Hypertension Flashcards
Types HTN/ Target organs
Essential/Primary HTN:
High BP with unrelated cause.
Secondary HTN:
HTN with Kidney or endocrine disease/caused by another medical condition.
Resistant HTN:
High BP that doesn’t respond well to aggressive medical treatment. Uncontrolled BP after 3 or more hypertensive treatments
Accelerated HTN:
Severe increase in BP ≥180/120 WITH
signs of:
- Retinal Haemorrhage
- &/or papilledema (swelling of optic nerve)
Usually comes with target organ damage
Target organs
- Heart
-Brain
-Kidney (CKD)
- Eyes (Retinopathy)
Normal damage to any of these organs would = V high BP.
Measurement methods/Causes/Risk factors
ABPM
Clinic - At Drs
Home
Causes
- Main cause unknown
Risk factors
- Age, Diet, Smoking, Exercise, Alcohol
Signs and symptoms (HTN)/ Stages of HTN/ Diagnosis
Often no symptoms but when BP is extremely high they can show:
Fatigue or confusion
Vision problems
Chest pain
Difficulty breathing
Irregular heartbeat
Blood in the urine
Pounding in chest, neck or ears
Stages of HTN*
STAGE 1 HTN:
- Clinic BP ≥140/90. ABPM/Home ≥135/85
STAGE 2 HTN:
- Clinic BP 160/100 -180/120. ABPM/Home ≥150/95
STAGE 3 HTN:
- Clinic systolic ≥180 or Diastolic ≥120
Stage 1 & 2 need both readings clinic and ABPM. 3 1 reading is ok
Diagnosis (check diagram)
In summary they do clinic BP if 140/90 to 180/120 - do ABPM.
If ABPM comes ≥135/85 then give drug unless <40 refer. If ABPM comes below that they are fine reassess in 5 years.
- However if target organ damage shows further investigation is needed
NOTE: If ABPM unsuitable use HBPM
BP Targets
IDEAL RANGE:
90/60 - 120/80.
Clinic BP
Age <80 - <140/90
Age >80 - <150/90
ABPM
Average BP <80 - <135/85
>80 - <145/85
Same day Specialist Referral
REFER same day IF severe HTN BP≥180/120 WITH any of:
- Retinal Haemorrhage
- Papilloedema (Accelerated HTN)
- Life threatening symptoms (HF signs, chest pain, confusion, AKI)
- SUS Pheochromocytoma (Postural hypotension, Headache, palpitations, abdo pain, pallor, diaphoresis[excess sweating])
If PTs have severe HTN but NO signs of same day referral investigate for target organ damage.
- IF target organ damage consider drug immediately without other results.
- If no damage repeat clinic BP within 7 days
Treatment (HTN)
Below mainly applies to stage 1.
Stage 1 can be age dependent.
Stage 2 you treat regardless of the age
Stage 3/Severe HTN: Treat ASAP with IV antihypertensive.
NON DRUG:
Regular exercise,
Healthy diet (2/3 portion of fish/week, lean meat, reduce fatty foods [cheese, fatty meats, fried food, butter])
Reduce salt and sodium intake,
Reduce alcohol
CHECK DIAGRAM
KEY:
HTN with Diabetes - 1st line ACEi/ARB
- If black/African/ afro-Caribbean ARB preferred.
HTN <55 & NOT black African/ African- Caribbean family origin - 1st line ACEi/ARB
HTN 55+/Black African/ African- Caribbean family origin - 1st line CCB
Step 2: Indapamide>Bendroflumethiazide unless already stable on bendro. - BC thiazide like don’t affect electrolytes as much as thiazides.
NB: ACEi normally can cause renal impairment but in diabetic it will protect kidney.
T1DM and HTN
1st line ACEi/ARB- start low dose titrate to max.
NEXT STEP CAN BE ANY OF BELOW:
B-blocker (ok despite PT on insulin) (Sometimes this drug is avoided with B-Blocker can help cause hyperglycaemia but in this case its ok)
CCB (only LONG acting [MR] Nifedipine MR or amlodipine
Diuretics (low dose thiazide) in combo with B-blocker
Pre-Eclampsia/ Pregnancy with HTN
Pre eclampsia - Mainly happens after 20 weeks pregnancy with features of multi organ involvement or soon after birth and is high BP with Pregnancy.
Usually >140/90 and large amounts of PROTEIN in urine.
Chronic HTN- HTN b4 pregnancy or found in first 20 weeks pregnancy.
Gestational HTN - New onset HTN after 20 week pregnancy.
Signs/Symptoms:
- Severe headache,
- Problems with vision,
- Severe pain below ribs,
- Vomiting and
- Sudden swelling of hands, feet or face accompanied with significant proteinuria and BP>140/90.
URGENT REFER to hospital if >160/110
More risk of pre eclampsia if: DM, CKD, autoimmune disease, chronic HTN, previous HTN in pregnancy.
PREVENTION:
- Advised to take aspirin FROM 12 week till baby is born.
If women has >1 risk factor for pre eclampsia (1st pregnancy, >40yrs old, Pregnancy with interval of 10 yrs, BMI>35, multiple pregnancy, Family Hx of Pre eclampsia):
- Advised with aspirin as above.
Female with chronic HTN STOP: ACEi, ARBs, thiazide or thiazide-like diuretics due to an increased risk of congenital abnormalities.
Treatment (Pre eclampsia, gestational or chronic HTN [pregnancy])
(EXAM Q)
BP 140/90 or +:
1st line - Oral Labetalol to get BP <135/85.
ALT nifedipine MR
ALT methyldopa.
BP>160/110:
1st line IV Labetalol, OR IV hydralazine OR oral nifedipine MR
IV magnesium sulphate in critical care or Severe HTN
POST BIRTH:
If on Methyldopa should STOP 2 days after birth and switch to regular treatment
Breastfeed
1st line enalapril (monitor renal function/serum K+). BUT for black African/African-Caribbean family origin - 1st line - Nifedipine or Amlodipine.
If BP not controlled combine Nifedipine/Amlodipine with enalapril.
FAIL - ADD Labetalol or Atenolol or switch 1.
Labetalol dose Pregnancy (EXAM Q)
Initial 100mg BD - dose to be increased at intervals of 14 days.
Usual dose 200mg BD - increased to 800mg/day if needed in 2 divided doses.
- Take with food
Higher doses to be given in 3/4 divided doses
MAX 2.4g/day
HTN in renal disease
People with CKD stage 3 or + or micro/macro albuminuria or people on dialysis OFFER BP lowering treatment.
TARGET BP 140/90. (if have CKD/Diabetes <130/80)
ACR target <70mg/mmol.
Try keep drugs OD.
ACEi/ARB mainly used in CKD for BP lowering - NICE
Hypertensive emergency
BP with reading 180/120 or +.
Symptoms in emergency:
Severe headaches/vomiting
Severe anxiety
SOB
Nosebleeds
Retinal haemorrhage
If BP is 180/110 with no acute target organ damage its hypertensive urgency and not emergency.
REQUIRE REFERAL TO HOSPITAL
