Treatment of Hypertension Flashcards
What is the definition of stage 1 hypertension?
- Clinic blood pressure is 140/90 mmHg or higher
- ABPM daytime average 135/85 mmHg or higher.
What is stage 2 hypertension?
•Clinic blood pressure is 160/100 mmHg or higher
ABPM daytime average 150/95 mmHg or higher
What is severe hypertension?
•Clinic systolic blood pressure is 180 mmHg or higher or diastolic blood pressure is 110 mmHg or higher.
How does blood pressure change in the night time?
Dips - Loss of nocturnal dip in blood pressure has massive health consequences
How do you assess risk of hypertensive patients? (6)
–Previous MI, stroke, IHD
–Smoking
–Diabetes mellitus
–Hypercholesterolaemia
–Family history
–Physical Examination
How can you assess end organ damage of left ventricular hypertrophy?
ECG and Echocardiogram
How do you measure kidney function for end organ damage?
Renal ultrasound
eGFR (estimated glomerular filtration rate)
Proteinuria
Presence of abnormal quantities of protein in urine, may indicate damage to kidneys.
What are the common treatable causes of hypertension?
Renal artery stenosis / fibromuscular dysplasia
Endocrine diseases - Chushings disease, Conn’s disease
Sleep apnoea
(Cushing’s syndrome is caused by either excessive cortisol-like medication such as prednisone or a tumour that either produces or results in the production of excessive cortisol by the adrenal glands. Cases due to a pituitary adenoma are known as Cushing’s disease)
(Conn’s disease excess production of hormone aldosterone by adrenal glands resulting in low renin levels. Often produces few symptoms. Most people have high blood pressure which may cause poor vision or headaches)
What is effective treatment for reducing left ventricular mass?
ACE or ARB
How does hypertension change with age?
Increases
What is the target blood pressure according to BHS?
< 135/80-85 mmHg
When does treatment for hypertension usually start?
CVD risk of 20% / 10 years
(no end organ damage, stage 1 hypertension)
What are the reasons for treating hypertension?
–reduce cerebrovascular disease by 40-50%
–reduce MI by 16-30%
What is the format of treatment of hypertensives?
Stepped approach
- introduce one drug, then a second then a third
- uses a dose less than maximum dose
- minimises max dose use so less side effects
Low doses of several drugs
- minimises adverse events and maximises patient compliance
What are the differences in renin between the young and the old?
Young - high renin
Old - low renin
What type of drugs do you give to young vs Elderly (over 55)
Young:
- ACE inhibitor / ARB - these are teratogenic
Elderly:
- Calcium channel blocker - Thiazide type diuretic
When should we start giving treatment to patients over 80 years old?
ABPM >135/85 with one or more of the following:
- target organ damage
- established cardiovascular disease
- renal disease
- diabetes
- 10-year cardiovascular risk equivalent to 20% or greater.
When do we give treatment to people who have stage 2 hypertension?
Offer antihypertensive drug treatment to people of any age with stage 2 hypertension
What should you do for patients under 40 years with stage 1 hypertension or greater?
Always refer if younger than 40 – usually due to lifestyle like alcohol and cocaine
How does treatment for patients who are 55-80 years differ for patients who are over 80 years old?
Same treatment taking into account co-morbidities - blood pressure target is different- (•<145/85)
Drugs reduce blood pressure – end up falling over – can’t achieve same amount of control
- Falling over affects confidence of old people
What would you suggest for people identified as having ‘white coat effect’?
ABPM / HBPM - measures blood pressure and monitors effect of antihypertensive drugs or lifestyle changes
What is step 1 treatment for a patient under 55 years?
ACEI or ARB (angiotensin receptor blocker)
Not if afro carribean or woman of child bearing age
Why can’t you give an afrocarribean or woman of child bearing age ACEI or ARB?
Afro- Caribbean
- low renin hypertension – ace inhibitor and ARB’s are less effective and more expensive.
- more susceptible to ankle oedema
- Can be life threatening
Women of child baring age
- teratogenic
What is step 2 treatment?
Add thiazide-type diuretic such as clortalidone or indapamide to CCB or ACEI/ARB
What is step 3 treatment?
Add CCB, ACEI, Diuretic together
What is step 4 treatment?
Further diuretic therapy - low dose spironolactone (spyro - no - lactonoe)
Can only use in people with low potassium-
•caution in people with reduced estimated GFR, increased risk of hyperkalaemia.
–Consider higher-dose thiazide-like diuretic treatment if the blood potassium level is higher than 4.5 mmol/l.
What is the effect of a thiazide like diuretic?
Acts on nephron at proximal part of distal tubule. Transfer of sodium and water across membranes is interrupted - increasing sodium excretion and urine volume - reduction in blood volume.
ALSO
In long-term, major haemodynamic effect is reduction in peripheral resistance due to subtle alterations in contractile responses of vascular smooth muscle.
If over 55 years?
A calcium channel blocker instead of ACEI/ARB