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Y3 GP: Hypertension, CKD and Lipid Modification > Hypertension > Flashcards

Hypertension Flashcards

1
Q

What is hypertension?

A

Hypertension is persistently raised arterial blood pressure.

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2
Q

What is the current clinic value for diagnosing hypertension?

A

The current standard threshold for suspecting hypertension is clinic systolic blood pressure sustained above or equal to 140 mmHg, or diastolic blood pressure sustained above or equal to 90 mmHg, or both.

The diagnosis is then confirmed with ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM).

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3
Q

Briefly differentiate between primary and secondary hypertension

A

Primary hypertension (which occurs in about 90% of people) has no identifiable cause.

Secondary hypertension (about 10% of people) has a known underlying cause, such as renal, endocrine, or vascular disorder, or the use certain drugs.

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4
Q

Give examples of secondary causes of hypertension

A
  • Renal disease
    • This is the most common cause of secondary hypertension
    • If the blood pressure is very high or does not respond to treatment consider renal artery stenosis
  • Obesity
  • Pregnancy
    • Pregnancy induced hypertension / pre-eclampsia
  • Endocrine
    • Most endocrine conditions can cause hypertension but primarily consider hyperaldosteronism (“Conns syndrome”) as this may represent 2.5% of new hypertension
    • A simple test for this is a renin:aldosterone ratio blood test
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5
Q

Briefly describe stage 1, 2 and 3 hypertension

A

Stage 1 hypertension

  • Clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg
  • ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg

Stage 2 hypertension

  • Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg
  • ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher

Stage 3 or severe hypertension

  • Clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher
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6
Q

What are the risk factors for hypertension?

A
  • Age
  • Sex
    • Up to about 65 years, women tend to have a lower blood pressure than men
    • Between 65 to 74 years of age, women tend to have a higher blood pressure
  • Ethnicity
    • People of Black African and Black Caribbean origin are more likely to be diagnosed with hypertension
  • Genetic factors
  • Social deprivation
  • Lifestyle e.g. smoking, excessive alcohol consumption, excess dietary salt, obesity and lack of physical activity
  • Anxiety and emotional stress
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7
Q

What are the signs of hypertension?

A
  • Retinopathy
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8
Q

What are the symptoms of hypertension?

A
  • Headaches
  • Visual disturbances
  • Dyspnoea
  • Chest pain
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9
Q

What investigations should be ordered for hypertension?

A
  • ECG
  • Fasting metabolic panel with estimated GFR
  • Lipid panel
  • Urinanalysis
  • Hb
  • Thyroid stimulating hormone
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10
Q

Briefly describe the NICE guidelines on measuring and diagnosing BP in clinic

A

Measure blood pressure in a relaxed, temperate setting, with the person quiet and seated and their arm outstretched and supported.

If blood pressure measured in the clinic is 140/90 mmHg or higher, take a second measurement during the consultation.

  • If the second measurement is substantially different from the first, take a third measurement
  • Record the lower of the last 2 measurements as the clinic blood pressure

If the person’s blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM).

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11
Q

According to NICE guidelines, what happens if a patient has a BP reading of 180/120 mmHg or higher?

A

If the person’s blood pressure is 180/120 mmHg or higher:

  1. Refer for same-day specialist assessment if there are:
    • Signs of retinal haemorrhage and/or papilloedema (accelerated hypertension)
    • Life-threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury
  • If there are no symptoms or signs indicating same-day referral, carry out investigations for target organ damage as soon as possible
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12
Q

In what patients specifically is manual BP reading more effective?

A

Be aware that automated devices may not measure blood pressure accurately if there is pulse irregularity (for example due to atrial fibrillation).

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13
Q

Why investigate using ECG?

A

May show evidence of left ventricular hypertrophy or old infarction.

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14
Q

Why investigate fasting metabolic panel with GFR?

A

Risk of hypertension is increased if there are features of the metabolic syndrome.

May show renal insufficiency, hyperglycaemia, hypokalaemia, hyperuricaemia or hypercalcaemia.

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15
Q

Why investigate lipid panel?

A

Risk of hypertension is increased in the setting of the metabolic syndrome.

May show high LDL, low HDL or high triglycerides.

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16
Q

Why investigate using urinalysis?

A

Increased albumin excretion suggests end-organ damage.

May show proteinuria.

17
Q

Why investigate Hb?

A

Anaemia accompanies chronic renal failure. Polycythaemia may be seen with phaeochromocytoma.

Anaemia or polycythaemia suggests secondary cause or complication.

18
Q

Why investigate thyroid-stimulating hormone?

A

Indicated if signs/symptoms of hypo- or hyperthyroidism.

High or low if thyroid dysfunction.

19
Q

Briefly describe lifestyle modifications for hypertension

A
  • Diet and exercise
  • Caffeine
  • Dietary sodium
  • Smoking
  • Alcohol
20
Q

Briefly describe the NICE guidance on diagnosis and treatment of hypertension

A
21
Q

Briefly describe the NICE guideance on the choice of antihypertensive, monitoring treatment and BP targets in hypertension

A
22
Q

What are the BP targets for <80 years?

Note: both clinic and ABPM/HBPM

A

Age <80 years:

  • Clinic BP <140/90 mmHg
  • ABPM/HBPM <135/85 mmHg
23
Q

What are the BP targets for ≥80 years?

Note: both clinic and ABPM/HBPM

A

Age ≥80 years:

  • Clinic BP <150/90 mmHg
  • ABPM/HBPM <145/85 mmHg
24
Q

What medication is used to treat hypertension in pregnancy?

A

Labetalol is usually considered the antihypertensive of choice and is effective as monotherapy in 80% of patients.

If not effective, oral nifedipine and methyldopa can be used.

25
Q

What occurs in annual BP reviews?

A

At the annual review:

  • Encourage adherence to treatment
  • Check BP
  • Check renal function by measuring serum creatinine, electrolytes, and estimated glomerular filtration rate (eGFR) and dipstick urine to check for proteinuria
  • For people who are not on an antiplatelet drug or a statin, reassess their cardiovascular disease risk using the QRISK® assessment tool
26
Q

What complications are associated with hypertension?

A
  • Heart failure
  • Coronary artery disease
  • Stroke
  • Chronic kidney disease
  • Peripheral arterial disease
  • Vascular dementia
27
Q

What differentials should be considered for hypertension?

A
  1. Drug-induced
  2. Chronic kidney disease
  3. Renal artery stenosis
28
Q

How does hypertension and drug-induced hypertension differ?

A

Differentiaing signs and symptoms:

  • There may be signs of acute intoxication, withdrawal or cravings with cocaine/sympathomimetics use

Differentiating investigations:

  • Drug toxicology screen may detect an illicit substance
29
Q

What drugs can cause drug-induced hypertension?

A

History of treatment with or ingestion of :

  • Non-steroidal anti-inflammatory drugs
  • Oral contraceptive pills
  • Sympathomimetics
  • Herbal medications
  • Liquorice
  • Immunosuppressants
  • Erythropoietin
  • Higher-dose corticosteroids
30
Q

How does hypertension and chronic kidney disease differ?

A

Differentiating signs and symptoms:

  • There may be pruritus, oedema, or change in urine output

Differentiating investigations:

  • High serum creatinine
  • Chronic anaemia may be seen
31
Q

How does hypertension and renal artery stenosis differ?

A

Differentiating signs and symptoms:

  • Typically younger patients with difficult-to-control hypertension or older patients at risk of atherosclerotic disease

Differentiating investigations:

  • Renal artery bruits may be present
  • Renal duplex ultrasound or magnetic resonance angiogram of renal arteries confirms diagnosis
32
Q

When examining for retinopathy what is assessed?

A

The fundus.

33
Q

Briefy describe the pathophysiology of hypertensive retinopathy

A

Increased BP damages retinal vessels. Hardened arteries are shiny (“silver wiring”) and ‘nip’ veins where they cross. Narrowed arterioles may become blocked caused localised retinal infarction, seen as cotton wool spots. Leaks from these in severe hypertension manifest as hard exudates or macular oedema.

34
Q

What does papiloedema or flame haemorrhage suggest?

A

Suggests accelerated hypertension requiring urgent treatment.

35
Q

What is shown in the fundoscopy?

Note: hypertensive retinopathy

A

Silver wiring

36
Q

What is shown in the fundoscopy?

Note: hypertensive retinopathy

A

AV nipping

37
Q

What is shown in the fundoscopy?

Note: hypertensive retinopathy

A

Cotton wool spots

38
Q

What is shown in the fundoscopy?

Note: hypertensive retinopathy

A

Papilloedema

39
Q

What is shown in the fundoscopy?

Note: hypertensive retinopathy

A

Flame haemorrhages

Y3 GP: Hypertension, CKD and Lipid Modification (3 decks)

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