Hypertension Flashcards
1
Q
What is hypertension?
A
https://www.youtube.com/watch?v=9CKihqqIokI&vl=en-US
The blood pressure above which the benefits of treatment outweigh the risks in terms of morbidity and mortality.
2
Q
What are risk factors for the development of hypertension?
A
- Cigarette smoking (adds 20/10 mmHg)
- Diabetes Mellitus (5-30x increased risk of MI)
- Renal Disease
- Male
- Hyperlipidaemia
- Previous MI or Stroke
- LVH
- Family history
- Low birth weight
3
Q
What are the different types of hypertension?
A
- Primary/Essential hypertension
- Secondary hypertension
- Malignant hypertension
- White coat hypertension
4
Q
What is primary hypertension?
A
This is hypertension of unknown cause. It accounts for the vast majority (> 95%) of cases. In these cases, hypertension is due to a combination of genetic, lifestyle and environmental factors.
5
Q
What is secondary hypertension?
A
Present when blood pressure is raised due to an identifiable and potentially treatable cause; examples include renal, renovascular and endocrine disorders, certain drugs (such as steroids or the oral contraceptive pill), coarctation of the aorta and pregnancy.
6
Q
What is malignant hypertension?
A
An acute rise in blood pressure (usually to > 180/110mmHg) with papilloedema (optic disc swelling) and/or retinal haemorrhage. Malignant hypertension is a medical emergency and may be associated with heart failure, cerebral oedema and renal failure.
7
Q
What is white coat hypertension?
A
Present when blood pressure is normal other than when checked during a medical consultation; 24-hour blood pressure monitoring may help decide whether the patient is truly hypertensive.
8
Q
What is benign hypertension?
A
Any stage 1 or stage 2 hypertension
9
Q
What are the criteria for stage 1 hypertension?
A
Clinic blood pressure = 140/90 mmHg or higher
+
ABPM or HBPM average BP = 135/85 mmHg or higher.
10
Q
What are the criteria for the diagnosis of stage 2 hypertension?
A
Clinic blood pressure = 160/100 mmHg or higher
+
ABPM or HBPM average BP = 150/95 mmHg or higher
11
Q
What are the criteria for the diagnosis of severe/Stage 3 hypertension?
A
Clinic systolic blood pressure = 180 mmHg or higher
Clinic diastolic blood pressure = 110 mmHg or higher
12
Q
What factors play a role in the development of primary hypertension?
A
- Genetic
- Age
- Foetal factors
- Obesity
- Alcohol intake
- Sodium intake
- Stress
- Humoral mechanisms
- Insulin resistance
- Race
13
Q
Why does age play a role in the development of hypertension?
A
Reduced arterial compliance
14
Q
What foetal factors play a role in the development of hypertension?
A
Low birth weight
15
Q
How does sodium intake influence blood pressure?
A
Sodium acts osmotically to pull more fluid into the vascular space
16
Q
What are cardivascular causes of secondary hypertension?
A
Coarctation of the Aorta
17
Q
What condition in pregnancy can cause secondary hypertension?
A
Pre-eclampsia
18
Q
What are endocrine causes of secondary hypertension?
A
- Cushing’s syndrome
- Acromegaly
- Thyroid disease
- Hyperparathyroid disease
- Conn’s syndrome
- Phaeochromocytoma
- Adrenal hyperplasia
19
Q
What are adrenal causes of hypertension?
A
- Conn’s syndrome
- Adrenal hyperplasia
- Phaeochromocytoma
20
Q
What are renal causes of secondary hypertension?
A
- Diabetic nephropathy
- Chronic GN
- Adult Polycystic disease
- Chronic tubulointersitial nephritis
- Renovascular disease
21
Q
What drugs can cause secondary hypertension?
A
- NSAIDs
- MAOIs
- Oral contraceptives
- Vasopressin
- Sympathomimetics
22
Q
What respiratory problems can cause secondary hypertension?
A
Sleep apnoea
23
Q
What are the features of hypertensive retinopathy?
A
- AV nipping
- Copper and Silver wiring
- Cotton wool spots
- Microaneurysms
- Retinal haemorrhages
24
Q
What is the following?
A
AV nipping - An enlarged retinal arteriole that crosses a vein can press down and cause swelling distal to the crossing. The vein will have an hourglass appearance on either side of the intersection.
25
What is the following and what is it a sign of?
**Cotton wool spots -** Small areas of yellow-white discolouration on the retina, often described as puffy white patches.
Diabetes and hypertension
26
What is the following, and what is it a sign of?
**Retinal haemorrhage** - Bleeding that occurs in or spills onto the retina. Can be ‘dot and blot’ or ‘streaking’ in appearance.
Sign of diabetes, hypertension or trauma
27
What are retinal microaneurysms?
## Footnote
Small, round, dark red dots on the retinal surface that are smaller than the diameter of major optic veins They often herald a progression to the exudative phase of hypertensive retinopathy.
As progression of hypertensive retinopathy occurs, there is capillary occlusion ischaemia and degeneration of the vascular smooth muscle, endothelial cell necrosis and formation of tiny aneurysms.
28
What is the mechanism behind the following?
**AV nipping** - Persistently elevated blood pressure causes hyperplasia of the arteriolar media and intimal thickening. The enlarged vessel impinges on the underlying vein, giving it a ‘nipped in’ appearance.
29
What is the mechanism behind the following?
**Cotton wool spots -** Principally due to damage and swelling of the nerve fibres. Prolonged hypertension results in distortion and blocking of retinal arterioles, blockage of axoplasmic flow (of proteins, lipids etc along the axon of the neuron) and a build-up of intracellular nerve debris in the nerve fibre layer. These insults result in swelling of the layer.
30
What is the mechanism of the following?
**Retinal haemorrhage** - Prolonged hypertension leads to intimal thickening and ischaemia. This causes degeneration of retinal blood vessels to the point where they leak plasma and bleed onto the retina.
31
What are features of end organ damage in hypertension?
* **Blindness** - hypertensive retinopathy
* **Cardiac failure** - LVH, MI, Pulmonary oedema
* **Vascular disease** - Atherosclerosis/Aneurysms/Dissections
* **CKD** - proteinuria, uraemia
* **Stroke/TIA** - Haemorrhage, seizure, Vascular dementia
32
What signs would indicate that coarctation of the Aorta could be causing hypertension?
* **Radio-femoral delay**
* **Radial-radial delay**
* **Hypertension**
* **Scapular bruit**
* **Systolic murmur** - over scapula
33
What is the mechanism behind the sign of radiofermoral delay?
## Footnote
Reduced amplitude and delayed timing of the pulses in the lower body with respect to the pulses in the upper body are classic features of aortic coarctation
Coarctation causes a decrease in the rate of ejection of blood because of vessel narrowing and the Venturi effect sucking the walls inwards, creating a reduction in the flow and amplitude of the pulse distal to the occlusion.
34
What is the mechanism behind radial-radial delay?
## Footnote
A disparity between the timing of pulses felt when simultaneously palpating the left and right radial pulse.
A coarctation or narrowing of the aorta occurs before the origin of the left subclavian artery, limiting the blood flow and causing a pressure drop distal to the narrowing. The pulse wave will arrive later in the left arm and the amplitudes of the left and right pulses will be different.
35
What features on ECG would indicate LVH?
* I**ncrease in QRS amplitude**
* **Left atrial enlargement.**
* **Left axis deviation.**
* **ST elevation in V1-3** - discordant to the deep S waves
* **Prominent U waves** - proportional to increased QRS amplitude
36
Why are young people (\<55) better to be started on ACEi or ARBs rather than CCBs or thiazide diuretics?
Young hypertension is likely to high renin hypertension, therefore ACEi are most appropriate
37
Why are the elderly (\>55) and black patients started on CCBs or thiazide diuretics?
They are more likely to have low renin hypertension
38
What tests would you do to confirm hypertension?
Clinic BP, then if high, ambulatory blood pressure monitoring
39
How would you investgate suspected high blood pressure?
* **Confirm high blood pressure**
* **Quantify risk**
* **Tests for end organ damage**
* **Tests for secondary causes**
40
How would you quantify risk in someone with hypertension?
* **Fasting glucose**
* **Cholesterol levels**
41
How would you assess for end organ damage?
* **ECG** - LVH, previous MI
* **Urine dipstick** - protein, blood
* **Opthalmoscopy** - hypertensive changes
* **ECHO** - LVH
42
How would you investigate for secondary causes of hypertension?
* **Bloods** - U+Es, Ca2+, renin and aldosterone levels
* **Renal ultrasound/arteriography**
* **Urinary free cortisol**
* **MRI aorta**
* **Urinary metanephrines/catecholamines**
43
Why would you look at U+E's and creatinine clearence when investgating for secondary causes of hypertension?
* **Polycystic disease**
* **Renal arterial disease**
* **Low K+ -** Conn's syndrome, Cushing's
44
What might low K+ indicate when investigating for secondary causes of hypertension?
Conn's or Cushing's syndrome
45
Why would you do a renal ultrasound as part of investigations for secondary causes of hypertension?
To look for signs fo Renal artery stenosis
46
Why would you look at urinary metanephrines/catecholamines when investigating for secondary causes of hypertension?
Look for Phaeochromocytoma
47
Why would you look at serum renin, aldosterone and cortisol when investgating hypertension?
Looking for conn's or cushings syndrome
48
Why would you perform an MRI scan of the aorta when investigating for secondary causes of hypertension?
Coarctation of the aorta
49
What are the features of grade I hypertensive retinopathy?
**Copper and silver wiring** - Tortuous arteries with thick shiny walls. Retinal arterioles appear orange or yellow instead of red ("copper wiring") Retinal arterioles look white if they have become occluded ("silver wiring")
50
What are the features of grade II hypertensive retinopathy?
**A-V nipping**
51
What are the features of grade III hypertensive retinopathy?
Retinal haemorrhages and cotton wool spots
52
What are the features of grade IV hypertensive retinopathy?
Papilloedema
53
What is the following and what can it indicate?
**Papilloedema** - is swelling and blurring of the optic disc margins.
Can indicate malignant hypertension
54
What is the mechanism behind the following?
**Papilloedema** - caused by increased intracranial pressure or a compression lesion of the optic nerve. Disc swelling papilloedema results from blockage of axoplasmic flow in neurons of the optic nerve, resulting in swelling of the axoplasm of the optic disc. Papilloedema is associated with other signs of optic nerve dysfunction (e.g. decreased visual acuity, relative afferent pupillary defect [RAPD], monocular vision loss).
## Footnote
The most common visual defects in acute papilloedema are enlargement of the physiological blind spot, concentric constriction and inferior nasal field loss
55
If someone had a ABPM of \<130/85, how would you manage them?
Reasses in 5 years
56
If someone had an ABPM of between 130-139/85-89, how would you manage them?
Reassess yearly
57
If someone was diagnosed with stage 1 hypertension, how would you manage them?
Assess risk and presence of end organ damage
\<80 years, ABPM \>135/85, plus one or more of:
* Target organ damage
* Established CVD
* Renal Disease
* Diabetes
* 10 year CV risk \>= 20%
**TREAT THEM**
58
If someone had stage II hypertension, how would you manage them?
Treat
59
If you were starting someone on antihypertensive medication, what would you want to determine first?
Age - \> 55 years
60
What are the general components to the overall management of hypertension?
* Lifestyle changes
* Medication
61
What lifestyle changes would you advise someone with hypertension?
* **Stop smoking**
* **Low fat diet**
* **Reduce alcohol**
* **Reduce sodium intake**
* **Increase exercise**
* **Reduce weight**
62
What would you start someone on for treatment of hypertension if they were under 55 (step 1 of NICE guidelines)?
ACEi, although if child bearing age in females, CCB or B-blocker
63
What would you start someone on for hypertension if they were over the age of 55 (step 1 of NICE guidelines)?
CCB (1st choice) or Thiazide diuretic
64
What medications would you add at step 2 of the treatment of hypertension (according to NICE guidelines)?
**\<55 years** - add CCB or Thiazide Diuretic
or
**\>55 years** - add ACEi
65
What medications would you add as part of step 3 of the NICE guidelines for treatment of hypertension?
**\<55 years** - add either CCB or Thiazide (depending on which has not been added)
or
**\>55 years** - add either CCB or Thiazide (depending on which has not been added)
Treatment for both should be ACEi, CCB and Thiazide together at this stage
66
What medications would you add as part of Step 4 of the NICE guidelines for treating hypertension?
**Consider spcialist advice**
Add B-blocker (1st choice), or alpha blocker or further diuretic treatment (spironolactone)
67
In someone with resistant hypertension, what further diuretic therapy would you consider using?
Spironolactone
Higher dose thiazide diuretics
68
When treating someone with resistant hypertension, when would you consider using spironolactone as a therapy?
If the blood potassium level is 4.5 mmol/l or lower
69
When treating resistant hypertension, when would you consider using higher dose thiazide diuretics?
if K+ \> 4.5 mmol/L
70
What are the different types of hypertension that can occur in pregnancy?
* **Chronic/pre-existing hypertension**
* **Gestational hypertension**
* **Pre-eclampsia**
71
What medications can you use pre-pregnancy for hypertension?
* **Nifedipine**
* **Methyldopa**
* **Atenalol**
* **Labetalol**
72
What treatments would you add to treatment for hypertension during pregnancy?
Thiazide diuretic +/- amlodipine
73
When would you use ARB's instead of ACEi?
When someone is expriencing a cough due to ACEi - 1 in 10 get this problem
74
What type of CCBs are used in hypertension?
Dihydropyridines are CCB of choice
75
What is hypertensive encephalopathy?
General brain dysfunction due to significantly high blood pressure - caused by cerebral oedema secondary to loss of cerebral autoregulation
76
How does hypertensive encephalopathy manifest?
* **Headache**
* **Nausea**
* **Vomiting**
* **Confusion**
* **Grade III/IV hypertensive retinopathy**
* **Late signs** - fits, coma, neuro signs
77
What is the defintion of hypertensive crisis?
Defined as severe elevation in BP (SBP \> 200mmHg, DBP \> 120mmHg)
78
What are the different classificaitons of hypertensive crises?
* **Hypertensive emergency**
* **Hypertensive urgency**
79
What are the subtypes of hypertensive emergencies?
* **Hypertensive emergency with retinopathy** - DBP \> 140 mmHg + retinal haemorrhage and exudate
* **Hypertensive emergency with pailloedema** - similar BP but with papilloedema (previously malignant hypertension)
80
What is the difference between hypertensive emergency and hypertensive urgency?
Emergency there is HTN + end organ damage, whereas urgency there is similar rise in BP, but no end organ damage
81
What endocrine disorders can present with hypertensive emergencies?
1. **Phaeochromocytoma**
2. **Cushing's**
3. **Primary hyperaldosteronism**
4. **Thyrotoxicosis**
5. **Hyperparathyroidism**
6. **Acromegaly**
7. **Adrenal carcinoma**
82
What conditions may present with hypertensive emergencies?
* **Essential HTN**
* **Renovascular HTN**
* **Renal parenchymal disease**
* **Endocrine disorders**
* **Eclampsia and pre-eclampsia**
* **Vasculitis**
* **Drugs**
* **Spinal cord injury**
* **Coarctation of Aorta**
83
What are renovascular causes of hypertensive emergency?
* **Atheroma**
* **Fibromuscular dysplasia**
* **Acute renal occlusion**
84
What renal parenchymal disorders can present with hypertensive emergencies?
* **Acute GN**
* **Vasculitis**
* **Scleroderma**
85
What mnemonic can you use to think of causes of secondary hypertension?
ABCDEF
* **A**pnea, **A**cromegaly,
* **B**irth control, **B**ad kidney
* **C**oarctation of the aorta, **C**ushing’s, **C**onn’s, **C**atecholamines
* **D**rugs (alcohol, nasal decongestants, estrogens)
* **E**ndocrine disorders, **E**rythropoietin
* **F**ibromuscular dysplasia
86
What investigations/monitoring should you perform if starting someone on durgs for resistant hypertension?
Monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter.
