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Hypertension Flashcards

1
Q

What is hypertension?

A

This is the persistent elevation of BP in the systemic arterial circulation to a level higher than expected for the age, sex and race of the individual, such that treatment does more good than harm

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2
Q

What is blood pressure?

A

This is the outwards hydrostatic pressure exerted on the blood vessel walls, by the blood

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3
Q

What are the 2 different blood pressures?

A

Systolic - during ventricular contraction
Diastolic - during ventricular relaxation

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4
Q

What is meant by mean arterial pressure (MAP)?

A

This is the average pressure over one whole cardiac cycle

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5
Q

What is the calculation for MAP?

A

. (2 x Diastolic) + Systolic
. MAP = ———————————-
. 3

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6
Q

What is the normal value of MAP?

A

70-105mmHg

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7
Q

What is the normal range of systolic blood pressure?

A

90 - 120 mmHg

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8
Q

What is the normal range of diastolic blood pressure?

A

60 - 80 mmHg

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9
Q

What is pulse pressure?

A

This is the difference between systolic and diastolic blood pressure

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10
Q

What is the normal range of pulse pressure?

A

30 - 50 mmHg

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11
Q

What receptors detect changes in blood pressure?

A

Baroreceptors

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12
Q

Where are the baroreceptors located in the body?

A

Aortic baroreceptors
Carotid baroreceptors

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13
Q

What is the site of first synapse in the medulla to baroreceptor signals?

A

Nuceus tractus solitarius (NTS)

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14
Q

How does increased blood pressure affect the firing rate of baroreceptors?

A

It increases the firing rate of baroreceptors

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15
Q

Via which nerve do impulses from the aortic baroreceptors reach the medulla?

A

Vagus nerve

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16
Q

Via which nerve do impulses from the carotid baroreceptors reach the medulla?

A

Hering’s branch of Glossopharyngeal nerve

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17
Q

What is released by the heart in response to cardiac distension?

A

Natriuretic peptides

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18
Q

What are the 2 types of natriuretic peptide?

A

ANP - Atrial distension
BNP - Ventricular distension

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19
Q

What is the effect of natriuretic peptide release?

A

They cause the secretion of water and Na+ from the kidneys, as well as decreasing renin release and therefore causing vasodilation to decrease blood pressure

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20
Q

How are most cases of hypertension found?

A

Incidentally during regular health checks

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21
Q

What are some symptoms of acute malignant hypertension?

A

Headache
Blurred vision
Nausea
Vomiting
Chest pain
Altered mental status

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22
Q

What are some clinical signs of hypertension?

A

Pulses bruits
Hypertensive retinopathy

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23
Q

What are some ways in which hypertension can be classified?

A

Primary / secondary
Stage 1 / Stage 2 / Severe
Benign / Malignant / White coat

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24
Q

What is meant by primary hypertension?

A

This is hypertension with no singular identifiable cause

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25
Q

What are some risk factors for primary hypertension?

A

Age
Smoking
Family history
Obesity
High alcohol intake
High salt intake

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26
Q

How do effervescent tablets increase risk of mortality from hypertension?

A

They have a high sodium level and so increase risk of mortality 2 fold

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27
Q

What is meant by secondary hypertension?

A

This is hypertension caused by an identifiable singular cause, removal or reversal of which will lead to normalisation of blood pressure

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28
Q

What are some common causes of secondary hypertension?

A

Renal disease
Obstructive sleep apnoea
Aldosteronism
Reno-vascular disease
Drugs e.g. corticosteroids, NSAIDs, contraceptive pill
Pregnancy e.g. pre-eclampsia

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29
Q

What is aldosteronism?

A

This is the autonomous excretion of aldosterone, without the need of the RAAS pathway

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30
Q

What are some less common causes of secondary hypertension?

A

Cushing’s syndrome
Liddel’s syndrome
Phaeochromocytoma
Aortic coarction
Hyperparathyroidism
Inter-cranial tumour
Polycystic kidney disease
Fibromuscular dysplasia

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31
Q

What is meant by benign hypertension?

A

This is the stable elevation of blood pressure over many years

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32
Q

What are some possible consequences of benign hypertension?

A

Left ventricular hypertrophy
Congestive heart failure
Atheroma formation
Thickening of tunica media
Aneurysm rupture
Renal disease

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33
Q

What is the more common name for malignant hypertension?

A

Accelerated phase hypertension

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34
Q

What is malignant hypertension?

A

This is an acute, severe elevation of BP, with a diastolic pressure >130-140 mmHg

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35
Q

What are some complications of malignant hypertension that make it an emergency?

A

Cerebral oedema
Acute renal failure
Acute heart failure
Haemorrhage (Haemorrhagic stroke)

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36
Q

What is white coat hypertension?

A

This is an increased blood pressure during medical consultations, often due to increased stress or anxiety

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37
Q

How is white coat hypertension clinically classified?

A

A discrepancy of more than 20/10 mmHg between clinical and daytime average ABPM

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38
Q

What blood pressure is defined as stage 1 hypertension?

A

Clinic BP > 140/90 mmHg
AMBP > 135/85 mmHg

39
Q

What blood pressure is defined as stage 2 hypertension?

A

Clinic BP > 160/100 mmHg
AMBP > 150/95 mmHg

40
Q

What blood pressure is defined as severe hypertension?

A

Clinical BP > 180/110 mmHg

41
Q

What is resistant hypertension?

A

Hypertension that does not respond to treatment using ACEis, ARBs or diuretics

42
Q

What are some possible causes of resistant hypertension?

A

Non-concordance
White coat effect
Pseudo-hypertension
Lifestyle factors (e.g. cocaine use)
Drug interactions
2º hypertension
True resistance

43
Q

What are the 2 methods of hypertension diagnosis?

A

Ambulatory blood pressure monitoring (AMBP)
Home blood pressure monitoring

44
Q

What does diagnosis via ambulatory pressure monitoring require?

A

At least 2 measurements per hour during the patients usual waking hours (14 / day)

45
Q

What does diagnosis via home blood pressure monitoring require?

A

2 consecutive seated measurements, 1 minute apart
BP is recorded twice a day for at least 4 days, but preferably 7
Measurements on the 1st day are discarded and the average of the remaining days is used

46
Q

What are some tests that can be performed in hypertension?

A

Urine sampling - Proteinuria - albuminurea
Blood testing - Glucose, Electrolytes, raised Creatine, eGFR, cholesterol
12-lead ECG
Fundoscopy

47
Q

What are the 4 grades of hypertensive retinopathy in fundoscopy?

A

I - Slight narrowing of retinal arterioles (≥1:2 arteriovenous ratio)
II - Severe narrowing of retinal arterioles (<1:2 arteriovenous ratio)
III - Bilateral soft exudates or flame haemorrhages
IV - Bilateral optic nerve oedema

48
Q

What are some ECG findings that may suggest hypertension?

A

ST depression on leads V4-6 due to LV hypertrophy

49
Q

What are some lifestyle management strategies in hypertension?

A

Exercise
Smoking cessation
Decrease salt, caffeine and alcohol intake

50
Q

How will stage I hypertension often by managed?

A

Through lifestyle factors alone

51
Q

How much does 1kg of weight loss decrease blood pressure by on average?

A

1mmHg

52
Q

How does exercise affect mortality in hypertension?

A

15 minutes of daily physical activity decreases mortality by 14%, with every extra 15 minutes reducing mortality by 4%

53
Q

What part of the kidneys controls the RAAS pathway?

A

Juxtaglomerular apparatus

54
Q

What are the 3 components of the juxtaglomerular apparatus?

A

Macula cells
Granular cells
Mesangial cells

55
Q

Describe the role of the juxtaglomerular apparatus in the RAAS pathway and blood pressure control

A

Macula dense cells are found in the renal tubule and detect low Na+ levels
Extra-glomerular granola cells detect renal artery hypotension
These stimulate the release of renin

56
Q

Describe the RAAS pathway

A

Renin coverts angiotensinogen to angiotensin I
ACE converts angiotensin I to II
Angiotensin II stimulates aldosterone release
Aldosterone stimulates ADH release

57
Q

Where is angiotensinogen synthesise?

A

The liver

58
Q

Where is angiotensin converting enzyme (ACE) found?

A

In the lung endothelium

59
Q

What is the action of angiotensin II?

A

This causes vasoconstriction and stimulates thirst

60
Q

What is the function of aldosterone?

A

This causes Na+ and thus water retention

61
Q

How do ACE inhibitors work?

A

They block the conversion of angiotensin I to angiotensin II, which prevents vasoconstriction and decreases Na+ and water retention, therefore decreasing blood pressure

62
Q

What are some examples of ACE inhibitors?

A

Lisinopril
Ramipril
Enalopril
Perindopril

63
Q

What are some side effects of ACE inhibitors?

A

Dry cough
Renal dysfunction
Angioneurotic oedema

64
Q

What form of hypertension are ACE inhibitors contraindicated in?

A

Pregnancy induced hypertension

65
Q

How do ARBs work?

A

They are angiotensin receptor blockers, so prevent the effects of angiotensin II on the body, preventing vasoconstriction and Na+ and water retention

66
Q

What are some examples of ARBs?

A

Losartan
Irbesartan
Candesartan
Valsartan

67
Q

What is a possible side effect of ARB use?

A

Renal dysfunction

68
Q

What type of hypertension are ARBs contraindicated in?

A

Pregnancy induced hypertension

69
Q

How do diuretics work?

A

They block the reabsorption of Na+ in the kidneys, thus increasing the levels of excreted water

70
Q

What are the 2 types of diuretic?

A

Thiazide diuretics - Mild
Loop diuretics - Stronger

71
Q

In what conditions are thiazide diuretics most indicated in?

A

Hypertension

72
Q

In what conditions are loop diuretics most indicated in?

A

Congestive heart failure
Oedema

73
Q

What are some examples of loop diuretics?

A

Furosemide
Bumetanide

74
Q

What are some examples of thiazide diuretics?

A

Bendroflumethiazide
Indapamide

75
Q

What are some side effects of diuretics?

A

Hypokalaemia -> Tiredness
Hyperglycaemia -> Diabetes
Hyperuricaemia -> Gout
Impotence
Arrhythmia

76
Q

How do calcium channel blockers work?

A

They block calcium channels in the heart, therefore slowing action potential triggering by the SA node and decreasing muscle contraction, therefore decreasing SVR and workload of the heart

77
Q

What are the 2 types of Ca2+ channel blockers?

A

Dihydropyridine
Rate-limiting

78
Q

Where do dihydropyridine Ca2+ work?

A

On vascular smooth muscle, not in the heart

79
Q

Where do rate-limiting calcium channel blockers usually work?

A

Mostly on the heart, decreasing heart rate

80
Q

What are some examples of dihydropyridine Ca2+ channel blockers?

A

Amplodipine
Nicardipine

81
Q

What are some examples of rate-limiting Ca2+ channel blockers?

A

Verapamil
Diltiazem

82
Q

In what conditions are rate limiting Ca2+ channel blockers indicated?

A

Hypertension
Heart failure
Angina
Supraventricular tachycardias

83
Q

What are some examples of potent vasodilator drugs?

A

Hydralazine
Minoxidil

84
Q

What is a common side effect of minoxidil?

A

Hypertrichosis (Excessive hair growth)

85
Q

What are some examples of alpha 2 agonists used as anti-hypertensives?

A

Methyldopa
Clonidine

86
Q

What are some examples of alpha 1 antagonists used as anti-hypertensives?

A

Prazosin
Terazosin
Doxazosin

87
Q

What type of drug is dobutamine?

A

A ß-adrenoceptor agonist

88
Q

What type of drug is digoxin?

A

A cardiac glycoside

89
Q

How do cardiac glycosides (Digoxin) work?

A

They are synthesised from foxgloves (Digitalis purpurea)
It blocks the sodium potassium pump
This prevents the building of a concentration gradient for the Na+/Ca2+ exchanger
This increases intracellular Ca2+ levels, leading to an increased force of contraction
They also increase vagal activity, slowing AV conduction and slowing heart rate

90
Q

What is the progression of treatment in patients with hypertension, who are under 55 and caucasian, or have diabetes?

A

1 - ACEi or ARB (Or ß-Blocker in young female)
2 - Add calcium channel blocker
3 - Add thiazide-like diuretic
4 - Add spironolactone

91
Q

What is the progression of treatment in patients over 55, or patients who are black afro-carribean?

A

1 - Calcium channel blocker
2 - Add ACEi or ARB (or ß-blocker in young female)
3 - Add thiazide-like diuretic
4 - Add spironolactone

92
Q

What are the treatment aims for blood pressure in people under 80 years old?

A

< 140/90 mmHg

93
Q

What are the treatment aims for blood pressure in people over 80 years old?

A

< 150/90 mmHg

94
Q

What are the treatment aims for blood pressure in patients with diabetes?

A

< 130/80 mmHg

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