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Cardiology > Hypertension > Flashcards

Hypertension Flashcards

1
Q

What is hypertension?

A

The blood pressure above which the benefits of treatment outweigh the risks in terms of morbidity and mortality.

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2
Q

What are risk factors for the development of hypertension?

A
  • Smoking
  • Diabetes Mellitus (5-30x increased risk of MI)
  • Renal Disease
  • Male
  • Hyperlipidaemia
  • Previous MI or Stroke
  • LVH
  • Family history
  • Low birth weight
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3
Q

What are the different types of hypertension?

A
  • Primary/Essential hypertension
  • Secondary hypertension
  • Malignant hypertension
  • White coat hypertension
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4
Q

What is primary hypertension?

A

This is hypertension of unknown cause

> 95% of cases

A combination of genetic, lifestyle and environmental factors.

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5
Q

What is secondary hypertension?

A

BP is raised due to an identifiable and potentially treatable cause;

E.G.

  • renal
  • renovascular
  • endocrine disorders
  • drugs (such as steroids or the oral contraceptive pill)
  • coarctation of the aorta
  • pregnancy.
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6
Q

What is malignant hypertension?

A

Acute BP rise ( > 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.

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7
Q

What is white coat hypertension?

A

Blood pressure rises in the presence of a medical professional

Use ABPM to get more accurate reading

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8
Q

What is benign hypertension?

A

Any stage 1 or stage 2 hypertension

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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.

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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

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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

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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
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13
Q

Why does age play a role in the development of hypertension?

A

Reduced arterial compliance

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14
Q

What foetal factors play a role in the development of hypertension?

A

Low birth weight

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15
Q

How does sodium intake influence blood pressure?

A

Increase BP

Sodium acts osmotically to pull more fluid into the vascular space

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16
Q

What are Vascular causes of secondary hypertension?

A

Coarctation of the Aorta

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17
Q

What condition in pregnancy can cause secondary hypertension?

A

Pre-eclampsia

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18
Q

What are endocrine causes of secondary hypertension?

A
  • Cushing’s syndrome
  • Acromegaly
  • Thyroid disease
  • Hyperparathyroid disease
  • Conn’s syndrome
  • Phaeochromocytoma
  • Adrenal hyperplasia
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19
Q

What are adrenal causes of hypertension?

A
  • Conn’s syndrome (primary aldosteronism)
  • Adrenal hyperplasia
  • Phaeochromocytoma
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20
Q

What are renal causes of secondary hypertension?

A
  • Diabetic nephropathy
  • Chronic Glomerularnephritis
  • Polycystic disease
  • Chronic tubulointersitial nephritis
  • Renovascular disease
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21
Q

What drugs can cause secondary hypertension?

A
  • Steroids
  • NSAIDs
  • MAOIs
  • Oral contraceptives
  • Vasopressin
  • Sympathomimetics
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22
Q

What respiratory problems can cause secondary hypertension?

A

Sleep apnoea

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23
Q

What are the features of hypertensive retinopathy?

A
  • AV nipping
  • Copper and Silver wiring
  • Cotton wool spots
  • Microaneurysms
  • Retinal haemorrhages
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24
Q

What are features of end organ damage in hypertension?

A
  • Blindness - hypertensive retinopathy
  • Cardiac failure - LVH, MI, Pulmonary oedema
  • Vascular disease - Atherosclerosis/Aneurysms/Dissections
  • CKD - proteinuria, uraemia
  • Stroke/TIA - Haemorrhage, seizure, Vascular dementia
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25
Q

What signs would indicate that coarctation of the Aorta could be causing hypertension?

A
  • Radio-femoral delay
  • Radial-radial delay
  • Hypertension
  • Scapular bruit
  • Systolic murmur - over scapula
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26
Q

What features on ECG would indicate LVH?

A
  • Increase 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
27
Q

Why are young people (<55) better to be started on ACEi or ARBs rather than CCBs or thiazide diuretics?

A

Young hypertension is likely to high renin hypertension, therefore ACEi are most appropriate

(ACEi are teratogenic!!!)

28
Q

Why are the elderly (>55) and black patients started on CCBs or thiazide diuretics?

A

They are more likely to have low renin hypertension

29
Q

What tests would you do to confirm hypertension?

A

Clinic BP,

if high; ABPM

30
Q

How would you investgate/manage suspected high blood pressure?

A
  • Confirm high blood pressure
  • Quantify risk
  • Tests for end organ damage
  • Tests for secondary causes
31
Q

How would you quantify risk in someone with hypertension?

A
  • Fasting glucose
  • Cholesterol levels
32
Q

How would you assess for end organ damage?

A
  • ECG - LVH, previous MI
  • Urine dipstick - protein, blood
  • Opthalmoscopy - hypertensive changes
  • ECHO - LVH
33
Q

How would you investigate for secondary causes of hypertension?

A
  • Bloods - U+Es, Ca2+, renin and aldosterone levels
  • Renal ultrasound/arteriography
  • Urinary free cortisol
  • MRI aorta
  • Urinary metanephrines/catecholamines
34
Q

Why would you look at U+E’s and creatinine clearence when investgating for secondary causes of hypertension?

A
  • Polycystic disease
  • Renal arterial disease
  • Low K+ - Conn’s syndrome, Cushing’s
35
Q

Why would you do a renal ultrasound as part of investigations for secondary causes of hypertension?

A

To look for signs for Renal artery stenosis and Polycystic disease

36
Q

Why would you look at urinary metanephrines/catecholamines when investigating for secondary causes of hypertension?

A

Look for Phaeochromocytoma

37
Q

Why would you look at serum renin, aldosterone and cortisol when investgating hypertension?

A

Looking for Conn’s or Cushings syndrome

38
Q

Why would you perform an MRI scan of the aorta when investigating for secondary causes of hypertension?

A

Coarctation of the aorta

39
Q

What is the following and what can it indicate?

A

Papilloedema - is swelling and blurring of the optic disc margins.

Can indicate malignant hypertension

40
Q

If someone had a ABPM of <130/85, how would you manage them?

A

Reassess in 5 years

41
Q

If someone had an ABPM of between 130-139/85-89, how would you manage them?

A

Reassess yearly

42
Q

If someone was diagnosed with stage 1 hypertension, how would you manage them?

A

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

43
Q

If someone had stage II hypertension, how would you manage them?

A

Treat with antihypertensives

44
Q

What lifestyle changes would you advise someone with hypertension?

A
  • Stop smoking
  • Low fat diet
  • Reduce alcohol
  • Reduce sodium intake
  • Increase exercise
  • Reduce weight
45
Q

What would you start someone on for treatment of hypertension if they were under 55 (step 1 of NICE guidelines)?

A

ACEi, although if child bearing age in females, CCB or B-blocker

46
Q

What would you start someone on for hypertension if they were over the age of 55 (step 1 of NICE guidelines)?

A

CCB (1st choice) or Thiazide diuretic

47
Q

What medications would you add at step 2 of the treatment of hypertension (according to NICE guidelines)?

A

<55 years - add CCB or Thiazide Diuretic

>55 years - add ACEi

48
Q

What medications would you add as part of step 3 of the NICE guidelines for treatment of hypertension?

A

<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

49
Q

What medications would you add as part of Step 4 of the NICE guidelines for treating hypertension?

A

Consider spcialist advice

Add B-blocker (1st choice), or alpha blocker or further diuretic treatment (spironolactone)

50
Q

In someone with resistant hypertension, what further diuretic therapy would you consider using?

A

K+ <4.5mEq/L Spironolactone

K+ >4.5mEq/L Higher dose thiazide diuretics

51
Q

What are the different types of hypertension that can occur in pregnancy?

A
  • Chronic/pre-existing hypertension
  • Gestational hypertension
  • Pre-eclampsia
52
Q

What medications can you use pre-pregnancy for hypertension?

A
  • Nifedipine
  • Methyldopa
  • Atenalol
  • Labetalol
  • Thiazide diuretic +/- amlodipine
53
Q

What type of CCBs are used in hypertension?

A

Dihydropyridines are CCB of choice

(amlodipine)

54
Q

What is hypertensive encephalopathy?

A

General brain dysfunction due to significantly high blood pressure

  • caused by cerebral oedema secondary to loss of cerebral autoregulation
55
Q

How does hypertensive encephalopathy manifest?

A
  • Headache
  • Nausea
  • Vomiting
  • Confusion
  • Grade III/IV hypertensive retinopathy
  • Late signs - fits, coma, neuro signs
56
Q

What is the defintion of hypertensive crisis?

A

A severe elevation in BP

Systolic BP > 200mmHg

Diastolic BP > 120mmHg

57
Q

What are the different classificaitons of hypertensive crises?

A
  • Hypertensive emergency
  • Hypertensive urgency
  • Hypertensive emergencies: impending or progressive target organ dysfunction
  • Hypertensive urgencies: without progressive target organ dysfunction
58
Q

What endocrine disorders can present with hypertensive emergencies?

A
  1. Phaeochromocytoma
  2. Cushing’s
  3. Primary hyperaldosteronism
  4. Thyrotoxicosis
  5. Hyperparathyroidism
  6. Acromegaly
  7. Adrenal carcinoma
59
Q

What conditions may present with hypertensive emergencies?

A
  • Essential HTN
  • Renovascular HTN
  • Renal parenchymal disease
  • Endocrine disorders
  • Eclampsia and pre-eclampsia
  • Vasculitis
  • Drugs
  • Spinal cord injury
  • Coarctation of Aorta
60
Q

What are renovascular causes of hypertensive emergency?

A
  • Atheroma
  • Fibromuscular dysplasia
  • Acute renal occlusion
61
Q

What renal parenchymal disorders can present with hypertensive emergencies?

A
  • Acute GN
  • Vasculitis
  • Scleroderma
62
Q

What mnemonic can you use to think of causes of secondary hypertension?

A

ABCDEF

  • Apnea, Acromegaly,
  • Birth control, Bad kidney
  • Coarctation of the aorta, Cushing’s, Conn’s, Catecholamines
  • Drugs (alcohol, nasal decongestants, estrogens)
  • Endocrine disorders, Erythropoietin
  • Fibromuscular dysplasia
63
Q

What investigations/monitoring should you perform if starting someone on drugs for resistant hypertension?

A

Monitor blood sodium and potassium and renal function within 1 month and repeat as required thereafter.

Cardiology (12 decks)

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