Hypertension

Question 1

What is the primary characteristic of hypertension?

Answer 1

Blood pressure rises to a level causing injury

Question 2

What are the potential adverse outcomes associated with hypertension?

Answer 2

Stroke, MI, malignant hypertension, advancing renal disease

Question 3

What percentage of hypertension cases are classified as ‘essential’ hypertension? Which ethnicities have a higher prevalence of essential hypertension? Approximately what percentage of men in the UK are diagnosed with hypertension? Approximately what percentage of women in the UK are diagnosed with hypertension? What percentage of all UK adults are affected by hypertension? What percentage of UK adults over the age of 60 are affected by hypertension?

Answer 3

90-95%
African or Caribbean
31%
26%
25%
50%

Question 4

According to PHE, what is the third leading cause of all disease? According to the WHO, what is the leading risk factor for death worldwide? How much does hypertension cost the NHS each year?

£2.1 billion

Answer 4

Hypertension

Question 5

Potential symptoms of hypertension

Answer 5

Headaches, visual disturbances, swelling of the macula

Question 6

How is hypertension often detected in patients?

Answer 6

Through regular check-ups
Patients present with target organ damage

Question 7

What blood pressure reading is currently focused on in practice? What setting is ideal for measuring BP?

Answer 7

Systolic
Relaxed, temperate, quiet, seated person

Question 8

What should you palpate before using an automated BP monitor? In which arm should BP be measured? What is important to check on automated BP monitors in-between patients?

Answer 8

Radial or brachial pulse
Both arms
Calibration

Question 9

When repeating blood pressure measurements, what difference in systolic readings requires you to use the higher reading? If initial BP measurement is >140/90 mmHg, what should be done? If repeated measurement is substantially different from the first, what should be done? After taking a third measurement, which reading should be recorded as the clinic blood pressure?

Answer 9

Greater than 15mmHg
Repeat the measurement
Take a third measurement
Lower of the last 2

Question 10

If clinic BP is between 140/90mmHg and 180/120mmHg, what is recommended? How often is blood pressure tested during ambulatory blood pressure monitoring?
What is the primary benefit of using ambulatory blood pressure monitoring (ABPM)? On average, how much higher are clinical blood pressure measurements compared to ABPM?

Answer 10

Ambulatory blood pressure monitoring
Every 30 mins for 24 hours
Better overview of daily BP
10/5mmHg

Question 11

What risk does ABPM remove? What discrepancy between clinic and ABPM/HBPM readings is significant? What other risk does ABPM remove? How does white coat syndrome tend to affect blood pressure readings?
What should be advised if ABPM is not tolerated? How many times should a patient repeat their BP measurement during HBPM, one minute apart?

Answer 11

‘White-coat’ syndrome
20/10 mmHg
‘Masked hypertension’
Raises systolic more than diastolic
HBPM
Twice

Question 12

When should BP be ideally recorded during HBPM? How long should home blood pressure be recorded before submitting to a clinician? Which day’s worth of readings should be discarded from HBPM recordings?

Answer 12

Morning and evening
4-7 days
1st day

Question 13

What ABPM/HBPM average confirms a diagnosis of hypertension? How often should blood pressure be checked if hypertension is suspected but not diagnosed?

Answer 13

> 135/85 mmHg
Every 5 years

Question 14

What clinic blood pressure range defines Stage 1 hypertension? What ABPM/HBPM average blood pressure range defines Stage 1 hypertension?

Answer 14

140/90 mmHg to 159/99 mmHg
135/85 mmHg to 149/94 mmHg

Question 15

What clinic blood pressure defines Stage 2 hypertension? What ABPM/HBPM average defines Stage 2 hypertension?

Answer 15

160/100 mmHg or higher but less than 180/120 mmHg
150/95 mmHg or higher

Question 16

What clinic blood pressure defines Stage 3 (Severe) hypertension?

Answer 16

Systolic ≥180 mmHg or diastolic ≥120 mmHg

Question 17

What is the approximate reduction in CVD risk for each 10mmHg reduction in BP? What is the associated risk of mortality due to IHD with each 2mmHg rise in systolic BP? What is the associated risk of mortality due to stroke with each 2mmHg rise in systolic BP?

Answer 17

~20%
7%
10%

Question 18

How much is the risk of CHF increased in patients with hypertension? How much does BP reduce per 1kg weight loss? What is the impact of exercise on systolic and diastolic blood pressure? What is the impact of relaxation therapy on systolic blood pressure?

Answer 18

Sixfold
1 mmHg
Reduces 2-3mmHg
Reduces 3-4mmHg

Question 19

What is the impact of alcohol cessation on blood pressure? What is the impact of dietary salt intake reduction on systolic blood pressure? What is the long term impact of stopping smoking on BP?

Answer 19

Reduction of 3-4mmHg
Lowers 2-3mmHg
Makes no difference to BP

Question 20

What should happen to patients under 40 with no predisposition that have hypertension? What should be the treatment for persistent stage 1 hypertension in patients under 40 years old?

Answer 20

Referral to cardiology
Lifestyle advice only

Question 21

What is the recommended treatment for persistent stage 1 hypertension in adults under 60 years old? What is the recommended treatment for persistent stage 1 hypertension in patients 60 to 80 years old? When should anti-hypertensives be offered for persistent stage 1 hypertension in patients 60-80 years old?

Answer 21

Consider antihypertensive drug treatment
Lifestyle advice and discuss starting anti-hypertensive
If diabetes mellitus

Question 22

When should anti-hypertensives be offered for persistent stage 1 hypertension in patients 60-80 years old? When should anti-hypertensives be offered for persistent stage 1 hypertension in patients 60-80 years old? When should anti-hypertensives be offered for persistent stage 1 hypertension in patients 60-80 years old?

Answer 22

If established CVD
If renal disease
If 10 year CVD >10%

Question 23

What treatment should be offered for persistent stage 2 hypertension? What is the recommended treatment for persistent stage 1 hypertension in patients over 80 years old if >150/90mmHg?

Answer 23

Anti-hypertensive and lifestyle advice
Lifestyle advice and discuss anti-hypertensive

Question 24

Why should any patient with severe hypertension be treated immediately? What initial pharmacological treatment is recommended for hypertension in patients <55 years and NOT of African or Caribbean heritage? What initial pharmacological treatment is recommended for hypertension in patients <55 years of age and/or are of African or Caribbean heritage?

Answer 24

Risk outweighs adverse effects
ACE inhibitor or angiotensin receptor blocker
Non-rate limiting Calcium channel blocker

Question 25

What is the first intensification step for hypertension treatment in patients <55 years and NOT of African or Caribbean heritage? What is the first intensification step for hypertension treatment in patients <55 years of age and/or are of African or Caribbean heritage?

Answer 25

Non-rate limiting Calcium channel blocker or thiazide diuretic ACE inhibitor or angiotensin receptor blocker or thiazide diuretic


Question 26

What is the second intensification step for hypertension treatment? What is the third intensification step for hypertension treatment?

Answer 26

Whichever agent not added in step 2 Low dose spironolactone, alpha-blocker or beta-blocker

Question 27

What is the initial pharmacological treatment recommended for hypertension in patients WITH diabetes? What is the first intensification step for hypertension treatment in patients WITH diabetes?

Answer 27

ACE inhibitor or angiotensin receptor blocker Non-rate limiting Calcium channel blocker or thiazide diuretic

Question 28

What is the second intensification step for hypertension treatment in patients WITH diabetes? What is the third intensification step for hypertension treatment in patients WITH diabetes?

Answer 28

Whichever agent not added in step 2 Low dose spironolactone, alpha-blocker or beta-blocker

Question 29

What is the clinic blood pressure/ABPM/HBPM target for patients <80 years old?
What is the clinic blood pressure/ABPM/HBPM target for patients >80 years old?

Answer 29

<140/90 mmHg <150/90 mmHg

Question 30

What specific diseases have different blood pressure targets?

Answer 30

CKD, frailty, Type 1 Diabetes Mellitus

Question 31

What is the blood pressure target without complications? What is the blood pressure target with complications? What is considered a physiological normal systolic blood pressure?

Answer 31

120/80 to 140/90 mmHg 120/80 to 130/80 mmHg 90/60 and 120/80 mmHg

Question 32

Case studies: what should you do when the patient's blood pressure is 234/129 mmHg and has lost vision?


Answer 32

Send for a same day referral via A&E

Question 33

What classification of hypertension does a patient presenting with severe hypertension fall into?

Answer 33

Accelerated hypertension

Question 34

What is the significance of a difference greater than 15 mmHg when measuring blood pressure in both arms?

Answer 34

Use the higher reading for diagnosis

Question 35

What is the rationale for using immediate dual therapy in patients with severe hypertension? What factors should be considered when choosing between ACE inhibitors and angiotensin receptor blockers as initial treatment?

Answer 35

To rapidly reduce blood pressure Age and ethnicity

Question 36

How does the presence of diabetes affect the pharmacological treatment approach for hypertension?
Why are specific blood pressure targets recommended for patients with CKD, frailty, and Type 1 Diabetes Mellitus?

Answer 36

The initial treatment is an ACE inhibitor or ARB Due to increased risk of complications

Question 37

What factors should be considered when deciding whether to treat hypertension in patients with diabetes? When a patient is diagnosed with hypertension, what information should be provided regarding lifestyle modifications?

Answer 37

Blood pressure readings and HbA1c levels Diet, exercise, alcohol, smoking, weight

Question 38

Why do patients with severe hypertension need screening for target organ damage?

Answer 38

To detect any damage

Question 39

What is the survival rate of untreated patients with severe hypertension one year post-diagnosis?

Answer 39

10%

Question 40

What are some specific emergencies associated with severe hypertension?

Answer 40

- Pulmonary oedema - ACS (Acute Coronary Syndrome) - Aortic dissection - Hypertension in pregnancy - Phaeochromocytoma - Stroke

Question 41

What are some intravenous options for managing severe hypertension?

Answer 41

- Furosemide (if pulmonary oedema) - Beta-blockers - GTN (Glyceryl Trinitrate) - Sodium Nitroprusside - Labetalol - Nicardipine

Question 42

What is the target blood pressure reduction strategy when managing severe hypertension? What is the initial target blood pressure to achieve within 1-2 hours when managing severe hypertension?

Answer 42

Reduce BP gradually by 15-20% over minutes/hours 160/100 mmHg

Question 43

How is postural hypotension defined in terms of systolic blood pressure reduction?

Answer 43

At least 20 mmHg within 3 minutes

Question 44

How is postural hypotension defined in terms of systolic blood pressure reduction?
How is postural hypotension defined in terms of diastolic blood pressure reduction?

Answer 44

At least 20 mmHg within 3 minutes At least 10 mmHg within 3 minutes

Question 45

What angle should the head be at on a tilt table to test for postural hypotension?

Answer 45

At least 60°

Question 46

What are some symptoms of postural hypotension?

Answer 46

- Light-headedness - Dizziness - Blurring of vision - Fainting - Falls

Question 47

What physiological responses usually counteract blood pooling in the lower extremities upon standing? Why does blood pool in the lower extremities upon standing?

Answer 47

Increased heart rate and vascular tone Due to gravity

Question 48

When should blood pressure be measured with the person standing after initially measuring it seated? In older people, what systolic blood pressure level is associated with an increased risk of falls?

Answer 48

If systolic BP falls by 20 mmHg 110mmHg or below

Question 49

How much does stopping cardiovascular medication reduce syncope and falls?


Answer 49

By 50%

Question 50

What actions should be undertaken to reduce the risk of falling from cardiovascular medication?

Answer 50

Cardiovascular assessment and medication review should be undertaken to assess if any medication is unnecessary and can be withdrawn in order to reduce their risk of falling

Question 51

Which drug class causes severe orthostatic hypotension and may precipitate urinary retention in men if stopped?

Answer 51

ALPHA BLOCKERS (Doxazosin, Indoramin, Prazosin, Tamsulosin, Terazocin, Alfluzosin)

Question 52

Which drug class has sedating effects and may cause severe orthostatic hypotension?

Answer 52

CENTRALLY ACTING ALPHA 2 ANTAGONISTS (Clonidine, Moxonidine)

Question 53

Which drug class can cause orthostatic hypotension, hypokalaemia-induced weakness and hyponatraemia?

Answer 53

THIAZIDE DIURETICS (Bendroflumethiazide, Metolazone)

Question 54

Which drug class can cause orthostatic hypotension, especially during accumulation due to reduced renal clearance?

Answer 54

ACE INHIBITORS (Captopril, Lisinopril, Enalapril, Ramipril, Perindopril)

Question 55

Which drug class can cause hypotension & paroxysmal hypotension, with GTN causing syncope due to sudden BP drop?

Answer 55

ANTIANGINALS (GTN, Isosorbide Mononitrate, Nicorandil)

Question 56

Which drug class can cause bradycardia, hypotension, carotid sinus hypersensitivity, orthostatic hypotension and vasovagal syndrome?

Answer 56

β-BLOCKERS - Especially non-cardioselective (Atenolol, Sotalol, Propranolol, Timolol eye drops, Bisoprolol, Carvedilol)

Question 57

Which drug class can cause orthostatic hypotension, hypokalaemia-induced weakness and hyponatraemia?

Answer 57

LOOP DIURETICS (Furosemide, Bumetanide)

Question 58

Which drug class can cause orthostatic hypotension, but less so than ACEIs?

Answer 58

ANGIOTENSIN RECEPTOR BLOCKERS (Losartan, Candesartan, Valsartan)

Question 59

Which drug class can cause hypotension & paroxysmal hypotension?

Answer 59

DIHYDROPYRIDINE CALCIUM CHANNEL BLOCKERS (Amlodipine, Felodipine)

Question 60

What is polypharmacy defined as?

Answer 60

Taking 4+ medications

Question 61

How does fludrocortisone work to increase cardiac output?

Answer 61

By increasing plasma volume

Question 62

How does fludrocortisone potentially increase peripheral vascular resistance?

Answer 62

By increasing sensitivity to sympathetic nerve stimulation

Question 63

After how many weeks gestation might high blood pressure indicate gestation-induced hypertension?

Answer 63

20 weeks

Question 64

When should treatment for hypertension in pregnancy be started?

Answer 64

When >150/100mmHg

Question 65

What condition is characterized by high blood pressure and proteinuria in pregnancy?

Answer 65

Pre-eclampsia

Question 66

What are symptoms of pre-eclampsia?

Answer 66

- Swelling in face/hands/ankles - Severe headache - Blurred vision - Generally unwell - Abdominal pain

Question 67

Diagnostically, when does pre-eclampsia occur related to blood pressure changes? Diagnostically, when does pre-eclampsia occur related to diastolic blood pressure?

Answer 67

BP rises >30/15 from early to late If diastolic BP >110 with proteinuria

Question 68

What drug is considered first-line for treating hypertension in pregnancy in practice? What is an alternative medication class for treating hypertension in pregnancy?


Answer 68

Beta-blockers (Labetalol) Centrally acting agents (Methyldopa)

Question 69

What calcium channel blocker formulation has been shown to be safe and well-tolerated in pregnancy?

Answer 69

Modified release nifedipine