Hypertension Flashcards
What blood pressure reading would need an immediate SAME DAY specialist referal?
- Accelerated Hypertension (BP reading of 180/120mmHg) with signs of
1. papilloedema,
2. and/or retinal haemorrhage
3. or life-threatening symptoms, such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury.
4. suspected pheochromocytoma (for example labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis).
What would be the appropriate course of action for someone who had a BP reading of 164/112mmhg after three readings in both arms?
Offer AMBPH and consider prescribing ti-hypertnesive medication immediately
What should AMBPH reading be under?
Under 135/85mmHG
What is the difference between primary hypertension and secondary hypertension?
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 of certain drugs.
What should be done for patients under 40 years old with hypertension?
Consider specialist investiagtion to see secondary cause of hypertension
If a patient’s first blood pressure reading is equal to or above 140mmHg (systolic) or equal to or above 90mmHg (diastolic), what should be the next course of action?
The diagnosis is then confirmed with ABPM or HBPM.
- While waiting for confirmation of a diagnosis of hypertension, the person should be offered:
Investigations for target organ damage and for secondary causes of hypertension.
-Assessment of cardiovascular risk.
What are the different stages of hypertension?
Stage 1 hypertension: CBP = 140/90 or HBPM = 135/85
Stage 2: CBP = 160/100 or HBPM = 150/95
Stage 3: CBP = 180/120
What is accelerated (or malignant) hypertension?
A severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve).
What are the target clinic BP reading?
- Under 80 years old: CBP <140/90 or HBPM <135/85
- Over 80 years old: CBP <150/90 or HBPM <145/85
What is the best course of action if a patient’s BP reading is less than 140/90mmHg?
- No medication needed
- Check BP reading every 5 years
What is a normal BP reading?
120/80mmHg
What is the initial management for patients who have a BP reading of 140/90mmHg - 180/120mmHg?
- Offer HBPM
- Offer lifestyle advice
- Investigate end organ damage
- Calculate QRISK Score
When do you treat a patient that had a CBP of 140/90 and a HBPM reading of 135/85?
- Offer Lifestyle advice
- If they are under 80 years old with:
1. Target organ damge ( e.g. Left Ventricular Hyperthrophy, CKD, Retinopathy)
2. CVD
3. Renal Disease
4. Diabetes
5. QRISK Score of over 10% - If they are under 60 years old with with a QRISK Score under 10%
What lifestyle advice can be given about sodium consumption in patients with hypertension?
Dietary sodium — encourage people to keep their dietary sodium intake low, by reducing or substituting sodium salt, as this can reduce blood pressure.
Be aware that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease, and people taking some antihypertensive drugs (such as angiotensin converting enzyme inhibitors and angiotensin-II receptor blockers). Encourage salt reduction in these groups of people.
What is the next step of managment for stage 2 hypertension (CBP = 160/100mmHg, HBPM 150/95mmHg)
Offer antihypertensive drug treatment in addition to lifestyle advice to adults with persistent stage 2 hypertension, regardless of age.
What is first line treatment?
- Under 55 years old and NOT african/carribean = ACEi or A2RBs
- Over 55 years old or African/Carribean = CCB
Can give Thiazide-Like Diuretic e.g. Indapamide if CCB is contraindicated or not tolerated
What to do if Heart failure is present alongside hypertension?
Offer a thiazide-like diuretic, such as indapamide.
If starting or changing diuretic treatment for hypertension, offer a thiazide-like diuretic, such as indapamide, in preference to a conventional thiazide diuretic, such as bendroflumethiazide or hydrochlorothiazide.
For people already having treatment with bendroflumethiazide or hydrochlorothiazide who have stable, well-controlled blood pressure, continue with their current treatment.
What is second line treatment?
- Before starting next step treatment check adherance and support adherence where possible
- If hypertension is not controlled with step 1 treatment of an ACE inhibitor or ARB, offer the choice of one of the following drugs in addition to step 1 treatment:
A CCB or
A thiazide-like diuretic. - If hypertension is not controlled with step 1 treatment of a CCB, offer the choice of one of the following drugs in addition to step 1 treatment:
1. An ACE inhibitor or ARB (consider an ARB in preference to an ACE inhibitor in people of black African or African–Caribbean family origin) or
2. A thiazide-like diuretic.
What is third line treatment?
Before considering next step treatment for hypertension:
- Review the person’s medications to ensure they are being taken at the optimal tolerated doses.
- Discuss adherence to treatment
If hypertension is not controlled with step 2 treatment, offer a combination of:
- An ACE inhibitor or ARB (consider an ARB in preference to an ACE inhibitor in people of black African or African–Caribbean family origin), and
- A CCB, and
- A thiazide-like diureti
What is fourth line treatment?
For people with confirmed resistant hypertension, seek specialist advice or add a fourth antihypertensive drug.
- For people with a blood potassium level of 4.5 mmol/l or less, consider further diuretic therapy with low-dose spironolactone. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia. Monitor blood sodium and potassium, and renal function within 1 month of starting further diuretic therapy, and repeat as needed thereafter.
- For people with blood potassium level of more than 4.5 mmol/l, consider an alpha-blocker or beta-blocker.
Which angiotensin-converting enzyme inhibitor is recommended?
- For people with heart failure and hypertension, enalapril, lisinopril, ramipril, and trandolapril may be preferred.
- For people who have diabetes and hypertension, enalapril, lisinopril, PERINDOPRIL, ramipril, or trandolapril may be preferred.
- For people who have had a previous myocardial infarction (without heart failure), lisinopril, perindopril, or ramipril may be preferred.
When is ACEi contraindicated?
- People with history of angioedema associated with previous exposure to an ACE inhibitor.
- People with hereditary or recurrent angioedema.
- People with diabetes mellitus, or with an estimated glomerular filtration rate (eGFR) less than 60 mL/minute/1.73 m2, who are also taking ALISKIREN.
- Pregnant women and those planning a pregnancy — due to risks to the fetus. Treatment with an ACE inhibitor should ideally be stopped as soon as pregnancy is detected and, if appropriate, alternative treatment should be started.
When do you use ACEi in caution
- Of black African or Caribbean origin, or with primary aldosteronism — may respond less well to ACE inhibitors.
- With renal impairment — hyperkalaemia and other adverse effects are more common, and the dose may need to be reduced.
- Taking diuretics.
- With peripheral vascular disease or generalised atherosclerosis — due to risk of clinically silent renovascular disease.
- With hypertrophic cardiomyopathy.
- With severe or symptomatic aortic stenosis — due to risk of hypotension.
- With collagen vascular disease — possible increased risk of agranulocytosis — blood counts recommended.
What are the ADR of ACEi?
- Renal impairment — monitor renal function 1–2 weeks after starting and after each increase in dose, and regularly throughout treatment.
- Hyperkalaemia — monitor serum electrolytes 1–2 weeks after starting an ACE inhibitor, after each increase in dose, and regularly throughout treatment.
- Cough
- Angioedema ( A2RBs can also trigger angioedema?)
- Dizziness and headaces (most commonly in people who are hypovolaemic or hyponatraemic)
- Hepato-biliary disorders — stop treatment if marked elevation of hepatic enzymes or jaundice occur. This is a very rare adverse effect
