Hypertension Flashcards
What is hypertension?
A persistent elevation of BP with values above 140/90 on two separate occasions.
What is the most accurate method for confirming hypertension?
Ambulatory blood pressure monitoring where there is continuous measurement over a 24 hour sleep/wake cycle. Prior to taking BP, patient should e seated for at least 5 mins and cuff should cover 80% of arm.
What should a patient do before measuring blood pressure?
Be seated for at least 5 minutes and ensure the cuff covers 80% of the arm.
What are the two main types of hypertension?
- Essential hypertension
- Secondary hypertension
Define essential hypertension.
No identifiable cause, linked to family history, obesity, and lifestyle. There is impaired response to RAAS and increased activation of sympathetic nervous system, which increases peripheral resistance and afterload.
Typically, patients will be asymptomatic and are diagnosed incidentally, or at later stages, may present with symptoms of end-organ damage.
What characterizes secondary hypertension?
Induced by other co-morbidities.
What is Stage 1 hypertension?
BP reading of 140/90.
What is Stage 2 hypertension?
BP reading of 160/100.
What is Stage 3 hypertension?
BP reading of 180/120, requiring same-day referral for investigation. this can be either systolic or diastolic value. With this reading, ambulatory blood pressure is not required and it should be immediately escalated.for same day referral to investigate for signs of target organ damage. If target organ damage is identified, begin antihypertensive drug treatment
-> this includes retinal haemorrhage
Papilloedema (swelling of the optic nerve)
New onset confusion, chest pain, signs of heart failure or kidney injury
What are signs of target organ damage in hypertension?
- Retinal hemorrhage
- Papilloedema
- New onset confusion
- Chest pain
- Signs of heart failure or kidney injury
What is accelerated/malignant hypertension?
Severe increase in BP to 180/120 mmHg or higher with grade 3/4 retinopathy. Patients may present with a headache, visual disturbances and findings include proteinuria and haematuria. This is a medical emergency that requires immediate treatment to prevent rapid progression to renal failure, heart failure or stroke.
What are common causes of malignant hypertension?
- Medication noncompliance
*hypoperfusion and ischaemia - Renovascular disease
- Use of amphetamines
- Head injury
- Cerebral infarction or hemorrhage
What symptoms may patients with malignant hypertension present?
- Headache
- Visual disturbances
- Proteinuria
- Hematuria
What is masked hypertension?
Normal BP in clinic but elevated BP outside of clinic.
What is the protocol for diagnosing hypertension?
Measure blood pressure in both arms; if readings differ by more than 15 mmHg, use the higher reading.
What should be done for BP readings between 140/90 and 180/120?
Offer ambulatory blood pressure monitoring.
What is the confirmed diagnosis of hypertension?
Clinic BP of 140/90 and ABPM average of 135/85 mmHg.
What evaluations should be completed for signs of end-organ damage?
- 12 lead ECG
- Fundoscopy
- FBC for creatinine, eGFR, and albumin-creatinine ratio
- Carotid Doppler ultrasound
What is the ideal method to assess peripheral arterial disease?
Ankle brachial pressure index is ideal to assess for peripheral arterial disease by comparing blood pressure in the upper and lower limbs by dividing ankle blood pressure from arm blood pressure
What factors can affect the accuracy of BP measurement?
- Distended bladder
- Unsupported back/arm
- Recent meal intake
- Caffeine and nicotine use
- Wrong cuff size
- Insufficient time between measurements
What is the white coat effect?
Higher BP of 20/10 mmHg at clinics compared to home BP.
What are the types of eye damage caused by hypertension?
- Retinopathy
- Choroidopathy
- Ischaemic optic neuropathy
- Retinal vascular occlusion
What are the types of eye damage caused by hypertension?
The eye has auto regulation of blood flow, absence of sympathetic norerve supply and blood-retinal barrier. Therefore excessive increase in BP causes damage to muscle layer and endothelium. There is a vasoconstriction phase, sclerotic phase, exudative phase where final haemorrhage, hard exudates form, necrosis of smooth muscle and Cotton wool spots from retinal ischaemia.
Patients may present with double vision, dimmed vision and headaches, hwoever symptoms do not occur until the late stages.
Describe Grade I retinopathy?
Tortuous arteries with thickened bright walls.
Describe Grade II hypertensive retinopathy.
Narrowing of vein where crossed by artery
Describe Grade III retinopathy?
Flame haemorrhages and cotton wool spots
What do cotton wool spots indicate?
Retinal ischaemia
What signifies Grade IV hypertensive retinopathy?
Papilloedema.
What is a TIA?
A medical emergency caused by neurologic dysfunction without acute infarction, lasting less than an hour.
What types of strokes are associated with hypertension?
- Haemorrhagic stroke
- Ischaemic stroke
What kidney diseases can hypertension cause?
- Chronic kidney disease
- Diabetic nephropathy
- Renal artery stenosis
- Polycystic kidney disease
How is the kidney affected in hypertension?
Hypertension causing hyper filtration and damage to the blood vessels and create thickening via protein deposition of hyaline causing hyaline arteriosclerosis. The high BP leads to hypoxia which damages the renal tubular cells and mesangial cells release TGF-beta that activates fibroblasts and leads to glomerulosclerosis. causes fibrosis of kidneys, indicated by proteinuria and albumin-creatinine ratio.
What are clinical signs of end-organ damage due to hypertension?
- Headaches
- Nausea and vomiting
- Visual disturbances
- Chest/back pain
- Dyspnoea
- Orthopnea
List endocrine disorders causing secondary hypertension.
- Phaechromocytoma
- Cushing’s syndrome
- Conn’s syndrome
- Hyperthyroidism
- Hyperparathyroidism
- Acromegaly
How does phaechromocytoma cause hypertension?
Catecholeamine secreting tumour from chromaffin cells in the adrenal medulla, associated with Von Hippel-Lindau disease that causes persistent vasoconstriction. It presents with persistent headache, labile/postural hypotension, palpitations, pallor, abdominal pain and diaphoresis. It can be diagnosed with 24-hour urinary catecholeamines
What should be included in investigations for hypertension?
- 12 lead ECG
- CXR
- Urinalysis
- Fasting glucose
- Full lipid profile
- U&Es, albumin-creatinine ratio
- Cardiac biomarkers
What lifestyle changes are recommended for managing hypertension?
- Diet
- Exercise
- Alcohol intake
- Smoking cessation
- Limit caffeine and sodium intake
What is the first-line treatment for those under 55 and non-African/ Caribbean with hypertension?
ACE inhibitor or ARB.
What is the second-line treatment for hypertension in non-Africans and non-diabetics?
Calcium channel blocker, however these commonly cause oedema.
What is the 3rd line treatment for hypertension in non-Africans?
3rd line is combination of ACE/ARB with calcium channel blocker and a thiazide Diuretic with bendorflumethiazide or thiazide-like diuretic such as indapamide.
What is the 4th line treatment for hypertension in non-Africans?
4th line is an alpha blocker, beta blocker or spironoclatone Spirionolactone should be considered for patients with resistant hypertension that have low eGFR and potassium of 4.5mmol/L or less due to risk of hyperkalemia.
What is the treatment for resistant hypertension?
Combination of ACE inhibitor/ARB with calcium channel blocker and thiazide diuretic.
What should be monitored in patients on antihypertensive medication?
Blood sodium, potassium, and renal function.
What is the first-line treatment for patients over 55 with hypertension?
Calcium channel blocker.
What is the preferred first-line treatment for diabetics with hypertension?
ACE inhibitor or ARBs
What is the antihypertensive for over 55s?
ACE inhibitors/ARB or a thiazide like diuretic
What is the 3rd line treatment for antihypertensive in over 55s?
ACE inhibitor/ARB and calcium channel blocker and thiazide-like diuretic
What is the 4th line treatment for antihypertensives in over 55s?
Addition of alpha blocker, beta blocker or spironolatone
What is the target BP for patients in their 80s?
145/80 mmHg based on ABPM.
What is malignant hypertension?
Severe BP elevation of SBP over 180 and DBP over 120, with end organ damage, causing fibrinoid necrosis of the small vessels.
It can cause hypertensive encephalopathy
Microangiopathic haemolytic anaemia
What are the causes of malignant hypertension?
Non compliance with medications
Drugs like cocaine and ampethamines
Renovasuclar disease or parenchyma
CNS issues like stroke or head injury
What is the presentation of hypertensive retinopathy?
Severe frontal headache with gradua onset
Visual disturbances
Confusion
SOB
Seizures
Papilloedema due to increased intracranial pressure
How is malignant hypertension treated?
Controlled drop in blood pressure to 160.100 over 24 hours to avoid ischaemic stroke
Oral antihypertensive medication is preferred with calcium channel blockers
Which CCB is best for malignant hypertension?
Amlodipine
Nifedipine
When should oral hypertensives be avoided for malignant hypertension?
IV is preferred for heart failure, aortic dissection or encephalopathy
When is trans
