Hypertension Flashcards
What is hypertension?
It is a condition in which individuals have a chronically raised blood pressure
What is the normal blood pressure?
Systolic blood pressure = 90 – 140mmHg
Diastolic blood pressure = 60 – 90mmHg
What are the two main causes of hypertension?
Essential hypertension
Secondary hypertension
What cause of hypertension is more common?
Essential hypertension (95%)
What is another term for essential hypertension?
Primary hypertension
What is essential hypertension?
It means that the hypertension has developed on its own and does not have a secondary cause
What are the five risk factors of essential hypertension?
Family History
Increased Age
Black Ethnicity
Obesity
Alcoholism
What is secondary hypertension?
It means that the hypertension is due to secondary disease
It is important to note that the removal of the secondary cause doesn’t guarantee resolution of the hypertension, it will just improve blood pressure
What are the five secondary diseases that cause hypertension?
ROPED
Renal disease
Obesity
Pregnancy/Pre-eclampsia
Endocrine disease
Drugs
What four renal diseases are associated with secondary hypertension?
Glomerulonephritis
Chronic pyelonephritis
Adult polycystic kidney disease
Renal artery stenosis
What six endocrine diseases are associated with secondary hypertension?
Primary hyperaldosteronism
Phaeochromocytoma
Cushing’s syndrome
Liddle’s syndrome
Congenital adrenal hyperplasia (11-beta hydroxylase deficiency)
Acromegaly
What is the most common cause of secondary hypertension?
Primary hyperaldosternosim
What is the most common cause of primary hyperaldosteronism?
Bilateral adrenal hyperplasia
What is the first line investigation in suspected primary hyperaldosteronism?
Plasma aldosterone:renin ratio
What five drugs can cause secondary hypertension?
Steroids
Monoamine oxidase inhibitors
Combined oral contraceptive pill
NSAIDs
Leflunomide
In which patients should we consider secondary hypertension?
It should be considered in individuals who present with an acute onset of hypertension at a young age
How does hypertension typically present?
Asymptomatically
At what blood pressure reading can hypertension become symptomatic?
> 200/120 mmHg
What are the three clinical features of hypertension?
Seizures
Headaches
Visual disturbances
What three investigations are used to diagnose hypertension?
Clinic Blood Pressure Readings
24 Hour Ambulatory Blood Pressure
Home Blood Pressure Readings
What is a 24 hour ambulatory blood pressure?
It is 30 blood pressure measurements which are taken over 24 hours
What is the gold standard investigation used to diagnose hypertension?
Home blood pressure readings over a period of seven days, in which the patient records blood pressure readings morning and night
What clinical blood pressure result indicates prehypertension?
Systolic = 120-139mmHg
OR
Diastolic = 80-89mmHg
What clinical blood pressure result indicates stage one hypertension?
> 140/90mmHg
Systolic = 140 - 159mmHg
OR
Diastolic = 90 - 99mmHg
What ambulatory/home blood pressure result indicates stage one hypertension?
> 135/85mmHg
Systolic = 135 - 149mmHg
OR
Diastolic = 85 - 94mmHg
What clinical blood pressure result indicates stage two hypertension?
> 160/100mHg
What ambulatory/home blood pressure result indicates stage two hypertension?
> 150/95mmHg
What is white coat hypertension?
This is when patients have an elevated clinic blood pressure but normal ABPM/home blood pressure readings
How is white coat hypertension managed?
These patients don’t require treatment, however are more likely to develop hypertension in the future
What is masked hypertension?
This is when patients have a normal clinic blood pressure but elevated ABPM
What four investigations are conducted in hypertensive patients following a diagnosis? Why?
Bloods
ECG scan
Urinalysis
Fundoscopy
To assess for the development of complications - such as end-organ damage
What three blood tests are conducted in hypertensive patients following a diagnosis?
U&Es
HbA1c
Lipids
When is conservative management used to treat hypertension?
It is the first line management option in stage one hypertension
In what five ways do we conservatively treat hypertension?
To Eat A Healthy Diet
To Reduce Salt Intake
To Exercise Regularly
To Reduce Alcohol Intake
To Stop Smoking
When is pharmacological management used to treat hypertension?
It is the first line management option in stage two hypertension
It is also recommended when stage one hypertension patients develop target organ damage, established CDV, renal disease or diabetes
What are the five pharmacological management options of hypertension?
ABCD
ACEIs/ARBs
Beta-blockers
Calcium channel blocker
thiazide Diuretics
What is the mechanism of action of ACEIs?
They inhibit the conversion angiotensin I to angiotensin II
What do all ACEIs end in?
- ‘pril’
What is the first line ACEI used to manage hypertension? What dose?
Ramipril
1.25mg up to 10mg once daily
What are the three side effects of ACEIs?
Cough
Angioedema
Hyperkalaemia
What is the most appropriate management step when ACEIs are not tolerated?
They should be stopped and switched for an ARB
What investigation do we conduct in individuals on ACEIs? How often?
U&E blood tests
It should be conducted prior to administration
This should then be rechecked within 2 weeks of initiation or with any change of dose
Once the maintenance dose has been achieved, we conduct further U&E tests at 1, 3 and 6 months
What U&E blood test result would indicate that ACEI patients need to consult a urologist?
Serum creatinine concentration increases by 30%
OR
eGFR decreases by 20%
What is the mechanism of action of ARBs?
They block the effects of angiotensin II at the AT1 receptor
What do all ARBs end in?
‘sartan’
What is the first line ARBs used to manage hypertension? What dose?
Candesartan
8mg up to 32mg once daily
What is the side effect of ARBs?
Hyperkalaemia
What is the mechanism of action of betablockers?
They bind to beta-adrenoreceptors and thereby block the binding of noradrenaline
What is the first line beta-blocker used to manage hypertension? What dose?
Bisoprolol
5mg up to 20mg once daily
What are five side effect of beta-blockers?
Cold peripheries
Erectile dysfunction
Reduced hypoglycaemic awareness
Insomnia
Plaque psoriasis
What is the mechanism of action of CBBs?
They block voltage-gated calcium channels relaxing vascular smooth muscle and force of myocardial contraction
What is the first line CCB used to manage hypertension? What dose?
Amlodipine
5mg up to 10mg once daily
What are the three side effects of dihydropyridine CCBs (amlodipine, nifedipine, felodipine)?
Flushing
Headache
Ankle swelling
What are the four side effects of diltiazem?
Hypotension
Bradycardia
Heart failure
Ankle swelling
What are the five side effects of verapamil?
Heart failure
Constipation
Hypotension
Bradycardia
Flushing
What is the mechanism of action of thiazide diuretics?
They inhibit sodium absorption at the beginning of the distal convoluted tubule
What is the first line thiazide diuretic used to manage hypertension? What dose?
Indapamide
2.5mg once daily
What are the six side effects of thiazide diuretics?
Hyponatraemia
Hypokalaemia
Hypercalcaemia
Hypocalciuria
Dehydration
Digoxin toxicity
What is step one for hypertension management?
In individuals less than 55 years old and non-black, we prescribe an ACEI
In individuals over 55 years old or black, we prescribe a CCB
What is step two of hypertension management?
In individuals who are < 55 years old and non-black, we add a CCB to ACEI
In individuals who are > 55 years old and black, we add an ARB
What is step three of hypertension management?
We administer ACEI, CCB and thiazide diuretics
What is step four of hypertension treatment - in individuals who have a serum potassium > 4.5mmol/l?
We add an alpha or beta blocker
What is a side effect of thiazide diuretics?
Hypokalaemia
What is step four of hypertension treatment - in individuals who have a serum potassium < 4.5mmol/l?
We add a potassium sparing diuretic - spironolactone
What is the mechanism of action of spironolactone?
It works by blocking the action of aldosterone in the kidneys resulting in sodium excretion and potassium reabsorption
What does spironolactone administration increase the risk of?
Hyperkalaemia
What other hypertensive drug increases the risk of hyperkalaemia?
ACEI
What is the first line management option of hypertension in diabetics - regardless of age?
ACE Inhibitors
OR
ARBs
What blood pressure reading do we aim for in hypertensive patients < 80?
< 140/90
What blood pressure reading do we aim for in hypertensive patients < 80 - who also suffer from CKD or diabetes?
<130/80
What blood pressure reading do we aim for in hypertensive patients > 80?
< 150/90
What are the five complications of hypertension?
Ischaemic heart disease
Cerebrovascular disease
Hypertensive retinopathy
Hypertensive nephropathy
Heart failure