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Hypertension Flashcards

1
Q

What are the 3 groups of hypertension?

A
  1. Stage I hypertension
  2. stage II hypertension
  3. Severe hypertension
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2
Q

What are the boundaries for stage I hypertension?

A
  • ABPM or HBPM >= 135/85 mmHg
  • clinic BP >= 140/90
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3
Q

What is the first step you should take if a patient’s clinic blood pressure reading is >= 140/90 mmHg?

A

Offer ABPM or HBPM

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4
Q

What is the boundary for stage 2 hypertension?

A
  • ABPM/ HBPM reading >= 150/95
  • clinic BP >= 160/100
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5
Q

When should stage I hypertension be treated? (5 cases)

A

<80 years AND any of the following:

  1. target organ damage
  2. established cardiovascular disease
  3. renal disease
  4. diabetes
  5. 10-year cardiovascular risk (QRISK) equivalent to 10% or greater
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6
Q

When should stage 2 hypertension be treated?

A

treat all patients, regardless of age

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7
Q

What are 2 benefits of ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM)?

A
  1. Helps prevent overdiagnosis of hypertension - white coat syndrome
  2. ABPM more accurate predictor of cardiovascular events than clinic readings
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8
Q

What are the boundaries for severe hypertension?

A
  • Clinic systolic BP >180 or clinic diastolic >120
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9
Q

How does NICE recommend that blood pressure is measured?

A
  • measure blood pressure in BOTH arms. Repeat if difference >20 mmHg. if remains >20, subsequent BP readings should be recorded from higher arm
      • listen to heart sounds
  • Take a second reading during the consultation if first reading >140/90, lower reading of two should determine management
  • Offer ABPM or HBPM to any patient with BP >140/90
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10
Q

If after 2 blood pressure measurements in both arms the difference is still >20 mmHg what should be done?

A

There are pathological causes of unequal blood pressure readings from arms, e.g. supravalvular aortic stenosis. Listen to heart sounds and further investigation if very large difference noted

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11
Q

Under what 3 conditions should you admit the patient for specialist assessment if BP is >180/120?

A
  • signs of retinal haemorrhage or papilloedema (accelerated hypertension)
  • life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury
  • referral if phaeochromocytoma is suspected: labile or postural hypotension, headache, palpitations, pallor and diaphoresis (sweating)
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12
Q

What should be done if none of the reasons for admission for specialist assessment are suspected and BP is >180/120? What should be done based on the results of this?

A
  • Arrange urgent investigations for end-organ damage e.g. bloods, urine ACR, ECG
    • If target organ damage identified, consider starting antihypertensive drug treatment immediately, without waiting for results of ABPM or HBPM
    • If no target organ damage identified, repeat clinic blood pressure measurement within 7 days
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13
Q

How does ABPM work?

A
  • Blood pressure monitored as you move around living normal daily life
  • measured for up to 24 hours
  • At least 2 measurements per hour during person’s usual waking hours (e.g. 0800-2200), use average value of at least 14 measurements
    *
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14
Q

What should be offered if ABPM is not tolerated or declined?

A

HBPM: home blood pressure monitoring

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15
Q

What does home blood pressure monitoring (HBPM) involve?

A
  • for each BP recording, 2 consecutive measurements need to be taken, at least 1 minute apart and with person seated
  • should be recorded twice daily, ideally in morning and evening
  • BP should be recorded for at least 4 days, ideally for 7 days
  • discard measurements taken on first day and use average value of all remaining
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16
Q

Why did NICE make a frther recommendation in 2019 that we should ‘CONSIDER antihypertensive drug treatment in addition to lifestyle advice for adults <60 with stage 1 hypertension and an estimated 10 year risk <10%’?

A

Evidence that QRISK may underestimate lifetime probability of developing cardiovascular disease

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17
Q

What is the importance of diagnosing hypertension?

A

It is an important risk factor for the development of cardiovascular disease such as ischaemic heart disease and stroke (unusual to itself cause symptoms unless very high)

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18
Q

What is the range in which normal blood pressure lies?

A

90/60 - 140/90

note that 24 hour BP average reading considers >=135/85 to be hypertension

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19
Q

What are the 2 categories for causes of hypertension? Which is more common?

A
  1. Primary/ essential hypertension: 90-95%
  2. Secondary hypertension
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20
Q

What is thought to be the cause of primary aka essential hypertension?

A

No single disease causes it, series of complex physiological changes which occur as we get older

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21
Q

What are 3 categories for causes of secondary hypertension?

A
  1. Renal disease
  2. Endocrine disorders
  3. Other causes
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22
Q

What are 4 renal causes for secondary hypertension?

A
  1. Glomerulonephritis
  2. Chronic pyelonephritis
  3. Adult polycystic kidney disease
  4. Renal artery stenosis
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23
Q

What are 6 endocrine causes of secondary hypertension?

A
  1. Primary hyperaldosteronism
  2. Phaeochromocytoma
  3. Cushing’s syndrome
  4. Liddle’s syndrome
  5. Congenital adrenal hyperplasia (11-beta hydroxylase deficiency)
  6. Acromegaly
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24
Q

What are 5 causes of secondary hypertension that fit into the ‘other’ category (i.e. not renal or endocrine)?

A
  1. Glucocorticoids
  2. NSAIDs
  3. Pregnancy
  4. Coarctation of the aorta
  5. Combined oral contraceptive pill
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25
Over what BP might someone start to experience symptoms, and what are 3 examples of these?
* \> 200/120 mmHg 1. headaches 2. visual disturbance 3. seizures
26
What are 4 ways that GPs can assess for end-organ damage when assessing a patient with newly diagnosed hypertension?
1. **Fundoscopy**: hypertensive retinopathy 2. **Urine dipstick**: check for renal disease as cause or consequence of HTN 3. **ECG**: check for left ventricular hypertrophy (Sokolov-Lyon: s wave depth V1 + tallest R wave heigh in V5/6 \>7 big squares) or ischaemic heart disease (ST segment depression of 1.0mm or greater, ST segment elevation and alternans, u wave inversion) 4. **Bloods**: U+Es, lipids
27
What are 5 tests to perform following diagnosis of hypertension?
1. U+Es 2. HbA1c 3. Lipids - hyperlipidaemia is another risk factor for CVD 4. ECG 5. Urine dispstick
28
What cardiac abnormality can hypertension cause?
Left ventricular hypertrophy (\>35mm V1 S wave + V5 or 6 R wave on ECG)
29
What are 3 overarching aspects of managing hypertension?
1. Drug therapy with antihypertensives 2. Modification of risk factors to reduce overall risk of cardiovascular disease 3. Monitoring patient for development of complications of hypertension
30
What is the mechanism of action og ACE (angiotensin converting enzyme) inhibitors?
Inhibit the conversion of angiotensin I to angiotensin II
31
What are 3 common side effects of ACE inhibitors?
1. Cough 2. Angioedema 3. Hyperkalaemia
32
What is a patient group in which ACE inhibitors must NOT be used?
Pregnant women
33
What monitoring must be performed after starting ACE inhibitors?
Renal function, check 2-3 weeks after starting due to risk of worsening renal function in patients with renovascular disease
34
What is the mechanism of action of calcium channel blockers?
Block voltage-gated calcium channels, relaxing vascular smooth muscle and force of myocardal contraction
35
What are 3 side effects of calcium channel blockers?
1. Flushing 2. **Ankle swelling** 3. Headache
36
What are 3 side effects of thiazide type diuretics?
1. Hyponatraemia 2. Hypokalaemia 3. Dehydration
37
How strong is the diuretic action of thiazide diuretics?
Very weak
38
What are 3 examples of thiazide diuretics?
1. Chlorthalidone 2. Hyrochlorothiazide 3. Methyclothiazide
39
What is the mechanism of action of angiotensin II receptor blockers (A2RB)?
Block effects of angiotensin II at the AT1 receptor
40
What is a side effect of angiotensin receptor blockers?
Hyperkalaemia
41
When are ARBs generally used?
Situations where patients have not tolerated an ACE inhibitor, usually due to the development of a dry cough
42
What is the NICE guidance for drug therapy to treat hyptertension?
* \<55 years or type 2 diabetes mellitus: * ACE inhibitor or ARB * Then ACE inhibitor/ARB + CCB OR A+thiazide diuretic * Then A+C+ thiazide diuretic. * Then step 4 * \>55, Afr-Caribbean and NO T2DM: * CCB * CCB+ ACEi/ARB OR ACEi/ARB+thiazide diuretic * A + C + D * then step 4 * step 4 * if potassium \<= 4.5 add low-dose spironolacton * if potassium \> 4.5 add an alpha or beta blocker * if not controlled on 4 drugs then specialist review
43
What are 3 pieces of lifestyle advice to give re lowering blood pressure?
1. Low salt diet: aim for less than 6g/day, ideally 3g a day. Reducing by 6g a day lower systolic BP by 10mmHg 2. Caffeine intake should be reduced 3. General advice: stop smoking, drink less alcohol, eat balanced diet rich in fruit and veg, exercise more, lose weight
44
What should be considered in patients \<40 with hypertension?
Specialist referral to exclude secondary causes
45
What are 3 things to consider/confirm before seeking specialist advice for a patient with hypertension on the optimal dose of 4 drugs?
1. confirm elevated clinic BP with ABPM or HBPM 2. assess for postural hypotension 3. discuss adherence
46
What is the blood pressure target for a patinet \<80 years? Both clinic and ambulatory/home?
* Clinic: \<140/90, * ABPM/HBPM: \<135/85
47
What is the blood pressure target for a patient \<80 years? Both clinic and ambulatory/home?
* Clinic: \<140/90, * ABPM/HBPM: \<135/85
48
What is the blood pressure target for a patient \>80 years? Both clinic and ambulatory/home?
* Clinic: \<150/90, * ABPM/HBPM: \<145/85
49
What is a new blood pressure drug and what is an example?
Direct renin inhibitors e.g. Aliskiren (branded Rasilez)
50
What is the mechanism of action of direct renin inhibitors e.g. Aliskiren?
Inhibit renin so block conversion of angiotensinogen to angiotensin I
51
What effects of direct renin inhibitors have trials found and what side effects are reported?
* Fall in blood pressure similar to ACEi/ARB but haven't looked at mortality in trials * SE: diarrhoea ocasionally seen, SEs uncommon * Only current role is for patient intolerant of more established drugs
52
What medication should be taken by women who are at high risk of developing pre-eclampsia?
Aspirin 75mg od from 12 weeks until birth of baby
53
What are 4 examples of women at high risk of developing pre-eclampsia in pregnancy?
* Hypertensive disease during previous pregnancies * Chronic kidney disease * Autoimmune disorders such as SLE or antiphospholipid syndrome * T1 or 2 diabetes mellitus
54
What are the normal changes in blood pressure in normal pregnancy?
* BP usually falls during first trimester (particuarly diastolic), continues to fall until 20-24 weeks * after this, usually increases to pre-pregnancy levels by term
55
What is hypertension in pregnancy defined as?
* Systolic \> 140 mmHg or diastolic \>90 mmHg (same as normal) * **or** increase above booking readings of **\> 30 mmHg systolic** of **\>15 mmHg diastolic**
56
What are the 3 groups that a pregnant woman who is hypertensive can be categorised into?
1. Pre-existing hypertension 2. Pregnancy-induced hypertension (PIH) aka gestational hypertension 3. Pre-eclampsia
57
What defines the 'pre-existing hypertension' category of pregnant women who are hypertensive?
History of hypertension before pregnancy OR elevated BP \>140/90 before 20 weeks gestation. No proteinuria and no oedema
58
What proportion of pregnancies does pre-existing hypertension occur in? Who is it more common in?
3-5%, more common in older women
59
What is the definition of pregnancy-induced hypertension (PIH aka gestational hypertension)?
* Hypertension in second half of pregnancy i.e. after 20 weeks. NO proteinuria or oedema * Resolves following birth typically after 1 month
60
In what proportion of pregnancies does pregnancy-induced hypertension occur?
5-7%
61
When does pregnancy-induced hypertension typically resolve?
typically after one month following birth
62
What are 2 things that women with pregnancy-induced hypertension are at increased risk of in later life?
1. Future pre-eclampsia 2. Hypertension in later life
63
What is the definition of pre-eclampsia?
Pregnancy-induced hypertension **in association with proteinuria** (\>0.3g/ 24 hours), after **20 weeks gestation** oedema may occur but less commonly used as a criterion
64
In what proportion of pregnancies does pre-eclampsia occur?
5%
65
What are 3 things to remember when measuring blood pressure in children?
1. correct cuff size is approximately 2/3 length of upper arm 2. 4th Korotkoff sound used to measure diastolic BP until adolescence, when 5th Korotkoff sound can be used 3. results should be compared with a graph of normal values for age
66
What causes the majority of hypertension in children?
Renal parenchymal disease - 80% (most are secondary causes)
67
What are 6 causes of hypertension in children?
1. Renal parenchymal disease 2. Renal vascular disease 3. Coarctation of the aorta 4. Phaeochromocytoma 5. Congenital adrenal hyperplasia 6. Essential or primary hypertension (becomes more common as children become older)
68
What are 5 drug causes of hypertension?
1. Steroids 2. Monoamide oxidase inhibitors (first antidepressants e.g. selegiline) 3. COCP 4. NSAIDs 5. leflunomide (DMARD for RA and PA)
69
What are 2 groups that hypokalaemia can be classified into?
those associated with hypertension, and those which are not
70
What are 5 causes of hypokalaemia with hypertension?
1. Cushing's syndrome 2. Conn's syndrome (primary hyperaldosteronism) 3. Liddle's syndrome (genetic disorder, high BP assoc with low plasma renin activity) 4. 11-beta hydroxylase deficiency (congenital adrenal hyperpasia - 10% of cases) 5. Cabenoxolone, anti-ulcer drug, and liquorice excess
71
What are 5 causes of hypokalaemia without hypertension?
1. Diuretics 2. GI loss e.g. diarrhoea, vomiting 3. Renal tubular acidosis (type 1 and 2) 4. Bartter's syndrome 5. Gitelman syndrome
72
In which age group is isolated systolic hypertension (ISH) common?
Elderly - affected 50% of people over 70
73
Which group identified that treating isolated systolic hypertension could reduce risk of strokes and IHD?
Systolic Hypertension in the Elderly Programe (SHEP)
74
How does NICE recommend that isolated systolic hypertension is treated?
Same stepwise fashion as normal (but 1991 advice was thiazides first line)
75
What is the recommended target for BP for patients with **type 2** diabetes?
Same as everyone (under 80): \<140/90, little benefit of lower targets
76
What is the target for blood pressure in **type 1** diabetics?
\<135/85 unless albuminuria or 2 or more features of metabolic syndrome, in which case \<130/80
77
What is the first line antihypertensive recommended for diabetics and why?
ACE inhibitors, because they have a **renoprotective effect in diabetes** If Afro-Caribbean, offer ACE inhibitor plus thiazide diuretic or calcium channel blocker
78
Why might diabetic patients have more postural symptoms when taking antihypertensive therapy than the average patient without diabetes?
**Autonomic neuropathy** may be present in diabetic patient
79
Why should routine use of beta blockers in uncomplicated hypertension be avoided, particularly in combo with thiazides?
May cause **insulin resistance**, **impair insulin secretion** and alter the **autonomic response to hypoglycaemia**
80
What antihypertensive treatment do the majority of patients with chronic kidney disease require?
\>2 drugs to treat hypertension
81
What is the first line drug to treat hypertension in CKD and why?
ACE inhibitors; particularly helpful in **proteinuric** renal disease e.g. **diabetic** nephropathy
82
What may be seen after starting an ACE inhibitor in CKD and why?
small fall in glomerular filtration pressure (GFR) and rise in creatinine, as these drugs **reduce filtration pressure**
83
According to NICE, what is an acceptable fall in GFR and rise in creatinine following ACE inhibitor treatment of hypertension in CKD?
* GFR: fall by up to 25% * Creatinine: rise by up to 30%
84
What should follow a fall in GFR/ rise in creatinine of any degree?
Prompt careful monitoring and exclusion of other causes e.g. NSAIDs; rise greater than 30% in creatinine/ GFR drop \>25% may indicate underlying renovascular disease
85
In addition to ACE inhibitors what drug is a useful anti-hypertensive in patients with CKD and why?
* **Furosemide** (loop diuretic) - particularly when GFR falls **\<45 ml/min**. Added benefit of **lowering serum potassium** * High doses usually required
86
What is a risk of the high doses of furosemide often required to treat hypertension in CKD? What should be done if it occurs?
Risk of dehydration e.g. gastroenteritis, consider temporarily stopping drug
87
What are 3 types of calcium channel blocker?
1. Verapamil 2. Diltiazem 3. Dihydropyridines: nifedipine, amlodipine, felodipine
88
What are 3 indications for verapamil?
1. Angina 2. Hypertension 3. Arrhythmias
89
Which drugs should NOT be given with verapamil and why?
Beta blockers: may cause heart block (verapamil highly negatively inotropic - reduces strength of heart contractions)
90
What are 5 side effects of verapamil?
1. Heart failure 2. Constipation 3. Hypotension 4. Bradycardia 5. Flushing
91
What are 2 indications for using diltiazem?
1. Angina 2. Hypertension
92
When should you exercise caution when using diltiazem?
When patients have heart failure or are taking beta-blockers (although less negatively inotropic than verapamil)
93
What are 4 side effects of diltiazem?
1. Hypotension 2. Bradycardia 3. Heart failure 4. Ankle swelling
94
What are 3 indications for dihydropyridine type calcium channel blockers (nifedipine, amlodipine, felodipine)?
1. Hypertension 2. Angina 3. Raynaud's
95
Why don't dihydropyridines cause a worsening of heart failure like verapamil and diltiazem?
affects peripheral vascular smooth muscle more than myocardium - but may cause ankle swelling
96
What are 3 side effects of dihydropyridine-type calcium channel blockers?
1. Flushing 2. Headache 3. Ankle swelling
97
How do thiazide diuretics work?
**Inhibiting** sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Cl- symporter. Potassium is lost as a result of more sodium reaching collecting ducts.
98
What are 2 examples of thiazide-LIKE diuretics (recommended for hypertension by NICE)?
1. Indapamide 2. Chlortalidone
99
What are 6 common adverse effects of thiazide-like diuretics?
1. Dehydration 2. Postural hypotension 3. Hyponatraemia, hypokalaemia, hypercalcaemia 4. Gout 5. Impaired glucose tolerance 6. Impotence
100
What are 4 rare adverse effects of thiazide-like diuretics/ thiazides?
1. Thrombocytopaenia 2. Agranulocytosis 3. Photosensitivity rash 4. Pancreatitis
101
If a patient's QRISK is greater than 10%, what should be offered regardless of blood pressure?
Statin
102
What is the aim for lipid reduction with statins and over what time frame?
40% reduction in non-HDL lipids in 3 months
103
What monitoring should be performed after starting a statin?
* baseline liver monitoring * LFTs within 3 months * LFTs again at 12 months

GP (43 decks)

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