Hypertension Flashcards
Define HTN
Blood pressure >=140/90 mmHg
HTN causes
> 90% cases = PRIMARY – essential/idiopathic
How do you correctly measure BP in clinic?
Offer to measure in both arms.
If difference between both arms >15mmHg –> repeat + measure from arm with higher BP
If BP >140/90 –> 2nd measurement –> 3rd measurement + record lower of last 2 measurements
Define white coat effect
Discrepancy of more than 20/10mmHg between clinic and average daytime ABPM
Secondary renal causes of HTN
Renal artery stenosis
Chronic glomerulonephritis
Pyelonephritis
Polycystic kidney disease
Renal failure
Secondary endocrine causes of HTN
Diabetes
Hyperthyroidism
Cushing’s
Conn’s
Hyperparathyroidism
Phaeochromocytoma
Congenital Adrenal Hyperplasia
Acromegaly
Secondary non-renal/endocrine causes of HTN
pre-eclampsia
CARDIO: coarctation of the aorta,increased intravascular volume
DRUGS: sympathomimetics, corticosteroids, oral contraceptives
What is stage 1 HTN?
Clinic BP >=140/90 mmHg
ABPM daytime/HBPM BP >=135/85 mmHg
What is stage 2 HTN?
Clinic BP >=160/100 mmHg
ABPM daytime average/HBPM average BP >=150/95 mmHg
What is stage 3 HTN?
Clinic systolic BP >= 180 mmHg OR
Clinic diastolic BP >= 110 mmHg
What do you do if someone comes into the clinic with BP >140/90?
Offer ABPM or HBPM
If a PT has BP >135/85 (stage 1 HTN) on A/H BPM what is the criteria for management?
(CORD10)
Treat if <80 years AND any of the following:
- Established CVD
- Target Organ damage
- Renal disease
- Diabetes
- 10 year CV risk equivalent to 10% or greater
If a PT has BP >150/95 (stage 2 HTN) on A/H BPM what is the criteria for management?
Treat all patients regardless of age
Management of HTN step 1 (give example)
If <55yr / T2DM:
- ACE-i - ends with ‘-pril’ -eg ramipril
- or ARB if not tolerated- ends with ‘-sartan’
If >55yrs / Afro-caribbean/black African:
- CCB- ends with ‘dipine’- eg amlodipine
Management of HTN step 2
If <55yr / T2DM:
- ACEi/ARB + CCB
OR
- ACEi/ARB + thiazide-like diuretic (bendroflumethiazide)
If >55yrs / Afro-caribbean/black African:
- CCB + ACEi/ARB
OR
- CCB + thiazide-like diuretic (bendroflumethiazide)
Management of HTN step 3
ACEi/ARB + CCB + thiazide-like diuretic
Management of HTN step 4
If K+ <= 4.5 mmol/L: add low-dose spironolactone
If K+ > 4.5 mmol/L: add an alpha- or beta-blocker
If BP not controlled on 4 drugs then specialist review
What lifestyle advice would you offer for hypertension?
Low salt (<6/day, ideally 3g), fruit + veg rich, reduce caffeine intake
Stop smoking
Drink less alcohol
Exercise, lose weight
ACE inhibitor MOA
Inhibit the conversion angiotensin I to angiotensin II
ACE inhibitor side effects
Cough
Angioedema
Hyperkalaemia
Renal failure (RAS)
ACE inhibitor contraindications/warnings
Must be avoided in pregnant women
Check renal function 2-3 weeks after starting (risk of worsening renal function in PTs with renovascular disease)
Name a common ACE inhibitor
Ramipril
Angiotensin II receptor blocker MOA
Block effects of angiotensin II at the AT1 receptor
Angiotensin II receptor blocker side effect
Hyperkalaemia
Angiotensin II receptor blocker indications
Generally used where patients have not tolerated an ACE inhibitor, usually due to the development of a cough
Name a common ARB
Losartan
MOA of CCBs
Block voltage-gated calcium channels relaxing vascular smooth muscle and force of myocardial contraction
CCB side effects
Flushing
Ankle oedema
Headache
Gum hyperplasia
Name a common CCB
amlodipine
MOA of thiazide like diuretics
Inhibit sodium absorption at the beginning of the distal convoluted tubule
Side effects of thiazide like diuretics
Hyponatraemia
Hypokalaemia
Dehydration
ECG changes/ arrythmia
Metabolic alkalosis
Hypercalcemia.
Hyperglycemia
Hyperuricemia.
Hyperlipidemia.
Side effects of spironolactone
Hyperkalaemia
Gynaecosmastia- decreases testosterone production, increasing peripheral conversion of testosterone to estradiol
BB side effects
Bronchospasm
Heart failure
Lethargy
When are BB contraindicated?
Asthma
Uncontrolled HF
Hypotension/marked bradycardia
When in spironolactone contraindicated?
Addison’s disease
Anuria
Hyperkalaemia
BP targets in HTN (once started on treatment)
Age < 80 years
- clinic 140/90 mmHg
- home 135/85 mmHg
Age > 80 years
- clinic 150/90 mmHg
- home 145/85 mmHg
What is malignant hypertension?
Severe increase in BP to >180/120 mmHg & signs of new or progressive target organ damage
e.g. retinal haemorrhage and/or papilloedema
(NOTE: urgency = high but no target organ damage)
RFs for malignant hypertension
uncontrolled HTN
CKD
RAS
renal transplant
phaeochromocytoms
pregnancy
1st line Tx for malignant hypertension
Specialist referral + IV labetalol
Reduce MAP by max 25% in 1st hour
then 160/100 or less within the next 2-6 hours
(avoid organ ischaemia)
Signs of target organ damage in HTN
Congestive heart failure
Encephalopathy: headache, CNS signs, seizures, coma
management of hypertensive urgency
if no target organ damage is identified, repeat clinic blood pressure measurement within 7 days
Grade 1 of hypertensive retinopathy
Tortuosity (twisting) of retinal arteries
Increased reflectiveness (SILVER WIRING)
Grade 2 of hypertensive retinopathy
Grade 1 + ARTERIOVENOUS NIPPING (thickened retinal arteries pass over retinal veins)
Grade 3 of hypertensive retinopathy
Grade 2 + FLAME HAEMORRHAGE and COTTON WHOOL exudates (due to small infarct)
Grade 4 of hypertensive retinopathy
Grade 3 + PAPILLOEDEMA (blurry margin of the optic disc)
A 58-year-old man is reviewed in a hypertension clinic, where it is found that his blood pressure is 165/105 mmHg. He is currently on ramipril, amlodipine and Bendroflumethiazide.
What would be your next stage in his management?
Measure serum potassium level
A 57-year-old man is reviewed in a hypertension clinic, where it is found that his blood pressure is 165/105 mmHg despite standard doses of amlodipine, perindopril, doxazosin and bendroflumethiazide. Electrolytes and physical examination have been, and remain, normal.
What would be your next stage in his management?
Arrange for his medication to be given under direct observation
One of the biggest issues is compliance- before specialist review you’d want to do this
A 43 year old patient is started on some medication to control his high blood pressure. He now presents to you complaining of ankle swell. O/E you find bilateral ankle oedema.
What is the most likely culprit?
Calcium Channel Blocker
A 45 year old gentleman with difficult to control hypertension presents to your practice for an annual review of his medication. On examination you notice gynaecomastia.
What is the most likely culprit?
Spironolactone
A 65-year-old man present to his GP complaining of headaches and problems with his vision. O/E the GP finds his BP to be 190/130 and on fundoscopy see the edges of the optic disc are blurred.
Which of the following would be your next stage in his management?
Send the patient to A&E for specialist review
this patient has malignant hypertension- before doing anything need to review in A+E (not done in GP setting)
