Hypertension Flashcards by James Reilly

Why is screening for hypertension important

Hypertension is often symptomless

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What can result for hypertension

Major cause of premature vascular disease, leading to cerebrovascular events, ischaemic heart disease and peripheral vascular disease.
Increased blood pressure means increased mortality rates

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Epidemiology of hypertension

Men
>35
Major risk factor for CVD
Under treated, under diagnosed and poorly controlled in UK

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What is considered normotensive

less than 140/90mmHg

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What are the stages of hypertension

Stage 1 hypertension
Stage 2 hypertension
Severe hypertension

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What classifies as Stage 1 hypertension

Equal to or >140/90mmHg

Daytime average Ambulatory blood pressure monitoring (ABPM - 24hr BP monitor) or Home blood pressure monitoring (HBPM); Equal to or >135/85mmHg

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What classifies as Stage 2 hypertension

Equal to or >160/100mmHg clinic BP

Daytime average ABPM or HBPM Equal to or >150/95mmHg

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What classifies as Severe hypertension

Clinic systolic BP Equal to or >180mmHg and/or
diastolic BP Equal to or >110mmHg
Start immediate anti-hypertensive drug treatment!

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What is the most common cause of atherosclerosis and cerebral haemorrhage

Hypertension

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How can you classify the causes of hypertension

Unknown - Essential (primary or idiopathic) hypertension (most cases)
Known - Secondary hypertension

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Essential hypertension is multifactorial - give examples of things that can contribute to the disease

Genetic susceptibility
Excessive sympathetic nervous system activity
Abnormalities of Na+/K+ membrane transport
High salt intake
Abnormalities in renin-angiotensin-aldosterone system

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Causes of Secondary hypertension

Renal disease
Pregnancy
Other potential underlying causes:
Endocrine causes, Coarctation of aorta, Drug therapy

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What is most common cause of secondary hypertension

Chronic Kidney Disease

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What is the most common cause of chronic kidney disease

Diabetes

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How can renal disease be exacerbated by hypertension

Hypertension accelerates atherosclerosis and endothelial cell dysfunction, promoting pheochromocytoma vasoconstriction - this can cause or exacerbate renal disease

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Endocrine causes of secondary hypertension

Cushings syndrome
Conn’s syndrome
Pheochromocytoma

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How does Cushings cause hypertension

Hypersecretion of corticosteroids (which enhance adrenalines resulting in a vasoconstrictive effect) is associated with systemic hypertension

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How does Conns cause hypertension

Adrenal tumour that secretes ALDOSTERONE (resulting in Na+ retention and thus water retention thereby increasing blood volume and pressure) can cause hypertension

How does Pheochromocytoma cause hypertension

Adrenal tumour that secretes CATECHOLAMINES (resulting in the stimulation of alpha-adrenergic receptors resulting in vasoconstriction, increased cardiac contractility as well as the stimulation of beta-adrenergic receptors resulting in an increase in heart rate and contractility) can cause hypertension

Describe presentation of hypertension in coarctation of aorta (systemic hypertension is one of most common features of coarctation)

Raised blood pressure will be detected in either arm, but NOT in the legs
The femoral pulse is often delayed relative to the radial

Untreated or undiagnosed patients with coarctation of aorta with hypertension can die from..

CF
Hypertensive Cerebral Haemorrhage
Dissecting aneurysm

Prescription drugs that can cause hypertension

Corticosteroids e.g. Prednisolone
Cyclosporin
Erythropoietin
Some types of the contraceptive pill

Non-prescription drugs that can cause hypertension

Alcohol
Amphetamines
Ecstasy
Cocaine

Risk Factors for hypertension

Age (risk increases as you age)
Race - hypertension is more common in blacks
Family history (hypertension runs in families)
Overweight and obese
Little exercise
Smoking
Too much salt in diet
Alcohol
Diabetes
Stress

Hypertension: Vascular Changes

* Hypertension accelerates atherosclerosis * Thickening of the media of muscular arteries * It is the smaller arteries and arterioles that are especially affected in hypertension * *The resulting endothelial cell dysfunction is associated with impaired nitric oxide-mediated vasodilatation and enhanced secretion of vasoconstrictors including endothelins and prostaglandins

Hypertension: Heart damage that could result

Hypertension is a major risk factor for ischaemic heart disease

Hypertension: Nervous system damage that could result

Intracerebral haemorrhage is a frequent cause of death in hypertension

Hypertension: Kidneys damage that could result

Hypertension can cause or result from renal disease Kidney size reduced Smaller vessels show intimal thickening and medial hypertrophy Numbers of sclerotic glomeruli are increased

Describe Malignant hypertension in body

Markedly raised diastolic blood pressure, usually over 120mmHg and progressive renal disease. Renal vascular changes Acute haemorrhage Papilloedema (optic disc swelling due to raised inter cranial pressure)

Who can get malignant hypertension

Can occur in previously fit individuals | Often black males in their 30-40s

Consequences of malignant hypertension

- Cardiac failure with left ventricular hypertrophy and dilatation - Blurred vision due to papilloedema and retinal haemorrhages - Haematuria and renal failure due to fibrinoid necrosis of glomeruli - Severe headache and cerebral haemorrhage

Clinical presentation of hypertension

``` Usually asymptomatic (except malignant hypertension) Found on screening ```

Diagnosis of hypertension

End-organ damage e.g. left ventricular hypertrophy, retinopathy and proteinuria (indicates severity and duration of hypertension and associated with a poorer prognosis) Urinalysis: protein/albumin:creatine ratio and haematuria Blood tests Fundoscopy/Opthalmscopy (looking for retinal haemorrhage or papilloedema) Echocardiography or ECG: LV hypertrophy 24 hour ambulatory BP monitoring

What would you look for on blood tests of hypertension

Serum creatinine eGFR Glucose (to assess diabetes risk)

What is the goal BP from treatment of hypertension

140/90mmHg

Non- drug treatment of hypertension

``` Change diet: High consumption of vegetable and fruits and low-fat diet Regular physical exercise Reduce alcohol intake Reduce salt intake Lose weight Stop smoking ```

Pharmacological treatment of hypertension

ACD pathway: A - ACE-inhibitor e.g. Ramipril or Enalapril C - Calcium channel blocker (CCB) e.g. Nifedipine or Amlodipine D - Diuretics e.g. Bendroflumethiazide (thiazide, distal tube - less potent) or Furosemide (loop diuretic, loop of henle - more potent)

If patient has coughing issues, what would you give instead of the contra-indicated ACE-inhibitor for treating hypertension

Angiotensin Receptor Blocker (ARB) e.g. Candesartan or Losartan

When would you consider Beta-blocker as treatment for hypertension

Not first line treatment Consider in young people especially if intolerant to ACEi/ARB In people where higher dose of drugs not tolerated

What drugs would you give to patients <55 yrs old to treat their hypertension

``` Ramipril/Candesartan + Nifedipine + Bendroflumethiazide + Furosemide (in stages?) ```

What drugs would you give to patients >55 yrs old/black/African-Carribean origin to treat their hypertension

Ramipril/Candesartan + Nifedipine + Bendroflumethiazide + Furosemide (3 stages)

What is essential hypertension

Hypertension with primary cause unknown

How does size of kidney change with hypertension

Reduces

*Investigations and their results

Urinalysis - protein; albumin:creatinine ratio; haematuria Blood tests - serum creatinine Fundoscopy/ophthalmoscopy - papilloedema ECG - LV hypertrophy