HTN

Question 1

Patient presents with 140/90 mmHg in clinical setting offer ??

Answer 1

Ambulatory BP monitoring (ABPM), / home BP monitoring if ABPM unsuitable, to confirm diagnosis and stage of HTN.

Question 2

Stage 1 HTN

Answer 2

clinic: 140/90 mmHg
home: 135/85

Question 3

START antihypertensive drug tx with pt aged <80 years w/ stage 1 HTN if 1 or more of following

Answer 3

target-organ damage (i.e. left ventricular hypertrophy, CKD or hypertensive retinopathy), established CVD, renal disease, diabetes, or 10 year CV risk ≥10%.

Question 4

Stage 2 HTN

Answer 4

clinic: 160/100 mmHg
home:150/95 +.

Treat ALL patients stage 2 HTN, regardless of age.

Question 5

Severe HTN

Answer 5

clinic systolic: 180 mmHg or higher, or clinic diastolic 120 mmHg or higher.

Treat severe hypertension promptly

Question 6

Clinic BP target for <80 years old

Answer 6

below 140/90 mmHg

Question 7

Clinic BP target for >80 years old

Answer 7

below 150/90 mmHg

Question 8

Ambulatory /home BP monitoring target for <80 years old

Answer 8

below 135/85 mmHg

Question 9

Ambulatory /home BP monitoring target for >80 years old

Answer 9

below 145/85 mmHg

Question 10

SIGN target for BP

Answer 10

target clinic BP below 140/90 mmHg regardless of age

Question 11

SIGN target for BP if organ damage/CVD

Answer 11

clinic BP below 135/85 mmHg

Question 12

SIGN / Royal College of Physicians BP target for stroke or TIA

Answer 12

clinic systolic BP below 130 mmHg

Question 13

CCB not tolerated, i.e. oedema

Answer 13

If starting / changing diuretic tx, offer indapamide in preference to conventional thiazide diuretics, i.e. Bendroflumethiazide or hydrochlorothiazide.

Continue current tx in patients with hypertension who already have stable, well-controlled BP whilst on Bendroflumethiazide or hydrochlorothiazide.

Question 14

STEPS in HTN + T2DM in all patients (any age or origin), or hypertension without type 2 diabetes in those aged 55 years or below and not of black African or African-Caribbean origin

Answer 14

Step 1: ACE inhibitor / ARB.

Step 2: ADD CCBs or thiazide-like diuretic. thiazide-like diuretic if evidence of heart failure.

Step 3: ACE inhibitor or ARB, CCB & thiazide-like diuretic.

Step 4: Before further tx, confirm elevated clinic BP using ambulatory / home BP recordings, assess for postural hypotension and discuss adherence. If further treatment required, consider seeking specialist advice, or addition of low-dose spironolactone [unlicensed indication] if potassium 4.5 mmol/litre or less; or alpha blocker or beta blocker if potassium greater than 4.5 mmol/litre.

When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium, potassium and renal function within 1 month of starting treatment and repeat as needed thereafter.

Seek specialist advice if blood pressure remains uncontrolled despite taking optimal tolerated doses of 4 drugs.

Question 15

STEPS in HTN without T2DM in patients aged 55 and over, or all ages of black African or African-Caribbean origin patients without type 2 diabetes

Answer 15

Step 1: CCB

Step 2: offer ACE inhibitor, ARB or thiazide-like diuretic.

Step 3: Offer ACE inhibitor or ARB, CCB and thiazide-like diuretic.

Step 4: Before further tx for person with resistant HTN, confirm elevated clinic BP measurements using ambulatory or home BP recordings, assess for postural hypotension and discuss adherence. If further tx required, consider seeking specialist advice, or consider low-dose spironolactone [unlicensed indication] if potassium 4.5 mmol/litre or less; or an alpha blocker or beta blocker if potassium greater than 4.5 mmol/litre.

When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium, potassium, and renal function within 1 month of starting treatment and repeat as needed thereafter.

Seek specialist advice if blood pressure remains uncontrolled despite taking optimal tolerated doses of 4 drugs.

Question 16

HTN in Type 1 diabetes

Question 17

HTN in Type 2 diabetes

Question 18

HTN in renal disease

Question 19

HTN in pregnancy

Question 20

Vasoconstrictor sympathomimetics MOA

Answer 20

RAISE BP by acting on alpha-adrenergic receptors to constrict peripheral blood vessels

===> for hypotension & shock

Question 21

Vasoconstrictor sympathomimetics e.g.

Answer 21

Noradrenaline
Phenylephedrine (longer acting,

Question 22

Vasoconstrictor sympathomimetics side effects

Answer 22

reduced perfusion to vital organs e.g. kidneys

Question 23

vasodilator anti-hypertensives

Answer 23

Hydralazine (side effect = fluid retention, tachycardia)

Minoxidil (side effects = tachycardia, fluid retention, increase cardiac output)

Question 24

centrally-acting anti-hypertensives

Answer 24

Methyldopa (SE = driving, drowsiness)
Clonidine (SE = flushing)
Moxonidine

Question 25

<80 normal BP target clinic

Answer 25

<140/90

Question 26

<80 atherosclerotic CVD, DM with kidney, eye, cerebrovascular disease BP target clinic

Answer 26

130/80

Question 27

>80 BP target normal clinc

Answer 27

<150/90

Question 28

clinic BP target if renal disease

Answer 28

<140/90

Question 29

clinic BP target if CKD, Diabetes, Proteinuria >1g in 24h

Answer 29

<140/80 consider ACEi/ARB if proteinuria

Question 30

clinic BP target if DM

Answer 30

<140/80

Question 31

clinic BP target if DM + complication of eye, kidney, cerebrovascular disease

Answer 31

<130/80

Question 32

clinic BP target if chronic HTN in pregnancy

Answer 32

<150/100

Question 33

clinic BP target if chronic HTN in pregnancy + target organ damage or given birth

Answer 33

<140/90 ~ labetalol (hepatotoxic) ~ methyldopa (stop 2 days after birth) ~ nifedipine (unlicensed)