Hypertension Flashcards
1
Q
Definition of hypertension
A
Essential hypertension can be defined as a rise in blood pressure of unknown cause that increases risk for cerebral, cardiac and renal events.
SBP >140mmHg or DBP >90mmHg or taking antihypertensive medicaiton
2
Q
Stages of hypertension
A
3
Q
Aetiology of hypertension
A
- Primary (essential) - 95%
- environmental factors (excess dietary salt intake, adrentergic tone)
- genetic factors
- immunological factors
- Secondary
- renal
- vascular
- endocrinal
- Malignant or accelerated hypertension - refers to a rapid rise in BP leading to vascular damage
4
Q
Pathogenesis of HTN causing cardiovascular disease
A
- The pathogenesis of essential hypertension is multifactorial and highly complex.
- Genetic predisposition, excess dietary salt intake, and adrenergic tone may interact to produce hypertension. There are growing evidence for immunological basis of HTN.
- Occasional–>Established–> Complicated hypertension (end-organ damage to the aorta and small arteries, heart, kidneys, retina, and central nervous system)
5
Q
Diagnosis of hypertension
A
- Measure blood pressure in both arms
- If difference more than 20mmHg, repeat measurement.
- If remains >20mmHg measure and record from the arm with the higher reading
- Take a second reading during the consultation if the first reading is >140/90 mmHg. The lower reading of the two should determine further management
- Offer ABPM or HBPM to any patient with a blood pressure > 140/90 mmHg
- If severe hypertension, start antihypertensive drug immediately without waiting for the results of ABPM
- While waiting for confirmation of diagnosis, carry out investigations for target end organ damage, and a formal assessment of CV risk using a CV risk assessment tool.
- If hypertension is not diagnosed, measure the persons clinic blood pressure at least every 5 years.
- Refer to speacilist the same day if they have
- Accelerated HTN = BP>180/110mmHg with signs of papilloedema and/or retinal haemorrhage or
- suspected phaeochromocytoma
6
Q
Signs and symptoms of hypertension
A
- Usually asymptomatic (except malignant hypertension)
- Patient occasionally complains of a headache
- Examine CVS fullly and check for retionopathy
-
Clinical signs
- Features of underlying cause: Radiofemoral delay or weak femoral pulses, bruit or renal enlargement or cushingoid appearance
- evidence of end organ damage (heart failure, retinopathy, aortic aneurysm, carotid or femoral bruit)
- Malignant hypertension
- Severe HTN (SBP>200 + DBP >130) + grade III-IV retinopathy
- patient often has headache and visual disturbances
- proteinuria and haematuria
- Medical emergency
7
Q
Two types of blood pressure monitoring
A
Two types of blood pressure monitoring
- Ambulatory Blood Pressure monitoring (ABPM)
- Home Blood pressure monitoring (HBPM)
8
Q
ABPM
A
ABPM: at least 2 measurements per hour during the person’s usual waking hours (for example, between 08:00 and 22:00)
use the average value of at least 14 measurements
If ABPM is not tolerated or declined HBPM should be offered.
9
Q
HBPM
A
HBPM: for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
BP should be recorded twice daily, ideally in the morning and evening
BP should be recorded for at least 4 days, ideally for 7 days
discard the measurements taken on the first day and use the average value of all the remaining measurements
10
Q
Investigations of Blood pressure
A
- To look for end organ damage - ECG( LVH), Urinalysis (haematuria or proteinuria)
- To help quantify overall risk- Fasting Glucose (cushings),Full lipid profile (total, HLD and LDL cholesterol and triglycerides)
- To exclude secondary causes- Urea and electroyltes (U&E) (e. K decreased in Conns) ; Ca2+ (increased in hyperparathyroidism)
- Special tests: Renal ultrasound (renal artery stenosis), 24hr urinary metanephrines, urinary free coritsol
- 24 hr ABPM- help in white coat or borderline hypertension
- Echocardiography - useful to assess end-organ damage
11
Q
Drug treatment of Hypertension
A
Stage 1
- <55yo: ACE-I or low-cost ARB (if not tolerated offer a low-cost ARB)
- >55 yo or Afrocarribean: Calcium channel blocker or offer thiazide diuretic if not suitable (oedema, intolerance or evidence of heart failure or high risk of heart failure)
NOTE do not combine an ACE-I with an ARB to treat hypertension
Thiazide – offer chlortalidone or indapamide
Stage 2
- ACE- I + CCB or ARB + CCB
Note
- If Calcium channel blocker not tolerated then offer thiazide like diuretic
- If African consider an ARB in preference to an ACE inhibitor in combination with a CCB
Stage 3
- Add a thiazide diuretic NICE now recommends chlortalidone or indapmide rather than bendroflumethiazide
Stage 4
- Consider further diuretic treatment
- If Potassium <4.5 mmol/l add spironolactone 25mg OD
- If potassium >4.5 mmol/l add higher dose- thiazide-like diuretic treatment
- If further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha or beta-blocker
12
Q
Who to treat?
A
- Offer antihypertensive drug treatment to people aged under 80 years with stage 1 hypertension who have one or more of the following: target organ damage,established cardiovascular disease,renal disease and diabetes and a 10-year cardiovascular risk equivalent to 20% or greater
- Offer antihypertensive drug treatment to people of any age with stage 2 hypertension.
- For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage.
- BP>180/110: immediate treatment
13
Q
Blood pressure targets
A
- Clinic BP
- < 140/90 mmHg under 80 years
- <150/90 mmHg over 80 years.
- ABPM
- < 135/85 mmHg under 80 years
- <145/85 mmHg over 80 years
- If diabetic
- BP <130/80 (BHS)
- BP <130/85 (ESC/ESH and WHO/ISH)
14
Q
Lifestyle interventions
A
- Ascertain diet and exercise patterns
- Relaxation therapies to reduce blood pressure
- Ascertain alcohol consumption
- Discourage excessive consumption of coffee
- Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure
- Smoking cessation
15
Q
Patient education and adherance to treatment
A
- Provide appropriate guidance and materials about the benefits of drugs and the unwanted side effects sometimes experienced in order to help people make informed choices.
- People vary in their attitudes to their hypertension and their experience of treatment. It may be helpful to provide details of patient organisations that provide useful forums to share views and information.
- Provide an annual review of care to monitor blood pressure, provide people with support and discuss their lifestyle, symptoms and medication.
- Because evidence supporting interventions to increase adherence is inconclusive, only use interventions to overcome practical problems associated with non-adherence if a specific need is identified. Target the intervention to the need.
- Interventions might include:
- suggesting that patients record their medicine-taking
- encouraging patients to monitor their condition
- simplifying the dosing regimen
- using alternative packaging for the medicine
- using a multi-compartment medicines system
