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CARDIOLOGY > Hypertension & Hypertensive Emergencies > Flashcards

Hypertension & Hypertensive Emergencies Flashcards

1
Q

what are the 3 stages of hypertension

A
  • stage 1: clinical BP > 140/90mmHg or ABPM >135/85mmHg
  • stage 2: clinical BP >160/100mmHg or ABPM >150/95mmHg
  • severe: clinical systolic >180mmHg or clinical diastolic >110mmHg
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2
Q

what are the symptoms of HTN

A
  • nil or headache
  • sweating, headache, palpitations or anxiety –> phaechromocytoma
  • muscle weakness or tetany –> hyperaldosteronism
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3
Q

what are you looking for in a history of HTN

A
  • PMHx: angina, CCF, palps, syncope, valvular heart disease
  • FHx: HTN, permature coronary disease, PKD
  • DHx: prior anti-HTN, drug intolerances
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4
Q

what are you looking for on physical assessment for HTN

A

look for secondary causes
- Cushing’s syndrome
- PCK enlarged kidneys
- renal bruit
- radio-femoral delay (coarctation)

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5
Q

what are the 2 broad categorisations of HTN

A
  • essential: 90% aka primary HTN
  • secondary
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6
Q

what are the secondary causes of HTN

ROPED

A
  • Renal disease: renal artery stenosis
  • Obesity
  • Pre-eclampsia
  • Endocrine: hyperaldosteronism Conn’s syndrome
  • Drugs e.g. alcohol, steroids, NSAIDs, oestrogen
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7
Q

how can renal artery stenosis be diagnosed

A

duplex USS
MR/CT angiogram

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8
Q

what are appropriate investigations into HTN

A
  • protein in urine: send urine sample for estimation of albumin:Cr ratio
  • haematuria using reagant strip
  • blood sample: plasma glucose, electrolytes, Cr, eGFR, serum total and HDL cholesterol
  • examine fundi for hypertensive retinopathy
  • 12 lead ECG
  • consider echo for LVH, valve disease/LVSD or diastolic dysfunction
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9
Q

what should be done whilst watiing for confirmation of diagnosis of HTN

A
  1. evidence for target-organ involvement
  2. CVS risk assessment (qrisk)
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10
Q

when should treatment for stage 1 HTN be offered

A

in those under 80:
- evidence of target organ damage
- established CVD
- renal impairment or diabetes
- Qrisk >20%

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11
Q

what is the target BP for patients with diabetes, previous stroke, IHD, CKD

A

< 130/80

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12
Q

what is a QRISK score

A

estimates the percentage risk that a patient will have a stroke or myocardial infarction in the next 10 years

When the result is above 10%, they should be offered a statin, initially atorvastatin 20mg at night

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13
Q

what is the non-pharmacological treatment of HTN

A
  • weight reduction if BMI>25
  • moderate salt intake
  • minimise alcohol
  • aerobic exercise
  • smoking cessation
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14
Q

what is the pharmacological step by step management of HTN

A

Step 1: Aged under 55 or type 2 diabetic of any age or family origin, use A. Aged over 55 or Black African use C

Step 2: A + C. Alternatively, A + D or C + D

Step 3: A + C + D

Step 4: A + C + D + fourth agent
- serum K <4.5mmol/L - spironolactone
- serum K >4.5 mmol/L: doxazosin or atenolol

A – ACE inhibitor (e.g., ramipril)
B – Beta blocker (e.g., bisoprolol)
C – Calcium channel blocker (e.g., amlodipine)
D – Thiazide-like diuretic (e.g., indapamide)
ARB – Angiotensin II receptor blocker (e.g., candesartan)

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15
Q

how does spironolactone work

A

potassium sparing diuretic which works by blocking the action of aldosterone in the kidneys
- sodium excretion and potassium reabsorption
- helpful when thiazide diuretics casues hypoK

monitor U&Es as can cause hyperkalaemia

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16
Q

what are the complications of high BP

A
  • Ischaemic heart disease (angina and acute coronary syndrome)
  • Cerebrovascular accident (stroke or intracranial haemorrhage)
  • Vascular disease (peripheral arterial disease, aortic dissection and aortic aneurysms)
  • Hypertensive retinopathy
  • Hypertensive nephropathy
  • Vascular dementia
  • Left ventricular hypertrophy
  • Heart failure
17
Q

a patient with HTN has develop LVH - what could you expect to find on examination

A
  • sustained and forceful apex beat
  • seen on an ECG using voltage criteria
  • best diagnosed with an echo
18
Q

how often do the NICE guidelines recommend monitoring BP

A

every 5 years to screen for HTN and every year in T2DM

19
Q

what BP readings would require 24-hr ABPM

A

clinic BP 140/90 - 180/120mmHg

20
Q

what is accelerated HTN aka malignant HTN

A

extremely high BP > 180/120 + retinal haemorrhages or papilloedema

21
Q

what is the management for patients with accelerated HTN

A
  • same day referral
  • fundoscopy exam
  • assess for secondary causes and end-organ damage
22
Q

what is a hypertensive crisis

A

an increase in BP which if sustained over the next few hours will lead to irreversible end-organ damage i.e. encephalopathy, LV failure, aortic dissection

23
Q

what are the 2 main presentations of a hypertensive crisis

A
  1. emergency: high BP associated w critical event e.g. encephalopathy, pulmonary oedema, acute kidney injury, myocardial ischaemia
  2. urgency: high BP without a critical illness, but may include ‘malignant hypertension’: associated with grade 3/4 hypertensive retinopathy
24
Q

what is the aim of therapy in a hypertensive crisis

A

reduce the diastolic BP to 110 mmHg in 3 - 12 hours (emergency) or 24 hours (urgency).

25
Q

what are IV treatment options in a hypertensive emergency

A
  1. Sodium nitroprusside
  2. Labetalol
  3. GTN (1 - 10 mg/hr)
  4. Esmolol acts within 60 seconds, with a duration of action of 10 - 20 minutes. Typically, the drug is given as a 0·5 - 1 mg/kg loading dose over 1 minute, followed by an infusion starting at 50 µg/kg/min and increasing up to 300 µg/kg/min as necessary
26
Q

what are the oral treatment options for hypertensive emergency

A
  • amlodipine 5-10mg OD
  • diltiazem 120-300mg OD
  • lisinopril 5mg OD
  • combination of ACEi/calcium antagonist effective and well tolerated
27
Q

what is the most effective treatment regimen for patients with hypertensive urgency

A

nifedipine 20mg MR BD + amlodipine 10mg OD for 3 days the continue with amlodipine 10mg OD after

28
Q

what is the classic triad of symptoms of phaemochromocytoma

A
  • episodic headache
  • sweating
  • tachycardia
29
Q

what is the most common sign of phaeochromocytoma

A

sustained or paroxysmal hypertension

30
Q

how is diagnosis of phaeochromocytoma confirmed

A

main test is 24hr urine collection
- measurements of urinary and plasma fractionated metanephrines and catecholamines
- CT/MRI scan of abdomen-pelvis may detect adrenal tumours

31
Q

what is the management once phaeochromocytoma is diagnosed

A

surgical resection

32
Q

how is HTN controlled pending surgery for phaeochromocytoma

A

combined alpha/beta adrenergic blockade
- phenoxybenzamine most commonly used; inital dose 10mg OD/BD then the dose is increased by 10-20mg in divided doses every 2-3 days as needed
- final dose is typically 20-100mg daily

After adequate alpha-adrenergic blockade has been achieved, beta-adrenergic blockade is initiated, which typically occurs two to three days preoperatively. The beta-adrenergic blocker should never be started first

33
Q

in the case that phenoxybenzamine is not tolerated for phaeochromocytoma, what can be used instead

A

CCB - nicardipine

34
Q

what are appropriate tests/investigations to diagnose Cushing’s

A
  • bloods may show hyperglycaemia
  • 24hr urine cortisol excretion will be elevated (diurnal
  • low dose dexamethasone suppression test
  • adrenal CT indicated
35
Q

what are appropriate tests/investigations to diagnose primary hyperaldosteronism

A

suspect this diagnosis if low serum K and high/normal Na (but in up to 50%, K is normal)
- consider in pt w hypoK and in pt w resistant HTN or FHx of premature HTN
- aldosterone:renin ratio in morning ( ratio is typically > 20-30)
- Plasma renin activity is typically very low or undetectable in patients with primary aldosteronism, and the plasma aldosterone concentration high
- investigated by hypertension specialists or endocrinologists as confirmatory testing will be required
- adrenal CT

CARDIOLOGY (3 decks)

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