Hypertension

Question 1

Before diagnosing hypertension, NICE recommend doing it in both arms. If one arm is hypertensive but the other isn’t, what do you do?

NOTE: What other pathological causes can cause a blood pressure variation between arms?

Answer 1

The lower reading of the two determines management.

I.e. use the lower arm in future.

NOTE: Aortic dissection, Aortic stenosis.

Question 2

If someone has postural hypotension what should you do as a GP?

Answer 2

1. Review their medication
2. Measure subsequent BPs with the person standing.
3. Consider referral if symptoms persist.

Question 3

Stage 1 Hypertension is classified as:

Answer 3

Clinic BP >= 140/90

OR

ABPM daytime average or HBPM average of >= 135/85

Question 4

Stage 2 Hypertension is classified as:

Answer 4

Clinic Bp >= 160/100 mmHg

OR

ABPM daytime average or HBPM daytime average of >= 150/95

Question 5

Severe hypertension is classified as:

Answer 5

Clinic SBP >= 180mmHg

OR

Clinic DBP of >= 110mmHg

Question 6

If someone has severe hypertension (SBP >=180 or DBP >=110) what should your work up and management strategy be?

Answer 6

1. Immediately start treating.
2. Fundoscopy -papilloedema or retinal haemorrhage => Specialist within 24 hours.
3. Referral if phaeochromcytoma is suspected. Symptoms:
   
   • Paroxysmal hypertension
   • Postural hypotension
   • Headache
   • Palpitations
   • Pallor
   • Diaphoresis (Excessive sweating)

Question 7

What lifestyle advise should be given?

Answer 7

1. A low salt diet is recommended - aiming for less than 6g/day, ideally 3g/day.
2. Caffeine intake should be reduced.
3. Other bits of advise: stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more and lose weight.

Question 8

When should we treat Stage 1 Hypertension?

Answer 8

Treat if <80 years old.

AND there is

• Target organ damage
• Established CVD
• Renal disease
• Diabetes
• 10 year cardiovascular risk equivalent to 20% or greater.

NOTE: Don’t forget to offer lifestyle advise.

Question 9

Someone has Stage 2 Hypertension. This needs treating. What investigations and workup should you do for the patient before deciding to treat?

Answer 9

1. Offer ambulatory BP monitoring
2. Look for end organ damage
   
   • ACR
   • Dipstick for haematuria
   • Bloods: HbA1C, U&Es, Cholesterol and HDL. Add CRP to screen for secondary causes.
   • Fundoscopy
   • ECG
3. CV Risk tool - QRISK2
4. Offer drug treatment regardless of age.

NOTE: If <40 years consider specialist referral to exclude secondary cause.

Question 10

Describe the stepwise treatment of Hypertension

Answer 10

1. <55 years offer ACE-i OR >55 years or Afro-carribean offer CCB.
2. ACE-i + CCB (If afro-carribean offer A2RB)
3. A+C+D (thiazide diruetic).
   
   • Clorthialidone 12.5-25mg OD or indapamide MR 1.5mg or SR 2.5mg OD.
4. Resistant Hypertension - Consider:
   
   • Further diuretic. (e.g furosemide)
   • If potassium <4.5mmol/l add spironolactone 25mg OD
   • If potassium >4.5mmol/l add higher dose thiazide-like diuretic treatment.
   • If further diuretic therapy not tolerated or is contraindicated or ineffective consider alpha-blocker or beta-blocker.
5. Refer to specialist

Question 11

What are the blood pressure targets by age?

Answer 11

< 80 years

• Clinic BP of 140/90mmHg or ABPM/HBPM of 135/85mmHg

>80 years

• Clinic BP of 150/90mmHg or ABPM/HBPM of 145/85 mmHg

Question 12

What is the definition of postural hypotension?

Answer 12

A fall in SBP of more than 20mmHg after 1 minute of standing.

Question 13

When measuring CVD risk, what assessment tool should we use?

Framingham or QRISK 2

Answer 13

QRISK 2 - it is more accurate for the British population.

Question 14

Why have beta-blockers been removed with regards to treating hypertension?

Answer 14

They are less likely to prevent stroke and potential impairment of glucose tolerance.

(As demonstrated in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA)

Question 15

What is a stronger factor for resistant hypertension? A high BMI, Alcohol or Poor diabetic control?

Answer 15

High BMI

Question 16

What % of cases of resistant hypertension have a secondary cause?

Answer 16

10%

Question 17

Your next appointment is with a 47-year-old woman. She has come for the results of her ambulatory blood pressure monitoring (ABPM). This was arranged as a clinic reading one month ago was noted to be 146/92 mmHg. The results of the ABPM show an average reading of 126/78 mmHg. What is the most appropriate course of action?

Answer 17

In this situation where the ABPM has shown a sub-threshold average blood pressure NICE recommend offering to measure the patient’s blood pressure at least every 5 years.

Question 18

How should ABPM be measured?

Answer 18

2 measurements per hour during waking hours.

Use the average of 14 values (7 days)

Question 19

When should HBPM be offered?

Answer 19

If ABPM is not tolerated or declined.

Question 20

How should HBPM be monitored?

Answer 20

• Each BP is 2 consecutive measurements.
• Taken whilst seated
• Recorded twice daily.
• Ideally for 7 days (Minimum of 4 days)
• Discard the measurements on the first day and use the average of the remaining days.

Question 21

NICE states CCBs are firstline in patients > 55 years. When would this differ?

Answer 21

If they have oedema, heart failure or the patient is at risk of heart failure.

Then NICE state they should be on thiazide diuretics like Indapamide or Chlorthalidone.