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Y4 - CCC & PC > Hypertension > Flashcards

Hypertension Flashcards

1
Q

How is hypertension defined?

Why is it difficult to define in absolute terms?

A

a state of chronically and abnormally high arterial blood pressure

  • it has a skewed normal distribution so is difficult to define in absolute terms
  • this means that HTN should be diagnosed with a range of readings and looking at the overall trend, rather than an isolated reading
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2
Q

Why is it important to identify patients with raised blood pressure?

A
  • it is one of the most important and treatable causes of premature morbidity and mortality
  • it is a major risk factor for cardiovascular disease
  • it also is a risk factor for stroke, MI, heart failure, chronic kidney disease and cognitive decline
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3
Q

What is the prevalence of HTN?

A

1 in 3 adults in the UK

  • it affects around 31% of men and 26% of women
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4
Q

Why can diagnosing HTN be difficult?

What are the consequences of this?

A
  • HTN can often be asymptomatic
  • in this case, diagnosis depends on clinician awareness and opportunistic measurements of BP
  • 50% of people with HTN remain undiagnosed and are not receiving treatment
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5
Q

What are the risk factors associated with HTN?

A
  • age
  • sex
    • women have a lower BP than men up to 65, then between 65-74 women have a higher BP
  • ethnicity
    • Black African and Black Caribbean at higher risk
  • genetic factors
  • social deprivation
  • lifesytle
    • smoking, excessive alcohol, excessive salt, obesity & lack of physical activity
  • anxiety / emotional stress
    • raises adrenaline and cortisol levels
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6
Q

What is ideal blood pressure and what blood pressure measurement is classed as hypertension?

What type of hypertension are patients assumed to have?

A

normal BP is < 120/80mmHg

  • ranges of 120-140 mmHg for systolic and 80-90mmHg are considered high normal
  • HTN is diagnosed with persistent systolic BP > 140mmHg and diastolic BP > 90mmHg or BOTH
  • assumed to have essential (primary) HTN as secondary HTN is very rare
    • this is HTN in the absence of any pathological cause
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7
Q

When might “white-coat” HTN be suspected?

A
  • if there is a discrepancy of more than 20/10mmHg between clinic and average daytime ABPM / HBPM measurements
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8
Q

When might masked HTN be suspected?

A
  • when clinic blood pressure measurements are normal (<140/90mmHg)
  • but average HBPM / ABPM measurements outside the clinic are higher
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9
Q

What is meant by stage 1 HTN?

A
  • clinic BP ranging from 140/90mmHg to 159/99mmHg
  • AND subsequent ABPM daytime average of 135/85mmHg to 149/94mmHg
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10
Q

What is meant by stage 2 HTN?

A
  • clinic BP of 160/100 mmHg or higher, but less than 180/120 mmHg
  • AND subsequent ABPM daytime average of 150/95 mmHg or higher
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11
Q

What is meant by stage 3 HTN?

A
  • clinic systolic BP of 180 mmHg or higher
  • OR clinic diastolic BP of 120 mmHg or higher
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12
Q

After coming to the conclusion that the patient does NOT have HTN, what would you do depending if there is evidence of target organ damage?

A

Evidence of target organ damage:

  • consider investigations to look for other causes of the damage

No evidence of target organ damage:

  • repeat clinic blood pressure readings every 5 years
  • consider repeating more frequently if clinic BP is close to 140/90mmHg
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13
Q

If someone is found to have high blood pressure in the clinic, what other investigations should be performed?

A
  • a full cardiovascular examination - including peripheral pulses, auscultation for carotid bruits
  • body mass index calculation
  • fundoscopy
  • dipstick urinalysis
  • U&Es
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14
Q

If someone is found to have BP > 140/90mmHg in clinic, what should be the next steps?

A
  • if BP >140/90 mmHg then take a second measurement during the consultation
  • if the second measurement is substantially different from the first, take a third BP measurement
  • record the lower of the last 2 measurements as the clinic BP
  • if BP > 140/90mmHg and <180/120mmHg, then offer ambulatory BP monitoring (ABPM) to confirm diagnosis
  • if ABPM is unsuitable, home BP monitoring (HBPM) is offered instead
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15
Q

What investigations would be performed to assess for target organ damage in a hypertensive patient?

A

this involves assessment of the heart, eyes and kidneys

Heart:

  • 12-lead ECG to look for LV hypertrophy and signs of coronary heart disease

Eyes:

  • fundoscopy to look for signs of hypertensive retinopathy

Kidneys:

  • dipstick urinalysis to look for proteinuria and/or haematuria
    • these are both signs of glomerular damage
  • U&Es, creatinine clearance and eGFR to assess renal function
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16
Q

How would cardiovascular risk be assessed in someone with HTN?

A

this involves fasting blood glucose and lipid profile

  • lipid profile measures the level of serum total cholesterol, HDL, LDL and triglycerides
  • high concentration of fasting blood glucose indicates possible diabetes and increases the risk
  • 10-year risk of developing CVD can be evaluated using QRISK tool
17
Q
A
18
Q

What is the treatment for stage 1 HTN?

(clinic BP 140/90 - 159/99 and ABPM 135/85 - 149/94)

A
  • assess cardiovascular risk and target organ damage
  • offer lifestyle advice
  • start drug therapy in cases of increased CVD risk, target organ damage or no improvement
  • consider specialist referral if patient <40 or HTN is resistant to treatment
19
Q

What lifestyle advice may be offered to someone with stage 1 HTN?

A
  • improve diet - especially reducing salt intake to <6g / day
  • reduce alcohol intake to no more than 3-4 units (men) or 2-3 units (women) daily
  • smoking cessation
  • weight loss and improvement in physical activity
  • discourage excessive consumption of coffee / caffeinated beverages
20
Q

What is the treatment for stage 2 HTN?

(BP > 160/100 and < 180/120 or > 159/95 ABPM)

A
  • assess cardiovascular risk and target organ damage
  • start drug therapy and advise on lifestyle interventions
  • consider specialist referral if <40 or HTN is resistant to treatment
21
Q

What is different in the treatment of stage 3 HTN?

A
  • drug therapy is started immediately without ABPM or HBPM and regardless of target organ damage and CVD risk
22
Q

How are BP targets different based on age?

A
  • the aim of treatment is to gradually reduce and maintain BP at the target

Age < 80 years:

  • clinic BP < 140/90mmHg
  • ABPM < 135/85mmHg

Age > 80 years:

  • clinic BP < 150/90mmHg
  • ABPM < 145/85mmHg
23
Q

What is involved in the first step of pharmacological treatment for HTN?

A
  • patients < 55 are started on an ACEi or ARB
  • patients > 55 or who are black or of African or Carribbean heritage (any age) are started on a CCB
  • patients with type 2 diabetes are started on a ACEi or ARB
24
Q

What is the involved in the second step of pharmacological treatment for HTN?

A

if patient is taking ACEi / ARB:

  • add CCB or thiazide-like diuretic

if patient is taking CCB:

  • add ACEi / ARB or a thiazide-like diuretic
25
Q

WHat is involved in the third step of the pharmacological management of HTN?

What happens if this is unsuccessful?

A
  • triple therapy involves ACEi / ARB + CCB + thiazide-like diuretic
  • if this is unsuccessful then confirm resistant HTN with elevated BP through ABPM or HBPM
  • consider specialist referral or add:
    • low dose spironolactone if K+ < 4.5 mmol/l
    • alpha or beta-blocker if K+ > 4.5 mmol/l
  • seek expert advice if BP not controlled on 4 drugs
26
Q

When should you refer someone with a clinic BP > 180/120mmHg (stage 3 HTN)?

A
  • evidence of retinal haemorrhage or papilloedema, suspected phaeochromocytoma or life-threatening symptoms
  • if not, consider starting drug therapy immediately without ABPM / assessing target organ damage
  • repeat clinic BP in 7 days to see if medication has had an effect
27
Q

What is important to remember when prescribing an ACEi?

A
  • repeat U&Es within 14 days of starting treatment
  • repeat after changing each titration dose
28
Q

What is meant by secondary HTN?

A
  • in 5% of patients, a specific cause for their high BP can be identified
  • secondary HTN is more likely when:
    • early onset HTN < 40 years
    • unexpectedly severe HTN
    • resistant HTN

Y4 - CCC & PC (34 decks)

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