Hypertension Flashcards
what signs and symptoms of hypertension
end organ damage
What are the three stages of hypertension
Stage 1
- 140/90 and ABPM 135/85
Stage 2
- 160/100 and ABPM 150/95
Stage 3
- Systolic> 180 or diastolic >110
ABPM what does it stand for
ambulatory blood pressure mean - get a day time mean and and a night time mean - the figure is for the day time mean
How do you measure postural hypotension
- Measure BP seated or supine
- Stand the patient for 1 minute
- Systolic drops by more than 20mm
What is the definition of postural hypotension
- this is when systolic drops by more than 20mm
What is the definition of malignant hypertension
- BP > 180/110 AND signs of papilloedema or retinal haemorrages
Describe how a ABPM work
- 24 hr monitoring
Machine size of half a BNF
- Take BP 3 times an hour during the day and hourly at night
- BP should dip at night; if not worse prognosis
in ABPM what should drop at night
BP should dip at night; if not worse prognosis
guidelines suggests that all patients should have a
ABPM before treatment
What is the alternative to ABPM
- Week of home blood pressure monitoring and then ask them to average it out
How should you take a history
CO
HPC
- Ask about pregnancy and the pill
- Ever had a BP check at work or for work eg HGV
PMH
- Diabetes
- CVA
- MI
- Renal disease
FH
- Cause and age of death
- Specifically ask about MI and CVA
- Parents and siblings
SH
- Smoking
- Alcohol
- Salt
- Dairy
- 5 a day
- Exercise
- Caffeine
- snoring
What should you look for in systems review for hypertension
- Cardiovascular
- Angina
- Claudication
- Exercise tolerance
- Erectile function
Females
- Pregnancy plans /contraception
How do you examine a patient with blood pressure
- Measure BP in both arms
- APBM before starting treatment
Look for end organ damage
- eyes
- urine - proteinuria
Look for secondary causes
- cushings
- coarctation
- renal artery stenosis
What does coarctation look like
Between the two arms
radial delay
What investigations can you use
- ABPM
- Urinalysis - for protein, albumin:creatine ratio and haematuira
U&E
- Conns
- hyperparathyroidism
Blood tests
- glucose
- electrolytes
- creatine
- eGFR
- total and HDL cholesterol
- Fundoscopy - check for retinopathy
- ECG - check for left ventricular hypertrophy
Secondary care
- ECHO
- Urinary Metanephrines
- Renin/aldo ratio (Conns)
- Renal/liver ultrasound
What are the two things can can effect measurement of blood pressure not due to hypertension
- Wrong cuff size - lead to wrong measurement
- White coat - doctors make patients anxious - picked up on ABPM
- masked hypertension - relaxed when they see the doctor but BP is high the other time - picked up on ABPM
What can cause essential hypertension
Genetic
Environmental
- City living
- Alcohol
- Obesity
- Salt
- Lack of exercise
- OSA - obstructive sleep apnea
What causes secondary hypertension
- Phaeochromocytoma
- Cushings
- OSA
- Obesity
- Conns
- Renal disease
- Renal artery stenosis
Drugs
- OC
- Steroids
- Recreational drugs e.g. cocaine
What type of end organ damage presents in hypertension
Heart
- MI
- CCF
Brain
- CVA
Kidney
- Nephrosclerosis
- Accelerates other forms of kidney disease
Depends on ethnicity
Legs
Erectile function
How do you manage stage 1 hypertension
Assess cardiovascular risk
- If target organ damage or 10% over 10 yrs risk give drugs
- Younger adults; consider drug treatment at a lower risk
- Life style intervention
How do you manage stage 2 hypertension
- Check with ABPM
- Drugs and lifestyle
How do you manage stage 3 hypertension
- Treat now with drugs
- then do an ABPM
- then recommend lifestyle
Describe what medications to give to what patients
Younger than 55 Step 1 - ACE 1st Step 2 - ACE + CCB or ACE + Thiazide type diruetics Step 3 - ACE + CCB + Thiazide like diuretics step 4 - add a further direutics or - alpha blocker or - beta blocker and consult specialist advice
Older than 55 or afro-carrabean or black patients of any age Step 1 - CCB or Thiazide Step 2 - ACE + CCB or ACE + thiazide Step 3 - ACE + CCB + Thiazide Step 4 - add a further direutics or - alpha blocker or - beta blocker and consult specialist advice
Why do black and Afro-Caribbean patients not respond to ACE inhibitors
- They have lower plasmin renin therefore something that acts on the RAAS it is less effective
- but if you stimulate the RAAS you raise the renin aldosterone levels and they become sensitive to the ACE
Describe what you should check before you prescribe an ACE
- Check pregnancy plans (can be tetrogenic)
- Under 55
- Not as monotherapy in Africans or Caribbean
Who should you give CCBs to
- over 55
- African or Caribbeans
What can be contradicted in calcium channel blockers
- Can cause ankle swelling - therefore caution if worried about heart failure or oedema
Name the types of calcium channel blockers
- Verapamil
- Dilitiazem
Dihydropyridines
- Amlodipine (common)
- nifedepine (in pregnancy and breast feeding)
- lacidipine (less ankle oedema)
Name a side effect of calcium channel blockers
- All cause gum hyperplasia - good dental hygiene is needed
- can cause ankle oedema
Name some examples of a loop diuretics
- Bumetanide
- Furosemide
Name some examples of a potassium sparing diuretics
Amilioride
Name some examples aldosterone antagonist
- Spironolactone
- eplenerone
What are the side effects of ACE inhibitors
- Angioedema
- dry cough
- causes high potassium
Name some examples of ACE inhibitors
- Ramipril
- perindopril
- lisinopril
What is the mechanism of action of ARBs
Block the A2 angiotensin receptor
What are the side effects of ARBs
- Increase potassium
Name some examples of ARBs
- Irbesarten
- losarten
- valsarten
- candarsarten
How does spironlactone work
- Aldosterone antagonist
- Affects renin angiotensin system
What are the side effects of aldosterone antagonists
- Spironolactone = Gynacomastia due to oestrogen effects
- Eplenerone less oestrogen effects so no gynacomastia
What blood pressure drugs can be used in pregnancy
- Labetolol
- Methyl Dopa
- Nifedipine
What are the targets for hypertension
- Reduce clinic BP to below 140/90
- ABPM or home monitoring 135/85
what would a U and E show if conns was the cause of hypertension
- decrease in potassium
What would a U and E show if hyperparathyroidism was a cause of hypertension
- increase in calcium
What are examples of end organ damage
- LVH
- Previous medical history of MI or angina
- previous medical history of stroke/TIA
- peripheral vascular disease
- renal failure
How does conns disease present in the clinical history and physical examination
- Muscle weakness
- family history of early onset hypertension
- cerebrovascular events aged before 40
Physical examination
- arrhythmias if severe hypokalaemia
What are the laboratory investigations for primary aldosteronism confirmation
- Hypokalaemia in U and E
- aldosterone:renin ratio under standardised conditions
- fludrocortisone suppression test
- adrenal CT scan
- adrenal vein sampling
what are the clinical presentation and physical examination on pheochromocytoma
- Paroxysmal hypertension
- headache
- sweating
- palpitations
- pallor
- family history
Physical examination
- skin stigmata of neurofibromatosis - cafe-au-lait spots
What investigations do you use to diagnose pheochromocytoma
- incidental discovery of adrenal mass
- measurement of urinary fractionated metanephrines or plasma free metaneprhines
- CT or MRI of abdomen and pelvis
- genetic screening
What are the clinical history of cushings syndrome
- weight gain
- polyuria
- polydipsia
- psychological disturbances
Physical examination
- central obesity
- moon face
- buffalo hump
- red striae
- hirsutism
What tests can you do to confirm Cushings syndrome
- hyperglycaemia
- 24 hour urinary cortisol excretion
- dexamethasone suppression tests
What is the clinical history of renal artery stenosis and what would you find on a physical examination
Fibromuscular dysplasia
- early onset hypertension
Atherosclerotic stenosis
- abrupt onset hypertension
- worsening or difficult to treat
- flash pulmonary oedema
physical examination
- abdominal bruit
What is the clinical history of renal parenchymal disease and what would you find on a physical examination
Clinical history
- history of urinary tract infection or obstruction
- haematuria
- family history of polycystic kidney disease
physical examination
- abdominal mass
Define accelerated hypertension
Accelerated hypertension is defined as a recent significant increase over baseline BP that leads to target organ damage
when is same day referral given with accelerated hypertension
- with palpilloedema and retinal haemorrhages
- with new onset confusion, chest pain, signs of heart failure or acute renal failure
- with suspected phaeochromocytoma
Describe the mechanism of action of atherosclerosis
- Endothelial wall damage
- shear stress - hypertension
- toxic damage - e.g. cigarette smoke
- exposure to high levels of LDL - Uptake and modification of LDL
- Following endothelial damage, LDL and monocytes infiltrate subendotheilal space
Once taken up LDL is modified
- oxidation - in the presence of reactive oxygen specific
- glycation in the presence of increased glucose
- Infiltration of macrophages into subendothelial space
- Oxidised LDL stimulates endothelial cells to produce inflammatory mediators required for uptake of monocytes
- Monocytes taken up and transform into macrophages - Formation of fatty streaks
- Macrophages take up excess LDL van scavenger receptors and transform into foam cells - Smooth muscle proliferation and fibrous cap formation
- Endothelial cells and macrophages release growth factors, inducing smooth muscle proliferation and collagen deposition (can form fibrous cap)
- Ca2+ deposits onto plaque, hardening it
- Smooth muscle cells can also take up LDL and become foam cells
- Fibrous cap is very fragile and can break off: collagen exposed to blood 🡪 thrombus formation (can break off and embolise)
What are the signs of accelerated phase HTN
- Severe hypertension (SBP>200, DBP >130)
- bilateral retinal haemorrhages
- exudates +/- papilloedema
What are the symptoms of accelerated phase hypertension
Headache +/- visual disturbance
What is the treatment for accelerated phase hypertension
- oral therapy unless there is encephalopathy or CCF
- aim is controlled reduction in blood pressure over days not hours
- avoid sudden drops in blood pressure as cerebral auto regulation is poor
- bed rest and hypotensive drug - atenolol or long acting CCBs
What are the grades of hypertensive retinopathy
- Tortuous arteries with thick shiny walls (silver or copper wiring)
- AV nipping
- Flame haemorrhages and cotton wool spots
- Papilloedmea
