Hypertension (Complete) Flashcards
Define hypertension
Persistently raised arterial blood pressure
List examples of complications that can arise due to hypertension (6).
Heart failure (due to ventricular hypertrophy)
Coronary artery disease
Stroke
Vascular dementia
Chronic kidney disease
Peripheral arterial disease
What are the two main types of hypertension based on its cause?
Primary hypertension: No obvious cause (90% of cases are primary)
Secondary hypertension: Has an underlying cause (e.g. renal, endocrine, vascular disorder, drugs).
List examples of causes of secondary hypertension.
Renal conditions:
* Diabetic nephropathy
* Polycystic renal disease
* Glomerular disease.
Endocrine:
* Cushings syndrome
* Hyper/hypothyroidism
* Hyperparathyroidism
* Phaeochromocytoma
* Aldosteronism.
Obesity
Sleep apneoa (oxidative damage to endothelium can increase BP due to changes in vasculature)
Pregnancy
Drugs
List 3 examples of renal causes of secondary hypertension
Diabetic nephropathy
Polycystic renal disease
Glomerular disease
List examples of endocrine causes of hypertension. (6)
Hyperthyroidism
Hypothyroidism
Cushing’s disease
Conn’s syndrome/aldosteronism
Hyperparathyroidism
Phaeochromocytoma
When should hypertension be suspected in clinic?
If systolic is sustained above 140mmHg
OR
If diastolic is sustained above 90mmHg
When should blood pressure be measure manually?
If patient has atrial fibrillation and there is an irregular pulse in the brachial/radial arteries.
What measures must be taken to ensure blood pressure is accurately measured at home and in clinic? (3)
Make sure equipment is properly calibrated
Make sure patient is in a calm, temperate environment.
Patient should be quiet and arm should be outstretched and supported
What are the stages of hypertension?
Stage 1:
1. Clinic: 140/90-159/99
2. ABPM: 135/85-149/94
Stage 2:
1. Clinic: 160/100-179/119
2. ABPM: 150/95 and above
Stage 3:
1. Clinic: 180/120
N.B. Clinic and ABPM criterion must be met
List 3 examples of hypertensive emergencies
Malignant hypertension
Assymptomatic high blood pressure
Pre-eclampsia
What is accelerated (malignant) hypertension?
Severe increase in blood pressure to 180/120 mmHg or higher with signs of retinal haemorrhage and/or papilloedema.
What are some associated symptoms that may present in patients with accelerated/malignant hypertension? (5)
Headaches (often occipital)
Visual disturbances
Chest pain (increased cardiac workload against high BP)
Dyspnoea
Neurological deficits (e.g. confusion)
Symptoms tend to present over course of days versus sudden onsent.
How is malignant hypertension managed?
Controlled drop in blood pressure, to around 160/100mmHg over at least 24 hours.
Medicine:
Oral CCB (e.g. nifedipine, amlodipine)
What symptoms alongside high BP are present in patients with phaeochromocytoma? (6)
Labile or postural hypotension
Headache
Palpitations
Anxiety
Abdominal pain
Pallor
Diaphoresis (excessive sweating)
(Definitely suspect in patients with normal thyroid functions as it could be due to high levels of adrenaline and noradernaline produced by phaeochromocytoma)
What first-line investigation should be done in patients suspected of phaechromocytoma?
Plasma metanephrine followed by urinary metanephrine.
Imaging should only be done after biochemical diagnosis obtained
How is phaechromocytoma managed?
1) Alpha blockade
2) Beta-blockade
3) Surgical resection
Referal for same-day specialist should be done for which patients? (2)
A clinic blood pressure of 180/120 mmHg and higher with signs of retinal haemorrhage or papilloedema or life-threatening symptoms.
Suspected phaeochromocytoma
What is the difference between malignant hypertension and assymptomatic hypertension?
Assymptomatic hypertension would have no signs of retinal haemorrhage or papilloedema or other organ involvement.
N.B. In cases of Assymptomatic hypertension. Make sure to check drug compliance, illicit drug use or secondary causes of hypertension.
What is pre-eclampsia?
New-onset persistent hypertension with proteinuria or evidence of systemic involvement in pregnant woman 20 weeks into gestation
How is pregnancy induced hypertension managed?
IV Magnesium Sulphate and IV Labetalol/Hydralazine/Methyldopa.
N.B. Magenesium sulphate has neuroprotective effects for both mother and fetus hence why it is first-line
Define white coat syndrome.
‘White-coat’ hypertension is blood pressure that is unusually raised when measured during consultations with clinicians but is normal when measured in other ‘non-threatening’ situations
A patient has come into clinic and has had a BP measurement of 143/90. What is the next step of action?
Repeat BP measurement and if different to the first, take an additional one and record the lowest of the last 2 measurements.
How is ABPM used to diagnose hypertension?
BP measurements are taking throughout the day during normal daily activity.
An average is calculated using at least 14 values from the patient during their normal waking hours.
How is HBPM used to diagnose hypertension? (3)
2 consecutive measurements with the person seated and:
Taken in the morning and evening
Taken at least 4-7 days
Discard 1st day measurements and calculate average with remaining.
After hypertension has been diagnosed, what examinations/investigations should be issued in all patients? (8)
Investigations to assess cardiovascular risk and target organ damage (e.g. kidneys and eyes)
Bedside:
Urine dipstick (Check for proteinuria)
ECG
Bloods:
HbA1c
U&Es
serum creatinine
eGFR
Total cholesterol and HDL cholesterol
Fundoscopy: Check for hypertensive retinopathy
What is the management plan for patients diagnosed with hypertension?
Lifestyle interventions: Low-salt diet, alcohol cessations, smoking cessation, reduced caffeine intake ect.
AND
Start anti-hypertensisve medication if stage 2
Start anti-hypertensive in stage 1 with any of following: diabetes, kidney disease, CVD, QRISK >10%, target organ damage.
List 4 examples of types of anti-hypertensive medication
ACE inhibitos
ARB
Calcium channel blockers
Thiazide diuretics
Which types of hypertensive patients should be given ACE/ARBs?
Have T2DM (regardless of ethncity)
Are under 55 and not Afro-Carribean or Black African.
When would ARBs be chosen over ACE inhibitors?
If patient develops complications from ACE inhibitors such as cough.
Which types of hypertensive patients should be given calcium channel blockers?
Non-diabetic patients who are Afro-carribean or Black african.
Over 55 who dont have Type 2 diabetes
When would you offer thiazide diuretics or thiazide-like diuretics?
If CCB is not well tolerated (e.g. ankle oedema).
Evidence of heart failure
N.B. If starting or changing treatment, offer a thiazide-like diuretic
Give an example of a thiazide-like diuretic
Indapamide
Name 2 examples of a thiazide diuretic
Bendroflumethiazide
Hydrochlorothiazide
If hypertension has not been managed even after starting anti-hypertensives, what must be checked before moving onto stage 2 of management?
Check drug adherence
What is the step 2 management plan for patients with hypertension which is poorly controlled?
First check adherance
ACE/ARB: Add CCB or thiazide-like diuretic.
CCB: Add ACE/ARB or thiazide-like diuretic
N.B. For Black African or Afro-carribean who do not have T2DM, add ARB over ACE
What is the step 3 management plan for patients with hypertension which is poorly controlled?
Check adherance
ACE/ARB + CCB + Thiazide-like diuretic
For Black-african or afro-carribean: ARB + CCB + Thiazide-like diuretics
List examples of target organ damage. (5)
Left ventricular hypertrophy
Hypertensive retinopathy
Increased ACR
CKD
Hypertensive encephalopathy
What is refractory hypertension?
Uncontrolled BP despite maximal antihypertensive therapy
How is hypertensive encephalopathy managed?
IV labetalol or IV infusion Sodium Nitroprusside
How is aortic dissection managed?
IV Labetalol or IV infusion Sodium Nitroprusside
Target 100-120mmHg systolic.
