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General practice > Hypertension > Flashcards

Hypertension Flashcards

1
Q

History in confirmed hypertension

A
  1. Duration and Previous treatment
  2. Past/current symptoms
    IHD
    Heart failure
    Cerebrovascular disease
    Peripheral arterial disease
  3. Symptoms of CKD
    Oliguria
    Nocturia
    Hematuria
  4. Suggestions of secondary cause
    Cushings: weight, mood, acne, myopathy, menstrual
    Conns: fatigue, headA, parasthesia
    Phaeochromocytoma: sweating, headA, tachyC
    Sleep apnea: daytime sleep, snoring, obesity
    Nephrogenic: PCKD, RAS, GN
    HyperPTH: stones, bone, groans, psychic moans
  5. Other chronic conditions influencing management/+CV risk
    Asthma, COPD
    Diabetes
    Lipids
    DM
    CKD
    Alcoholism
    Heart failure
  6. Lifestyle
    Smoking
    Alcohol
    Diet
    Physical activity
    Weight
  7. Medication, FHx, occupation etc
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2
Q

Physical examination

A
  1. Vitals
  2. Evidence of underlying cause
    Endocrine
    Focal neurological
  3. Complications
    CVS: ++pulse, CCF, bruits, PVD, aneurysms
    Palpable kidneys, bruits
    Optic fundi: nipping, hemorrhage, exudates, cotton wool, papilloedema
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3
Q

Goals of HTN evaluation

A
  1. Identify all risk factors
  2. Detect end organ damage
  3. Identify secondary causes
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4
Q

Overview of management

A 
1. Lifestyle
Weight reduction
Diet
Limit alcohol
Physical activity
Smoking cessation
2. Pharmacotherapy
3. Manage comorbidities
Low dose aspirin
Lipid management
Diabetes management
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5
Q

Principles of drug treatment

A
  1. Start with lowest does
  2. If not tolerated->change
  3. If not managed 6 weeks->add second drug
  4. Still not, tolerated->+dose of one type
  5. Can add third drug
  6. Consider other reasons for non-responding
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6
Q

When is pharmacotherapy intervention required immediately

A

When >180/110, >160/15% CVD risk

ATSI w/ hypertension

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7
Q

Associated conditions

A 
PVD
\+Cholesterol >7.5
CKD
Diabetes
Aortic
FHx of premature CVD
Cerebrovascular
CAD
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8
Q

Evidence of end organ

A
  1. CKD: proteinuria:creatinin >30mg/mmol, >300mg protein, eGFR a:cr >2 M, >2.5 F
  2. LVH on ECG
  3. Vascular disease->bruits, HTN retinopathy
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9
Q

Options for pharmacotherapy

A
  1. ACEi
  2. ARB
  3. B blocker
  4. CCB
  5. Diuretics
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10
Q

Defining

A

High normal 130-139/85-89
Mild 140-159/90-99
Moderate 160-179/100-109
Severe >180/110

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11
Q

Grading HTN retinopathy

A
  1. Tortuous silver/copper wiring
  2. AV nipping
  3. Flame hemorrhages and cotton wool spots
  4. Papilloedema
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12
Q

Define malignant hypertension

A

Systolic >200/130 + bilateral retinal hemorrhages and exudates +papilloedema (may or may not)

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13
Q

Management of malignant and why

A

Renal failure, cardiac failure, encephalopathy

Fibriniod necrosis

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14
Q

Investigations in HTN

A 
1. Quantify risk
Glucose
Cholesterol
2. End organ damage
ECG
Urinalysis
UEC
FBC and Hct
3. Exclude secondary
UEC (low K in conns), +Ca in hyperPTH
Consider other secondary tests
TSH
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15
Q

Treatment resistance

A
  1. Volume overload->CKD
  2. White coat
  3. Medications that +BP
  4. Secondary causes
  5. Non-adherence
  6. Undisclosed alcohol/drug use
  7. Sleep apnea
  8. High salt
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16
Q

Treatment with comorbidities: angina, AF, Asthma/COPD, bradyC, Depression, HF, diabetes w/ albumin, post stroke, pregnancy, CKD

A 
1. Angina->ACEi, BB, CCB
Atenolol/metoprolol
Peridopril
Amlodipine
2. Asthma/COPD->Cardioselective CCB
Verapamil
Diltiazem
XBB
3. AF->BB, ACEi, cardio CCB
4. BradyC/heart block
Verapamil
Diltiazem
XBB
5. Depression
Avoid BB, clonidine, methyldopa
17
Q

Treatment with HF, diabetes w/ albumin, post stroke, pregnancy, CKD

A 
1. HF
ACEi, ARB
Thiazide
BB->bisoprolol, carvedilol
Spirinolactone
2. Diabetes
ACEi, ARB
Avoid BB, thiazide diuretics
3. Post-stroke
ACEi, ARB,
low dose thiazide (hydrochlorthiazide)
4. Pregnancy
Methyldopa
Nifedipine
5 CKD
ACEi
ARB->candesartan
18
Q

Combinations of anti-hypertensives to avoid

A

ACEi +ARB
ACEi+K sparing
Verapamil + beta blocker

19
Q

Good combination anti-HTN

A

ACE- + CCB or thiazide

20
Q

Side effects of thiazide diuretics

A

Low potassium, low sodium, postural hypotension, impotence

Not in gout!

21
Q

Side effects of CCB

A

Flushes
Fatigue
Gum hyperplasia
Ankle edema

22
Q

Side effects of ARB

A

Urticaria
Vertigo
Pruritus

23
Q

Side effects of beta blocker

A 
Bronchospasm
Heart failure, block
Cold peripheries
Lethargy
Impotence

Caution in asthma, heart failure, heart block

24
Q

Features of hypertensive emergency

A 
BP >210/130
Neurological, cardiovascular
Oliguria, polyuria
Abnormal fundoscopic examination
Abnormal neurological examination
25
Q

Investigations in HTN emergency

A 
ECG
FBC w/ smear
UEC
Urinalysis MCS
CXR
CT without contrast
MRI
Spot urine or plasma metanephrine
26
Q

Management of HTN emergency

A
  1. Labetolol
  2. If LVF-> GTN + frusemise
  3. Aortic dissection->Labetolol or esmolol
  4. ARF->fenoldopam
  5. Hyperandrogenic->Benzodiazepines
  6. Eclampsia->Hydralazine, labetolol or nicardipine
27
Q

Contraindications to diuretic

A 
Hypokalemia
Hyponatremia
Hyperuricemia
Hyperlipidemia (thiazide)
Gout (Loop)
28
Q

Side effects of clonidine

A

Postural hypoT
Dry mouth
Rebound HTN with abrupt withdrawal

29
Q

Side effects of ACEi

A 
Leukopenia
Pancytopenia
Hypotension
Cough
Angioedema
Urticarial rash
Hyperkalemia
Acute renal failure (if RAS)
30
Q

Secondary causes

A
  1. Renal
    PCKD
    RAS
    GN
  2. Endocrinology
    Cushings: weight, mood, acne, myopathy, menstrual
    Conns: fatigue, headA, parasthesia
    Phaeochromocytoma: sweating, tachyC. headA, palpitations
    HyperPTH: stones, bone, groans, psychic moans
    Hyperthyroidism
  3. Drugs: caffiene cocaine, sympathomimetic,TCA
  4. Sleep apnea: daytime sleep, snoring, obesity
  5. Coarctation of the aorta
  6. Carcinoid
31
Q

Hypertensive encephalopathy

A

Severely elevated BP
Confusion
+ICP
+/- seizures

32
Q

DIfferentiate HTN urgency vs emergency

A

Emergency is associated with end organ damage

33
Q

Normal range of cerebral autoregulation

A

MAP of 60-120 mm

34
Q

Goal reduction in hypertensice emergency in chronic HTN

A

Reduction in MAP no more than 25% or to diastole 100-110

35
Q

Why is labetolol good in HTN emergency

A

Combined alpha and beta->lowers resistance and prevents reflex tachC

36
Q

Should people with HTN crises and stroke have immediate lowering of BP and why

A

No, may worsen ischemia

General practice (26 decks)

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