Hypertension Flashcards
what is the definition of hypertension?
Stage 1 hypertension:
- More than or equal to 140/90mmHg clinic BP
- Daytime average Ambulatory blood pressure monitoring (ABPM - 24hr BP monitor) or Home blood pressure monitoring (HBPM); greater than or equal to 135/85mmHg
Stage 2 hypertension:
- More than or equal to 160/100mmHg clinic BP
- Daytime average ABPM or HBPM greater than or equal to
150/95mmHg
Severe hypertension:
- Clinic systolic BP greater than or equal to 180mmHg and/or diastolic BP greater than or equal to 110mmHg
- Start immediate anti-hypertensive drug treatment!
what is the epidemiology of hypertension?
- Often symptomless so screening is vital
- Major risk factor for CVD
- Remain under diagnosed, under treated and poorly controlled in the UK
- Prevalence is in those older than 35
- More common in men
what is the aetiology of hypertension?
-Primary - cause unknown, genetic, sympathetic nervous system overload, transporter protein=en abnormalities, high salt intake
-Secondary - renal disease or pregnancy
-Also:
Endocrine causes (cushings, conn’s, phaeochromocytoma (rare tumour)
Coarctation of the aorta
Drugs (corticosteroids, cyclosporin, erythropoietin, contraceptive pill)
what are the risk factors for hypertension?
- Age - risk increases as you age
- Race - hypertension is more common in blacks
- Family history - hypertension runs in families
- Overweight and obese
- Little exercise
- Smoking
- Too much salt in diet
- Alcohol
- Diabetes
- Stress
what is the pathophysiology of hypertension?
Vascular changes:
• Hypertension accelerates atherosclerosis
• Also causes the thickening of the media of muscular arteries
• It is the smaller arteries and arterioles that are especially affected in hypertension
• The resulting endothelial cell dysfunction is associated with impaired nitric oxide-mediated vasodilatation and enhanced secretion of vasoconstrictors including endothelins and prostaglandins
Heart:
• Hypertension is a major risk factor for ischaemic heart disease
Nervous system:
• Intracerebral haemorrhage is a frequent cause of death in hypertension
Kidneys:
• Hypertension can be the cause or result of renal disease
• Kidney size is often reduced and small vessels show intimal thickening and medial hypertrophy and the numbers of sclerotic glomeruli are increased
Malignant hypertension:
• Characteristic features are a markedly raised diastolic blood pressure, usually over 120mmHg and progressive renal disease
• Quite rare
• Renal vascular changes are prominent and there is usually evidence of acute haemorrhage and papilloedema (optic disc swelling caused by increased intracranial pressure)
• Can occur in previously fit individuals, often black males in their 30s-40s
what is the key presentation of hypertension?
usually asymptomatic
headaches, nosebleeds, visual symptoms, or neurological symptoms.
what are the signs of hypretension?
high blood pressure, end organ damage, albumin in urine
what are the symptoms of hypertension?
usually asymptomatic unless malignant headaches, nosebleeds, visual symptoms, or neurological symptoms.
what are the first line and gold standard investigations for hypertension?
Blood pressure measure
pulse (rule out arrhythmia)
Urinalysis:
• For protein, albumin:creatinine ratio and haematuria
Blood tests:
• Serum creatinine
• eGFR
• Glucose (to assess diabetes risk)
Fundoscopy/Ophthalmoscopy:
• Looking for retinal haemorrhage or papilloedema
ECG:
• To detect left ventricular hypertrophy
Echocardiography:
• To further detect left ventricular hypertrophy
24 hour ambulatory blood pressure monitoring
Check for end organ damage:
left ventricular hypertrophy, retinopathy and proteinuria, papilloedema, acute kidney injury, acute stroke, ACS, aortic dissection- indicates severity and duration of hypertension and associated with a poorer prognosis
what are the differential diagnoses of hypertension?
hyperaldosteronism, coarctation of the aorta, renal artery stenosis, chronic kidney disease, obstructive uropathy
how is hypertension managed?
Treatment GOAL is 140/90mmHg
Change diet:
• High consumption of vegetable and fruits and low-fat diet
Regular physical exercise
Reduce alcohol intake
Reduce salt intake
Lose weight
Stop smoking
ACD pathway:
• A - ACE-inhibitor e.g. Ramipril or Enalapril, or Angiotensin receptor blocker (ARB) (use if ACEi is contraindicated e.g. due to cough) e.g. Candesartan or Losartan
• C - Calcium channel blocker (CCB) e.g. Nifedipine or Amlodipine
• D - Diuretics e.g. Bendroflumethiazide (thiazide, distal tube - less potent) or Furosemide (loop diuretic, loop of henle - more potent)
• NOTE: Beta-blocker e.g. Bisoprolol or Metoprolol (B1 selective) are NOT the FIRST LINE TREATMENT FOR HYPERTENSION but consider in young people especially if they are intolerant of ACEi/ARB
• Less than 55 yrs old:
- Ramipril/Candesartan
- + Nifedipine
- + Bendroflumethiazide
- + Furosemide
• Older than 55 yrs/black/African-Caribbean origin:
- CCB )(nifedipien / amlodipine)
- Ramipril/Candesartan + Nifedipine
- + Bendroflumethiazide
- + Furosemide
• If higher dose not tolerated then consider beta-blocker
how is hypertension monitored?
Regular blood pressure monitoring (at home 24 hour monitoring), medication reviews
what are the complications of hypertension?
Cardiac failure, atherosclerosis, cerebral haemorrhage, MI, aneurysm
what is the prognosis of hypertension?
Increased risk of mortality, untreated = increased risk of arteriosclerotic disease in 30%, organ damage in 50% people after 8-10 years
