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MBBS IV - Junior Clerkship WCS > JC10 (Medicine) - Hypertension > Flashcards

JC10 (Medicine) - Hypertension Flashcards

1
Q

Etiologies of Hypertension

A 
Essential hypertension (95%):
→ Environmental: high salt intake, heavy alcohol consumption, obesity, lack of exercise, IUGR
→ Genetics

Secondary hypertension (5%): distinct, identifiable cause

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2
Q

Pathogenesis of hypertension

A

Mechanism: complex interplay between neurohormonal mechanisms

  • Young patients: predominantly ↑SN and ↑RAAS activities → ↑SVR ↑CO
  • Elderly patients: predominantly arterial degeneration → ↑SVR

Chronic hypertension causes target organ damage (TOD) in heart, brain, kidneys, vessels

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3
Q

3 methods of BP monitoring/ diagnosis

A

Office BP: Average of three readings, risk of masked HTN and White-coat hypertension

Home BP monitoring (HBPM): better adherence and correlation with prognosis

Ambulatory BP monitoring (ABPM): better accuracy and correlation with prognosis

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4
Q

Diagnosis of white-coat hypertension, masked hypertension and true hypertension

A

High office BP but normal ABPM/HBPM - white coat hypertension
High office BP and high ABPM/HBPM - True hypertension
Normal office BP but high ABPM/HBPM - Masked Hypertension

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5
Q

Cut-off BP for hypertension stages

A
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6
Q

Diagnosis of true hypertension

A

□ Hypertensive crisis, i.e. >180/120
□ Evidence of Target organ damage (TOD) + High BP (≥160/100)
□ High office BP (≥130/80) confirmed by HBPM/ABPM

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7
Q

Presentation of hypertension

A

□ Asymptomatic (incidental finding)
□ ↑BP: headache, dizziness, palpitations, easy fatigability, impotence
□ HTN vascular disease: epistaxis, haematuria, blurring of vision, episodes of weakness/dizziness, angina, dyspnoea
□ S/S of 2o cause

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8
Q

Risk factors of cardiovascular disease

A

Previous history of CVD

DM

HTN

Low HDL-C <1 mmol/L

Smoking

Age: ≥45y (M) or ≥55y (F)

Premature CHD in first degree relatives

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9
Q

Outline history taking questions for hypertension

A

□ Age: consider 2oHTN <35y or >55y
□ Duration of HTN and previous BP levels
□ Family Hx of HTN: essential HTN
□ Other risk factors: smoking, DM, lipid disorders, FHx of early CVD deaths
□ Lifestyle: diet, physical activity, family status, work

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10
Q

Outline physical exams for hypertension

A

□ BP/P: bilateral arms, supine and standing
□ BMI and waist circumference
□ CVS: standard + palpation/auscultation of all peripheral arteries
□ Fundus

Target organ damage (see pic)

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11
Q

First-line investigations for hypertension

A

Blood:
→ RFT and electrolytes: baseline renal function test, r/o renal parenchymal disease,
→ Hormone: hyperAldosteronmism and hyperPTH
→ Lipid profile for dyslipidemia
→ Serum fasting glucose: r/o DM
→ ± serum urate: baseline and look for hyperuricaemia

Urinalysis: haematuria (r/o renal disease), UACR (albuminuria)

ECG: LVH, MI, cardiac failure, heart block

Echocardiogram: for LVH

Calculation of 10y CVD risk

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12
Q

Causes of secondary hypertension

A 
Aetiology: DANCER
□ Drugs
□ Apnoea
□ Neurological: ↑ICP, stress, others
□ Coarctation of aorta

□ Endocrine:
→ Thyroid: hyperthyroidism, hypothyroidism
→ Adrenals: Cushing’s, Conn’s, phaeochromocytoma
→ Parathyroid: hyperparathyroidism
→ Others: pre-eclampsia, acromegaly

□ Renal:
→ Renal vascular: renal artery stenosis (RAS)
→ Renal parenchymal: GN, polycystic kidney, kidney failure

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13
Q

List drugs that can cause secondary hypertension

A

SN-related/ psychiatric: caffeine, amphetamines/ cocaine, levodopa, MAOI, antidepressants, decongestants

Fluid retention: OCP, anabolic steroids, mineralocorticoids, corticosteroids

Immunosuppressants (cyclosporine)

NSAIDs, COX-2 inhibitors

Alcohol, nicotine

Anti-cancer: chemotherapy, angiogenesis inhibitor, TKIs

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14
Q

Indicators of secondary hypertension

A

General:
→ Age of onset: <30y or diastolic HTN for ≥65y
→ Severity: accelerated or malignant HTN, disproportionate TOD for degree of HTN
→ Course: abrupt onset, drug-resistant or exacerbation of previously controlled HTN

Specific:

  • Unprovoked or excessive hypoK (thiazide diuretics use)
  • Renal HTN: palpable kidney, renal bruit, abnormal urinalysis
  • Endocrine: S/S of phaeochromocytoma, unexplained hypoK, signs of Cushing’s sundrome
  • Coarctation: radiofemoral delay
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15
Q

primary aldosteronism and secondary hypertension

  • Clinical features
  • Indications for screening
  • Screening tests
A
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16
Q

Renal artery stenosis and secondary HTN

  • Clinical features
  • Indications for screening
  • Screening tests
A
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17
Q

Renal parenchymal disease and secondary HTN

  • Clinical features
  • Indications for screening
  • Screening tests
A
18
Q

OSA and secondary hypertension

  • Clinical features
  • Indications for screening
  • Screening tests
A
19
Q

Coarctation of aorta and secondary HTN

  • Clinical features
  • Indications for screening
  • Screening tests
A
20
Q

Pheochromocytoma and secondary HTN

  • Clinical features
  • Indications for screening
  • Screening tests
A
21
Q

Cushing’s disease and secondary HTN

  • Clinical features
  • Indications for screening
  • Screening tests
A
22
Q

List all major target organs damaged by Hypertension

A

Vessels: Aorta, carotid arteries, peripheral arteries, coronary arteries… etc

Heart: Ventricles, Coronary arteries

Kidneys: renal vessels, tubules

Brain: Cerebral vessels, cerebral edema

Retina

23
Q

List cardiovascular damage caused by hypertension

A
24
Q

List renal and retinal damage caused by hypertension

A

Renal: Hypertensive nephrosclerosis, Hypertensive nephropathy

Retina: Hypertensive retinopathy, central retinal vein occlusion and blindness

25
Q

List cerebral damages caused by hypertension

A

TIA due to carotid atherosclerosis

Stroke due to small vessel hyalinosis or intracerebral haemorrhage from microaneurysms

HT encephalopathy due to cerebral edema

26
Q

Stages of hypertensive retinopathy

A
27
Q

Treatment options for hypertension

A
27
Q

Treatment options for hypertension ***

A

Lifestyle modifications:

  • Weight reduction
  • Diet: Low sodium, Low fat, High fruit/ vegetables, High K, DASH diet
  • Exercise: 30min/day
  • Alcohol: moderation ≤2 (M) or ≤1 (F) drinks/day

Medical therapy: Change dose/ combination therapy accordingly

  • First line: ACEI/ARB, CCB, thiazide diuretic (+/- BB)
  • Second line: Alpha blocker, Aldosterone antagonist or vasodilator
  • Adjunctive drugs: Aspirin (lower CVD risk), Statins (hyperlipidemia)
  • Substitute drugs: Methyldopa, hydralazine for pregnancy; Loop diuretics for CKD

Compelling indications: DM, CKD, CAD, LV dysfunction, Ischemic stroke

28
Q

Resistant HTN

  • Definition
  • Diagnosis
A

Definition:

  • Poor HTN control under 3 antihypertensive with 1 diuretic
  • HTN only controlled by ≥4 drugs
Diagnosis: Exclude pseudoresistance:
→ Adherence
→ Timing of drugs
→ Home and ambulatory BP
→ Exclude secondary hypertension
→ Identify confounding factors: diet, obesity, drugs
29
Q

Resistant HTN

  • Treatment
A

Increase dosage of existing therapy

Use second-line drugs: Aldosterone blockers, Loop diuretics

Alter combination of therapy

30
Q

Malignant hypertension

  • Clinical features
A

ABCDEF:

  • Azotemia
  • BP ≥220/120
  • Cardiac failure
  • Distress
  • Encephalopathy
  • Fundus

Clinical presentation: ↑BP + rapidly progressive TOD
□ Retina: papilloedema, retinal haemorrhages and exudates
□ HTN encephalopathy: severe headache, vomiting, visual disturbances, transient paralyses, convulsions, stupor and coma
□ Heart: acute LV failure
□ Kidneys: acute RF with oliguria, proteinuria

31
Q

Malignant hypertension

  • Mechanism
A

Mechanism: accelerated microvascular damage including
□ Fibrinoid necrosis in small vessel wall
□ Intravascular thrombosis

32
Q

Differentiate hypertensive emergency with hypertensive urgency

A

Hypertensive emergency (i.e. with TOD)

  • BP >180/120 + worsening/new TOD
  • Indication for acute BP control
  • e.g. aortic dissection, pheochromocytoma, eclampsia

Hypertensive urgency (i.e. no TOD)

  • Malignant HTN without TOD
  • HT with grade III or IV retinal changes
  • e.g. Hypertension with pre-op/ perioperative bleeding, Hypertension complicated by pregnancy, AMI, unstable angina
  • e.g. Catecholamine excess or sympathomimetic overdose
33
Q

First-line investigations for malignant hypertension

A

Ix:

  • CBC,
  • L/RFT,
  • cardiac enzymes,
  • aPTT/PT,
  • CXR, ECG,
  • urine RBC/albumin

Confirm BP twice, BP/P Q1H

Intra-arterial BP monitoring

34
Q

Treatment of malignant hypertension

- HTN emergency and HTN urgency

A

HTN emergency:

  • IV Labetalol
  • Sodium nitroprusside
  • Hydralazine
  • Phentolamine

HTN urgency:
- Oral antihypertensive: ACBD

35
Q

Specific treatment for malignant hypertension associated with following conditions

Acute Pulmonary edema
Angina/ AMI
Aortic dissection

A

Acute pulmonary edema: Nitroprusside/nitroglycerin + loop diuretic

Angina/AMI: Nitroglycerin, nitroprusside, labetalol, calcium channel blocker

Aortic dissection: Labetalol/propranolol IV + nitroprusside

36
Q

Treatment of malignant hypertension during pregnancy

A

IV hydralazine, nicardipine, labetalol

37
Q

Advantages and disadvantages of ABPM and HBPM

A
38
Q

ABCDE acronym for cause of HTN

A
39
Q

Investigations for target organ damage due to hypertension

A
40
Q

Indications for emergency BP reduction with IV treatments

A

MBBS IV - Junior Clerkship WCS (131 decks)

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