Hypertension Flashcards
Define hypertension
Systolic > 140 mm Hg and/or diastolic > 90 mm Hg measured on three separate occasions
Malignant Hypertension: BP > 200/130 mm Hg
Summarise the epidemiology of hypertension
VERY COMMON
10-20% of adults in the Western world
Explain the aetiology/risk factors of hypertension
Primary
Essential or idiopathic hypertension
Responsible for > 90% of cases
Secondary Renal Renal artery stenosis Chronic glomerulonephritis Chronic pyelonephritis Polycystic kidney disease Chronic renal failure
Endocrine Diabetes mellitus Hyperthyroidism Cushing's syndrome Conn's syndrome Hyperparathyroidism Phaeochromocytoma Congenital adrenal hyperplasia Acromegaly
Cardiovascular
Coarctation of the aorta
Increased intravascular volume
Drugs
Sympathomimetics
Corticosteroids
COCP
Pregnancy
Pre-eclampsia
Recognise the presenting symptoms of hypertension
Often ASYMPTOMATIC
Symptoms of complications or cause
Accelerated or Malignant Hypertension - Scotomas (visual field loss) Blurred vision Headache Seizures Nausea and vomiting Acute heart failure
Recognise the signs of hypertension on physical examination
Blood pressure should be measured on 2-3 different occasions before diagnosing hypertension
The lowest reading should be recorded
Examination may reveal information about causes:
Radiofemoral delay = coarctation of the aorta distal to the left subclavian artery
Renal artery bruit = renal artery stenosis
Fundoscopy to detect hypertensive retinopathy
Keith-Wagner Classification of Hypertensive Retinopathy
i. Silver wiring
ii. As above + arteriovenous nipping
iii. As above + flame haemorrhages + cotton wood exudates
iv. As above + papilloedema
Identify appropriate investigations for hypertension
Bloods: U&Es, Glucose, Lipids
Urine Dipstick - Blood and protein (e.g. glomerulonephritis)
ECG - May show signs of left ventricular hypertrophy or ischaemia
Ambulatory blood pressure monitoring - Excludes white coat hypertension
Other investigations may be performed if a secondary cause of the hypertension is suspected (e.g. renal angiogram)
Generate a management plan for hypertension
Conservative - Stop smoking, Lose weight, Reduce alcohol intake, Reduce dietary sodium
Investigate for secondary causes (mainly in young patients)
Medical - treatment recommended if systolic > 160 mm Hg and/or diastolic > 100 mm Hg, or if evidence of end
-organ damage. Multiple drug therapies often needed.
ACE Inhibitors or Angiotensin Receptor Blockers, first line if: < 55 yrs Diabetic Heart failure Left ventricular dysfunction
CCBs - first line if: > 55 yrs Black NOTE: thiazide diuretics can be used if CCBs are not tolerated
Beta-Blocker
Not preferred initial therapy
May be considered in younger patients
May increase risk of heart failure
CAUTION: combining with thiazide diuretic may increase risk of developing diabetes
Alpha-Blockers - 4th line, May be used in patients with prostate disease
Consideration in managing diabetic, severe and malignant hypetension?
Target BP
Non-Diabetic: < 140/90 mm Hg
Diabetes without proteinuria: < 130/80 mm Hg
Diabetes WITH proteinuria: < 125/75 mm Hg
Severe Hypertension Management (Diastolic > 140 mm Hg)
Atenolol
Nifedipine
Acute Malignant Hypertension Management:
IV beta-blocker (e.g. esmolol)
Labetolol
Hydralazine sodium nitroprusside
CAUTION:avoid rapid lowering of blood pressure because it can cause cerebral infarction
This is because the autoregulatory mechanisms within the brain for regulating blood flow will cause vasoconstriction of the vessels in the brain when blood pressure is very high -> won’t adapt quick enough after treatment -> infarct
Identify the possible complications of hypertension
Heart failure Coronary artery disease Cerebrovascular accidents Peripheral vascular disease Emboli Hypertensive retinopathy Renal failure Hypertensive encephalopathy Posterior reversible encephalopathy syndrome (PRES) Malignant hypertension
Summarise the prognosis for patients with hypertension
Good prognosis if well controlled
Uncontrolled hypertension is associated with increased mortality
Treatment reduces incidence of renal damage, stroke and heart failure
