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Consultation skills > Hypertension > Flashcards

Hypertension Flashcards

1
Q

What is therapeutic empathy?

A

The ability to identify an individual’s unique situatin (perspective, feelings, opinions, ideas), to communicate that understading back to the individual and to act on that understanding in a helpful way.

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2
Q

What is the ICE approach?

A

What are the patients:
Ideas
Concerns
Expectations

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3
Q

What is the patient/person centred approach to consultations?

A

The patient is considered holistically, socially, physically, psychologically and behaviourally, in a discussion where power and decision making is shared.

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4
Q

What impact does patient understanding of their conditions have on medicines adherence?

A

Evidence shows that patients who have a clear understanding of their conditions and how to manage them through lifestyle and medication are much more likely to follow a care plan and be less anxious about their treatment.

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5
Q

What are the steps to the Calgary-Cambridge Consultation Guide?

A 
Initiate the session. 
Gather information
Physical examination (if needed)
Explanation and planning 
Closing the session
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6
Q

What type of consent must we get from the patient?

A

Informed consent.

Consent is VOLUNTARY, INFORMED and given with CAPACITY.

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7
Q

When would a chaperone be needed?

A

A female chaperone should be offered when a woman is being examined.

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8
Q

What are the four stages to examining a patient?

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
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9
Q

What is the percussion step?

A

Useful in a respiratory exam. Method of tapping on a surface to determine the composition of the underlying body.

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10
Q

What is auscultation?

A

BP, respiratory, bowel soun examinations. IT is the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope, as a part of medical diagnosis.

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11
Q

How should the patient be sat for a blood pressure examination?

A

Relaxed, temperate setting with the patient seated and rested. The arm should be out-stretched, in line with mid-sternum and supported.

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12
Q

What is the first stage of measuring someones blood pressure?

A

Correctly wrap a cuff containing an appropriately sized bladder around the upper arm and connect to a manometer.

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13
Q

What is the second stage to measuring someones blood pressure?

A

Palpate the brachial pulse in the antecubital fossa of that arm.

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14
Q

What is the third stage of measuring someones blood pressure?

A

Rapidly inflate the cuff to 20 mmHg above the point where the brachial pulse disappears.

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15
Q

What is the fourth stage of measuring someones blood pressue?

A

Deflate the cuff and note the pressure at which the pulse reappears; the approximate systolic pressure.

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16
Q

What is the fifth stage to measuring someones BP?

A

Re-inflate the cuff to 20mmHg above the point at which the brachial pulse disappears. Using one hand, place the stethoscope over the brachial artery ensuring complete skin contact with no clothing in between.
Slowly deflate the cuff at 2-3 mmHg per second listening for the korotkoff sounds.

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17
Q

What occurs if a stethoscope is placed over the brachial artery of a person without arterial disease?

A

No sound should be audible. As the heart beats, these pulses are transmitted smoothly via laminar (non-turbulent) blood flow throughout the arteries, and no sound is produced. Similarly, if the cuff of a sphygmomanometer is placed around a patient’s upper arm and inflated to a pressure above the patient’s systolic blood pressure, there will be no sound audible. This is because the pressure in the cuff is high enough such that it completely occludes the blood flow. This is similar to a flexible tube or pipe with fluid in it that is being pinched shut.

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18
Q

When using a sphygmomanometer when will the first Korotkoff sound be heard?

A

If the pressure is dropped to a level equal to that of the patient’s systolic blood pressure, the first Korotkoff sound will be heard. As the pressure in the cuff is the same as the pressure produced by the heart, some blood will be able to pass through the upper arm when the pressure in the artery rises during systole. This blood flows in spurts as the pressure in the artery rises above the pressure in the cuff and then drops back down beyond the cuffed region, resulting in turbulence that produces an audible sound.

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19
Q

What causes the thumping sounds heard as the pressure in a manometer cuff is allowed to fall further?

A

As the pressure in the cuff is allowed to fall further, thumping sounds continue to be heard as long as the pressure in the cuff is between the systolic and diastolic pressures, as the arterial pressure keeps on rising above and dropping back below the pressure in the cuff.
Eventually, as the pressure in the cuff drops further, the sounds change in quality, then become muted, and finally disappear altogether. This occurs because, as the pressure in the cuff drops below the diastolic blood pressure, the cuff no longer provides any restriction to blood flow allowing the blood flow to become smooth again with no turbulence and thus produce no further audible sound.

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20
Q

What type of sphygmomanometer is used to measure BP?

A

Anaeroid

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21
Q

What is the white coat effect?

A

15-30% pop affected, difference of 5-10mmHg between home and clinic readings.

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22
Q

Why bother measuring BP?

A

Hypertension is one of the most important preventable causes of premature morbidity and mortality in the UK.

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23
Q

According to NICE 127 what is Stage 1 hypertension?

A

Clinic BP of >140/90mmHg and ABPM/HBPM >135/85mmHg.

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24
Q

According to NICE 127 what is stage 2 hypertension?

A

Clinic BP >160/100mmHg, Home BP >150/95mmHg.

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25
Q

According to NICE 127 what is severe hypertension?

A

Clinic BP >180 or >110mmHg.

26
Q

How should hypertension be managed?

A

Reduce all identifiable cardiovascular risk factors:

  • BP, hyperlipidaemia, diabetes, smoking, obesity.
  • Non-pharmacological approaches
  • simple well tolerated drug regimen.
27
Q

When would pharmacological intervention be offered for someone with stage 1 hypertension?

A 
Under 80 and any of:
target organ damage,
established cardiovascular disease, 
renal disease, 
diabetes
10-year CV risk >10%
28
Q

What lifestyle changes are known to reduce BP?

A

Lower alcohol intake, <14 units per week for m and f.
Reduce weight to target BMI of 20-25.
Reduce salt intake.
Regular physical exercise.

29
Q

What lifesyle changes don’t reduce BP but are known to reduce CV risk?

A

Stopping smoking.
Reduce intake of saturated fats.
Increase intake of oily fish.

30
Q

How do ACEIs and ARBs work?

A

Either prevent the formation of or action of angiotensin II a potent vasoconstrictor. Cause arterial and venous dilation.

31
Q

Why does K+ levels increase with ACEI and ARB use?

A

Reduction in aldosterone

32
Q

Why are ACEI and ARB first choice in patients under <55 years?

A

They have renin and therefore there is a better response.

33
Q

Why are ACEI and ARB first line in diabetic patients?

A

Due to renoprotective effects.

34
Q

Why are ACEI/ARB not 1st line for black patients?

A

They have lower circulating renin.

35
Q

What monitoring is needed for ACEI/ARB?

A

Baseline U and Es, repeat after 10-14 days, 3 months and with every dose increase and thereafter annually.

36
Q

What are the side effects of ACE-I?

A

First dose hypotension - especially in those who are volume depleted i.e. elderly on high dose diuretics.

Cough develops after first few weeks - sometimes up to a year later. Switch to low cost ARB if develops.

Renal impairment.

Hyperkalaemia.

37
Q

When should ACEI be stopped due to renal impairment?

A

If creatinine increases by >20% or eGFR falls by >15%.

38
Q

How do CCB work?

A

Interfere with inward displacement of calcium ions through the channels into cell membranes. Relaxation of vascular smooth muscle causes vasodilation.

39
Q

What are the three types of CCB?

A
  1. Dihydropyridines such as amlodipine, felodipine and nifedipine.
  2. Phenylalkalamines such as verapamil a rate limiting drug which reduces heart rate - NEVER USE WITH BETA BLOCKER.
  3. Benzothiazipine derivatives such as diltiazem a rate limiting drug which reduces heart rate.
40
Q

CCB are first line in:

A

Those who are >55 yrs age and those black patients of any age.

41
Q

Why are CCBs preferred to diuretics?

A

They have demonstrated greater cost effectiveness except in patients >80 yrs and the combination of ACEI + CCB is more effective than ACEI + Diuretic.

42
Q

CCBs are contraindicated in:

A

Those with evidence of or high risk of heart failure or those who cannot tolerate them for any reason.

43
Q

What are the main side effects of CCBs?

A 
Headaches,
Abdominal pain, 
Flushing, 
Impotence,
Ankle oedema.
44
Q

What are the diuretics of choice for hypertension?

A

Indapamide or Chortalidone.

Chrotalidone however is generally ignored as a 25mg strength tablet does not exist.

45
Q

Diuretics are ineffective in patients with an eGFR of below_____

A

eGFR: <30

46
Q

What monitoring should accompany diuretics use?

A

U&Es and urinalysis should be done at iniatation, after 1 month and annually thereafter.

47
Q

NICE recommends what strength and form of Indapamide?

A

indapamide 1.5mg MR or 2.5mg standard.

No evidence for MR over Standard.

48
Q

Can bendroflumethethiazide be used to treat hypertension?

A

NICE no longer recommends new initiations.

Those who are well controlled using it already can keep using it. 2.5mg dose only for hypertension.

49
Q

What are the side effects usually associated with diuretics? [6]

A
  1. GI effects
  2. Plasma lipid disturbances
  3. Impotence - RARE
  4. Electrolyte disturbances: hyponatraemia
  5. Hyperglycaemia - caution diabetes.
  6. Hyperuricaemia - caution gout in women.
50
Q

Why should diuretic use in diabetics be done with caution?

A

Diuretics can cause hyperglycaemia.

51
Q

When would beta blockers be used for hypertension before step 4?

A

For younger people if ACEIs and ARBs are C/I or not tolerated ot if there is evidence of increased sympathetic tone.

52
Q

What are the mechanisms of action of beta blockers such as atenolol and bisprolol?

A
  1. Heart: reduce HR
  2. Kidneys: reduce renin
  3. CNS & PNS: reduces release of neurotransmitters and sympathetic nervous activity.
53
Q

In the treatment of hypertension, BBs are useful in those with what other co-morbidities?

A

Angina, Arrhythmias

54
Q

What side effects are associated with beta blockers? [4]

A 
Higher doses normally:
Fatigue and lethargy
Bronchospasm 
Cold extremeties. 
Lipids: Reduce HDL, increase triglycerides.
55
Q

What is doxazosin?

A

Alpha blocker.
Very powerful vasodilator associated with 1st dose hypotension, flushing, headache.

Need high doses, 1mg wont work.

56
Q

What is doxazosin used for?

A

Hypertension treatment.

PRostatic hyperplasia.

57
Q

When is doxazosin used?

A

In those who need 4 drugs to treat hypertension, prostatic hyperplasia.

58
Q

What is moxonidine?

A

A newer centrally acting antihypertensive treatment.

59
Q

How does moxonidine work to lower blood pressure?

A

Moxonidine is a selective agonist at the imidazoline receptor subtype 1 (I1). This receptor subtype is found in both the rostral ventro-lateral pressor and ventromedial depressor areas of the medulla oblongata. Moxonidine therefore causes a decrease in sympathetic nervous system activity and, therefore, a decrease in blood pressure.

60
Q

What are the 4 key symptoms of low blood pressure?

A

Lethargy
Fatigue
Weakness
Dizziness

61
Q

Why do hypertension patients often not take their medication?

A

Asymptomatic, drugs have side effects they don’t like. They feel they are fine anyway.

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