Hypertension. Flashcards

0
Q

how is blood pressure calculated?

A

Cardiac output x peripheral resistance.

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1
Q

What is hypertension?

A

A disorder in which the level of sustained arterial pressure is higher than expected for the age, sex, and race of the individual. WHO defines this as being greater than 140/90. It must be measured over a sustained period of time due to normal fluctuation.

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2
Q

What can alter cardiac output?

A

HR, contractility of the heart and the blood volume.

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3
Q

What can alter peripheral resistance?

A

Constrictors e.g. Angiotensin II and catecholamines and dilators e.g. Nitric oxide and prostaglandins.

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4
Q

What is the global incidence of hypertension?

A

Varies between countries, higher in black populations, lower in the South Pacific. Age (main driving factor) and genetics are key.

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5
Q

What is the ideal blood pressure?

A

120/75

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6
Q

What is normal blood pressure?

A

120-129/75-84

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7
Q

What is high normal blood pressure?

A

130-139/85-89.

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8
Q

What is stage 1 (mild) hypertension?

A

140-159/90-99.

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9
Q

What is stage 2 (moderate) hypertension?

A

160-179/100-109.

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10
Q

What is severe hypertension?

A

Grater than or equal to 180/110.

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11
Q

Who do we treat for hypertension?

A

All with stage 2 hypertension. For those with stage 1 the choice depends on the risk of coronary events, the presence of DM or end organ damage.

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12
Q

How do we classify hypertension?

A

Either according to cause (primary or secondary) or consequences (benign or malignant).

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13
Q

What is primary hypertension?

A

Also called essential hypertension. Makes up 90-95% of cases. It has no obvious cause but has genetic factors and is linked to salt intake, protein intake (RAAS) and sympathetic activity.

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14
Q

What amount of primary hypertension cases are said to be salt sensitive?

A

Around 25%

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15
Q

What is salt sensitive hypertension?

A

Increased dietary salts lead to increased bp. It can be controlled by a low salt diet.

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16
Q

What is a common type of secondary hypertension in renal disease?

A

Salt sensitive.

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17
Q

What is secondary hypertension?

A

Hypertension where an underlying cause is implicated. Comprises about 5% of cases.

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18
Q

What is the most common cause of secondary hypertension?

A

Renal disease.

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19
Q

What are the two different types of renal diseases that cause secondary hypertension?

A

75% Intrinsic and 25 % renovascular disease.

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20
Q

What are some examples of intrinsic renal diseases?

A

Glomerulonephritis, polyarteritis nodosa (PAN). Systemic sclerosis, chronic polynephritis or polycystic kidneys.

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21
Q

What different types of renovascular disease and who gets them?

A

Fibromuscular dysplasia - rare but usually young females.

More commonly atheromatous - elderly male smokers with PVD for example.

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22
Q

What types of disease and factors are liable to cause secondary hypertension?

A

Renal, endocrine and others e.g. Coarctation, pregnancy and drugs e.g. MAOIs and the pill.

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23
Q

Give examples of endocrine diseases that cause secondary hypertension?

A

Cushings, Conn’s syndrome, phaeochromocytoma, acromegaly and hyperparathyroidism.

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24
Q

What does cushings result in?

A

Results in an over secretion of corticosteroids.

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25
Q

What does Conn’s syndrome result in?

A

Excess aldosterone.

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26
Q

What does Phaeochromocytoma result in?

A

Excess noradrenaline.

27
Q

What is isolated systolic hypertension?

A

Most common form in the UK, affecting over 50% of over 60’s. Results from arteriosclerosis of the large arteries. Doubles the risk of MI and trebles the risk of CVA.

28
Q

What is benign hypertension?

A

Asymptomatic and often found incidentally. Causes increased morbidity.

29
Q

What are the eventual outcomes of hypertension?

A

LVH, congestive cardiac disease. Increased atheroma, increased aneurysm rupture and aortic dissection. Berry aneurysms and renal disease.

30
Q

What is malignant hypertension?

A

Severe hypertension e.g. Systolic over 200 and diastolic over 130-140 plus bilateral retinal haemorrhages and exudate. May or may not show papillodema.

31
Q

What can malignant hypertension develop from?

A

Benign primary or secondary hypertension or de novo.

32
Q

What are the symptoms of malignant hypertension?

A

Headaches plus or minus visual disturbance.

33
Q

What are the survival rates for malignant hypertension?

A

Untreated 90% die in a year. Treated 70% survive for 5 years.

34
Q

What are the outcomes of malignant hypertension?

A

Acute renal failure, heart failure, encephalopathy, cerebral oedema (seen as papillodema).

35
Q

What is papillodema?

A

Swelling of the optic disc.

36
Q

What are the mythological hallmarks of malignant hypertension?

A

Fibrinoid necrosis and endarteritis of blood vessel walls.

37
Q

What is pregnancy associated hypertension?

A

Affects up to 10% of pregnancys and causes increased maternal and foetal morbidity and mortality. Comes in the form of pre-eclampsia or eclampsia. It resolves following birth.

38
Q

What are features of pre-eclampsia?

A

Hypertension and proteinuria.

39
Q

What examinations should we do for hypertension?

A

Full CVS exam. Check for retinopathy. Look for signs of underlying disease e.g. Renal - renal Bruits or palpable kidneys. Radial femoral delay. Weak femoral pulse from coarction. Cushings syndrome. Look for end organ failure e.g. LVH and retinopathy.

40
Q

What tests should we do for hypertension?

A

Quantify overall risk: fasting glucose and cholesterol.
Tests for end organ damage: ECG and urine analysis to look for proteinuria.
Exclude secondary causes: blood tests for raised creatinine. U+E (e.g. Low potassium in Conns and raised calcium in hyperparathyroidism).
If clinical BP is over 140/90 offer ABPM.

41
Q

How do we grade hypertensive retinopathy?

A

I - torturous arteries with thick shiny walls. Slight or modest narrowing of the retinal arterioles with an arterial venous ratio of greater than or equal to 1:2.
II - av nipping or modest to severe narrowing with a:v or under 1:2.
III - flame haemorrhages and cotton wool spots.
IV - papilloedema.

42
Q

What is ABPM?

A

Ambulatory blood pressure monitoring. 2 measurements per hour for waking hours, usually over 14 days. Readings are usually lower then clinical readings so we must add 12/7.

43
Q

What is HBPM?

A

Home blood pressure monitoring. Two seated measurements 1 min apart twice a day for four to seven days. The measurements for the first day are discarded and the rest averaged.

44
Q

What is the treatment for hypertension?

A

Stage 1- offer lifestyle interventions, if under 40 years old, offer this and specialist intervention.
Stage 1 plus target organ damage or ten year risk of CVD over 20%. Offer the above and anti-hypertensive drug therapy.
Stage 2 - straight to drug treatment.

45
Q

What is the goal of hypertension treatment?

A

To get a bp of under 140/85 or 130/80 for diabetic patients.

For patients over the age of 80 we aim for under 150/90.

46
Q

What lifestyle interventions do we advise?

A

Reduced sodium and caffeine diet. Weight reduction (1mmHg for each kg lost). Exercise 15 mins minimum per day. Alcohol reduction and smoking cessation.

47
Q

What should NOT be the first choice in treatment for primary hypertension and why?

A

Beta blockers, as they can turn uncomplicated hypertension into complicated, with increased arrhythmias, CAD and CHF.

48
Q

Is monotherapy best for hypertension? Why?

A

No. Starting with two drugs is always better than 1 so we shouldn’t just start with the maximum tolerated dose of 1. Adding a second drug is 5x more effective than titration 1. It also gives fewer side effects.

49
Q

What drugs are commonly used to treat hypertension?

A

Ade inhibitors, angiotensin II receptor blockers (ARB)’ calcium channel blockers and thiazides. Sometimes use, alpha blockers, beta blockers and other diuretics if these don’t work.

50
Q

What is step 1 in hypertension treatment?

A

55 years, or a person of any age of African or Caribbean descent. Calcium channel blocker or thiazides.

51
Q

What is step 2 in hypertension treatment?

A

Ace inhibitor or ARB and either CCB or thiazides for all patients.

52
Q

What is step 3 in hypertension treatment?

A

Ace inhibitor or ARB and CCB and thiazides.

53
Q

What is step 4 in hypertension treatment?

A

It’s for resistant hypertension. So we give an ace inhibitor or ARB, a CCB, a thiazides and conSider adding Either: a further diuretic or an alpha or beta blocker, and consider seeking specialist advice.

54
Q

What is a side effect of ace inhibitors and what can we give instead in this case?

A

A cough and we can give an ARB.

55
Q

When should we consider beta blockers other than in resistant hypertension?

A

In young people - particularly if they are intolerant or have a contraindication to ace or ARB’s. If they are a woman of child bearing age or there is increased sympathetic drive.

56
Q

Should be give beta blockers and thiazides together? Why?

A

No as they increase the risk of new onset diabetes. If already on beta blockers, consider calcium channel blockers instead.

57
Q

What can be some causes of resistant hypertension?

A

Non-concordance, white coat effect, pseudo hypertension, lifestyle factors, drug interactions, secondary hypertension or true resistance.

58
Q

What treatment should we give for hypertension to those suffering from angina?

A

Beta blockers or calcium channel blockers.

59
Q

What treatment should we give for hypertension to those suffering from CCF?

A

Ace inhibitors and beta blockers.

60
Q

What treatment should we give for hypertension to those suffering from diabetic neurophathy?

A

Ace inhibitors or ARBs.

61
Q

What treatment should we give for hypertension to those suffering from prostatism?

A

Alpha blockers with caution.

62
Q

What treatment should we give for hypertension to the elderly?

A

Thiazides.

63
Q

How should we treat malignant hypertension?

A

Bed rest and beta blockers or CCB po.

64
Q

What should we never try to do when managing hypertension?

A

Lower BP immediately. Instead gradually over days not hours. Sudden Bp drops can cause strokes.

65
Q

What drug should we never use for malignant hypertension and why?

A

Sublingual nifedipine. It will cause a sudden drop in Bp and therefore is a stroke risk.