Hypertension Flashcards
How is the decision made whether to a treat hypertensive patient?
Treat all patients with BP>160/100
If patients have BP>140/90, the decision depends on the risk of coronary events, presence of diabetes or end organ damage
What is the most common form of hypertension in the UK? What causes it?
Isolated systolic hypertension
Caused by stiffening of the large arteries- arteriosclerosis
What is malignant or accelerated phase hypertension?
Rapid rise in BP leading to vascular damage
What is the pathological hall mark of accelerated phase hypertension?
Fibrinoid necrosis
What are the signs of accelerated phase hypertension?
Severe hypertension (systolic >200, diastolic >130) Bilateral retinal haemorrhages and exudates +/- papilloedema
What are the symptoms of accelerated phase hypertension
Head aches
Visual disturbance
What hypertensive emergencies may be caused by accelerated phase hypertension?
Acute renal failure
Heart failure
Encephalopathy
What is meant by the term “essential hypertension”? How common is it?
Primary cause is unknown
Approx 95% of cases
What are causes of secondary hypertension
Renal disease: Most common secondary cause Endocrine disease Other causes (pregnancy; OCP; steroids; coarctation)
What are renal causes of hypertension
75% form intrinsic renal disease: golmerulonephritis; polyarteritis nodosa- PAN, systemic sclerosis; polycystic kidneys; chronic pyelonephritis
25% due to renovascular disease, most commonly atheromatous- elderly, male, cigarette smokers
What are endocrine causes of hypertension?
Cushing's Conn's Phaeochromocytoma Acromegaly Hyperparathyroidism
What tests should be done in a hypertensive patient?
To quantify overall risk: fasting glucose; cholesterol
To look for end organ damage: ECG (LV hypertrophy; past MI); urine analysis (protein, blood);
To exclude secondary causes: U&Es (low potassium in Conn’s for e.g.); Calcium (high in hyperparathyroidism)
Special tests: Renal ultrasound/arteriography to look for renal artery stenosis. 24 hour urinary metanephrines, Urinary free cortisol. Renin. Aldosterone.
24 hour ambulatory BP monitoring- helpful in white coat syndorme or borderline hypertension. Now recommended in all newly diagnosed hypertensives.
How is hypertensive retinopathy graded?
I: Tortuous arteries with thick shiny walls
II: AV nipping - narrowing where arteries cross veins
III: Flame haemorrhages and cotton wool spots
IV: papilloedema
What is the treatment goal for BP in hypertension
80
What is first choice therapy for black patients of any age and for patients >55 years?
Calcium channel blocker or thiazide
What is first choice therapy for patients <55 years?
ACEi or ARB if ACEi intolerant
When might beta-blockers be used as first line treatment in hypertension?
In younger people, particularly:
- If intolerant to ACEi and ARB
- If patient is a woman of child bearing potential
- If there is increased sympathetic drive
What is combination therapy for hypertension?
ACEi + calcium channel blocker or thiazide
If a patient is only on a beta blocker and a second drug is needed, what drug should be chosen? What drug should not be chosen and why?
Calcium channel blocker should be chosen
Not thiazide to reduce risk of diabetes
If hypertension is still uncontrolled in a patient taking ACEi, calcium channel blocker and thiazide. What treatment options should be considered?
- Higher dose thiazide
- Add another diuretic e.g. spironolactone- monitor potassium
- Add beta blocker
- add selective alpha-blocker
What are the side effects of thiazides?
Low potassium and sodium
Impotence
Diabetes
When are thiazides contraindicated?
Gout
What are the side effects of calcium channel blockers?
Flushes
Fatigue
Gum hyperplasia
Ankle oedema
When are ACEi contraindicated?
bilateral renal artery or aortic valve stenosis
