Hypertension Flashcards
General cut offs for hypertension?
blood pressure above 140/90 in clinic or 135/85 with ambulatory or home readings
Stage 1 hypertension
clinic reading : >140/90
ambulatory/ home: >135/85
Stage 2 hypertension
Clinic reading: >160/100
Ambulatory/home: >150/95
Stage 3 hypertension
Clinic reading: >180/120
what is essential hypertension?
Essential hypertension accounts for 95% of hypertension. This is also known as primary hypertension. It essentially means that the hypertension has developed on its own and does not have a secondary cause.
Secondary causes of hypertension?
ROPE
R – Renal disease. This is the most common cause of secondary hypertension. If the blood pressure is very high or does not respond to treatment consider renal artery stenosis.
O – Obesity
P – Pregnancy induced hypertension / pre-eclampsia
E – Endocrine. Most endocrine conditions can cause hypertension but primarily consider hyperaldosteronism (“Conns syndrome”) as this may represent 2.5% of new hypertension. A simple test for this is a renin:aldosterone ratio blood test.
Complications of hypertension
Ischaemic heart disease
Cerebrovascular accident (i.e. stroke or haemorrhage)
Hypertensive retinopathy
Hypertensive nephropathy
Heart failure
Investigations of hypertension to assess for any end organ damage?
Urine albumin:creatinine ratio for
proteinuria and dipstick for microscopic haematuria to assess for kidney damage
Bloods for HbA1c, renal function and lipids
Fundoscopy: for hypertensive retinopathy
ECG : check for left ventricular hypertrophy or ischaemic heart disease
Medications for hypertension
A – ACE inhibitor (e.g. ramipril 1.25mg up to 10mg once daily)
B – Beta blocker (e.g. bisoprolol 5mg up to 20mg once daily)
C – Calcium channel blocker (e.g. amlodipine 5mg up to 10mg once daily)
D – Thiazide-like diuretic (e.g. indapamide 2.5mg once daily)
ARB – Angiotensin II receptor blocker (e.g. candesartan 8mg to up 32mg once daily)
Angiotensin receptor blockers are used in place of an ACE inhibitor if the person does not tolerate ACE inhibitors (commonly due to a dry cough) or the patient is black of African or African-Caribbean descent. ACE inhibitors and ARBs are not used together.
Initial management of hypertension
Establish a diagnosis.
Investigate for possible causes and end organ damage.
Advise on lifestyle. This includes recommending a healthy diet, stopping smoking, reducing alcohol, caffeine and salt intake and taking regular exercise.
Medical management of hypertension: Steps
Medical management is offered to:
All patients with stage 2 hypertension
All patients under 80 years old with stage 1 hypertension that also have a Q-risk score of 10% or more, diabetes, renal disease, cardiovascular disease or end organ damage.
There are slightly different guidelines for younger patients and those aged over 55 or black:
Step 1: Aged less than 55 and non-black use A. Aged over 55 or black of African or African-Caribbean descent use C.
Step 2: A + C. Alternatively A + D or C + D. If black then use an ARB instead of A.
Step 3: A + C + D
Step 4: A + C + D + additional (see below)
For step 4, if the serum potassium is less than or equal to 4.5 mmol/l consider a potassium sparing diuretic such as spironolactone. If the serum potassium is more than 4.5 mmol/l consider an alpha blocker (e.g. doxazosin) or a beta blocker (e.g. atenolol).
Seek specialist advice if the blood pressure remains uncontrolled despite treatment at step 4.
Medical management of hypertension: Steps
Medical management is offered to:
All patients with stage 2 hypertension
All patients under 80 years old with stage 1 hypertension that also have a Q-risk score of 10% or more, diabetes, renal disease, cardiovascular disease or end organ damage.
There are slightly different guidelines for younger patients and those aged over 55 or black:
Step 1: Aged less than 55 and non-black use A. Aged over 55 or black of African or African-Caribbean descent use C.
Step 2: A + C. Alternatively A + D or C + D. If black then use an ARB instead of A.
Step 3: A + C + D
Step 4: A + C + D + additional (see below)
For step 4, if the serum potassium is less than or equal to 4.5 mmol/l consider a potassium sparing diuretic such as spironolactone. If the serum potassium is more than 4.5 mmol/l consider an alpha blocker (e.g. doxazosin) or a beta blocker (e.g. atenolol).
Seek specialist advice if the blood pressure remains uncontrolled despite treatment at step 4.
Potassium balance + hypertension
Spironolactone is a “potassium-sparing diuretic” that works by blocking the action of aldosterone in the kidneys, resulting in sodium excretion and potassium reabsorption. This can be helpful when thiazide diuretics are causing hypokalaemia.
Using spironolactone increases the risk of hyperkalaemia. ACE inhibitors can also cause hyperkalaemia. Thiazide like diuretics can cause also electrolyte disturbances. For this reason it is important to monitor U+Es regularly when using ACE inhibitors and all diuretics.
Treatment targets BP?
< 80 years:
systolic <140
diastolic <90
> 80 years:
systolic <150
diastolic <90
Angiotensin-converting Enzyme (ACE) inhibitors? Moa, common side effects, notes
Inhibit the conversion angiotensin I to angiotensin II
Cough
Angioedema
Hyperkalaemia
First-line treatment in younger patients (< 55 years old)
Less effective in Afro-Caribbean patients
Must be avoided in pregnant women
Renal function must be check 2-3 weeks after starting due to the risk of worsening renal function in patients with renovascular disease
Drug names end in ‘-pril’
