Hypertension

Question 1

If a patient who is previously well presents with an unusual infection what should you consider?

Answer 1

Diabetes

Question 2

How would you treat a skin infection?

Answer 2

Oral flucloxicillin 500mg QDS, if pen allergic then Erythromycin 500mg qds

Question 3

If the skin infection was itchy, what should you prescribe?

Answer 3

Cetirizine 10mg od (non-drowsy) or chlorpheniramine (piriton) 4mg prn qds (can cause drowsiness but useful if pt not sleeping well due to pain/ itching).

Question 4

If it was painful?

Answer 4

Ibuprofen 400mg tds

Question 5

If someone has a high bp, what else should you examine?

Answer 5

Weight/BMI, pulse, bp in other arm, heart sounds, lungs, fundi

Question 6

If the blood pressure in the clinic was >140/90, what should you offer next?

Answer 6

Ambulatory blood pressure monitor

Twice a day for 7 days
Each BP recording must be done twice, at least 1 minute apart with patient seated
Discard readings for Day 1
Take an average of the rest

Question 7

What is stage 1 hypertension?

Answer 7

Clinic BP > 140/90

and…

ABPM/ HBPM 135/85

Question 8

What is stage 2 hypertension?

Answer 8

Clinic BP > 160/100

and…

ABPM/ HBPM > 150/95

Question 9

What is stage 3 hypertension?

Answer 9

Clinic systolic 180

or

Clinic diastolic 110

Question 10

What is the white coat effect?

Answer 10

Discrepancy of > 20/10mmHg between clinic & average home or ambulatory BPs at the time of diagnosis

Question 11

Which q risk score is defined as high risk?

Answer 11

Over 20% (more then a 20% chance of having cardiovascular disease in the next 10 years)

Question 12

What is first line bp treatment in below 55s?

Answer 12

Ace-inhibitor

Question 13

What is first line treatment in afro-carribeans over 55s?

Answer 13

Calcium- channel blockers

Question 14

What is step 2 for afro-carribeans?

Answer 14

Add an ARB

Question 15

And step 2 for <55s?

Answer 15

Ace + calcium channel

Question 16

Step 3?

Answer 16

Ace+ calcium channel + thiazide (these decrease body sodium, therefore reduce blood volume and venous return)

Question 17

Step 1

Answer 17

ACE Inhibitor if aged<55
CCB if aged >55 or African/ Caribbean family origin
BUT if heart failure or high risk of heart failure – opt for a thiazide-like diuretic
Indapamide/ Chlortalidone

Question 18

Step 2

Answer 18

A + C

Patients of African/ Caribbean family origin can have an ARB at this stage instead of ACE1

B-Blockers + Thiazides = increased risk of diabetes

Question 19

Step 4 treatment?

Answer 19

Consider Spironolactone if potassium level 4.5 or lower (caution in patients with low eGFR as higher risk hyperkalaemia)

Higher dose thiazide-like diuretic if K+ > 4.5

Alpha or beta-blocker

Question 20

Recommendations with ramipril?

Answer 20

Start Ramipril 2.5mg od
Take first one in bed at night to avoid hypotension
Thereafter, take every morning
Sfx – dry cough, impotence
Check U&E in 2 weeks (renal artery stenosis)
Review pt and recheck BP in 4 weeks

Question 21

Side effects of calcium channels?

Answer 21

Ankle swelling
Headache, dizziness
Flushing
Nausea

Question 22

What should you cover at annual review?

Answer 22

BP
Urine dipstick
U&E
Lifestyle – diet, exercise
Weight
Side effects