HTN

Question 1

HTN Mx [NICE updates!]

Answer 1

• classifying hypertension into stages
• recommending the use of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM)
• calcium channel blockers are now considered superior to thiazides
• bendroflumethiazide is no longer the thiazide of choice

Question 2

Blood pressure classification

Answer 2

Question 3

NICE GUIDELINES: htn diagnosis

Answer 3

Question 4

mx of htn

Answer 4

Lifestyle advice should not be forgotten and is frequently tested in exams:

a low salt diet is recommended, aiming for less than 6g/day, ideally 3g/day. The average adult in the UK consumes around 8-12g/day of salt. A recent BMJ paper* showed that lowering salt intake can have a significant effect on blood pressure. For example, reducing salt intake by 6g/day can lower systolic blood pressure by 10mmHg

caffeine intake should be reduced

the other general bits of advice remain: stop smoking, drink less alcohol, eat a balanced diet rich in fruit and vegetables, exercise more, lose weight

ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)

treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater

ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension)

offer drug treatment regardless of age

For patients < 40 years consider specialist referral to exclude secondary causes.

Question 5

step wise mx of htn according to NICE

Answer 5

Step 1 treatment

patients < 55-years-old: ACE inhibitor (A)

patients >= 55-years-old or of Afro-Caribbean origin: calcium channel blocker

Step 2 treatment

ACE inhibitor + calcium channel blocker (A + C)

Step 3 treatment

add a thiazide diuretic (D, i.e. A + C + D)

NICE now advocate using either

• chlorthalidone (12.5-25.0 mg once daily) or i
• indapamide (1.5 mg modified-release once daily or 2.5 mg once daily)

in preference to a conventional thiazide diuretic such as bendroflumethiazide

NICE define a clinic BP >= 140/90 mmHg after step 3 treatment with optimal or best tolerated doses as resistant hypertension. They suggest step 4 treatment or seeking expert advice

Step 4 treatment

consider further diuretic treatment

• if potassium < 4.5 mmol/l add spironolactone 25mg od
• if potassium > 4.5 mmol/l add higher-dose thiazide-like diuretic treatment

if further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker

Patients who fail to respond to step 4 measures should be referred to a specialist. NICE recommend:

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained.

Question 6

BP targets

Answer 6

Question 7

Hypertensive retinopathy classification

Answer 7

The table below shows the Keith-Wagener classification of hypertensive retinopathy

Stage Features

• I - Arteriolar narrowing and tortuosity
• Increased light reflex - silver wiring
• II - Arteriovenous nipping
• III - Cotton-wool exudates
• Flame and blot haemorrhages
• IV - Papilloedema