Hypertension Flashcards
What are some end complications of hypertension?
Haemorrhage Stroke Cognitive Decline Peripheral Vascular Disease Renal Failure Retinopathy LVH CHD CHF MI
What is optimal BP?
<120/80
What are the NICE definitions for hypertension?
Stage I
- Clinic >140/90
- ABPM daytime average >135/85
Stage II
- Clinic >160/100
- ABPM daytime average >150/95
Severe
- systolic >180
- or diastolic >110
What are the causes of hypertension?
90% Primary (idiopathic)
Secondary
- chronic renal disease
- renal artery stenosis
- endocrine disease, Cushing’s, Conn’s, phaeochromocytoma
Lifestyle causes:
- smoking (+20/10)
- diabetes
- male (2x risk)
- hyperlipidaemia
- LVH (2x risk)
What are the endogenous BP control systems?
Sympathetic NS
RAAS
- maintains Sodium balance
- controls blood volume and therefore BP
What factors of the RAAS control BP?
Stimulated by fall in BP, circulating volume, or Na
These stimulate renin release
Renin converts ATogen to ATI
ACE then converts ATI to ATII
ATII
- vasoconstrictor
- anti natriuretic peptide
- stimulates aldosterone release
Aldosterone
- anti-natriuretic and anti-diuretic
Risk factors contributing to BP and hypertension?
Age (increases) Genetics (>30 genes implicated) Environment Weight Salt/Diet - decreased salt reduces in hypertensives, but not normals Alcohol Race - black are salt retainers
How do you assess an individuals risk for and from hypertension? What targets might you set?
PMH - stroke, MI, IHD Smoking Diabetes Hypercholesterolaemia FH
End-organ damage:
- ECG and/or ECHO for LVH
- proteinuria for ACR (albumin/creatinine ratio)
- renal ultrasound
- eGFR for renal function
Use Assign risk calculator
Assess risk and set target
- <135/80-85
If over 80, <145/85
What is the first line treatment in hypertension?
In under 55s:
- ACEi/ARB
- (ramipril/losartan)
55+, AfroCaribbean:
- CCB (amlodipine (dilatory), verapamil (rate))
Use thiazide diuretic instead if oedema, intolerance or (risk of) heart failure
What would second line and beyond treatment be in hypertension, before it would be considered ‘resistant’?
Thiazide diuretic:
- Indapamide
- Clortalidone
Then add whichever hasn’t been already between CCB, ACEi/ARB, diuretic
What is the treatment in ‘resistant’ hypertension?
Consider low dose spironolactone if low K
Consider higher dose thiazide if high K (>4.5mM/L)
Beta-blocker (atenolol)
Less common agents
- alpha antagonist (doxazosin)
- centrally acting (methyldopa)
- vasodilators (hydralazine)
What are some contraindications of ACEis?
Renal artery stenosis
Renal failure
Hyperkalaemia
Pregnancy/Child-bearing age (consider beta-blocker/CCB instead)
NSAIDs
Potassium supplements
Potassium sparing diuretics
What are some contraindications in CCBs?
MI
Heart failure and/or bradycardia (rate-limiting CCBs)
How might you treat hypertension in pregnancy/expected pregnancy?
NO ACEi or ARB
Pre-pregnancy:
nifedipine/methyldopa/atenolol/labetalol
Pregnancy:
- add thiazide and/or amlodipine
Pre-eclampsia:
- as above + IV esmolol, labetalol, hydralazine
What is the criteria for a ‘hypertensive emergency’?
BP >180/110 with target organ damage
