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hypertension Flashcards

1
Q

what is pre-hypertension?

A

Systolic 130-139, Diastolic: 85-89

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2
Q

how should prehypertension treated?

A
  • Lifestyle modification should be encouraged

* Don’t give drugs unless they have compelling indications e.g. diabetes

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3
Q

what is the goal blood pressure for people with prehypertension?

A

<130/80

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4
Q

what is isolated systolic hypertension?

A

Systolic >140mmHg, diastolic <90mmHg (systolic high, diastolic normal)

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5
Q

how do you treat isolated systolic hypertension?

A
  • Lifestyle interventions are the first stage of successful treatment
  • Drug treatment recommended if lifestyle changes aren’t effective
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6
Q

which is more serious - hypertension or isolated systolic hypertension?

A

hypertension

unless theyre elderly, then isolated systolic hypertension is more serious

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7
Q

define hypotension

A

systolic blood pressure (SBP) <90mmHg or diastolic less than 60mmHg

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8
Q

what is another name for postural hypotension?

A

orthostatic hypotension

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9
Q

when is postural hypotension present?

A

if SBP decrease in standing >20 mmHg or DBP >10 mmHg when associated with dizziness/fainting

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10
Q

who commonly experiences hypotension?

A

elderly esp diabetics

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11
Q

what can cause hypotension?

A

drugs e.g. antihypertensives (diuretics, vasodilators), some psychotrophic drugs, alcohol

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12
Q

what are the 3 main categories of symptoms associated with hypotension?

A

CNS effects
Muscle effects
Heart effects

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13
Q

what are the CNS effects that occur with hypotension?

A

dizziness, impaired cognition (esp in elderly), lethargy, fatigue, visual disturbance (e.g. blurred vision, tunnel vision, ‘greying out’ colour deficits) bc of hypoperfusion of the brain

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14
Q

what are the muscle effects that occur with hypotension?

A

paracervical (upper back) ache, general fatigue

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15
Q

what are the heart effects that occur with hypotension?

A

angina (bc of hypoperfusion of heart esp during exercise)

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16
Q

define hypertension

A

Present if systolic is persistently >140 and diastolic persistently >90mmHg

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17
Q

how should you prepare to take a blood pressure?

A
  • Repeated measurements need to be taken on separate days.
  • Seat them quietly for 5 mins, properly prepare and position.
  • Caffeine, exercise and smoking should be avoided for 30mins before
  • Appropriate-sized cuff should be use
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18
Q

when should 24 hour ambulatory BP monitoring be used?

A

Borderline/suspected ‘White Coat’ effect

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19
Q

why do you have to measure bp to diagnose hypertension?

A

rarely has any symptoms

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20
Q

why does systolic blood pressure increase with age?

A

loss of compliance of arteries –> loss of elastin + collagen

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21
Q

what is primary hypertension and what % of hypertension cases does it make up?

A

90-95% of cases. No obvious underlying cause. Strong familial trend

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22
Q

what are the causes of secondary hypertension?

A
  • renal or renovascular disease
  • endocrine disease;
     Phaeochomocytoma (tumour of chromaffin cells)
     Cushings syndrome (adrenal cortical tumour)
     Conn’s syndrome (hypersecretion of aldosterone)
     Acromegaly and hypothyroidism
  • coarctation of the aorta
  • Iatrogenic – hormonal/oral contraceptive, NSAIDs
  • Thyroid (either hypo or hyper) or parathyroid disease
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23
Q

what are the framingham studies?

A

A classical epidemiology study on the long-term effects of hypertension
• Big cohort of people who hadn’t developed CVD or had a stroke/MI and they were monitored over a long period to identify the major CVD risk factors

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24
Q

what were the results of the framingham studies?

A

elevated arterial blood pressure is a major cause of premature vascular disease leading to stroke, coronary heart disease, renal impairment and peripheral vascular disease

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25
Q

how does concentric hypertrophy happen?

A
  • high diastolic pressure in the aorta - more work for the heart to push blood through the aortic valve
  • increase symp output to the heart
  • increase HR (tachycardia)
  • heart muscle thickens over time to produce a higher end systolic pressure - also decreases ventricular diameter
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26
Q

what is concentric hypertrophy?

A

heart wall thickens and the lumen diameter is decreased

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27
Q

why does ischaemia damage occur in concentric hypertrophy?

A
  • hypertrophied cardiac muscle has a poor blood supply

- ischaemia damage happens esp after exercise or other cardiac death

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28
Q

what is eccentric hypertrophy?

A

whole ventricle enlarges (wall may or may not increase in thickness too)

29
Q

what causes eccentric hypertrophy

A

Happens in conditions that cause increase in preload (not systemic hypertension) e.g. mitral regurgitation

30
Q

how can eccentric hypertrophy lead to heart failure?

A

Enlarged heart = weaker force of contraction bc of Laplace’s Law –> reduces SV –> increased residual volume –> makes larger heart –> weaker heart –> heart failure

31
Q

why don’t anaerobic exercise regimes reduce ventricular volume?

A
  • raise BP by compressing vessels in the contracting muscles

- leads to cardiac remodelling and a healthy form of concentric hypertrophy where the ventricular volume isnt reduced

32
Q

what effect does aerobic training have on the heart?

A

increases preload

healthy eccentric remodelling bc heart gradually increases in size to accommodate increased venous return

33
Q

what blood vessels are particularly sensitive to chronic hypertension?

A

retinal blood vessels

34
Q

what are signs of damage to the retinal blood vessels caused by hypertension?

A
  • arteriolar narrowing where arterioles and venules cross - silver/copper wire arterioles
  • haemorrahges in the retinal capillaries
35
Q

what are silver/copper wire arterioles?

A

manifestation of arteriolar narrowing where arterioles and venules cross - the centre of swollen arterioles shines bc of reflected light

36
Q

how do retinal capillary haemorrhages appear in an opthalamoscope?

A

 Blot and flame haemorrhages
 ‘Cotton wool spots’
 In severe cases - swelling of the optic disc (papilledema, or optic disc edema)

37
Q

what do diabetes and hypertension cause?

A

frequent haemorrhage of the retinal capillaries until eventually severe sight loss occurs (unless treated)

38
Q

what are the possible causes of hypertension?

A
  • overactivity of the sympathetic nervous system
  • impaired production of NO
  • elevated renin release
  • reduced atrial natriuretic
39
Q

how does overactivity of the sympathetic nervous system cause hypertension?

A
  • SNS controls systemic vascular resistance
  • SNS increases SVR
  • BP = SVR x CO - increase in SVR with no increase in CO means increased BP
40
Q

what can cause overactivity of the SNS?

A
  • Vasomotor control system is found in the medulla of the brainstem
  • Local hypoxia in the brainstem caused by sclerosis/narrowing of arteries can cause overstimulation of the SNS –> chronic hypertension
41
Q

what effect does NO have?

A
  • diffuses into smooth muscle under the endothelium and relaxes it
  • balances the vasoconstrictor effects of angiotensin and noradrenaline
42
Q

what can decrease NO production?

A

• Endothelial injury by free radicals or pro-inflammatory cytokines can decrease NO production

43
Q

why does impaired production of NO cause hypertension?

A

causes vasoconstriction and therefore a raised SVR

44
Q

what effect does ANP have?

A

o Dilation of the glomerular afferent arterioles
o Constriction of the efferent arterioles
o Relaxes the mesangial cells that line the glomerulus

• Increases pressure in the glomerular capillaries –> increases GFR –> increases water excretion

45
Q

name potassium rich foods

A

most vegetables, beans, potatoes, leafy greens, most fruits esp. bananas and avocados

46
Q

define hyponatremia

A

if ECF sodium (inc blood plasma) is below 135mmol/L

47
Q

why is hyponatremia serious

A

bc it affects AP production and can cause brain swelling

48
Q

what are symptoms of mild hyponatremia?

A

loss of energy and fatigue; confusion; muscle weakness

49
Q

what are symptoms of severe hyponatremia?

A

nausea and vomiting, headache, spasms, restlessness and irritability, seizures, coma (all bc of brain swelling)

50
Q

how can diabetes cause hypertension?

A

Suspected that diabetes damages the endothelium and reduces NO production

51
Q

what is leptin?

A

hormone from fat cells which increases satiety in normal individuals and maintains body weight

52
Q

how is leptin affected in obese people?

A

obese people have increased leptin but decreased sensitivity to it – ‘ponderostat’ control is set too high.

53
Q

how does leptin lead to hypertension?

A

o High leptin levels produce overstimulation of SNS – esp supply to the kidney  directly stimulates excess renin release

54
Q

how does hyperinsulinamia lead to hypertension?

A

o Hyperinsulinaemia can damage endothelial walls and decrease NO production –> increases SVR and induces hypertension

55
Q

what is stage 1 hypertension?

A

where blood pressure is 140/90 mmHg or higher

56
Q

what is stage 2 hypertension?

A

where blood pressure is 160/100 mmHg or higher

57
Q

what lifestyle changes should a person with hypertension made?

A

lose weight
• Moderate exercise without weight loss is often v effective
• Diet rich in vegetables and low in sugar
• Low salt diet is advisable bc it helps lower BP in salt-sensitive individuals and does no harm in others

58
Q

how would you treat someone <55 years old for hypertension?

A

antihypertensive treatment with ACE inhibitor or a low-cost angiotensin-II receptor blocker (ARB) - Don’t combine the 2 to treat hypertension
o If ACE-inhibitor isn’t tolerated then offer low-cost ARB

59
Q

how would you treat someone >55 years or of African/Caribbean origin?

A

offer calcium channel blocker

if CCB not suitable then offer thiazide like diuretic

60
Q

why might a calcium channel blocker not be suitable?

A

bc of oedema, intolerance or evidence of heart failure/risk of heart failure

61
Q

name thiazide like diuretics

A

chlortalidone (12.5–25.0 mg once daily) or indapamide

62
Q

why are beta blockers no longer a preferred initial therapy for hypertension?

A

bc of risk of developing diabetes

63
Q

which group of people are beta blockers considered as a treatment for?

A

considered in younger people, particularly
o People with intolerance to ACE inhibitors and ARBs
o Women of child-bearing potential
o People with increased sympathetic drive

64
Q

if a second drug is needed with beta blockers, what should be given and why?

A

add a CCB not a thiazide-like diuretic to reduce risk of diabetes

65
Q

when is step 2 treatment given?

A

when step 1 doesnt control blood pressure

66
Q

what is step 2 treatment for hypertension?

A
  • CCB in combination with either an ACE inhibitor or an ARB
  • If CCB isn’t suitable then give thiazide-like diuretic
  • For black people of African or Caribbean family origin, consider an ARB in preference to an ACE inhibitor, in combination with a CCB
67
Q

what is step 3 treatment for hypertension?

A

give a 3-drug combination of ACE inhibitor, angiotensin II receptor blocker, CCB and thiazide-like diuretic

68
Q

what is resistant hypertension

A

If BP remains at higher than 140/90 mmHg

69
Q

what is step 4 treatment for hypertension?

A

Consider adding a fourth antihypertensive drug and/or seeking expert advice

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