Hypertension Flashcards
What is hypertension?
BP >140/90mmHg on 3 separate occasions a week apart.
Important Hx questions in HTN?
How high when first diagnosed? Current/past Rx? Who monitors? When last checked? Well controlled? End organ damage? Vascular RFx.
Important examination features in HTN?
- BP: Check for postural drop. If very high, repeat in other arm and at end of exam.
- Fundoscopy: hypertensive retinopathy. Describe according to Keith-Wagener-Barker classification.
- Heart: apical heave and loud aortic component of S2 suggestive of LVH.
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Exclude 2” cause of HTN:
- Renal bruits, adrenal masses, polycystic kidneys, bitemporal hemianopia, acromegalic body habitus and cushingoid body habitus.
Describe the features of hypertensive retinopathy (mild -> severe).
**Mild: **focal and generalised arteriolar narrowing; copper and silver wiring or arterioles; AV nipping.
**Moderate: **blot, dot or flame-shape haemorrhages, cottonwool spots, microaneurysm, yellow and white exudates.
Severe: papilloedema (in addition to haemorrages and exudates).
What is retinopaty indicative of increased for?
Stroke, MI and death.
Odds increase with worsening severity
What are the clinical issues in a patient with HTN?
- Is BP actually high or just white coat htn?
- How much target organ damage is present? How does this influence prognosis?
- Is there an underlying renal or endocrine cause amenable to treatment other than lowering BP?
- What other CV RFx are present?
What Ix should be ordered in patient with HTN?
- ECG
- Electrolyte profile and renal function indices
- CXR
- Echocardiogram
- Urinalysis
- Fasting BGL and lipid profile
What is the purpose of electrolyte and renal functions tests in HTN Ix?
Looking for evidence of renal failure. Abnormal renal function indices should prompt further investigations to rule out parenchymal renal disease.
What is the purpose of ECG in HTN?
Looking for LVH by voltage as well as strain criteria and evidence of ischaemic heart disease.
What is the purpose of CXR is HTN?
To exclude cardiomegaly, LVH and CCF.
ALTHOUGH CXR only capable of detecting relatively gross LV damage.
What is the purpose of echocardiogram in HTN?
To assess LV wall thickness, chamber size and any evidence of diastolic dysfunction (esp if evidence of LVH or heart failure).
What is the purpose of urinalysis in HTN?
Looking for proteinuria.
If positive, follow up with 24h urine collection to quntify proteinuria and assess creatinine clearance.
What does proteinuria >2g /24 indicate?
Much more likely to inidcate primary renal disease. Usually indicates a need for renal biopsy.
Can Cr clearance distinguish between primary and secondary HTN?
Cr clearance cannot really distinguish:
primary renal disease –> HTN
vs
HTN –> hypertensive nephrosclerosis
If no significant proteinuria, trial BP lowering Rx for 6/12.
What would indicate phaeochromocytoma and how should it be investigated?
Tachycardia, palpitations, sweating, anxiety, postural hypotension ==> indicate phaeo.
Perfom serum catecholamine level, urinary metanephrines and urinary vanillylmandelic acid level.
When should you treat HTN at first Dx?
Malignant HTN
End organ damage
Significant vascular RFx
Comorbidity
Diastolic >100mmHg; Systolic >200mmHg (or >160mmHg + end organ damage)
What should be the initial management for HTN?
Observation for 3-6 months with non-pharmacological interventions:
weight loss; exercise; stop smoking; reduce salt and alcohol intake. Treat hyperlipidemia and DMII.
What end organ damage may result from HTN?
CV: MI, LVH, cardiac failure, stroke
Hypertensive nepropathy
Hypertensive retinopathy
Arteriosclerosis
What is the most appropriate HTN therapy in DM?
What should be avoided?
ACEi or ARB. Useful synergy in severe HTN and diabetic nepropathy.
B-blockers and thiazides can interfere with glycaemic control.
What Rx and indicated/should be avoided in a HTNsive patient with gout?
ACEi, ARB, B-blockers all useful.
Thiazide diuretics can exacerbate gout.
Rx indicated/avoided in HTNsive patient with dyslipidemia?
ACEi, ARB indicated.
B-blockers less desirable – adverse effects on lipid profile.
Rx indicated/avoided in HTNsive patient with IHD?
Diuretics, B-blockers, ACEi and ARBs all suitable due to protective effects in coronary vascular disease.
CCF Rx for HTN indicated/avoided?
Ideal = B-blockers, ACEi, ARBs diuretics. All have proven benefit in management of HF.
Rx indicated/avoided in peripheral vascular disease?
CCBs, alpha-adrenergic receptor blockers, diuretics desirable.
B-blockers contraindicated.
