

CCB e.g. amlodipine/nifedipine

38
Q

What are some side effects of CCBs e.g. amlodipine? (3)

A
  • ankle swelling (peripheral oedema)
  • headache
  • flushing
39
Q

What is offered if a hypertensive patient has a Q-risk score of >10%?

A

Statin e.g. atorvastatin

40
Q

What thiazide-like diuretics could we give for hypertension? (3)

A
  • indapamide
  • hydrochlorothiazide
  • chlorthalidone
41
Q

In what condition are thiazide-like diuretics contraindicated?

A

Gout

42
Q

What are some side effects of thiazide-like diuretics? (5)

A
  • hypercalcaemia
  • hyponatraemia
  • hypokalaemia (T-wave flattening, U-waves, long QT, prolonged PR interval, ST depression)
  • impaired glucose tolerance
  • erectile dysfunction
43
Q

What can you add on if a patient has poorly controlled hypertension, already taking ACEi, CCB and standard dose thiazide-like diuretic?

A
  • 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
Q

Summarise the treatment ladder for hypertension.

A
  • 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
Q

What are the target BPs for different types of hypertensive patients?

A
  • <80: aim for 135/85
  • > 80: aim for 145/85
  • diabetes: 140/90
46
Q

What is the 1st line management for a hypertensive patient with CHD?

A

Beta blocker & CCB

47
Q

What is the 1st line management for a hypertensive patient with HFrEF?

A

ACEi or ARB + beta blocker

48
Q

What is the 1st line management for a hypertensive patient with left ventricular hypertrophy/renal disease/diabetes?

A

ACEi or ARB

49
Q

What is the 1st line management for a hypertensive patient with atrial fibrillation?

A

Beta blocker 1st line
(CCB 2nd line)

50
Q

What are some complications of hypertension?

A
  • 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
Q

Describe the prognosis of hypertension.

A

Even modest reductions in BP decrease morbidity and mortality due to complications

Year 3 (80 decks)

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