Hypertension - booklet Flashcards
Stages of hypertension
1
2
Severe
Stage 1 hypertension
- Clinic BP 140/90 or higher
- Ambulatory or home average 135/85 or higher
Stage 2 hypertension
- Clinic BP 160/100 or higher
- Ambulatory or home average 150/95 or higher
Severe hypertension
- Clinic systolic 180 or higher
- Or Clinic diastolic 120 or higher
- Treatment should be considered immediately without the need for ambulatory/home readings
When should ambulatory monitoring be offered?
If BP is higher than 140/90
Alternative is home monitoring
Symptoms of high blood pressure
- None/headache
- Sweating, headache, palpitations and anxiety could point to phaechromocytoma
- Muscle weakness or tetany could point to hyperaldosteronism
CVS risk factors
- TIA
- Stroke
- Diabetes
- Previous renal disease
- Smoking
- Cholesterol
- NSAID excess
- PMH of angina, CCF, palpitations, syncope/valvular heart disease
CVS risk factors - FH
- Hypertension
- Premature coronary disease
- PCKD
CVS risk factors - drugs
- All
- Inc any prior antihypertensives
- Drug intolerances/allergies
- Ask about compliance
Investigations for hypertension
- UACR
- Urine dip for haematuria
- Glucose
- U&Es
- Lipid profile
- Examine fundi - hypertensive retinopathy?
- ECG - 12 lead
- Consider echo if suggestion of LVH, valve disease or LVSD or diastolic dysfunction
CVS risk assessement
QRISK3 tool
When should treatment be offered?
- Stage 1 hypertension under 80 - treatment offered in those with evidence of organ damage, established CV disease, renal impairement, diabetes and 10yr QRISK of 10% or more
- Stage 2 - any age treatment should be offered
Blood pressure targets when on medication
- Clinic - If under 80 - target is less than 140/90
- If over 80 - target is 150/90
-
- Ambulatory under 80 is 135/85
- Over 80 is 145/85
Non-pharmacological treatment hypertension
- Weight reduction if BMI greater than 25kg/m2 - each kg weight loss = 3/2 mmHg reduction in BP
- Reduce salt intake
- Minimise alcohol intake
- Aerobic exercise
- Smoking cessation
Guidance for pharmacological management of BP
When to measure sitting and standing BP?
- Type 2 diabetes
- Postural hypotension symptoms
- Aged 80 and older
What is a hypertensive crisis?
- Increase in blood pressure, which if sustained over the next few hours, will lead to irreversible end organ damage (eg encephalopathy, LV failure, aortic dissection, unstable angina, renal failire)
How can people in hypertensive crisis present?
Emergency presentation:
* High BP with critical event eg encephalopathy, pulmonary oedema, AKI, MI)
Urgency presentation:
* High BP without critical illness but may include malignant hypertension associated with grade 3/4 hypertensive retinopathy
Aim of treatment in hypertensive emergencies
- Reduce diastolic BP to 110mmHg in 3-12hrs in emergency, 24hrs in urgency
- BMJ says: 25% within minutes-1hr
- If patient stable reduce BP to 160 systolic and 100-110 diastolic within next 2-6hrs
Treatment for hypertensive crisis emergency options
IV:
* Sodium nitroprusside
* Labetalol
* Glyceryl trinitrate
* Nicardipine
What is hypertensive urgency?
- Blood pressure that will damage organs within days
- Diastolic usually greater than 130mmHg, retinal changes present
Aim treatment in hypertensive urgency
- Reduce BP to diastolic of 100mmHg over 48-72hrs using oral regime
Options for oral treatment of hypertensive crisis
- Amlodipine
- Diltiazem
- Lisinopril
- ACEi and CCB icombo s effective and well tolerated
- Majority pts nifedipine + amlodipine is best
Classic triad of symptoms phaeochromocytoma
Episodic
* Headache
* Sweating
* Tachycardia
Most patients will not have all three
Classic sign of phaechromocytoma
- Sustained or paroxysmal hypertension
Diagnosing phaeochromocytoma
- Urinary and plasma metanephrines and catecholamines
- 24hr urine test main test
- CT and MRI scan abdo pelvis for adrenal tumours
- MIBG scan can detect if not showing on CT/MRI if diagnosis is likely
How is BP controlled in phaechromocytoma pending surgery?
- Alpha and beta blockade
- Alpha - Phenoxybenzamine
- Alpha ALWAYS before beta
When to suspect Cushings as cause of HTN?
- Physical appearance characteristics
- Hyperglycaemia bloods
- 24hr urine cortisol elevated
- Confirm with low dose dexamethasone supression test
When to suspect primary aldosteronism as cause of HTN?
- Low serum potassium
- High/normal sodium
- Resistant hypertenson
- FH of premature HTN
Investigations for primary aldosteronism
- Aldosterone:renin ratio in morning
- Plasma renin low in primary
- Adrenal CT
