Hypertension 1/2

Question 1

list the benefits of lowering blood pressure (4)

Answer 1

Decreases risk of:

1) stroke
2) coronary events
3) heart failure
4) renal impairment

Question 2

list the lifestyle advice that should be provided to reduce BP (5)

Answer 2

1) smoking cessation
2) reducing weight
3) reduce excessive alcohol and caffeine intake
4) reduce dietary salt
5) increase fruit and vegetable intake

Question 3

If BP was measured in clinic, what reading would lead you to suspect hypertension?

Answer 3

Hypertension should be suspected if clinic systolic BP is sustained above or equal to 140 mmHg, or diastolic BP is sustained above or equal to 90 mmHg, or both

Question 4

1) if a patient presents with a BP of 140/90mmHg or higher when measured in a clinic, how should this be managed?
2) why is this offered?

Answer 4

1) Offer ambulatory BP monitoring (ABPM) or home blood pressure monitoring (HBPM)
2) To confirm diagnosis and stage of hypertension

Question 5

Describe Stage 1 hypertension

Answer 5

clinic blood pressure at least 140/90 mmHg, and subsequent ABPM daytime average or HBPM average at least 135/85 mmHg

Question 6

Describe Stage 2 hypertension

Answer 6

clinic blood pressure at least 160/100 mmHg, and subsequent ABPM daytime average or HBPM average is at least 150/95 mmHg.

Question 7

Describe Stage 3 hypertension

Answer 7

Severe hypertension — clinic systolic blood pressure at least 180 mmHg or clinic diastolic blood pressure at least 110 mmHg.

Question 8

would you initiate treatment in the following patient?

1) Less than 80 years with stage 1 hypertension with any of the following:
- Target organ damage.
- Established cardiovascular disease.
- Renal disease.
- Diabetes.
- QRISK ≥ 20%
2) Does this differ if the patient does not have any of the above conditions?

Answer 8

1) yes- Offer antihypertensive drug treatment

2) yes- in the absence of these conditions advise lifestyle changes and review annually

Question 9

How would you manage a patient under 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease, or diabetes

Answer 9

consider seeking specialist evaluation of secondary causes of hypertension

Question 10

Would you treat a patient who has stage 2 hypertension?

Answer 10

yes - Treat all patients with stage 2 hypertension regardless of age

Question 11

what is the target clinical BP for the following patients:

1) Aged under 80 years with treated hypertension ?
2) Aged 80 years and over with treated hypertension?
3) Those with established CV disease or diabetes in the presence of kidney, eye, or cerebrovascular disease

Answer 11

1) 140/90 mmHg ( Below 135/85mmHg ABPM or HBPM)
2) 150/90 mmHg (Below 145/85 mmHg ABPM or HBPM )
3) Below 130/80mmHg

Question 12

1) is a single anti-hypertensive drug adequate in the management of hypertension?
2) How many weeks should be allowed to determine response from therapy?

Answer 12

1) no- single agent is often inadequate

2) 4 weeks

Question 13

which two factors affect response to Anti-hypertensive therapy?

Answer 13

1) Age

2) Ethnicity

Question 14

Anti-hypertensive drugs are added on using a step wise approach. what should be ensured at each step before adding on another agent?

Answer 14

Anti-hypertensive drug is titrated to the optimum or maximum tolerated dose at each step

Question 15

1) What anti-hypertensive drug treatment is indicated in step 1 for people aged under 55 years? (Not African or Caribbean)
2) if the first line option is not tolerated or suitable?
3) if the first two options are not suitable?

Answer 15

1) ACE inhibitor.
2) If an ACE not tolerated (e.g. due to cough) offer ARB
3) B-blocker (avoid for uncomplicated hypertension in patients with diabetes or those at high risk of developing diabetes especially along with thiazide)

Question 16

1) outline step 2 of anti-hypertensive treatment for people aged under 55 years. (Not African or Caribbean)
2) if above option is not tolerated or there is evidence of heart failure ?
3) If a B-blocker was given in step 1 which drug would be given in preference in step 2 and why?

Answer 16

1) CCB in combination with either ACE or ARB.
2) Thiazide related diuretic (e.g. indapamide or chlortalidone)
3) A CCB rather than a thiazide-like diuretic to reduce the person’s risk of developing diabetes.

Question 17

outline step 3 of anti-hypertensive treatment for people aged under 55 years. (Not African or Caribbean)

Answer 17

A combination of an ACE or ARB , a CCB, and a thiazide-like diuretic.

Question 18

outline step 4 of anti-hypertensive treatment for people aged under 55 years. (Not African or Caribbean)

2) what should be monitored in these patients?
3) what class of drugs can be added on if additional diuretic therapy is contraindicated/ not tolerated?

Answer 18

1) low dose spironolactone 25mg od (unlicenced) if the blood potassium level is 4.5 mmol/l or lower, or high dose thiazide related diuretic if K+ conc above 4.5mmol/l
2) Renal function and electrolytes
3) An alpha- or beta-blocker if further diuretic therapy is contraindicated, not tolerated.

Question 19

outline step 1, 2 for people aged over 55 years, and black people of African or Caribbean origin of any age.

↳ step 3 and 4 treated as for patients under 55 years

Answer 19

1) Step 1: CCB
↳ if not tolerated or evidence of or risk of heart failure, give Thiazide related diuretic
2) Step 2: CCB or Thiazide related diuretic + an ACE or ARB
↳ CCB + ARB preferred in African or Caribbean

Question 20

what two assessments need to be conducted on all people with confirmed hypertension?

Answer 20

1) Serum total cholesterol and HDL cholesterol

2) QRISK

Question 21

1) Up to what age can the benefits of anti-hypertensive treatment be seen?
2) when patients reach this age should they stop treatment?
3) how should newly diagnosed people over 80 years be treated?

Answer 21

1) 80 years
2) if patient already on treatment when they reach 80 they should continue if its of benefit and no SE.
3) if >80 and newly diagnosed with stage 1, decision based on presence of other co-mobidities.
↳ If stage 2 treat as per patients over 55 years

Question 22

1) Hypertension is common in Type 2 diabetes, what can anti-hypertensive treatment prevent in these patients?
2) what is the benefit of using an ACE inhibitor or ARB in these patients?

Answer 22

1) macrovascular and microvascular complications

2) can delay progression of microalbuminuria to nephropathy

Question 23

what can hypertension usually indicate in type 1 diabetics?

Answer 23

presence of diabetic nephropathy (ACE or ARB might have a role in the management of this condition)

Question 24

which hypertensive drug should be used in patients with proteinuria?

Answer 24

1) ACE (or ARB) should be considered-use in caution in renal impairment
↳ thiazide may be ineffective and high doses of loop may be required