Hypertension- risk prediction and lifestyle interventions

Question 1

Learning outcomes

Answer 1

• Discuss clinical assessment of hypertension with regard to key points in the history, examination and investigation
• Discuss hypertension risk assessment in the context of other risk factors for cardiovascular disease and determine which hypertensive patients are at particular risk of cardiovascular disease
• Determine risk using a cardiovascular disease risk predictor (such as QRISK3)
• Discuss the evidence base underpinning recommendations for various lifestyle interventions for systemic hypertension
• Discuss thresholds for drug intervention and recommended target levels
• Summarise current guidelines regarding therapeutic management of uncomplicated hypertension in adults

Question 2

Assessing a patient with hypertension- History taking

Answer 2

•History
–Past history
•Cardiovascular disease, kidney disease, BP in pregnancy–Other risk factors
–Drug history
•Non-steroidal anti-inflammatory drugs
•Herbal remedies
•Oral contraceptive pill
•Compliance with treatment
•Other drugs

•Family history
–Hypertension
–Cardiovascular disease
–Kidney disease
–Endocrine disease

•Lifestyle
–Weight, height >BMI
–Alcohol
–Salt
–Diet
–Exercise

Question 3

Examination of a patient with hypertension

Answer 3

• Pulse–Rate, rhythm, symmetry, radio-femoral delay (wrist and femur checked to see if pulse in sync- coarctation of aorta)
• Blood pressure–Supine: both arms–Standing
• Heart, chest, abdomen
• Fundoscopy

Question 4

2. Target organ damage

Answer 4

•Heart -left ventricular hypertrophy (excessive muscle growth, heart failure more common)
ECG/ echocardiography
•Kidney –protein leak in the urine (microalbuminuria) and declining glomerular filtration rate
•Eye –retinal disease
•Artery walls -atherosclerosis

Question 5

Secondary causes recap and investigation

Answer 5

• Primary hyperaldosteronism –an excessive production of aldosterone- blood test for aldosterone
• Cushing’s syndrome –an excess of corticosteroid production- cortisol volume in urine/24hrs
• Phaeochromocytoma –excessive catecholamine production- tested in urine
• Renal artery stenosis –a narrowing of the main artery supplying the kidney- scan/whooshing noise over artery
• Intrinsic renal disease –such as glomerulonephritis- blood/urine tests
• Coarctation of the aorta –a narrowing in the aorta: rad-fem delay

Question 6

Predicting cardiovascular risk

Answer 6

Qrisk- a prediction algorithm for (CVD) that uses traditional risk factors (age, systolic BP, smoking status and ratio of total serum cholesterol to HDL cholesterol) together with body mass index, ethnicity, measures of deprivation, family history, chronic kidney disease, rheumatoid arthritis, AF, diabetes mellitus, and antihypertensive treatment.

•Cautions when calculating risk–Only applicable to primary prevention
•Secondary prevention = highest risk already
–Approximate risk only
–Not all risk factors are included
•HIV•Drugs•Autoimmune disorders•Already on treatment•Recently stopped smoking•High triglycerides
–Risk is generally very low in young people
–Risk is always high in older people
–NICE currently do not recommend using with
•Type 1 diabetes, chronic kidney disease, familial hypercholesterolaemia

Question 7

Managing HT- lifestyle interventions

Answer 7

•Stop smoking
•Achieve a healthy body weight i.e. BMI 20-25 kg/m2
–if ideal body mass cannot be achieved, losing 5% can have a significantly helpful effect on blood pressure.
–A healthy waist line measurement is also important
•Eat a healthy diet–diet high in fruit/vegetables and low in fat can reduce blood pressure.
•Restrict salt intake -avoid salt added at the table and choose foods low in salt-<1500 mg sodium per day is ideal for adults
•Moderate alcohol intake (no more than 14 units per week)
-Take adequate exercise
•Discourage excessive caffeine intake

Question 8

Who needs drug treatment?

Answer 8

•Persistent stage 2 hypertension
•Stage 1 hypertension < 80 years + ≥ 1 of:
–Target organ damage
–Established cardiovascular disease
–Renal disease
–Diabetes
–Estimated 10 year risk ≥ 10%
•Consider treatment if <60 years and 10 year risk < 10%
•Consider treatment if >80 years and BP >150/90 mmHg

Question 9

Targets for HT patients

Answer 9

•General target <140/90 mmHg
•If ≥ 80 years, <150/90 mmHgTargets are 5/5 mmHg lower if using ABPM / HBPM
•Specific targets apply if:
–Chronic kidney disease
–Type 1 diabetes
–Pregnancy