plenary

Question 1

hypertension

Answer 1

the level of blood pressure at which intervention with treatment outweighs the risk of treatment.
conventionally an office BP of 140/90 or home/ambulatory BP of 135>85mmHg

Question 2

classification of hypertension

Answer 2

grade I:
SBP 140-159
DBP 90-99

grade II:
SBP 160-179
DBP 100-109

grade III:
SBP>180
DBP>110

Question 3

assess for signs of target organ damage (TOD)

Answer 3

• renal- urine albumin/creatine ratio (ACR)
• heart- ECG evidence of Left Ventricular Hypertrophy LVH
• eyes- hypertensive retinopathy

Question 4

hypertensive retinopathy grading

Answer 4

grade I: ‘silver wiring’- increased reflectiveness and tortuosity

grade II: Grade I + AV nipping

Grade III: Grade II + haemorrhage and cotton wool exudates ( infarction)

grade IV: Grade III + papilloedema

Question 5

lifestyle modification

Answer 5

Low salt diet (<5g per day)
Caution Lo Salt (KCL) with ACEI/ARB/Sprionolactone/Renal impairment due to hyperkalaemia

Alcohol <14 units/week for men and women, ideally over at least 3 days and avoid binge drinking (increased risk of stroke).
Consider more strict reductions (14 units men, 8 units women according to Hypertension guidelines)

Mediterranean diet. Fresh fruit and vegetables, low red meat.

Weight control (BMI<30, waist <102 cm for men and < 88 cm for women – aim for ideal BMI 20-25)

Regular exercise (activity every day, 150 mins moderate exercise or 75 mins vigorous exercise per week)

Smoking cessation! (Recommend formal support systems, nicotine replacement or specific smoking cessation pharmacotherapy as indicated)

Question 6

pharmacological treatment

Answer 6

First line
ACE I/ARB for young patients less than 55 years (contraindicated in pregnancy!) and not of Afro-Caribbean ethnicity, otherwise CCB
Second line
CCB or ACE I/ARB depending on what was used first line
Third line
Thiazide like diuretics Fourth line (resistant hypertension)
Alpha blockers/Spironolactone if K not high

Betablockers – reserved for those with a compelling indication to receive them in addition to hypertension (Angina, post-MI, LV dysfunction, AF rate control)

Question 7

resistant hypertension

Answer 7

Poor COMPLIANCE/ADHERENCE Main reason for poor control of BP! Largely asymptomatic condition
Perceived side effects of medication Polypharmacy
Remember mono-therapy with one drug often ineffective (One third patients will require 3 drugs for good control)
Combination of different drugs at lower doses may work synergistically and cause less side effects
Increasingly guidelines recommend combined agents in one tablet –POLYPILLS even as first line therapy (more effective, less side effects, greater adherence)

Question 8

secondary causes of hypertension

Answer 8

Unusual
Commoner in younger patients, those with resistant hypertension and non-dippers (loss of circadian variation in BP)
Check for causative medications NSAIDs/OCP/Steriods/Decongestants/Cocaine/Liquorice/amphetamines
Renal – Renal artery stenosis (watch for sudden fall in renal function with ACEI/ARB), renal parenchymal disease, Chronic Kidney disease
Primary Hyperaldosteronism (Conn’s Syndrome) – look for low potassium on U and E test as a clue! Check plasma renin/aldosterone ratio
Phaeochromocytoma - check urine metanephrines
Cushing’s Syndrome – Elevated cortisol levels (24 hour urine cortisol)
Aortic Coarctation – check for radio-femoral pulse delay
Obstructive Sleep Apnoea

Question 9

who to refer to for secondary care?

Answer 9

Emergency referral:

Accelerated/ ‘Malignant’ Hypertension – severe hypertension >180/120 mmHg (but often less than this) with Grade IV retinopathy (haemorrhages and papilloedema) and symptoms of chest pain, heart or renal failure, TIA/Stroke

Routine referral:

Suspected secondary cause for hypertension
Less than 40 years of age and > Grade II Hypertension
Treatment resistant hypertension (remember often non adherence) TOD where treatment of this may improve outcome
Sudden onset > Grade II hypertension

Question 10

heart attack symptoms

Answer 10

• chest pain- heavy, squeezing
• short of breath
• sweating
• nausea and vomiting
• persisting symptoms

Question 11

ST segments

Answer 11

Elevated – AMI/ LV aneurysm/pericarditis/printzmetals

Depressed – ischaemia/LVH with strain/medication/posterior MI

Question 12

STEMI ECG criteria

Answer 12

ST elevation in 2 contiguous leads

> 1mm limb leads or > 2mm chest leads

chest pain or cardiac symptoms of an MI in the past 12 hours (or ongoing pain)

Question 13

immediate treatment

Answer 13

Oxygen
IV Analgesia
IV Anti-emetic
PO Aspirin
PO Ticagrelor/Prasugrel