Hypertension (pathology) Flashcards
What are the NICE BP values for stage 1, 2, 3 primary hypertension (clinical and ABPM daytime average)?
Stage 1: Clinic = >140/90mmHg ABPM daytime = >135/85mmHg Stage 2: Clinic = >160/100mmHg ABPM daytime = >150/95mmHg Stage 3: Clinic = >180/120mmHg
What are different types of primary hypertension (3)?
Primary hypertension - no cause found
White coat hypertension - hypertension when in the clinic
Masked hypertension - hypertension normal in clinic but elevated outside of clinic
What does a nocturnal dip in BP indicate?
Better prognosis
What are risk factors for primary hypertension (14)?
Smoking Diabetes mellitus Renal disease Male sex Hyperlipidaemia Previous MI/ stroke Left ventricular hypertrophy Age (decreased arterial compliance) Salt intake Alcohol intake High BMI Stress Low birthweight African populations (salt retainers)
What are investigations for primary hypertension?
- ABPM (ambulatory blood pressure monitoring)
- HBPM (home blood pressure monitoring)
Assess end organ damage: - ECG & echo —> LVH
- urine analysis (proteinuria)
- renal ultrasound
- renal function test (creatinine, eGFR, urea)
Quantify risk: - ASSIGN score
- Q-risk
- HBPM (home blood pressure monitoring)
What is the treatment/management criteria for stage 1 hypertension?
Stage 1 >135/85mmHg ABPM Treat if <80*years old AND one of: - target organ damage - established CVD - renal disease - diabetes - 10 year CV risk >=10%
*If >80 year old target BP >140/85mmHg
What is the treatment/management criteria for stage 2 hypertension?
ABPM >150/95mmHg = treat ANY age
What is the stepped treatment/management approach for hypertension in <55 y.o.? (4 steps)
High Renin
Step 1: ACEi/ARB (CCB or beta blocker if female in childbearing age)
Step 2: ACEi/ARB + CCB or thiazide diuretic
Step 3: ACEi/ARB +CCB + thiazide diuretic
Step 4: confirm resistant hypertension (postural hypertension, compliance) + add on therapy:
- low dose spironolactone if K+ < 4.5mmol/L
- alpha or beta blocker if K+ >4.5mmol/L
What is the stepped treatment/management approach for hypertension in >55 y.o. Low renin (No ACEi) + black people of African/Caribbean origin of any age? (4steps)
Step 1: CCB
Step 2: CCB + ACEi/ARB or thiazide diuretic
Step 3: CCB + ACEi/ARB + thiazide diuretic
Step 4: confirm resistant hypertension (postural hypertension, compliance) + add on therapy:
- low dose spironolactone if K+ < 4.5mmol/L
- alpha or beta blocker if K+ >4.5mmol/L
What is secondary hypertension?
Hypertension due to identifiable cause
What are causes of secondary hypertension?
- Chronic renal disease (polycystic kidney, chronic pyelonephritis)
- Renal artery disease (stenosis, fibromuscular dysplasia)
- Endocrine disease (Cushing’s disease, Primary hyperaldosteronism, Phaeochromocytoma, acromegaly, hypo- and hyperthyroidism, Glucocorticoid remediable aldosteronism (GRA))
- Pregnancy (pre-eclampsia, gestational hypertension)
- Vascular (coarctation of aorta)
- Sleep apnoea (resistant nocturnal hypertension)
Which drugs may induce secondary hypertension? (4)
- NSAIDs
- Combined oral contraceptive
- Corticosteroids
- Cocaine and other stimulants
What other factors may make you consider presenting hypertension is secondary hypertension?
- Severe/ resistant hypertension
- Child/ adolescent
- Worsening of previously stable hypertension
- Malignant hypertension- medical emergency
No other RF and age <30
What investigations used to identify secondary hypertension?
- Renal function and urinalysis
- Renal imaging (US, MRI renal a.)
- aldosterone to renin ratio (ARR)
- 24h urine for catecholamines/metanephrines for phaeochromocytoma/paraganglioma
What is the treatment/management for conditions causing secondary hypertension? (Multifocal fibromuscular dysplasia, Renal artery stenosis, Renal artery stenosis, Phaeochromocytoma, Cushing’s disease)
Multifocal fibromuscular dysplasia:
- stent if patient young and no atheroma
Renal artery stenosis:
- no stent but standard medical therapy if older patient and atheroma
Polycystic kidney:
- remove kidney —> transplant or dialysis
Phaeochromocytoma:
- refer to endocrinology and surgery
Cushing’s disease:
- surgery, chemotherapy and regular antihypertensive therapy
What are the 4 hypertension in pregnancy?
Chronic hypertension = patient with pre-existing hypertension
Gestational hypertension = new onset hypertension but no proteinuria
Preeclampsia = rise in BP >140/90 mmHg from 20 w. gestation + proteinuria > 300 mg/24h
Eclampsia = preeclampsia + seizures
What are the treatments/management of chronic, gestational & preeclampsia hypertension in pregnancy?
Chronic hypertension:
- Nifedipine MODIFIED RELEASE, Methyldopa, Labetalol, Atenolol
Gestational hypertension:
- Nifedipine MR, Methyldopa, Labetalol
Preeclampsia:
- Nifedipine MR, Methyldopa, Labetalol + IV Hydralazine or Esmolol
Acute severe hypertension, what is a Hypertensive emergency/malignant hypertension?
BP>180/120mmHg AND acute target organ damage
Acute severe hypertension, what is a Hypertensive urgency/accelerated hypertension?
Elevated BP (>180/120mmHg) but NO acute target organ damage
What is the treatment/management for hypertensive emergency (in everyone apart from acute ischaemic stroke + aortic dissection)?
- Hospital admission and rapid blood pressure lowering
- Lower systolic BP by 10-20% within 1st hour then to 160/80 mmHg in next 6 hours
- Oral medication once target BP is reached
When would you used rapid blood pressure lowering in hypertension? What are the risks of this?
- Ischaemic stroke if BP > 185/110 if received or eligible for thrombolysis
- ischaemic BP> 220/120 mmHg if not eligible for thrombolysis
- Aortic dissection-> lower systolic BP to 100/120 mmHg
Risk:
- If lower the BP too much in ischaemic stroke -> block flow
What is orthostatic hypotension?
Blood pressure drop while shifting from lying/sitting to standing
Pressure decrease of 20 mmHg systolic and/or diastolic pressure decrease of 10 mmHg within 3 minutes of standing
What are the risk factors for orthostatic hypotension?
- Age
- Diabetes
- Antihypertensive drugs
- autoimmune systemic diseases
- neurological syndromes
- Pure autonomic failure
- Multiple system atrophy
- Parkinson’s disease
What are the treatment/management strategies for orthostatic hypotension?
- Teach manoeuvres to mobilise blood from lower body or stimulate pressure receptors leading to vasoconstriction (rising on the heels or isometric handgrips)
- Tilting the bed so patient is head up
- Ice cold water before bed
MIDODRINE for neurogenic OH-> alpha 1 adrenoreceptor agonist
