Hypertension ☺️ Flashcards
Description
- diagnostic threshold
- diagnosis
140/90+ (135/85+ with home readings
Stage 1 - 140/90+
Stage 2 - 160/100+
Stage 3 - 180/110+
Measure blood pressure
- 140/90+ => repeat
- if 2nd v different => repeat, record lower of last 2
- confirm with 24hr ambulatory BP/1wk home readings (135/85+)
Epidemiology
Affecting more than 1 in 4 adults.
The prevalence increases to more than 50% after the age of 60
Aetiology
-essential hypertension
MAJORITY OF CASES Age Genetics African Americans, South Asians High fat, salt diet Lack of physical activity and being overweight Alcohol
Aetiology
-secondary hypertension
Renal disease
- intrinsic renal disease
- renovascular disease (atheroma, PVD, renal artery stenosis)
Endocrine disease
- Cushings, Conns (high cortisol, RAAS activation)
- Phaeochromocytoma (high SNS)
- hyper (increased netabolism)/hypothyroid (increased fluid retention)
AI
- lupus
- scleroderma
Functional
-Pregnancy
Drugs
- steroids
- cocaine, amphetamines, alcohol
Pathophysiology
- impaired renal function (impaired fluid excretion)
- abnormal levels of hormones that regulate salt and water excretion (eg, Ang2, Aldosterone)
- excess SNS activation (eg, vasoconstriction) all contribute.
Symptoms
Asymptomatic
Malignant hypertension (rapid increase 180/120+) => AKI, HF
- headache
- visual changes (papilloedema, retinal hemorrhage)
- nosebleeds
- SOB
Differential diagnoses
The most common differentials include
Renal artery stenosis
CKD
Obstructive uropathy leading to post renal AKI
Red flag conditions
- Coarctation of the aorta
- Preeclampsia
- Phaeochromocytoma (postural hypotension, headache, palpitation, pallor, sweating, abdominal pain)
- Ilicit drug use
Signs
There are no specific signs that indicate hypertension but you can look for the impacts, secondary causes and risk factors
Physical examination
-BMI, waist circumference
CV exam findings
- Carotid bruit
- Peripheral edema
GI exam findings
- Abdominal bruit
- Palpate for enlarged kidneys, masses distended bladder, abnormal aortic pulsations
- Signs of heavy alcohol consumption leading to hypertension due to liver problems (spider nevi, gynecomastia, thinning body hair)
Neurological exam findings
-papiloedema from fundoscopy
Diagnostic criteria
HTN Stage 1
- 140-159
- 90-99
HTN Stage 2
- 160-179
- 100-119
HTN Stage 3
- 180+
- 120+
Additional investigations
Overall CVD risk - QRISK
- Cholesterol, HDL
- HbA1C => diabetes
End organ damage
- ECG/echo - LVH, past MI
- urinalysis => protein, blood
- U&E, eGFR => CKD
2ndary causes?
- U&E - low K in Conns, high Ca in high PTH
- Renal US - renal stenosis
- urinary metanephrines - phaerochromocytoma
- urinary free cortisol - Cushings
- TFTs - hypo/hyperthyroid
Management - lifestyle for all patients
Reduce risk factors
- smoking cessation
- low alcohol, salt, fat diet
- physical activity - 3min moderate/day
- weight loss if obese
Management - pharmacological
- U55, diabetic
- if Stage 2
- if Stage 1 and target organ damage, CVD, renal disease, diabetes, QRISK of 10%+
- Step 1 - ACEi or ARB
- Step 2 - ACEi or ARB and CCB or thaizide
- Step 3 - ACEi or ARB + CCB + thiazide
Aim
- U140/90
- U130/80 in diabetics
Management - pharmacological
- 55+ or Black
- if Stage 2
- if Stage 1 and target organ damage, CVD, renal disease, diabetes, QRISK of 10%+
- Step 1 - CCB
- Step 2 - CCB + ACEi or ARB or thiazide
- Step 3 - ACEi or ARB + CCB + thiazide
Aim -
- U140/90 in U80
- U150/90 in 80+
Management - drug induced
If safe -
- add pharmacological treatment
- stop causative medication, prescribe alt if possible
What would you address in a follow up?
During follow up
- ask about adherence and measure BP
- in older patients, ask about recent falls and postural hypotension as a result of antihypertensives
- check renal function (creatinine, U&E, eGFR) and dipstick urine for proteinuria)
- may assess QRISK
