Hypertension Flashcards
What is stage 1 hypertension
140 / 90
ABPM 135 / 85
What is stage 2 hypertension
160 / 100
ABPM 150 / 95
What is severe hypertension
> 180 / >100
What are the essential causes of hypertension (95%)
No cause
- Age
- Genetics
- Low birth weight
- Obesity
- Alcohol
- Stress
- High salt
- Excessive sympathetic
- Renin angio system dysfunction
- Insulin resistance
- Abnormalities in Na excretion
What are secondary causes (more common in <40)
Chronic renal disease = most common Endocrine disease Coartication of aorta Drugs - NSAIDs, pill, steroid Sleep apnoea Pregnancy - CO inc but drop in resistance so low BP
What are renal causes
Renal artery stenosis
Pyelonephritis
GN - cause increased BP
PCKD
What are endocrine causes
How do you Dx Phaeochromocytoma
Cushing’s
Acromegaly
Phaeochromocytoma - 24 hour urine catelcoamine
Primary hyperaldosteronism - Conn’s (most common) - do renin-aldosterone ratio
HyperPTH
Hyperthyroid
How should you monitor BP
Every 5 years by GP
Lying and standing if elderly or DM
Isolated systolic hypertension common in elderly but treat as normal
How do you investigate hypertension when Dx
Home blood pressure reading
24 hour ABPM if BP found to be abnormal >140 / >90
Both arms and lying and standing
Blood - FBC, U+E, LFT, TFT, lipids, BM or HBA1c
Urinanalysis - renal - blood and protein
ECG
How do you assess end-organ damage / other tests that could be done to look for cause
CXR - cortication Renal USS - stenosis Renin aldosterone for Conn's Urine catecolamine Urinanlysis - blood / protein Blood glucose Sleep study
End-organ Fundoscopy for retinopathy ECHO - LVH ECG - LVH ACR - proteinuria Urinanalysis - haematuria U+E for renal damage
What treatable causes can you screen for
Renal stenosis Cushing's Conn's - if K low Hyperthyroid Sleep apnoea
What are RF for hypertension
Age – lose arterial compliance FH Race Male Smoking Alcohol Hyperlipidaemia Obesity DM Renal disease Previous MI / stroke Left ventricular hypertrophy Environment Low birth weight
What are symptoms of hypertension
Asymptomatic unless very high Headache Epistaxis Nocturia SOB due to LVF
What are signs of malignant hypertension
Visual disturbance
Seizure
Loss of consciousness
HF
What do you look for in examination
CVS Retinopathy - cotton wool / haemorrhage/ papilloedema Look for signs of HF - 3rd HS - 4th HS - Murmur - Pulses - Loud 2nd - Sinus tachy Signs of underlying cause - obesity / Cushing / Xanthelomata / anaemia of renal Abdo exam - PCKD / stenosis
What do you use to assess risk in hypertension
ASSIGN Previous MI IHD Smoking DM Hyperlipid FH
When do you start RX
CVD 10 year risk = 20%
Sometimes start at 10%
What is target BP
135 / 80
Higher in elderly = 150
Lower in type I DM or end organ = 130
What are lifestyle changes
Lose weight Reduce salt Exercise Diet Stop smoking
What do you do for diabetics
What is common issue in DM
What drug should you avoid
Aim 130 / 80 if end organ damage or type II
140 / 90 otherwise
ACEI = 1st line as protects renal even if >55
Thiazide + CCB
Postural hypo due to neuropathy
BB avoided as cause insulin resistance with diuretic
What are complications of hypertension
Commonest cause of cardiac failure Atherosclerosis RF IHD Stroke Peripheral arterial disease Renal failure due to reduced perfusion Haemorrhage Retinopathy Nephropathy
What are complications of hypertension in pregnancy
PET
Treat if >160 to protect mother
What happens in chronic hypertension
CO normal
Increased HR to maintain CO ( CO = SV x HR)
Further increases BP
Sympathetic activated = tachy / constriction = increased BP
Difficult to bring BP down
What is hypertension in children
> 98th centile
What causes hypertension in children
Congenital renal malformation
Fibromuscular dysplasia
Cortication
What are complications of hypertension in children
Hypertension in adult + risks Organ damage LVH Decreased vascular response Decreased GFR Cognition
What is accelerated hypertension
Increase to >180 / >110
IMMEDIATE RX if signs of organ damage
What is accelerated hypertension associated with
Vascular damage Papilloedema Retinal haemorrhage Headache Nausea Raised ICP signs Seizure Chest pain LOC
What is malignant hypertension
Accelerated + grade IV fundal changes
What requires urgent assessment
Papilloedema
Retinal haemorrhage
What does pheochromocytoma chase
Hypertension Postural hypo Headache Palpitations Diaphoresis - sweating
How do you treat malignant / what agents
Must treat ASAP or consider referral
Reduce arterial pressure by <25% for 1st hour then reduce slowly after that
BB / long act CCB
Then to 160/100 2-6 hours
Then to normal over 24
Once stabilised = oral
Treat anxiety to Rx as often due to poor control as afraid of hypo
Why do you reduce slowly
Lose cerebral autoregulation
May cause stroke
When do you use IV
Signs of encephalopathy or CCF
What causes postural hypotension
Autonomic neuropathy - Parkinson / DM (no compensatory tachycardia) Dehydration Aortic stenosis A blocker in BPH Diuretic Nitrates / vasodilator Anti-cholinergic - TCA / histamine / psychotic / dopamine agonist Anti-hypertensive L-dopa Sedatives Hypovolaemia Alcohol
How do you treat postural
Increase fluid and salt Discontinue vasodilator drugs - diuretic/. nitrate / anti-hypertensive Compression Fludrocortiosne Midoderine
What should you be careful of in DM
Autonomic neuropathy may increase risk of postural hypo
What suggest renal artery stenosis
Vascular disease
Proteinuria
Asymmetrical
What does midoderine do
A adrenergic so increases arterial resistance
What is hypertension urgency
Marked elevation in BP with no end organ damage
What do you do
Take BP both sides
Fundoscopy
U+E
ECG
How do you Rx
Add in more BP medication to reduce BP
What does everyone on BP meds need
Annual review BP U+E etc Urine dip + urine ACR if protein found Reasses CVD risk using QRISK
What is orthostatic hypo
Drop in SBP of 20 or DBP of 10 after 3 mins standing
