Revision Flashcards
What do you do if the clinical BP is =/>140/90 mmHg? (3)
Offer ABPM. HBPM is a suitable alternative.
Calculate CV risk
Look for end organ damage
What do you do if clinical BP is =/>180/110 mmHg? (2)
Consider starting anti-hypertensive drug Rx immediately
Consider referral
When do you refer do specialist care?
BP >180/110mmHg with signs of papilloedema and/or retinal haemorrhage
OR
Suspected phaeochromocytoma
What is Stage 1 hypertension?
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg
What is Stage 2 hypertension?
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg
What is Stage 3 hypertension/Hypertensive Crisis?
> 180 mmHg systolic, >110 mmHg diastolic
What lifestyle advice would be offered to those with hypertension?
- Healthy diet and regular exercise
- Relaxation therapies
- Reduced alcohol intake
- Discourage excessive consumption of coffee/other caffeine-rich products
- Low salt intake
- Stopping smoking
Who should be offered anti-hypertensives?
Those under the age of 80 with stage 1 HTN + target organ damage, established CVD, renal disease, diabetes, CVD risk >20%
Anyone with stage 2 HTN
What is the target clinical BP for treated HTN?
140/90 mmHg for those under 80
150/99 mmHg for those over 80
What is 1st line treatment for hypertension for those under 55 years?
Angiotensin-converting enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB).
What is 1st line treatment for hypertension for those over 55 year and/or afro-Caribbean people?
Calcium-channel blockers. Thiazide-like diuretic if CCB is unsuitable.
What is the 2nd step of treatment?
CCB + ACE-I or ARB
What is the 3rd step of treatment?
CCB + ACE-I/ARB + Diuretic (thiazide-like)
Which medication is first line for HTN in diabetic patients
ACE-I
What is HTN a risk factor for? (4)
Stroke, IHD, HF, CKD
When measuring BP in the clinic multiple times, which reading should you record?
The lowest
What types of end organ damage can occur (3)?
Left ventricular hypertrophy, CKD, hypertensive retinopathy
What tool is used to calculate CVD risk?
QRISK2
How is end organ damage investigated for? (4)
Bloods, urine, ECG, CXR
What is the definition of hypertensive urgency?
elevated BP (>180/110) but no target organ damage.
What is the definition of hypertensive emergency?
Elevated BP with end organ damage.
What complication can occur in hypertensive emergency?
Encephalopathy
How is a hypertensive emergency managed?
IV nitroglycine (vasodilator)/CCB/beta-blocker, ICU admission
What are the symptoms of hypertensive urgency? (4)
o Headache
o SoB
o Nosebleeds
o Severe anxiety
What are the symptoms of a hypertensive emergency? (6)
o Chest pain o SoB o Back pain o Numbness/weakness o Vision change o Difficulty speaking
How is BP calculated?
Cardiac Output x Total Peripheral Resistance
What modifies BP in short term?
baroreceptors, chemoreceptors, ANS
What modifies BP after 4-6 hours?
RAAS
How is arterial pressure raised by CNS? (4)
1) The SNS releases noradrenaline from nerve terminals
2) NA acts on alpha-adrenergic receptors of vascular smooth muscle cell (VSMC)
3) arterioles constricted
4) Heart directly stimulated
What does activation of beta-adrenoreceptors cause? (2)
Reduced contractility of blood vessels and increased contractility of the heart
When is adrenaline clinically used? (3)
Anaphylactic shock, cardiogenic shock, cardiac arrest
When is NA used? (2)
severe hypotension, septic shock
When are dopamine and dobutamine clinically used? (2)
Heart failure and cardiogenic shock
Which nerve innervates the carotid body?
Hering’s nerve, which is branch of the glossopharyngeal
Which nerves innervates the aortic arch baroreceptors?
Vagus
What happens when you stand up?
strong sympathetic discharge from baroreceptors
What to the chemoreceptors detect?
low O2, high Co2 and acidosis
What is the atrial volume reflex?
Increased Atrial stretch due to increase pressure causes reduced water reabsorption & Increased filtration of fluid into renal tubule. This fluid loss via kidneys decreasing BP.
What does the macula densa detect?
Rise in Na+ concentration (low arterial pressure)
What does the macula densa do when it detects an increased Na+ concentration?
Causes release of renin which causes efferent arteriole resistance
What produces angiotensinogen?
the liver
What does aldosterone cause?
increased Na+ absorption and secretion of K+ and H+
What does angiotensin II cause? (5)
Increased sympathetic activity, increased Na+Cl- + H20 reabsorption, aldosterone release, arteriole vasoconstriction , ADH release
What happens to arteries in HTH and T2DM?
Increase in wall thickness, impairment of endothelial function
How does obesity cause hypertension?
Reduction in adiponectin (vasodilator) cause increased contractility of small arteries and increased vascular tone
What is the main side-effect of ACE-I?
Tickly cough
Which anti-hypertensives can be used safely during pregnancy?
Nifedipine, labetolol, methyldopa
What is a main side-effect of Calcium channel blockers?
Ankle swelling
What is a main side effect of loop diuretics?
Gout attack
What is a main side effect of thiazide diuretics?
Hyponatriemia
What is a main side effect of aldosterone antagonists?
Hyperkalaemia
How does renal disease cause secondary HTN?
Kidneys don’t function optimally which causes increased fluid retention
How does glomerular disease cause secondary HTN?
glomerulus doesn’t filter waste and sodium which increases plasma volume
How does renovascular disease lead to secondary HTN?
lack of perfusion to kidney which causes increased fluid retention
How does pheochromacytoma cause secondary HTN?
It’s a tumour which occurs in the adrenal gland and causes increased release of adrenaline and Noradrenaline which increases BP
How does Sleep Apnea lead to secondary HTN?
lack of oxygen causes increased heart contractility at night
How do brain tumours and enchepalitis lead to secondary HTN?
There is decreased blood flow in the brain and the body attempts to counteract this by increasing BP
What 4 features are suggestive of secondary HTN?
resistant HTN, a sudden acute rise from a previous stable value, proven age of onset before puberty, under 30 with no FH
What medications can cause secondary HTN?
NSAIDs, stimulants, OCP, antidepressants, calcineurin inhibitors (tacrolimus)
What causes a string-of-beads appearance on CT angiogram?
medial fibromuscular dysplasia
What is the target average ABPM/HBPM?
<135/85 if under 80 y/o
<145/85 if >80 y/o
What medication is preferred in hypertensive emergency in patients with coronary ischaemia and CCF?
IV nitroglycine
What are the complications of giving ACE-i in someone with renal artery stenosis?
Flash pulmonary oedema
