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Cardiology > Hypertension > Flashcards

Hypertension Flashcards

1
Q

What is hypertension? What are the 2 different classifications?

A

Persistently raised arterial blood pressure
=>140/90 in clinic
=>135/85 ambulatory BP

Primary/essential HTN= no single identifiable cause but associated with multiple risk factors

Secondary HTN= known underlying cause

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2
Q

What are the common risk factors for essential hypertension?

A 
Male 
Increased age 
Smoking 
Dyslipidaemia 
Raised fasting glucose (5.6-6.9)
Obesity (especially central obesity)
FH of CVD 
Diabetes 
CKD
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3
Q

What are the causes of secondary hypertension? Which is the most common?

A

Most common- primary hyperaldosteronism (Conn’s disease) i.e. Na+ retention leads to water retention = expansion of BV

ROPE ++

Renal disease

Obesity

Pregnancy/Pre-eclampsia

Endocrine disorders i.e. Cushings/phaeochromocytoma/hyperparathyroidism/acromegaly/pregnancy/hyperthyroidism

Aortic coarctation= narrowing of portion of aorta
-presents with delayed femoral pulse

Alcohol

Caffeine

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4
Q

What are the possible complications of high blood pressure?

A 
CHD (MI)
LVH 
HF
Stroke
Peripheral vascular disease 
Retinopathy 
Aortic aneurysm 
Chronic kidney disease

I.e. increased risk of mortality with increase in systolic BP

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5
Q

What neurological signs should you be looking for in patient with history of hypertension and why?

A

UMN signs

  • hypertonia
  • hyperreflexia
  • Positive babinski sign
  • pyramidal weakeness= weakness in LL flexors and UL extensors
  • cerebellar signs
  • visual defects= heminopia

Indication there has been stroke

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6
Q

What are signs of peripheral vascular disease?

A

Increased CRT
Problems with palpating peripheral pulse or change to character/volume
Bruits
Cold shiny pale skin

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7
Q

If patient has secondary hypertension not responding to treatment, what should you suspect?

A

Renal artery stenosis

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8
Q

What investigations should be done for HTN patient to determine if causes renal disease?

A

Urinalysis- proteinuria

U+Es= raised creatinine

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9
Q

What signs might patient with CVS end organ damage related to HTN present with?

A

Signs of HF:

  • raised JVP
  • Displaced apex= hypertrophy
  • S3= due to large amount of blood hitting compliant LV (i.e. HF associated with “flabby” heart)
  • pitting oedema
  • SOB + crepitations in lung bases= pulmonary oedema
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10
Q

What are important fundoscopic signs to note which may indicate hypertensive retinopathy? Which sign is particularly important to look for and why?

A 
Arteriolar narrowing 
Flame haemorrhage 
Hard exudate 
Cotton wool spot= due to nerve damage 
Retinal oedema= sign of malignancy
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11
Q

What are the 3 different types of blood pressure measurement?

A

Clinic
-manual BP done if patient has irregular pulse

Ambulatory blood pressure (ABPM)
-24 hr BP which records multiple measurements of systolic and diastolic BP

Home blood pressure monitoring (HBPM)
-patients check BP 2x a day for 4 days

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12
Q

When is ABPM or HBPM indicated?

A

Confirmation of diagnosis of HTN
White-coat syndrome
Masked hypertension
Variability in clinic BP over visits
Hypotensive episodes
Suspected pre-eclampsia or hypertension in pregnancy
Resistant hypertension i.e. when hypertension resistant to 3+ antihypertensive drugs

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13
Q

When is anti-hypertensive treatment started regardless of ABPM?

A

When >=180 systolic

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14
Q

What is the definition of white coat hypertension?

A

Clinic blood pressure <149/90

Daytime ambulatory pressure <135/85

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15
Q

What would you want to assess in clinical examination of someone with hypertension?

A

Fundi with fundoscope
Abdomen for AAA/kidney/bruits
CVS for HF/pulses/peripheral vasc
L-R arm difference and diminished femoral pulse= aortic coarctation

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16
Q

What investigations/ examinations are done to assess for end organ damage?

A

Fundus examination= hypertensive retinopathy
Bloods= HbA1c/U+E/ eGFR
Urine albumin:creatinine ratio= proteinuria
ECG= cardiac abnormalities

17
Q

If you suspected secondary hypertension, what investigations would you need to do?

A

Renin/aldosterone tests
Thyroid function test
U+Es

18
Q

What is the target clinical blood pressure? How is this different for people over 80?

A

BP<140/90

80+= <150/90

19
Q

A patient presents with a blood pressure of 150/100 to GP. What stage of hypertension are they? How is this patient likely to be managed?

A

May be asked to do ABPM or HBPM to determine their average BP outside of clinical environment to determine if this is one-off event due to white coat syndrome or if patient needs to be diagnosed with hypertension

Stage 1 i.e. >140/90
Stage 2 = 160/100
Stage 3= 180

Life style changes recommended 1st before medical intervention

  • ensure moderate alcohol consumption
  • moderate consumption of caffeine
  • decrease salt intake
  • smoking cessation
  • regular exercise
  • physical activity
  • weight reduction
  • dietary advice i.e. increase fruit and veg consumption
  • regular sleep pattern
  • relaxation therapies i.e. stress management advice
20
Q

When is anti-hypertensive medication started immediately? When else is medical managment offered?

A

Stage 3 hypertension (>180 systolic)

Stage 2

21
Q

What are the 4 main forms of anti-hypertensive therapy? What add ons can be used for additional control?

A 
ACEi/ARBs i.e. ramipril 
Beta blockers i.e. bisoprolol 
Calcium channel blockers amlodipine 
Diuretics 
-thiazide-like i.e. indapamide (diuretic of choice) 
-spironolactone 
-amiloride

Add ons:

  • alpha blockers i.e. doxazosin
  • vasodilators (in emergencies) i.e. nitrates
  • centrally acting antihypertensives i.e. moxonidine
22
Q

Why would a patient be put on ARB rather than ACEi?

A

When ACEi not well tolerated due to causing dry cough due to accumulation of bradykinin in airways

23
Q

What is the mechanism of centrally acting antihypertensives?

A

Act on alpha2 adrenoreceptor in brain stem to induce fall in BP

24
Q

A 35 yo white patient with stage 2 hypertension requires anti-hypertensive medication. Which drug should they be given first and what is the step-wise progression if this does not control their hypertension?

A

A= mono therapy
ACEi i.e. ramipril 1.25mg to 10mg per day

A+C or A+D= dual therapy
Add calcium channel blocker (amlodipine) or diuretic (Indapamide)

A+C+D= triple therapy

Addition
Extra diuretic i.e. spironolactone
Beta-blocker i.e. bisoprolol

25
Q

A 50 yo black patient requires has BP of 160/100. What medial management is indicated?

A

C or D
Calcium channel blocker= amlodipine
Diuretic= indapamide
-D used when CCB not tolerated or patient has oedema or HF i.e. CCB worsens HF and diuretics can help with oedema and HF

C+A or D+A

A + C + D

26
Q

Why can ACEi not be used as 1st line in African-Caribbean patients or 55+but can then be used as 2nd line?

A

Plasma renin levels are decreased in this ethnic group and also decrease with age meaning that ACEi will be less affective

Renin rises secondary to use of CCB meaning ACEi will be more effective as 2nd line treatment in these patients

27
Q

What is the MOA of ACEi? What are the adverse affects and when are they contraindicated?

A

“Pril”
Inhibits action of ACE which normally converts Ag1 to Ag2. This prevents vasoconstriction and release of aldosterone

Dry cough= Bradykinin accumulation in airways
Reversible AKI
Hyperkalaemia
Angioedema i.e. lip swelling (rare)

Pregnancy
Breast feeding
Bilateral renal stenosis due to patient relying on high renal drive

28
Q

What is the MOA of ARBs? When are ARBs used instead of ACEi?

A

They prevent Ag2 from binding to AT1 receptors, inhibiting its action

When ACEi not tolerated due to dry cough
I.e. ACE function maintain with ARBs meaning still able to break down bradykinin

29
Q

What are the 2 main types of CCB and how do they differ?

A

Dihydropyridine (amlodipine)

  • non rate limiting
  • acting SM preferentially

Non-dihydropyridine (verapamil or Diltiazem)

  • rating limiting
  • shorter 1/2 life
30
Q

What are the adverse side effects associated with amlodipine?

A

Ankle swelling
Acid reflux
Flushing
Gingival hyperplasia

31
Q

What are the possible adverse effects of verapamil?

A

Worsen HF
Bradycardia
Heart block
Constipation

32
Q

What is the most commonly used anti-hypertensive diuretic? What is the MOA? What are the potential limitations of using this drug?

A

Indapamide = thiazide-like diuretic

Blocks Na+/Cl- channel in DCT= leads to increased Na+ and H2O loss

Limitations:

  • reliant on excretions in tubule i.e. not effective in renal impairment
  • can disturb electrolyte balance
  • can cause gout
  • impaired glucose tolerance
  • can cause hypercalcaemia
33
Q

What are the additional drugs which can be used as part of step 4 of hypertension management? Name examples and briefly how they work?

A

Alpha-adrenoreceptor blockers = doxazosin
-block alpha-mediated vasoconstriction to induce vasodilation

Beta-blockers

  • bisoprolol= cardioselective (decrease cardiac rate and force)
  • Propranolol= non-selective (vasodilation, bronchodilation, visceral SM relaxation, hepatic glycogenolysis, muscle tremor

Centrally acting drugs
-Imidazoline I2 receptor agonists in brain stem to alter drive

Cardiology (15 decks)

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