Hypertension

Question 1

How do we diagnose hypertension?

Answer 1

• if BP measured in clinic is 140/90mmHg or higher
• then offer ABPM-over 24 hr period. 2 readings per hour during waking hours. If unsuitable, offer
• HBPM- 2 readings per day for ideally 7 days with 2 consecutive readings 1 minute apart at any one time. disregard first day measurement

Question 2

When can a diagnosis of hypertension be confirmed?

Answer 2

• clinic BP 140/90mmHg or higher AND

- ABPM or HBPM average of 135/85mmHg or higher

Question 3

What is the target BP for diabetics?

Answer 3

• clinic 140/80mmHg

- home 135/80mmHg

Question 4

What is the target BP for elderly (>80?)

Answer 4

• clinic < 150/90mmHg

- home 145/85mmHg

Question 5

What lifestyle interventions should be offered?

Answer 5

• healthy Mediterranean diet
• less than 14 units alcohol per week
• 150 mins moderate exercise per week and 75 mins intense exercise
• low salt diet
• stop smoking

Question 6

What does lowering BP help to prevent?

Answer 6

stroke
coronary events
heart failure
renal impairment

Question 7

Treatment guideline steps for HTN < 55yrs

Answer 7

STEP 1: ACEI if not tolerated ARB, if both not tolerated offer beta blocker

STEP 2: ACEI/ARB+CCB, if CCB not tolerated or at high risk of Heart failure, give thiazide-like diuretic, if BB given step 1, give CCB

STEP 3: ACEI/ARB + CCB + THIAZIDE like diuretic

STEP 4: (resistant HTN) refer to specialist, add low dose spironolactone or high dose thiazide-like diuretic in those who have blood K level of 4.5mmol/l or less. monitor renal function and electrolytes.
OR Consider alpha-blocker or beta-blocker when 4.5 or less

Question 8

Treatment guidelines for patients > 55yrs and patients of any age of African or Caribbean origin

Answer 8

STEP 1: CCB, if not tolerated or evidence/high risk of heart failure, give THIAZIDE related diuretic

STEP 2: CCB OR THIAZIDE like diuretic + ACEI OR ARB
*ARB+CCB is preferred in African

STEP 3+4: treat as for patients <55yrs

Question 9

ACE inhibitors examples (4)

Answer 9

rampril (first line)
enalapril
lisinopril
captopril

*monitor baseline potassium and 2 weeks after starting
treatment - risk of hyperkalaemia

Question 10

Angiotensin 2 receptor antagonist (ARB) examples (4) ?

Answer 10

Candesartan
Irbesartan
Losartan
Valsartan

Question 11

Calcium Channel Blocker (CCB) examples (6) ?

Answer 11

Amlodipine (rate limiting)
Diltiazem 
Felodipine 
Nicardipine 
Nifedipine 
Verapamil (non-rate limiting)

Question 12

Thiazide-like diuretic examples (3)?

Answer 12

metolazone
Indapamide
chlorthalidone

Question 13

When should beta blockers especially combined with thiazide-like diuretics be avoided?

Answer 13

In people with or high risk of diabetes

Question 14

What is stage 1 hypertension?

Answer 14

• clinic 140/90mmHg - 159/99mmHg
• home 135/85mmHg-149/94mmHg

*A discrepancy of more than 20/10 mmHg between clinic and ABPM/HBPM

Question 15

What is stage 2 hypertension?

Answer 15

• clinic 160/100mmHg or higher but less than 180/120mmHg
• home 150/95mmHg or higher

*treat stage 2 regardless of age

Question 16

What is stage 3 or severe hypertension?

Answer 16

• clinic systolic 180mmHg or higher

- clinic diastolic 120mmHg or higher

Question 17

What parameters need to be monitored for thiazide like diuretics?

Answer 17

1. Serum creatinine
2. eGFR
3. Serum electrolytes (Na,K,Mg)
4. Uric acid if gout suspected

measure at baseline and again 4-6 weeks after starting treatment

*2-4 weeks after for ACE/ARB

Question 18

What needs to be monitored when on CCBs?

Answer 18

1. heart rate (>55bpm)

checkup at least 4 weeks after starting treatment

Question 19

Side effects of CCBs? (6)

Answer 19

headache
facial flushing
dizziness 
tiredness
palpitations
ankle oedema - reduce dose add in ACEI or ARB and elevate ankles

Question 20

Side effects of ACEIs? (4)

Answer 20

First dose hypotension - reduce diuretic, use longer acting ACE e.g. Ramipril

Hyperkalaemia - monitor

Impaired renal function - 20% reduction in eGFR

Cough (excess of bradykinin)- try ARB instead

Question 21

Side effects of thiazide like diuretics (2)?

Answer 21

Hypokalaemia - monitor

fluid loss