Hypertension Flashcards
ESSENCE
High blood pressure
>140/90 in clinic or 135/85 with ambulatory or home readings
AETIOLOGY
- Essential hypertension (primary hypertension) accounts for 95% and is idiopathic
- Secondary causes remember ROPE
- Renal disease
- Obesity
- Pregnancy induced/pre-eclampsia
- Endocrine
Most common cause of secondary hypertension
Renal disease
What cause should be considered if BP very high or dose not respond to treatment
Renal artery stenosis
Most common endocrine cause
Hyperaldosteronism (Conns syndrome)
Simple test for is renin aldosterone ratio test
COMPLICATIONS
- Ischaemic heart disease
- Cerebrovascular accident (i.e. stroke or haemorrhage)
- Hypertensive retinopathy
- Hypertensive nephropathy
- Heart failure
Drug incuded causes of hypertension
- Oral contraceptives
- Glucocortocoids
- Phenylephrine
- NSAID
CLINICAL FEATURES
Presentation
- Asymptomatic until complications develop
- Complications present with
- Shortness of breath
- Chest tightness
- Headache
- Vision changes
CLINICAL FEATURES
Signs
- Displaced PMI
- Retinal changes
- A/V nipping and copper wire changes to arterioles
- Papilledema and retinal haemorrhages
- Systolic ejection click
- Loud S2
- Possible S4
DIAGNOSIS
- Screening every 5 years, more often patients that are borderline and every year in T2 diabetes
- If clinic BP >140/90 should have 24h ambulatory BP monitoring to confirm diagnosis
- Avoid white coat syndrome
STAGES
- Stage 1
- Clinic reading >140/90 or ambulatory >135/85
- Stage 2
- Clinic reading >160/100 or ambulatory >150/95
- Stage 3
- >180/120
INVESTIGATIONS
- 24h ambulatory BP - confirm diagnosis
- Assess for end stage organ damage
- Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria
- Bloods - HbA1c, renal function and lipids
- Fundus examination - hypertensive retinopathy
- ECG - cardiac abnormalities
Medications used for management
- Remember A B C D ARB
- ACE inhibitor
- Beta blocker
- Calcium channel blocker
- thiazide like Diuretic
- Angiotensin II Receptor Blocker
What should be noted about ARBs
- Used in place of ACE inhibitor when they not tolerated (commonly due to dry cough)
- Or if patient is black of African or Afro-carribean descent
- Cannot be used together with ACE inhibitor
MANAGEMENT
Initial
- Establish diagnosis
- Investigate for end stage organ damage
- Advice on lifestyle
- Possible next line of medical management
Who is medical management offered to
- All patients with stage 2 hypertension
- All patients under 80 years with stage 1 and also Q-risk score of 10% or more, diabetes, renal disease, CVD or end stage organ damage
MANAGEMENT
Medication steps
- 1) If age < 55 ACEI, if age >55 or black then CCB
- 2) ACEI + CCB, alternatively can use ACEI + diuretic or CCB + diuretic. If black use ARB instead of ACEI
- 3) ACEI + CCB + diuretic
- 4) ACEI + CCB + diuretic + potassium sparing diuretic or alphablocker or beta blocker
MANAGEMENT
Medical management line 4, when is which additional drug used
- Potassium sparing diuretic if serum K <= 4.5mmol/L
- Alpha blocker or beta blocker if serum K >4.5mmol/L
Example of potassium sparing diuretic
Spironolactone
When should U+Es be monitored
- When using ACEI or all diuretics
- They both increase risk of hyperkalaemia
MANAGEMENT
Treatment targets
- <80 years
- <140/<90
- >80 years
- <150/<90
AETIOLOGY
Risk factors
- Obesity
- Lack of exercise
- Alcohol intake
- Metabolic syndrome
- Diabetes
- Black ancestry
- Age > 60
- FH
- Sleep apnoea
