Hypertension Flashcards
Degrees of hypertension.
Stage 1
Stage 2
Severe
Stage 1 hypertension
Clinic 140/90 or higher
Ambulatory or home BP of 135/85 or higher
Stage 2 hypertension
Clinic 160/100 or higher
Ambulatory or home 150/95 or higher
Severe hypertension
Clinic 180 mmHg or higher, or a clinic diastolic blood pressure of 120 mmHg or higher.
This is called malignant hypertension
Refer for same-day specialist assessment if the person has:
A clinic blood pressure of 180/120 mmHg and higher with:
Signs of retinal haemorrhage and/or papilloedema (accelerated hypertension) or
Life-threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
When should ambulatory monitoring of BP be offered?
When BP is over 140/90
Explain ambulatory BP.
Discontinuously measures BP over 24 hours.
Most commonly every 20-30 minutes during waking hours and every 30-60 minutes during sleep.
Symptoms of hypertension.
Usually asymptomatic.
Can have a headache.
Rarely have epistaxis, visual disturbances and dizziness.
What does hypertension with sweating, headache and anxiety suggest?
Phaeochromocytoma
What does hypertension with muscle weakness and tetany suggest?
Hyperaldosteronism
What increases the CVS risk along with hypertension?
TIA, stroke, diabetes, previous renal disease, smoking, cholesterol and NSAIDs excess.
History of angina, CCF, palpitations, syncope and valvular heart disease.
FH of hypertension, premature coronary disease and PCK (polycystic kidney disease)
Drug history of any prior anti-hypertensive therapy and details of drug intolerances.
Physical examination of hypertension.
Look for secondary causes such as Cushing’s syndrome, enlarged kidneys in PCK, renal bruits and radio-femoral delay (coarctation).
Out of office BP
Asymptomatic organ damage of eyes, kidneys and heart
ECG
Estimation of total cardiovascular risk.
Investigations of hypertension.
Presence of protein in urine
Albumin:creatinine ratio
Haematuria
Plasma glucose, electrolytes, creatinine, eGFR, cholesterol, HDL cholesterol.
Fundoscopy
ECG
Consider echocardiography if suggestion of LVH, valve disease or LVSD or diastolic dysfunction.
Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
Bloods for HbA1c, renal function and lipids
Fundus examination for hypertensive retinopathy
ECG for cardiac abnormalities
While waiting for confirmation of hypertension, what should be assessed?
Cardiovascular risk by QRISK or jbs3risk.
Which patients should receive treatment when diagnosed with stage 1 hypertension?
Evidence of target organ damage
Established cardiovascular disease
Renal impairment
Diabetes
10 year risk >10%
Which patients should receive treatment in stage 2 hypertension?
Any age
Any person
Give examples of drugs that can raise BP.
Alcohol
Stimulants
COCP
NSAIDs
Corticosteroids
Calcineurin inhibitors
VEGFi
Antidepressants
What is the target BP in low-moderate risk?
< 140 mmHg
What is the target BP in diabetes, previous stroke/TIA and CKD?
< 130/80
What is the target BP in elderly less than 80 with systolic > 160?
140-150 mmHg but if less is tolerated aim for that.
Target BP in over 80 yo.
Less than 150/90.
If less is tolerated then shoot, however be careful.
What is the diastolic target BP?
< 90 mmHg
Unless diabetic < 85 mmHg.
Non-pharma treatment of hypertension.
Weight reduction if BMI > 25
Moderate salt intake
Minimise alcohol intake
Aerobic exercise
Smoking cessation.
Who should receive pharmacological treatment?
Treatment algorithm of hypertension.
1st Offer an ACE inhibitor or an ARB (do not combine) to adults
- type 2 diabetes and are of any age or family origin
- are aged under 55 but not of black African or African–Caribbean family origin.
1st CCB to adults
- aged 55 or over and do not have type 2 diabetes or
- of black African or African–Caribbean family origin and do not have type 2 diabetes.
2 - If ACE/ARB is not enough in step 1 add…
a CCB or
a thiazide-like diuretic.
2 - If CCB is not enough in step 1 add…
an ACE inhibitor or
an ARB or
a thiazide-like diuretic.
Step 3 treatment of hypertension.
First off review maximal tolerated dose and discuss adherence.
If hypertension is still not controlled in step 2 add…
an ACE inhibitor or ARB and
a CCB and
a thiazide-like diuretic
Step 4 treatment of hypertension.
This is called resistant hypertension.
Confirm ambulatory hypertension, discuss adherence and assess for postural hypotension.
If still not enough add…
spironolactone (<4.5 K+) or alpha or beta-blocker (>4.5 K+) to existing treatment.
Causes of secondary hypertension.
Divided into renal, neural, vascular and endocrine.
Glomerulonephritis, polyarteritis nodosa, systemic sclerosis, PCK, renal artery stenosis.
Cushings, hyperaldosteronism, phaeochromocytoma, acromegaly, hyperparathyroidism, hyperthyroidism
Coarctation, pregnancy, liquorice, drugs.
What is white coat hypertension?
Elevated in clinic BP.
Should not be treated but has a risk of developing into hypertension.
How is hypertensive retinopathy graded?
1 - Tortuous arteries with thick shiny walls
2 - AV nipping
3 - flame hamorrhages, cotton-wool spots and fibrin exudate.
4 - Papilloedema
What is an hypertensive crisis?
Increase in BP sustained over the next few hours that leads to irreversible end-organ damage.
Give examples of end organ damage in hypertensive crisis.
Encephalopathy
LV failure
Aortic dissection
Unstable angina
Renal failure
What are emergency hypertensive crises?
High BP with a critical event such as encephalopathy, pulmonary oedema, AKI or myocardial ischaemia.
What are urgency hypertensive crises?
High BP without critical illness.
It may include malignant hypertension associated with grade 3/4 hypertensive retinopathy.
What is the aim of emergency hypertensive crisis?
Reduce diastolic BP to 110 mmHg in 3-12 hours.
What is the aim of urgency hypertensive crisis?
Reduce diastolic BP to 110 mmHg in 24 hours.
Treatment in hypertensive emergency.
IV to start:
1 - Sodium nitroprusside
2 - Labetalol
3 - GTN (1-10 mg/hr)
4 - Esmolol which acts within 60 seconds and a duration of 10-20 minutes. Drug is usually given 0.5-1mg/kg loading dose over 1 minute and then 50mcg/kg/min increasing up to 300mch/kg/min as necessary.
Treatment of hypertensive urgency.
An oral regime to reduce diastolic to 100-110 over 48-72 hours.
Amlodipine 5-10 mg OD or diltiazem 120-300mg OD, or lisonopril 5 mg OD etc…
A combination of ACEi and calcium antagonist is effective and well tolertaed.
Most effective treatment in majority of patients is nifedipine 20 mg MR BD and amlodipine 10 mg OD for three days and then continue with amlodipine 10 mg OD thereafter.
Classic triad of symptoms in phaeochromocytoma.
Headache
Sweating
Tachycardia
Sustain or paroxysmal hypertension.
Diagnosis of phaeochromocytoma.
Urinary and plasma fractionated metanephrines and catecholamines.
24 hour urine collection is the main test.
CT or MRI scan of the abdomen and pelvis for adrenal tumours.
MIBG scan if tumours are not detected by CT/MRI.
Treatment of phaeochromocytoma.
All should undergo resection.
While waiting for surgery they should be started on alpha blockers (if not tolerated then CCB nicardipine can be used) of phenoxybenzamine 10 mg OD/BD and then increased to 20mg to control BP and increasingly. Last phenoxybenzamine dose is usually around 20-100 mg.
After adequate alpha blockade has been achieved, beta-blockade should be initiated. This usually occurs two to three days before operation. Beta-blocker should never be started first.
Diagnosis of primary adolsteronism.
Low serum potassium and high/normal sodium.
In up to 50% however the potassium is normal.
Aldosterone:renin ratio is measured in the morning.
Renin should be low or undetectable and plasma aldosterone very high.
Ratio is usually >20-30.
Adrenal CT should be done as well.
Secondary causes of hypertension.
R – Renal disease. This is the most common cause of secondary hypertension. If the blood pressure is very high or does not respond to treatment consider renal artery stenosis.
O – Obesity
P – Pregnancy induced hypertension / pre-eclampsia
E – Endocrine. Most endocrine conditions can cause hypertension but primarily consider hyperaldosteronism (“Conns syndrome”) as this may represent 2.5% of new hypertension. A simple test for this is a renin:aldosterone ratio blood test.
