Hypertension Flashcards
What is the primary characteristic of hypertension?
Blood pressure rises to a level causing injury
What are the potential adverse outcomes associated with hypertension?
Stroke, MI, malignant hypertension, advancing renal disease
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?
90-95%
African or Caribbean
31%
26%
25%
50%
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
Hypertension
Potential symptoms of hypertension
Headaches, visual disturbances, swelling of the macula
How is hypertension often detected in patients?
Through regular check-ups
Patients present with target organ damage
What blood pressure reading is currently focused on in practice? What setting is ideal for measuring BP?
Systolic
Relaxed, temperate, quiet, seated person
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?
Radial or brachial pulse
Both arms
Calibration
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?
Greater than 15mmHg
Repeat the measurement
Take a third measurement
Lower of the last 2
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?
Ambulatory blood pressure monitoring
Every 30 mins for 24 hours
Better overview of daily BP
10/5mmHg
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?
‘White-coat’ syndrome
20/10 mmHg
‘Masked hypertension’
Raises systolic more than diastolic
HBPM
Twice
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?
Morning and evening
4-7 days
1st day
What ABPM/HBPM average confirms a diagnosis of hypertension? How often should blood pressure be checked if hypertension is suspected but not diagnosed?
> 135/85 mmHg
Every 5 years
What clinic blood pressure range defines Stage 1 hypertension? What ABPM/HBPM average blood pressure range defines Stage 1 hypertension?
140/90 mmHg to 159/99 mmHg
135/85 mmHg to 149/94 mmHg
What clinic blood pressure defines Stage 2 hypertension? What ABPM/HBPM average defines Stage 2 hypertension?
160/100 mmHg or higher but less than 180/120 mmHg
150/95 mmHg or higher
What clinic blood pressure defines Stage 3 (Severe) hypertension?
Systolic ≥180 mmHg or diastolic ≥120 mmHg
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?
~20%
7%
10%
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?
Sixfold
1 mmHg
Reduces 2-3mmHg
Reduces 3-4mmHg
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?
Reduction of 3-4mmHg
Lowers 2-3mmHg
Makes no difference to BP
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?
Referral to cardiology
Lifestyle advice only
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?
Consider antihypertensive drug treatment
Lifestyle advice and discuss starting anti-hypertensive
If diabetes mellitus
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?
If established CVD
If renal disease
If 10 year CVD >10%
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?
Anti-hypertensive and lifestyle advice
Lifestyle advice and discuss anti-hypertensive
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?
Risk outweighs adverse effects
ACE inhibitor or angiotensin receptor blocker
Non-rate limiting Calcium channel blocker
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?
Non-rate limiting Calcium channel blocker or thiazide diuretic
ACE inhibitor or angiotensin receptor blocker or thiazide diuretic
What is the second intensification step for hypertension treatment? What is the third intensification step for hypertension treatment?
Whichever agent not added in step 2
Low dose spironolactone, alpha-blocker or beta-blocker
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?
ACE inhibitor or angiotensin receptor blocker
Non-rate limiting Calcium channel blocker or thiazide diuretic
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?
Whichever agent not added in step 2
Low dose spironolactone, alpha-blocker or beta-blocker
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?
<140/90 mmHg
<150/90 mmHg
What specific diseases have different blood pressure targets?
CKD, frailty, Type 1 Diabetes Mellitus
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?
120/80 to 140/90 mmHg
120/80 to 130/80 mmHg
90/60 and 120/80 mmHg
Case studies: what should you do when the patient’s blood pressure is 234/129 mmHg and has lost vision?
Send for a same day referral via A&E
What classification of hypertension does a patient presenting with severe hypertension fall into?
Accelerated hypertension
What is the significance of a difference greater than 15 mmHg when measuring blood pressure in both arms?
Use the higher reading for diagnosis
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?
To rapidly reduce blood pressure
Age and ethnicity
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?
The initial treatment is an ACE inhibitor or ARB
Due to increased risk of complications
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?
Blood pressure readings and HbA1c levels
Diet, exercise, alcohol, smoking, weight
Why do patients with severe hypertension need screening for target organ damage?
To detect any damage
What is the survival rate of untreated patients with severe hypertension one year post-diagnosis?
10%
What are some specific emergencies associated with severe hypertension?
- Pulmonary oedema
- ACS (Acute Coronary Syndrome)
- Aortic dissection
- Hypertension in pregnancy
- Phaeochromocytoma
- Stroke
What are some intravenous options for managing severe hypertension?
- Furosemide (if pulmonary oedema)
- Beta-blockers
- GTN (Glyceryl Trinitrate)
- Sodium Nitroprusside
- Labetalol
- Nicardipine
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?
Reduce BP gradually by 15-20% over minutes/hours
160/100 mmHg
How is postural hypotension defined in terms of systolic blood pressure reduction?
At least 20 mmHg within 3 minutes
How is postural hypotension defined in terms of systolic blood pressure reduction? How is postural hypotension defined in terms of diastolic blood pressure reduction?
At least 20 mmHg within 3 minutes
At least 10 mmHg within 3 minutes
What angle should the head be at on a tilt table to test for postural hypotension?
At least 60°
What are some symptoms of postural hypotension?
- Light-headedness
- Dizziness
- Blurring of vision
- Fainting
- Falls
What physiological responses usually counteract blood pooling in the lower extremities upon standing? Why does blood pool in the lower extremities upon standing?
Increased heart rate and vascular tone
Due to gravity
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?
If systolic BP falls by 20 mmHg
110mmHg or below
How much does stopping cardiovascular medication reduce syncope and falls?
By 50%
What actions should be undertaken to reduce the risk of falling from cardiovascular medication?
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
Which drug class causes severe orthostatic hypotension and may precipitate urinary retention in men if stopped?
ALPHA BLOCKERS
(Doxazosin, Indoramin, Prazosin, Tamsulosin, Terazocin, Alfluzosin)
Which drug class has sedating effects and may cause severe orthostatic hypotension?
CENTRALLY ACTING ALPHA 2 ANTAGONISTS
(Clonidine, Moxonidine)
Which drug class can cause orthostatic hypotension, hypokalaemia-induced weakness and hyponatraemia?
THIAZIDE DIURETICS
(Bendroflumethiazide, Metolazone)
Which drug class can cause orthostatic hypotension, especially during accumulation due to reduced renal clearance?
ACE INHIBITORS
(Captopril, Lisinopril, Enalapril, Ramipril, Perindopril)
Which drug class can cause hypotension & paroxysmal hypotension, with GTN causing syncope due to sudden BP drop?
ANTIANGINALS
(GTN, Isosorbide Mononitrate, Nicorandil)
Which drug class can cause bradycardia, hypotension, carotid sinus hypersensitivity, orthostatic hypotension and vasovagal syndrome?
β-BLOCKERS - Especially non-cardioselective
(Atenolol, Sotalol, Propranolol, Timolol eye drops, Bisoprolol, Carvedilol)
Which drug class can cause orthostatic hypotension, hypokalaemia-induced weakness and hyponatraemia?
LOOP DIURETICS
(Furosemide, Bumetanide)
Which drug class can cause orthostatic hypotension, but less so than ACEIs?
ANGIOTENSIN RECEPTOR BLOCKERS
(Losartan, Candesartan, Valsartan)
Which drug class can cause hypotension & paroxysmal hypotension?
DIHYDROPYRIDINE CALCIUM CHANNEL BLOCKERS
(Amlodipine, Felodipine)
What is polypharmacy defined as?
Taking 4+ medications
How does fludrocortisone work to increase cardiac output?
By increasing plasma volume
How does fludrocortisone potentially increase peripheral vascular resistance?
By increasing sensitivity to sympathetic nerve stimulation
After how many weeks gestation might high blood pressure indicate gestation-induced hypertension?
20 weeks
When should treatment for hypertension in pregnancy be started?
When >150/100mmHg
What condition is characterized by high blood pressure and proteinuria in pregnancy?
Pre-eclampsia
What are symptoms of pre-eclampsia?
- Swelling in face/hands/ankles
- Severe headache
- Blurred vision
- Generally unwell
- Abdominal pain
Diagnostically, when does pre-eclampsia occur related to blood pressure changes? Diagnostically, when does pre-eclampsia occur related to diastolic blood pressure?
BP rises >30/15 from early to late
If diastolic BP >110 with proteinuria
What drug is considered first-line for treating hypertension in pregnancy in practice? What is an alternative medication class for treating hypertension in pregnancy?
Beta-blockers (Labetalol)
Centrally acting agents (Methyldopa)
What calcium channel blocker formulation has been shown to be safe and well-tolerated in pregnancy?
Modified release nifedipine
