Hypertension 1 and 2 - Hypertension and Management Flashcards
2 categories of hypertension according to cause?Definition
Primary (essential) - not caused by another disease process - 90% of cases of hypertensionSecondary - caused by an underlying disease
What is the blood pressure value for hypertension?
Clinical B.P. > 140/90 mmHgABPM = 135/85 mmHg (24 hour average)
What are some of the factors associated with primary hypertension? (6)
GeneticsFoetal factorsObesityAlcohol intakesodium intakestress
What are some underlying diseases that can cause secondary hypertension? (6 - with examples)
Fibromuscular dysplasia (abnormal growth within the wall of an artery)Obstructive sleep apnoeaRenal disease e.g. renal artery stenosisDrug therapyEndocrine disease e.g. Cushing’s , hyperparathyroidism, phaeochromocyctoma, aldosteronismAortic disease e.g. coarctation
What is white coat syndrome?
Hypertension only in a clinical setting
What is masked hypertension?
Hypertension normal in clinical setting but patient is hypertensive outwith clinical setting
Classification of hypertension according to consequence?Defintion?
Benign - often asymptomatic and develops over a relatively long period of timeMalignant - BP rises rapidly and is associated with severe hypertension, requires urgent treatment
Stage 1 hypertension?
Clinical = > or equal to 140/90ABPM/ HBPM = > or equal to 135/85
Stage 2 hypertension?
Clinical = > or equal to 160/100ABPM/ HBPM = > or equal to 150/95
Severe hypertension/ stage 3 hypertension?
Clinical = > or equal to 180 sys. OR 110 diast.
What does hypertension increase the risk of?
Vascular disease (ischaemic heart disease, peripheral vascular disease, cerebrovascular disease)LVH -> Heart FailureRetinopathyKidney disease*for each increase in b.p. of 20mmHg systolic or 10mmHg diastolic, risk of CV disease doubles
What can be used to measure the risk of CVD? (2)
Assign scoreUK JBS3 lifetime risk calculator
What can be used to look for retinopathy?
Fundoscopy
What can be used to look for kidney disease? (4)
Raised creatineProteinuria ( including Microalbuminuria)Estimated glomerular filtrate rateUrea and electrolytes
What tests should be carried out to look for signs of CVD due to hypertension?
12 lead ECG (looking LVH and signs of ischaemic heart disease)Patients have their blood glucose and cholesterol levels measured
How is the diagnosis of hypertension confirmed?
If b.p. > 140/90mmHg, ambulatory (home blood pressure monitoring is also a suitable alternative) is carried out to confirm the diagnosis
What is involved in ABPM?
At least 2 measurements are taken per hour during patients normal waking hours (usually 14/day) + 1 measurement per hour for non-waking hours(for 24 hours)
What is involved in HBPM?
Measurement taken twice a day by the patient at home for at least 4 days (preferentially 7 days)Measurements for day 1 are disregarded and average value for remaining is taken For each blood pressure reading, take 2 consecutive readings 1 minute apartTake average of all readings (apart from day 1) to confirm diagnosis of hypertension
What is added to a home bp measurement to convert it to a clinical measurement
10/5
Can you use an automatic blood pressure monitor if the patients blood pressure is irregular?
No, measure it manualyl
What are the 4 blood pressure statuses that can be measured?
NormotesntionSustained hypertensionMasked hypertensionWhite coat hypertension
What is postural hypertension?
Increase in systolic bp by 20mmHg or more when standing
If patient has symptoms of postural hypertension, how should their blood pressure be measured?
Sitting/ supine and then again after 1min of standing
What are the 4 areas of change in a patients lifestyle that can help improve hypertension?
Smoking DietWeight reduction and exerciseAlcohol consumption
What diet make be recommended to patients with hypertension
DASH diet (reduces BP in hypertemsive by approx. 11.4/5.5 mmHg)
Do calcium, magnesium, potassium or combination supplements have any evidence for BP reduction?
No
What is the major component of the diet that has to be decreased in hypertensives? What other product should be especially minimised in hypertensives?
Salt (long term sodium reduction may also reduce long term risk of CV events)No salt added diet reduced BP by 2-4mmHgCoffee and caffeine rich products
What are some of the benefits of weight reduction/ exercise for hypertension?
15min/ day = 14% reduced mortalityEvery extra 15 min/day = extra 4% reduced mortalityAerobic exercise reduce blood pressure 3.8/ 2.6mmHg1 mmHg reduction for every lkg of weight lost
Look at hypertension care pathway
…
What is the bp target for treated hypertension in 80 yo
80 yo = 150/90 mmHg (
What hypertensive drug is given if the patient is under 55?
ACEI or low cost angiotensin II receptor blocker (ARB)
What drug is considered if the patient is under 55 yo and younger with intolerance to ARB or ACEI or are of child-bearing age (women) or have evidence of increased sympathetic drive?
Bets blockers
What is the first line hypertension drug used to treat patient over 55 years or of african or Caribbean family origin (of any age)?
Calcium channel blocker
What is the second step of hypertension treatment?
Add A or C depending on the first treatment used
What is the second line treatment given if the patient is coloured?
ARB (in preference to ACEI)
What is the second a beta blocker was used as the first line treatment, what is the second line treatment?
Calcium channel blocker (not diuretic) to prevent diabetes
What is the third line hypertension treatment?
Thiazide-like diuretic
What is the 4th line treatment for hypertension?
Further diuretic or alpha or beta blocker if diuretic doesn’t workThis is resistant hypertension Consider seeking expert advice if bp remains elevated after using maximum tolerated doses of 4 drugs
What is resistant hypertension?
Clinical bp > 140/90 after treatment with A+C+D at highest tolerated dose
What diuretics can be used for 4th line hypertension treatment?
Low dose spironolactone (25mg OD) if potassium level is 4.5 mol/l or lower - use with particular caution in patients with a reduced estimated glomerular filtration rate because they have an increased risk of hyerkalaemiaIf potassium level is higher than 4.5mmol/l consider using a higher-dose thiazide-like diuretic(when using further diuretics, monitor blood sodium and potassium levels as well as renal function within 1 month)*consider alpha or beta blockers if diuretics don’t work
What may be used in place of a calcium channel blocker?
A thiazide-like diuretic (if the patient has oedema or evidence/ risk of heart failure)
Are ACEIs or ARBs used first?
ARBs
What do all ACEIs end in?
-pril
What other conditions are ACEIs/ ARBs also used to treat (2)
CCFDiabetic nephropathy
What type of kidney problems are ACEIs bad for?
Renal artery stenosis
Side effects of ACEIs? (4)
Renal dysfunctionOedemaFoetal abnormalitiesCough
Side effects of ARBs? (2)
Cough (rarer than when using ACEIs)Renal Dysfunction
Are ACEIs/ ARBs vasodilators or vasoconstrictors?
Vasodilators
What do ARBs end in?
-artan
What type of drug should calcium channel blockers never be used with?
Beta blockers (both slow down the heart)
Are calcium channel blockers vasodilator or vasoconstrictors?
Vasodilators
What is a side effect of calcium channel blockers?
Ankle oedema
What are calcium channel blockers also used to treat?
Angina
What do beta blocker names end in?
-olol
when are beta blockers used to treat hypertension? Examples?
When hypertension is complicated e.g.arrhythmiasincreased sympathetic activityCoronary artery diseaseCongestive heart failure
What conditions are beta blockers also used to treat?
CCFAngina
Side effects of calcium channel blockers?
AsthmaTirednessHeart failureCold peripheries
In what age group of patents are thiazide like diuretics especially used in?
Elderly
Side effects of thiazide like diuretics? (4)
ImpotenceHypokalaemiaHyperglycaemiaGout
What is the most effective treatment for resistant hypertension?
Spirolactone
When using spirolactone, what patients should particular caution be taken in?
Patients with diabetes and low GFR (start low, go slow)
How do alpha blockers cause vasodilation?
They block alpha adrenoceptors
What is a side effect of alpha blockers?
Postural hypotension
Which type of drugs have side effects that are to dose dependent? (3)
DiureticsCalcium blockers Beta blockers
Is adding or titrating a drug more effective?
Adding = 5X more effective
Are combo therapies or mono therapies more effective for treating bp?
Combo therapies + no increase in adverse effects
What is pseudo hypertension?
Falsely elevated bp due to non-compressible vessels (mainly seen in the elderly)
What are some reasons for resistant hypertension?
Non-cocordanceWhite coat effectLifestyle factorsDrug interactionsSecondary hypertensionPseudohypetensionTrue resistance
What are some examples of new technology used to treat hypertension?
Baro-receptor stimulationRenal denervation (no red. in BP after 6 months)Rox coupler (fistula created between coronary artery and vein - used also to treat COPD)
