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Leicester Year 3 GP > GP/ Medicine - Hypertension > Flashcards

GP/ Medicine - Hypertension Flashcards

1
Q

What range of BP is considered normal?

A

120/80 mmHg

(Range: 90/60 mmHg - 140/90 mmHg)

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2
Q

What are the causes of hypertension?

A

Primary (or Essential) hypertension - idiopathic and related to old ages

Secondary hypertension (CREEP):

Coarctation of aorta

Renal/ RAAS activation e.g. glomerulonephritis, CKD, PCKD, Renal artery stenosis

Endocrine e.g. Conn’s syndrome, phaeochromocytoma, Cushing’s syndrome, Hyperthyroidism

Eclampsia

Pill/ Pregnancy e.g. alcohol, cocaine, COCP, NSAIDs, glucocorticoids, beta/ alpha-adrenoceptor agonists, antidepressants, calcineurin inhibitors (ciclosporin/ tacrolimus), EPO

Obstructive Sleep Apnoea

(Decreased O2 level causes the heart to pump fast with more force, so an increase in SV and HR causes an increase in CO which raises the BP)

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3
Q

Give 3 modifiable and 3 non-modifiable risk factors

A

Modifiable risk factors:

  • Obesity
  • Diabetes
  • High salt intake

Non-Modifiable risk factors

  • Old age
  • FH
  • Gender (BP is higher in men 65 yrs old)
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4
Q

What is stage 1 HTN?

A

Clinic BP >/= 140/90 mmHg + subsequent ABPM or HBPM >/= 135/ 85 mmHg

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5
Q

What is stage 2 HTN?

A

Clinica BP >/= 160/100 mmHg + subsequent ABPM or HBPM >/= 150/95 mmHg

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6
Q

What is stage 3 HTN?

A

Clinical SBP >/= 180 mmHg OR clinical DBP >/= 120 mmHg

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7
Q

What is ABPM?

A

A device that takes serial BP measurements over a 24-hr period, as you are moving around and living your normal daily life.

Since it’s measured for up to 24 hrs, it’s also called 24-hr blood pressure monitoring

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8
Q

What is HBPM?

A

Self-recorded BP mreasurement taken at home or work

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9
Q

When should ABPM or HBPM be offered?

A

If Clinic BP >/= 140/90

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10
Q

Why do we need to do ABPM or HBPM?

A

Avoid overdiagnosing patients with ‘white coat HTN’

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11
Q

What should you do next if the first clinical BP reading is > 140/90?

A

NICE guideline recommends taking a second reading. The lower reading of the two should determine further management. If the second reading is > 140/90, offer ABPM/ HBPM

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12
Q

When would you NOT offer ABPM/ HBPM and instead jump straight to starting treatment right away?

A

If the patient has severe hypertension i.e. if their clinical SBP >/= 180 or clinical DBP > 120

  • If there are signs of papilloedema or retinal haemorrhages –> SAME DAY REFERRAL to an ophthalmologist
  • If suspected phaeochromocytoma –> SAME DAY REFERRAL to an endocrinologist)
  • If there are life-threatening symptoms e.g. confusion, chest pain, signs of heart failure, or AKI –> SAME DAY REFERRAL to a cardiologist
  • If patients have none of the above (i.e. no worrying signs), then arrange urgent investigations for end-organ damage e.g. bloods, fundoscopy, urine dip, ECG
    • If target organ damage is identified, start antihypertensive IMMEDIATELY, without waiting for the results of ABPM/ HBPM
    • If no target organ damage is identified, repeat clinic BP measurement within 7 days
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13
Q

What are the different stages for hypertensive retinopathy?

A

Grade 1 - generalised arteriolar narrowing

Grade 2 - Areas of focal narrowing + arteriovenous nipping (AV-nipping)

Grade 3 - Retinal haemorrhages, cotton wool spots, hard exudates

Grade 4 (Malignant hypertension) - optic disc swelling (papilloedema) + macular star (ring of exudates around the macula)

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14
Q

What are the clinical features of hypertension?

A
  • Asymptomatic, unless it’s very high e.g. > 200/120 mmHg
  • Headaches
  • Visual disturbances
  • Seizures
  • Features of an underlying cause:
    • Palpitations, headaches, sweating in phaeochromocytoma
    • Muscle weakness, tetany or numbness in hyperaldosteronism due to hypokalaemia
    • Central/ truncal obesity, moon face, weight gain, buffalo hump in Cushing’s syndrome
    • ‘SWEATING’ (mnemonic), exophthalmos, pre-tibial myxoedema in hyperthyroidism
    • Enlarged kidneys and haematuria in PCKD; renal bruits in renal artery stenosis
    • Radio-femoral delay in coarctation of aorta
  • Assess for end-organ damage:
    • Fundoscopy - check for hypertensive retinopathy
    • Urine dipstick - to check for renal disease e.g. proteinuria, haematuria
    • ECG - check for LVH and IHD (due to increased afterload)
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15
Q

What are the features of end-organ damage secondary to severe hypertension?

A

Features of end-organ damage:

Hypertensive retinopathy e.g. papilloedema, retinal haemorrhages

Proteinuria, haematuria, high urine ACR

LVH, IHD

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16
Q

What examinations/ investigations would you carry out as a GP?

A
  • ABPM (also known as 24-hr BP monitoring)
  • Blood tests - FBC, U&Es, HbA1c, lipid profile (total cholesterol)
    • May suggest secondary cause e.g. low K+ and high Na+ suggest hyperaldosteronism; also look at creatinine and eGFR in U&Es to check for any renal damage
  • Fundoscopy to check for hypertensive retinopathy
  • Urine dipsticks to test for proteinuria and haematuria,
  • Urine ACR
  • ECG to check for LVH and IHD
  • Echo if LVH and valvular disease
  • Assess QRISK
17
Q

Further investigations depend on the cause of secondary hypertension. Give 3 examples.

A
  • Renal USS/ arteriography if renal artery stenosis
  • 24-hr urinary metanephrines if phaeochromocytoma
  • Overnight dexamethasone suppression and urinary free cortisol for Cushing’s syndrome
  • Low renin: aldosterone ratio in Conn’s syndrome
18
Q

How to diagnose hypertension?

A
  • Measure BP in both arms
    • If the difference in readings between arms is > 20 mmHg, then repeat the measurements. If the difference remains > 20 mmHg, then subsequent BP should be recorded from the arm with the highest reading
    • If the first clinical BP reading > 140/90, NICE guideline recommends taking a second reading. The lower reading of the two should determine further management
  • Offer ABPM or HBPM to any patient with a BP > 140/90 mmHg
  • If, however, the patient has severe hypertension (i.e. their clinical SBP >/= 180 or clinical DBP > 120) with NO worrying signs, arrange urgent investigations for end-organ damage e.g. bloods, fundoscopy, urine dip, ECG
    • If target organ damage is identified, start antihypertensive IMMEDIATELY, without waiting for the results of ABPM/ HBPM
    • If no target organ damage is identified, repeat clinic BP within 7 days
  • If patient has severe hypertension WITH worrying signs:
    • Signs of papilloedema or retinal haemorrhages –> SAME DAY REFERRAL to an ophthalmologist
    • Signs of phaeochromocytoma –> SAME DAY REFERRAL to an endocrinologist)
    • Life-threatening symptoms e.g. confusion, chest pain, signs of heart failure, or AKI –> SAME DAY REFERRAL to a cardiologist
19
Q

What should you do next to diagnose a patient with a clinical BP >/= 140/90?

(please specify whether or not you will treat this patient)

A
  • Offer ABPM or HBPM
    • If < 135/85 mmHg –> not hypertensive –> only needs monitoring
    • If >/= 135/85 mmHg –> stage 1 HTN –> Treat if < 80 yrs old AND with one of the following:
      • Target organ damage
      • Established cardiovascular disease
      • Renal disease
      • Diabetes
      • QRISK (10-yr cardiovascular risk) >/= 10%
    • If >/= 150/ 95 mmHg –> stage 2 HTN –> Treat all patients regardless of age
20
Q

What is the management of hypertension?

(both non-pharmacological and pharmacological)

A

Non-pharmacological Mx:

  • Lifestyle changes
    • Weight loss, exercise more
    • Low salt intake
    • Reduced caffeine intake
    • Stops smoking
    • Drink less alcohol
    • Balanced diet rich in fruits and vegetables

Pharmacological Mx:

  • Step 1 treatment
    • < 55 yrs old or T2DM –> ACEi (ramipril) / ARB (losartan)
    • >/= 55 yrs old or of Afro-Caribbean origin + No T2DM
      • CCB (amlodipine)
  • Step 2 treatment
    • If already on ACEi/ ARB, add a CCB or a thiazide diuretic
    • If already on CCB, add an ACEi/ ARB
      • For patients of Afro-Caribbean origin taking a CCB, if they require a second agent consider an ARB over ACEi
  • Step 3 treatment
    • Add a third drug
      • If already taking (A+C), add a D
      • If already taking (A+D), add a C
  • Step 4 treatment
    • If K+ < 4.5 mmol/L, add a spironolactone
    • If K+ > 4.5 mmol/L, add either alpha-blocker or beta-blocker
    • If BP on 4 drugs are still not controlled, then referral for specialist review
21
Q

What are the blood pressure targets in age < 80 yrs?

A

Clinic BP 140/90 mmHg

ABPM/ HBPM 135/85 mmHg

22
Q

What are the blood pressure targets for age > 80 yrs?

A

Clinic BP 150/90 mmHg

ABPM/ HBPM 145/85 mmHg

23
Q

Give 3 complications of HTN

A

Heart failure

IHD

CKD

Stroke

PAD

24
Q

What is hypertensive crisis?

A

An increase in BP (SBP > 180 and/or DBP > 120), which if sustained over the next few hrs, will cause irreversible end-organ damage e.g. LVF, renal failure, MI, aortic dissection, intracranl haemorrhage, encephalopathy

25
Q

What is the difference between hypertensive emergency and hypertensive urgency?

A

Hypertensive emergecy = High BP WITH a critical event or evidence of acute end-organ damage

Hypertensive urgency = High BP, but WITHOUT a critical event or evidence of acute end-organ damage (may include malignant hypertension which is assciated with grade 4 hypertensive retinopathy)

26
Q

How would you manage hypertensive emergency?

A

The aim is to reduce the DBP to 110 mmHg in 3-12 hrs using an IV regimen:

IV Sodium nitroprusside

IV Labetolol

IV GTN

IV Esmolol

27
Q

How would you manage hypertensive urgency?

A

If left untreated, it can become hypertensive emergency in days

The aim is to reduced DBP to 100 mmHg over 48 hrs using an oral regimen

Nifedipine + Amlodipine for 3 days, then continue with amlodipine thereafter

Leicester Year 3 GP (36 decks)

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