Hypertension Flashcards
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?
The lower reading of the two determines management.
I.e. use the lower arm in future.
NOTE: Aortic dissection, Aortic stenosis.
If someone has postural hypotension what should you do as a GP?
- Review their medication
- Measure subsequent BPs with the person standing.
- Consider referral if symptoms persist.
Stage 1 Hypertension is classified as:
Clinic BP >= 140/90
OR
ABPM daytime average or HBPM average of >= 135/85
Stage 2 Hypertension is classified as:
Clinic Bp >= 160/100 mmHg
OR
ABPM daytime average or HBPM daytime average of >= 150/95
Severe hypertension is classified as:
Clinic SBP >= 180mmHg
OR
Clinic DBP of >= 110mmHg
If someone has severe hypertension (SBP >=180 or DBP >=110) what should your work up and management strategy be?
- Immediately start treating.
- Fundoscopy -papilloedema or retinal haemorrhage => Specialist within 24 hours.
- Referral if phaeochromcytoma is suspected. Symptoms:
- Paroxysmal hypertension
- Postural hypotension
- Headache
- Palpitations
- Pallor
- Diaphoresis (Excessive sweating)
What lifestyle advise should be given?
- A low salt diet is recommended - aiming for less than 6g/day, ideally 3g/day.
- Caffeine intake should be reduced.
- Other bits of advise: stop smoking, drink less alcohol, eat a balanced diet rich in fruits and vegetables, exercise more and lose weight.
When should we treat Stage 1 Hypertension?
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.
Someone has Stage 2 Hypertension. This needs treating. What investigations and workup should you do for the patient before deciding to treat?
- Offer ambulatory BP monitoring
- 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
- CV Risk tool - QRISK2
- Offer drug treatment regardless of age.
NOTE: If <40 years consider specialist referral to exclude secondary cause.
Describe the stepwise treatment of Hypertension
- <55 years offer ACE-i OR >55 years or Afro-carribean offer CCB.
- ACE-i + CCB (If afro-carribean offer A2RB)
-
A+C+D (thiazide diruetic).
- Clorthialidone 12.5-25mg OD or indapamide MR 1.5mg or SR 2.5mg OD.
-
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.
- Refer to specialist
What are the blood pressure targets by age?
< 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
What is the definition of postural hypotension?
A fall in SBP of more than 20mmHg after 1 minute of standing.
When measuring CVD risk, what assessment tool should we use?
Framingham or QRISK 2
QRISK 2 - it is more accurate for the British population.
Why have beta-blockers been removed with regards to treating hypertension?
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)
What is a stronger factor for resistant hypertension? A high BMI, Alcohol or Poor diabetic control?
High BMI
