Hypertension Flashcards
What is hypertension?
High blood pressure
What are the two types of hypertension?
Primary and secondary
What is primary hypertension?
AKA essential hypertension, accounting for 95% of hypertension
Occurs on its own without secondary cause
What are the causes of secondary hypertension?
THINK ROPE
Renal
Obesity
Pregnancy induced hypertension / pre-eclampsia
Endocrine
Why does hypertension occur?
Reduced elasticity of large arteries, due to age-related and atherosclerosis-related calcification, and degradation of arterial elastin.
What is more important - raised systolic pressure or raised diastolic pressure?
Raised systolic pressure is more important than raised diastolic pressure as a risk factor for cardiovascular and renal disease.
What are the complications of hypertension?
Ischaemic heart disease
Cerebrovascular accident (i.e. stroke or haemorrhage)
Hypertensive retinopathy
Hypertensive nephropathy
Heart failure
According to NICE guidelines, what blood pressure reading can diagnose hypertension?
Clinical - 140/90
Ambulatory or home readings - 135/85
What patients should have 24H ambulatory blood pressure to confirm diagnosis?
Patients with a clinic blood pressure between 140/90 mmHg and 180/120 mmHg
What is white coat syndrome?
Having your blood pressure taken by a doctor or nurse often results in a higher reading.
When would you suspect white coat syndrome?
More than a 20/10 mmHg difference in blood pressure between clinic and ambulatory or home readings.
What is stage one hypertension?
Clinical: >140/90
Ambulatory/home: >135/85
What is stage two hypertension?
Clinical: >160/100
Ambulatory/home: >150/95
What is stage 3 hypertension? Malignant hypertension
> 180/120
When can ARBs be 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
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.
Who is medical management of hypertension 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.
Step one medical management of hypertension
Aged less than 55 and non-black use ACE inhibitor - eg ramipril.
Aged over 55 or black of African or African-Caribbean descent use calcium channel blocker - eg amlodipine.
Step two medical management of hypertension
ACE inhibitor + calcium channel blocker.
If black then use an ARB instead of A.
Step three medical management of hypertension
ACE inhibitor + calcium channel blocker + Diuretic
Step four medical management of hypertension
ACE inhibitor + calcium channel blocker + Diuretic + another med
Seek specialist advice if the blood pressure remains uncontrolled despite treatment at step 4.
What medicine is given at stage 4 and what does it depend on?
Depends on serum potassium level
If the serum potassium is ≤ 4.5 mmol/l consider a potassium sparing diuretic such as spironolactone.
If the serum potassium is >4.5 mmol/l consider an alpha blocker (e.g. doxazosin) or a beta blocker (e.g. atenolol).
What medications increase the risk of hyperkalaemia?
ACE inhibitors
Thiazide like diuretics
For this reason it is important to monitor U+Es regularly when using ACE inhibitors and all diuretics.
What is the treatment target in under 80s?
Systolic Target: <140
Diastolic Target: <90
What is the treatment target in over80s?
Systolic Target: <150
Diastolic Target: <90
What is malignant hypertension?
Severe elevation of arterial blood pressure, resulting in end-organ damage.
Malignant hypertension stats.
Blood pressure ≥180 mm Hg systolic and ≥120 mm Hg diastolic
Malignant hypertension complications
Evidence of end-organ damage
Papilloedema and/or retinal haemorrhages
New-onset confusion (encephalophathy)
Seizure
Chest pain
Signs of heart failure
Acute kidney injury
Malignant hypertension management
Guidelines in treatment suggest aiming for controlled drop in blood pressure, to around 160/100mmHg over at least 24 hours.
What can cause an uncontrolled drop in malignant hypertension?
Ischaemic stroke due to poor cerebral autoregulation and perfusion.
First line treatment in malignant hypertension
Oral medication is preferred to IV, unless there is encephalopathy, heart failure or aortic dissection.
Oral calcium channel blockers such as amlodipine or nifedipine are often used first line.
When would you suspect secondary hypertension?
Younger patients with few comorbidities.
Severe hypertension or hypertension resistant to treatment
New hypertension in patients with previously stable or low readings.
Hypertension with associated symptoms or electrolyte disturbances
