hypertension

Question 1

Managing hypertension through lifestyle?

Answer 1

//LOW SALT DIET - LESS THAN 6G/DAY, IDEALLY 3G/DAY
CAFFEINE INTAKE SHOULD BE REDUCED
OTHER GENERAL BITS OF ADVICE REMAIN: STOP SMOKING, DRINK LESS ALCOHOL, EAT A BALANCED DIET RICH IN FRUIT AND VEGETABLES, EXERCISE MORE, LOSE WEIGHT//

Question 2

what is stage 1 hypertension

Answer 2

// ABPM/HBPM >= 135/85 mmHg //

CLINIC BP >= 140/90 MMHG AND SUBSEQUENT

Question 3

indication of treating stage 1 hypertension?

Answer 3

< 80 years of age AND any of the following apply;
target organ damage,
established cardiovascular disease, renal disease,
diabetes or a 10-YEAR CARDIOVASCULAR RISK EQUIVALENT TO 10% OR GREATER

NICE made a further recommendation, suggesting that we should ‘consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%

Question 4

what is stage 2 hypertension?

Answer 4

ABPM/HBPM >= 150/95 MMHG

CLINIC BP >= 160/100 MMHG

Question 5

treating stage 2 hypertension step 1 ?

Answer 5

< 40 years consider specialist referral to exclude secondary causes.

patients < 55-years-old
or a background of type 2 diabetes mellitus:
ACE inhibitor or a Angiotensin receptor blocker (ACE-i or ARB): (a)

patients >= 55-years-old
or of black African or African–Caribbean origin:
Calcium channel blocker (C)
Then ARB preferred

Question 6

treating stage 2 hypertension step 2 ?

Answer 6

if already taking an ACE-i or ARB 
add 
a Calcium channel blocker 
or
 a thiazide-like Diuretic (D) - chlortalidone, indapamide 

if already taking a Calcium channel blocker add
 an ACE-i 
or 
ARB 
or a thiazide-like Diuretic (d)

patients of black African or African–Caribbean origin - taking a calcium channel blocker - require a second agent consider an ARB in preference to an ACE inhibitor

Question 7

treating stage 2 hypertension step 3 ?

Answer 7

add a third drug to make, i.e.:
if already taking an (A + C) then add a D
if already (A + D) then add a C
(A + C + D)

Question 8

NICE define step 4 as

Answer 8

resistant hypertension and suggest either adding a 4th drug or seeking specialist advice

if potassium < 4.5 mmol/l add low-dose spironolactone

if potassium > 4.5 mmol/l add an alpha- or beta-blocker

Question 9

before step 4 taken what to assess?

Answer 9

confirm elevated clinic BP with ABPM or HBPM
assess for postural hypotension.
discuss adherence

Question 10

Patients who fail to respond to step 4 measures should be?

Answer 10

referred to a specialist.

If blood pressure remains uncontrolled with the optimal or maximum tolerated doses of four drugs, seek expert advice if it has not yet been obtained.

Question 11

what are the blood pressure targets ?

Answer 11

Clinic BP
Age < 80 years 140/90 mmHg
Age > 80 years 150/90 mmHg

ABPM / HBPM
Age < 80 years 135/85 mmHg
Age > 80 years 145/85 mmHg

Question 12

because of over treatment of hypertension what is the right way of diagnosing hypertension.

Answer 12

2 reading of BP

recommend measuring blood pressure in both arms

If the difference in readings between arms is more than 20 mmHg then the measurements should be repeated. If the difference remains > 20 mmHg then subsequent blood pressures should be recorded from the arm with the higher reading

Ambulatory blood pressure monitoring (ABPM)
at least 2 measurements per hour during the person’s usual waking hours (for example, between 08:00 and 22:00)
use the average value of at least 14 measurements

If ABPM is not tolerated or declined HBPM should be offered.

Home blood pressure monitoring (HBPM)
for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
BP should be recorded twice daily, ideally in the morning and evening
BP should be recorded for at least 4 days, ideally for 7 days
discard the measurements taken on the first day and use the average value of all the remaining measurements

then AMBULATORY BP - better predictor of cardiovascular disease

Question 13

for a patient with hypertension who is already taking ACEi with a history of gout what is the second line?

Answer 13

calcium channel blocker
first line

second like - thiazide like diuretic

Question 14

what is stage 3 / severe hypertension ?

Answer 14

Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg

Question 15

If the blood pressure is >= 180/120 mmHg:
admit for specialist assessment if:

Answer 15

signs of retinal haemorrhage or papilloedema (accelerated hypertension) or
life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury