Managing Hypertension in Primary Care

Question 1

What is pre-hypertension

Answer 1

• systolic blood pressure 120-139 mmHg

- diastolic blood pressure 80-89 mmHg

Question 2

Define stage 1 hypertension

Answer 2

clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average ranging from 135/85 mmHg to 149/94 mmHg

Question 3

define stage 2 hypertension

Answer 3

clinic blood pressure ranging from 160/100 mmHg to 179/119 mmHg and subsequent ABPM daytime average or HBPM average is 150/95 mmHg or higher

Question 4

define stage 3 hypertension

Answer 4

clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 120 mmHg or higher

Question 5

Who gets hypertension

Answer 5

• ethnic origin - highest in african-caribbean people and from the Indian subcontinent

Question 6

hypertension is usually…

Answer 6

asymptomatic

Question 7

When is hypertension detected

Answer 7

• opportunistic screening
• routine consultations
• medical examinations for insurance, travel or occupational purposes
• may present with complications of hypertension

Question 8

what devices can be used to measure blood pressure

Answer 8

• The traditional mercury sphygmomanometer: although reliable, this is becoming less widespread, partly due to environmental concerns about disposal of mercury
• Aneroid sphygmomanometers
• Automated sphygmomanometers: these are becoming more popular in primary care but may not measure accurately if there is pulse irregularity.

Question 9

what happens if the cuff size is too small or too large

Answer 9

• too small= overestimation of blood pressure

- Too large = underestimation of blood pressure

Question 10

what does it mean if you have lower blood pressure in the legs compared with the arms

Answer 10

• if you have lower blood pressure in the legs compared with the arms it indicates peripheral vascular disease and is associated with increased mortality

Question 11

what patients should you look for in postural hypotension

Answer 11

• elderly
• have diabetes
• have dizziness or falls

Question 12

when should you admit patients as a medical emergency

Answer 12

• Symptoms or signs of a cardiovascular event
• Clinic blood pressure 180/120 mmHg or higher with signs of papilloedema or retinal haemorrhages (accelerated hypertension), or life-threatening symptoms such as new-onset confusion, chest pain, signs of heart failure, or acute kidney failure
• Signs or symptoms of phaeochromocytoma (labile or postural hypotension, headache, palpitations, pallor, abdominal pain or and diaphoresis).

Question 13

what should you do if a patient has severe hypertension of 180/120mmHg or higher but no symptoms or signs indicating same day referral for specialist care

Answer 13

• investigate for target organ damage as soon as possible
• if target organ damage is found consider starting antihypertensive treatment immediately
• advise about lifestyle changes
• request ambulatory or home blood pressure monitoring but do not wait for the results before treating
• if no target organ damage is identified you should repeat the clinic blood pressure measurement within 7 days

Question 14

what should you do if blood pressure is greater than 140/90

Answer 14

• take a second confirmatory reading at the same consultation
• if the second blood pressure is different from the first take a third measurement
• record the lower of the last two measurements as the clinic blood pressure
• if the blood pressure remains between 140/90 and 180/120 at the first consultation then you shoulder offer the patient a 24 hour ABPM

Question 15

How often should patients with an ABPM lower than 135/95 have there blood pressure checked

Answer 15

• every 5 years

Question 16

What are the risk factors for cardiovascular disease

Answer 16

• Age
• Sex
• Socioeconomic group
• Smoking habits throughout the patient’s lifetime
• Family history of cardiovascular disease (particularly a history of a proven cardiovascular event in a first degree relative when they were younger than 60)
• Personal history of diabetes, kidney disease, or elevated cholesterol.

Question 17

What are the symptoms of cardiovascular disease

Answer 17

• chest pain
• breathlessness
• ankle swelling
• palpitations

Question 18

name causes of secondary hypertension

Answer 18

• Chronic renal disease
• Cushing’s syndrome
• Primary aldosteronism
• Thyrotoxicosis
• Phaeochromocytoma.

Question 19

What are common clinical features of secondary hypertension

Answer 19

• age younger than 30
• sudden worsening of hypertension
• poor response to treatment

Question 20

What are common findings of secondary hypertension

Answer 20

• elevated serum creatine on initial assessment (suggesting renal disease)
• hypokalaemia (may suggest renovascular hypertension or hyperaldosteronism)
• a large rise in serum creatinine after starting an angiotensin converting enzyme inhibitor

Question 21

What should you find in a clinical examination of someone with hypertension

Answer 21

• Fundoscopy for evidence of papilloedema or retinal haemorrhage
• Observation of neck veins. If these are distended it could indicate a raised jugular venous pulse, which is a sign of congestive cardiac failure
• Assessment of the apex beat to look for left ventricular hypertrophy
• Auscultation of the heart for murmurs (indicating valve disease or cardiac failure)
• Auscultation of the lungs for basal crepitations (suggesting congestive cardiac failure)
• Palpation of the radial, popliteal, and foot pulses. Weak or absent pulses in the lower limbs may indicate peripheral vascular disease
• Assessment of the ankles and sacrum for any evidence of oedema
• Auscultation of the carotid arteries for bruits (may indicate carotid stenosis, which carries an increased risk of a stroke).

Question 22

What clinical investigations should you do to look for secondary hypertension or signs of target organ damage

Answer 22

• urinalysis with a dipstick to detect protein and blood as possible markers for kidney disease and send a sample for urinary albumin:creatine ratio
• ECG - look for evidence of left ventricular hypertrophy, myocardial ischaemia, old myocardial infarctions or arrhythmias

Serum biochemistry

• electrolytes and creatine
• glycated haemoglobin
• serum lipid profile
• estimated glomerular filtration rate (eGFR)

Question 23

How do you establish the total risk of cardiovascular disease

Answer 23

• NICE guidelines currently recommend that the QRISK2 tool is used to assess the 10 year risk of developing cardiovascular disease in those aged between 25 and 84 years who do not have type 1 diabetes and have no pre-exisiting cardiovascular disease

Question 24

When should you refer a patient with hypertension

Answer 24

• suspected secondary hypertension
• drop in systolic blood pressure of over 20mmHg when standing and persistent symptoms of a postural hypotension
• poor response to antihypertensive drug treatment

Question 25

What is isolate diastolic hypertension thought to be due to

Answer 25

The mechanism for it is thought to be increased arteriolar resistance, in the presence of low or normal arterial stiffness, reflecting a healthy arterial vasculature with minimal atherosclerosis.
- should be followed up in the long term though to check that systolic hypertension does not happen

Question 26

What lifestyle changes should you recommend for people with hypertension

Answer 26

• Weight reduction - even moderate weight loss has a beneficial effect on blood pressure - 10kg of weight loss leads to a mean reduction in systolic blood pressure of 5-10mmHg
• Physical activity - encourage sedentary patients to increased aerobic activity
• Alcohol intake
• dietary changes - reduce salt

Question 27

What are the measures that do not impact on blood pressure directly but reduce the risk of cardiovascular disease

Answer 27

• stop smoking
• increasing consumption of oily fish
• replace saturated fats with monounsaturated fats

Question 28

which stage of hypertension should you introduce antihypertensive drug treatment to

Answer 28

• persistent stage 2 hypertension

Question 29

in what stage 1 patients should you introduce antihypertensive drug treatment

Answer 29

Adults aged less than 80 years who have persistent stage 1 hypertension and one of the following:

• target organ damage
• established cardiovascular disease
• renal disease
• diabetes
• estimated 10 year risk of cardiovascular disease of 10% or more

Question 30

Name the 5 classes of antihypertensive drugs

Answer 30

• Thiazide diuretics
• ACE inhibitors
• Angiotensin II receptor blockers
• Calcium channel blockers
• Beta blockers (preferably cardioselective beta blockers)

Question 31

What is step 1 hypertension treatment

Answer 31

Offer an ACE inhibitor or an ARB to adults who:

• Have type 2 diabetes (any age or family origin) or
• Are aged less than 55 years old and are not of African or Caribbean origin
• Offer an ARB if ACE inhibitor is not tolerated. Do not combine ACE inhibitor and ARB to treat hypertension

Offer a calcium-channel blocker (CCB) to adults who:

• Are aged 55 years or older and do not have type 2 diabetes or
• Are of African or Caribbean origin and do not have type 2 diabetes

Offer a thiazide-like diuretic if CCB is not tolerated or if there is evidence of heart failure

• A thiazide-like diuretic (such as indapamide) is preferred over a conventional thiazide diuretic (such as bendroflumethiazide or hydrochlorothiazide) if starting or changing diuretic treatment for hypertension.
• If the patient is already receiving conventional thiazide diuretic and has stable, well-controlled blood pressure, continue with current treatment.

Question 32

what is step 2 hypertensive treatment

Answer 32

• You should first review your patient to check they are taking medication as prescribed in step one.
• For adults whose blood pressure is not controlled with step one treatment of an ACE inhibitor or ARB, offer a CCB or a thiazide-like diuretic in addition to the step one regimen
• For adults whose blood pressure is not controlled with step one treatment of a CCB, offer an ACE inhibitor, or an ARB, or a thiazide-like diuretic in addition to the step one regimen
• For adults whose blood pressure is not controlled with step one treatment of a thiazide-like diuretic, offer an ACE inhibitor or an ARB in addition to the step one regimen
• For adults of African or Caribbean origin who do not have type 2 diabetes, offer an ARB in preference to an ACE inhibitor in addition to step one treatment

Question 33

What is step 3 hypertensive treatment

Answer 33

• Review your patient’s medication to ensure they are being taken at optimal tolerated doses.
• For adults whose blood pressure is not controlled with step two treatment, offer a combination of three drugs: an ACE inhibitor or ARB, a CCB, and a thiazide-like diuretic.

Question 34

What is step 4 hypertensive treatment

Answer 34

• Adults whose blood pressure is not controlled with optimal tolerated doses of a combination of an ACE inhibitor or ARB, a CCB, and a thiazide-like diuretic are considered to have resistant hypertension
• You should confirm blood pressure measurements using ABPM or HBPM, assess your patient for postural hypertension, and review their adherence to medication before considering additional treatment.
• If resistant hypertension is confirmed, consider adding a fourth drug:
• Low-dose spironolactone for adults who have blood potassium level 4.5 mmol/L or less (monitor blood sodium and potassium and renal function within one month of starting treatment)
• Alpha-blocker or beta-blocker for adults who have blood potassium level more than 4.5 mmol/L
• Seek specialist advice or refer the patient if blood pressure remains uncontrolled in those taking optimal tolerated doses of four drugs.

Question 35

what are the recommended targets for optimal blood pressure control

Answer 35

• For patients aged under 80 years: clinic blood pressure lower than 140/90 mmHg. This equates to a daytime average blood pressure of lower than 135/85 mmHg on ABPM or HBPM during waking hours.
• For patients aged over 80 years: clinic blood pressure lower than 150/90 mmHg This equates to a daytime average blood pressure of lower than 145/85mmHg on ABPM or on HBPM during waking hours.
• It is recommended that you use clinical judgement for people with frailty or multimorbidity.