Hypertension Flashcards
Why do we pay so much attention to HTN?
Most important risk factor for premature death and CVD
Accounts for 50% vascular deaths
Stages of HTN
Stage 1:
Clinic BP >= 140/90
ABPM or HBPM >=135/85
Stage 2:
Clinic BP >=160/100
ABPM or HBPM >= 150/95
Stage 3:
Clinic BP >= 180/110
Who do we treat for HTN?
Stage 1 HTN: judge based on their cardiovascular risk - QRISK, if QRISK >10% in 10 years then treat
Stage 2 and stage 3 are treated
What is malignant HTN?
Rapid rise in BP
>200/130
Bilateral retinal haemorrhages + exudates ± papilloedema
Commonly causes headaches and visual disturbance
If untreated 90% die within 1 year
NICE guidelines for BP measurement
Measure in both arms and take the highest reading
If measuring >140/90 then repeat and take the lower score
(If the two measurements vary widely, repeat for a third time
If patients BP measures between 140-180 offer ABPM or HBPM to confirm they have HTN
When would we refer a patient based on BP measurement?
If a patients BP is 180/120+ and they have signs of retinal haemorrhage or papilloedema
Or if they have any life-threatening symptoms (shook)
What else do we want to look for in patients with HTN?
Signs of end organ damage and quanitification of CVD risk
ECG: cardiac damage
Echo: any valvular changes due to HTN
Urinalysis: protein or blood
Eyes: retinopathy
Reversible causes of HTN that are important to rule out
Conn’s: bloods will show low K+
Hyperparathyroidism: bloods will show high Ca2+
Renal artery USS to look for RAS
MRI of aorta to rule out coarctation
How is hypertensive retinopathy graded?
- Tortuous arteries with thick shiny walls - described as silver or copper wiring
- AV nipping: when thickened retinal arteries pass over veins
- Flame haemorrhages + cotton wool spots: exudates due to infarcts
- Papilloedema
Patient is not diagnosed with HTN after investigation - what is done?
Monitor every 5 years
Monitor more frequently if they are close to 140/90 cut off
Discuss the management of HTN
Lifestyle: regular exercise and monitor diet, decrease caffeine and alcohol intake, reduce salt intake
Medication: see previous card for who to treat
1st line = 1 drug
With T2DM: ACE or ARB (if black)
Without T2DM: 1st line = ACEi or ARB
Unless patient is black = CCB
Unless patient >55 yrs = CCB
2nd line = 2 drugs together
+ in either a CCB, an ARB or ACEi OR a thiazide diuretic
3rd line = 3 drugs together
CCB + ACEi or ARB + thiazide diuretic
Step 4: patient has resistant HTN
Check medication adherence + consider seeking expert help
+ spironolactone if K+ =<4.5
+ alpha or beta blocker if K+ >4.5
What is meant by primary or secondary HTN?
Primary = 95% cases, no underlying cause
Secondary = 5% cases, where HTN occurs due to underlying disease
- Renal disease: most common cause, 75% due to intrinsic renal disease e.g. glomerulonephritis or PKD, 25% due to renovascular disease e.g. fibromuscular dysplasia or atheroma
- Endocrine: cushings, conns, phaeochromocytoma, acromegaly, hyperparathyroidism
- Other: coarctation of aorta, pregnancy, liquorice, cocaine, MAOis
What is the BP aim in DM?
Same as general population
Why do we avoid using ACEi in black patients?
They don’t work very well
Common side effects of antihypertensives
ACEi: dry cough, renal dysfunction if renal function is impaired
ARBs: increase in hepatic enzyme levels
CCBs: headache, flushing, N&V
Thiazides: hypochloreamia, gout, constipation
Spironolactone: gynaecomastia, hyperkalaemia
What are the two types of calcium channel blockers?
1. Non-dihydropyridine: verapamil and diltiazem - work on the myocardium as well as vessels
Anti-arrhythmic properties
2. Dihyropyridines: amlodipine, felodipine, nifedipine - work on the vessels only
Anti-hypertensive properties
2 high so dipin(e) water to lower BP 🥵
