Lecture 2 - Hypertension

Question 1

How many adults in the UK have high blood pressure and how many aren’t currently receiving treatment?

Answer 1

Nearly 30% have high BP
And up to half receiving no treatment

Question 2

How many people in the UK live with undiagnosed high blood pressure, without knowing they are at risk?

Answer 2

5-7 million people

Question 3

How likely are people with high blood pressure to develop heart disease or have a stroke?

Answer 3

Three times more likely

Question 4

What is hypertension a major risk factor for?

Answer 4

Ischaemic and haemorrhage stroke
MI
Heart failure
Chronic Kidney Disease
Conginitive Decline
Premature death

Question 5

What is hypertension?

Answer 5

Raised blood pressure

Question 6

What percentage of hypertension cases are primary?

Answer 6

95%

Question 7

What percentage of hypertension cases are secondary?

Answer 7

<5% of cases

Question 8

What are the signs and symptoms?

Answer 8

Some patients will not feel anything
Dizziness
Headache
Blurred/ Double Vision
SOB
Subconjunctival haemorrhage
Nausea
Nose bleeds
Drowsiness
Irregular heartbeats

Question 9

How is hypertension diagnosed?

Answer 9

Measure BP in both arms:
- If the difference in readings between arms is more than 15mmHg repeat the measurements
- If the difference in readings between arms remains more than 15mmHg on the 2nd measurement - measure the subsequent blood pressure with the higher reading

Question 10

If the blood pressure measured in clinic is above 140/90 mmHg what happens next..

Answer 10

Take the 2nd measurement during the consultation, is 2nd measurement subsequently different from the 1st take a 3rd measurement
Record the lower of the last 2 measurements as the clinic’s blood pressure

Question 11

If the clinic BP is measured between 140/90 mmHg and 180/120 mmHg what happens next….

Answer 11

Offer ambulatory pressure monitoring (ABPM) or HBPM to confirm diagnosis of hypertension
should also carry out a CVD risk

Question 12

Describe ABPM

Answer 12

At least two consecutive measurements are taken, at least 1 minute apart and wit the person seated and blood pressure is recorded twice daily, ideally in the morning and the evening
Blood pressure recording continues for at least 4 days, ideally for 7 days
Use the average values to confirm diagnosis of hypertension

Question 13

Define stage 1 hypertension

Answer 13

Clinical BP ranging from 140/90 mmHg to 155/99 mmHg and subsequent ABPM daytime average
HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg

Question 14

Define stage 2 hypertension

Answer 14

Clinic BP of 160/100 mmHg or higher but less than 180/120 mmHg and ABPM daytime average
HBPM average blood pressure from 150/95 mmHg or higher

Question 15

Define stage 3 hypertension

Answer 15

Clinical systolic BP of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher

Question 16

Name the lifestyle interventions which lower BP

Answer 16

Reduce alcohol intake, reduce weight loss, reduce salt intake and regular physical exercise

Question 17

Name the lifestyle modifications which don’t reduce BP but reduce CV risk

Answer 17

Stopping smoking, reducing total intake of saturated fats, increase intake of oily fish

Question 18

Name the pharmacological treatments of hypertension

Answer 18

Diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, Angiotensin II receptor antagonists, alpha1 antagonists, centrally acting anti-hypertensives

Question 19

Give examples of ACEIs and ARBs

Answer 19

Ramipril, Lisinopril, Losartan, Candesartan

Question 20

What do ACEIs and ARBs do?

Answer 20

Either prevent formations of or action of angiotensin II (potent vasoconstrictor)
Increase K+ by reducing aldosterone

Question 21

When is ACEIs and ARBS first line for hypertension?

Answer 21

Patients < 55 yrs old
Diabetic patients due to renoprotective effects

Question 22

What monitoring is required on ACEIs and ARBS?

Answer 22

Baseline U and Es - potassium levels particularly in patients taking other drugs which raise potassium levels - repeat 10-14 days then 3 months and with every dose increase and therefore annually after

Question 23

What are the side effects of ACEIs and ARBs?

Answer 23

First dose hypotension
Persistent dry cough
Renal impairment - frequent U and E monitroing
Best to take at night

Question 24

What do calcium channel blockers do?

Answer 24

Interfere with inward displacement of calcium ions through the channels into the cell membrane
Relaxation of vascular smooth muscle and causes vasodilation

Question 25

Name the 3 types of CCBs

Answer 25

Dihydropyridines - amlodipine and felodipine - cause vasodilation of coronary and peripheral arteries with little effect on HR
Benzothiazipine - diltiazem - reduces HR
Phenylalkamines - verapamil - reduces HR

Question 26

When are CCBs first line for hypertension?

Answer 26

Over 55 yrs old or black African or African Caribean family origin and not diabetic
not used in patients at risk of HF

Question 27

What are the side effects of CCBs?

Answer 27

Headaches, abdominal pain, flushing, impotence, ankle oedema

Question 28

Before increasing therapy what should you do?

Answer 28

Always consider adherence before increasing therapy, and always optimise the dose before adding in a second or third drug
Consider patient’s overall CVD risk
Involve patients in all decisions and explain the reasons

Question 29

What is important when withdrawing therapy?

Answer 29

Hypotension - can result in falls and hospital admissions
Always enquire about any dizziness or light headedness, especially in elderly
Check for postural hypotension
Consider withdrawal if CV risk low and BP well controlled

Question 30

What are the three options when treating patients with high blood pressure?

Answer 30

• Do nothing
• Pharmacological therapy
• Non-pharmacological therapy

Question 31

When is the best time to take an anti-hypertensive?

Answer 31

Bedtime hypertension treatment improves CVD risk reduction

Question 32

What do beta blockers do?

Answer 32

Reduce HR
Reduces renin CNS and PNS - reduces the release of neurotransmitters and sympathetic nervous activity

Question 33

What are the side effects of beta-blockers?

Answer 33

Fatigue and lethargy
Bronchospasm, cold extremities

Question 34

When are beta-blockers not used?

Answer 34

In diabetics and asthmatics