Hypertension Flashcards
Phaeocromocytoma
Tumour of the adrenal gland
Paroxysmal secretion of catecholamines results in hypertension, palpitations, sweating, headache and anxiety
What is the value for hypertension?
140/90
Aetiological Classification
Primary - No obvious cause
Secondary - Underlying disease implicated
Clinicopathological Classification
Benign
Malignant
Factors contributing to primary hypertension
Genetics Salt intake Protein intake RAAS Sympathetic activity
Causes of secondary hypertension
Renal disease Obstructive Sleep Apnoea Endocrine disease Aortic disease - e.g. coarctation of the aorta Renal artery stenosis Drug therapy - including corticosteroids
Renal causes of secondary hypertension
Any renal disease, especially renal artery stenosis and diabetic renal disease
Reduced renal blood flow -> excess renin release -> salt and water overload -> hypertension
Endocrine causes of secondary hypertension
Adrenal gland hyperfunction/tumours
Conn’s syndrome (excess aldosterone)
Cushing’s syndrome (excess corticosteroid)
Phaeochromocytoma (excess noradrenaline)
What is benign hypertension?
Asymptomatic hypertension
What are the complications of benign hypertension?
Left ventricular hypertrophy Congestive cardiac failure Increased atheroma Increased aneurysm rupture (aortic dissection, Berry aneurysms) Renal disease
What is malignant hypertension?
Serious, life threatening in short term
Diastolic pressure >130-140
Developed from being primary or secondary hypertension, or rarely de novo
What are the complications of malignant hypertension?
Cerebral oedema
Acute renal failure
Acute heart failure
Headache and cerebral haemorrhage
If clinic BP is 140/90 mmHg, what is the next step of diagnosis?
Ambulatory blood pressure
When using ABPM to confirm hypertension, how often should measurements be taken?
At least two per hour during the patients normal waking hours (usually 14 per day)
When using HBPM to confirm hypertension, how often should measurements be taken?
Two consecutive seated measurement, 1 minuted apart
BP recorded x2 daily for at least 4 days, but preferably 7
Discard first day measurement and average the rest
Define Stage 1 Hypertension
Cinic BP =>140/90mmHg
AND
ABPM or HBPM daytime average =>135/85mmHg
Define Stage 2 Hypertension
Clinic BP =>160/100mmHg
AND
ABPM or HBPM daytime average =>150/95
Define Severe Hypertension
Clinic systolic BP => 180mmHg
OR
Clinic diastolic BP => 110mmHg
Risk Factors for End Organ Damage
AGE Left ventricular hypertrophy Creatinine raised Albuminuria/microabuminuria Retinopathy Established vascular disease
Target BP with drug treatment
Clinic BP
80y/o
White Coat Effect (ABPM/HBPM BP)
80y/o
Hypertension Management - Lifestyle Interventions
Diet = reduce sodium and caffeine intake
Weight reduction and increased exercise
Reduce alcohol consumption
Quit smoking
How much does BP drop for every kg lost?
1mmHg
Which classes of drugs can be used as anti-hypertensives?
Thiazide diuretics ACE inhibitors/ARBs Calcium channel blockers Beta blockers Spironolactone Alpha blockers
Which anti-hypertensive is ideally suited in a patient who also has angina?
Beta blockers (or calcium channel blockers)
Which anti-hypertensives are ideally suited in a patient who also has CCF?
ACE inhibitors
Beta blockers
Which anti-hypertensive is ideally suited in a patient who also has diabetic nephropathy?
ACE inhibitors/ARBs
Which anti-hypertensive is ideally suited, with caution, in a patient who also has prostatism?
Alpha blockers
Which anti-hypertensive is ideally suited in elderly patients?
Thiazide diuretics
Antihypertensive Drug Treatment = Step 1 for
ACE inhibitor or low cost ARB
Antihypertensive Drug Treatment = Step 1 for >55y/o or person of Afro-Carribean family origin
Calcium channel blocker
can use thiazide-like diuretic if CCB not tolerated
Why might a CCB not be tolerated?
Oedema
Evidence of heart failure
High risk of heart failure
Antihypertensive Drug Treatment = Step 2
ACE inhibitor (or low cost ARB) \+ CCB (or thiazide-like diuretic if CCB not tolerated)
Antihypertensive Drug Treatment = Step 3
Review medication to ensure optimal or best tolerated dosage
ACE inhibitor (or low cost ARB) + CCB + Thiazide-like diuretic
Antihypertensive Drug Treatment = Step 4
A + C + D
Consider further diuretic treatment, spironolactone, alpha blocker or beta blocker
Seek expert advice
What are the advantages to combination therapy?
Fewer side effects than mono therapy
Gives a greater reduction in BP than mono therapy
What factors might explain resistant hypertension?
Non-concordance White Coat Effect Pseudo-hypertension Lifestyle factors Drug interactions Secondary hypertension True resistance
What is the most effective treatment for resistant hypertension?
Spironolactone
How should spironolactone be given?
Start low go slow
Caution in diabetes and low GFR
In young women, what may ACE inhibitors be replaced with, and why?
Beta Blockers
Risk of foetal toxicity
