Hypertension Flashcards
How do we diagnose hypertension?
- 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
When can a diagnosis of hypertension be confirmed?
- clinic BP 140/90mmHg or higher AND
- ABPM or HBPM average of 135/85mmHg or higher
What is the target BP for diabetics?
- clinic 140/80mmHg
- home 135/80mmHg
What is the target BP for elderly (>80?)
- clinic < 150/90mmHg
- home 145/85mmHg
What lifestyle interventions should be offered?
- 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
What does lowering BP help to prevent?
stroke
coronary events
heart failure
renal impairment
Treatment guideline steps for HTN < 55yrs
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
Treatment guidelines for patients > 55yrs and patients of any age of African or Caribbean origin
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
ACE inhibitors examples (4)
rampril (first line)
enalapril
lisinopril
captopril
*monitor baseline potassium and 2 weeks after starting
treatment - risk of hyperkalaemia
Angiotensin 2 receptor antagonist (ARB) examples (4) ?
Candesartan
Irbesartan
Losartan
Valsartan
Calcium Channel Blocker (CCB) examples (6) ?
Amlodipine (rate limiting) Diltiazem Felodipine Nicardipine Nifedipine Verapamil (non-rate limiting)
Thiazide-like diuretic examples (3)?
metolazone
Indapamide
chlorthalidone
When should beta blockers especially combined with thiazide-like diuretics be avoided?
In people with or high risk of diabetes
What is stage 1 hypertension?
- clinic 140/90mmHg - 159/99mmHg
- home 135/85mmHg-149/94mmHg
*A discrepancy of more than 20/10 mmHg between clinic and ABPM/HBPM
What is stage 2 hypertension?
- clinic 160/100mmHg or higher but less than 180/120mmHg
- home 150/95mmHg or higher
*treat stage 2 regardless of age
What is stage 3 or severe hypertension?
- clinic systolic 180mmHg or higher
- clinic diastolic 120mmHg or higher
What parameters need to be monitored for thiazide like diuretics?
- Serum creatinine
- eGFR
- Serum electrolytes (Na,K,Mg)
- Uric acid if gout suspected
measure at baseline and again 4-6 weeks after starting treatment
*2-4 weeks after for ACE/ARB
What needs to be monitored when on CCBs?
- heart rate (>55bpm)
checkup at least 4 weeks after starting treatment
Side effects of CCBs? (6)
headache facial flushing dizziness tiredness palpitations ankle oedema - reduce dose add in ACEI or ARB and elevate ankles
Side effects of ACEIs? (4)
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
Side effects of thiazide like diuretics (2)?
Hypokalaemia - monitor
fluid loss
