Week 24 - Hyperlipidaemia, HHS, Hypertension Flashcards
what is the clinical diagnosis of hypertension
above 140/90 confirmed with ambulatory or home readings above 135/85
what is essential hypertension
means high blood pressure developed on its own and does not have a secondary cause
what is the mneumonic to remember secondary causes of hypertension
ROPED
what does the mneumonic for secondary causes of hypertension ‘ROPED’ stand for
R – Renal disease
O – Obesity
P – Pregnancy-induced hypertension or pre-eclampsia
E – Endocrine
D – Drugs (e.g., alcohol, steroids, NSAIDs, oestrogen and liquorice)
what is the most common cause of secondary hypertension
renal disease
when the blood pressure is very high or does not respond to treatment, what should one consider
renal artery stenosis
how is renal artery stenosis diagnosed
with duplex ultrasound or an MR or CT angiogram
what is an important endocrine cause of hypertension
hyperaldosteronism (Conn’s syndrome)
what does high blood pressure increase the risk of
Ischaemic heart disease (angina and acute coronary syndrome)
Cerebrovascular accident (stroke or intracranial haemorrhage)
Vascular disease (peripheral arterial disease, aortic dissection and aortic aneurysms)
Hypertensive retinopathy
Hypertensive nephropathy
Vascular dementia
Left ventricular hypertrophy
Heart failure
what may happen to the heart with high blood pressure
left ventricular hypertrophy
the left ventricle is straining to pump blood against increased resistance in the arterial system, so the muscle becomes thicker.
what may be seen in left ventricular hypertrophy on examination
a sustained and forceful apex beat. it can be seen on an ECG using voltage criteria and is best diagnosed with an echo
what do NICE recommend as a screening programme for hypertension
recommend measuring BP every 5 years to screen for hypertension.
it should be measured more often in borderline cases and every year in patients with type 2 diabetes
Patients with a clinic blood pressure between 140/90 mmHg and 180/120 mmHg should have what?
should have 24 hour ambulatory blood pressure or home readings to confirm the diagnosis
what is stage 1 hypertension classed as
above 140/90
what is stage 2 hypertension classed as
above 160/100
what is stage 3 hypertension classed as
above 180/120
what does NICE recommend that all patients with a new hypertension diagnosis have;
- Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
- Bloods for HbA1c, renal function and lipids
- Fundus examination for hypertensive retinopathy
- ECG for cardiac abnormalities, including left ventricular hypertrophy
what is the QRISK score
estimates the percentage risk that a patient will have a stroke or MI in the next 10 years
when the QRISK score is above 10%, what should the patient be offered
a statin, initially atorvastatin 20mg at night
what is the pneumonic used for medications in management of hypertension
ABCDARB
what do these stand for
A – ACE inhibitor (e.g., ramipril)
B – Beta blocker (e.g., bisoprolol)
C – Calcium channel blocker (e.g., amlodipine)
D – Thiazide-like diuretic (e.g., indapamide)
ARB – Angiotensin II receptor blocker (e.g., candesartan)
when are ARBs recommended instead of ACE
in patients of Black African or African-Caribbean family origin. In the steps below, you can replace A with ARB for these patients.
can ACE and ARB be used to gether
NO
what are used as an alternative if a patient does not tolerate CCB
thiazide like diuretics
what is a common side effect of CCBs
ankle oedema
describe the NICE recommendations for medication treatment steps
The NICE recommendations vary for patients under 55 or over 55, type 2 diabetics and patients of Black African or African-Caribbean family origin:
Step 1: Aged under 55 or type 2 diabetic of any age or family origin, use A. Aged over 55 or Black African use C.
Step 2: A + C. Alternatively, A + D or C + D.
Step 3: A + C + D
Step 4: A + C + D + fourth agent (see below)
what does step four depend on
Step 4 depends on the serum potassium level:
Less than or equal to 4.5 mmol/L consider a potassium-sparing diuretic, such as spironolactone
More than 4.5 mmol/L consider an alpha blocker (e.g., doxazosin) or a beta blocker (e.g., atenolol)
how does spironalactone work
by blocking the action of aldosterone in the kidneys, resulting in sodium excretion and potassium reabsorption.
when is spironolactone given
when thiazide diuretics are causing hypokalaemia
what does spironolactone increase the risk of
hyperkalaemia
what do ACE inhibitors risk causing
hyperkalaemia
what can thiazide-like diuretics cause
electrolyte disturbances
what is it essential to monitor with hypertension drugs
U+Es
what are the treatment targets for hypertension in under 80 yr olds
<140/<80
what are the treatment targets for those over 80
<150/<90
what is a hypertensive emergency and what does it present with
Accelerated hypertension, also called malignant hypertension, refers to extremely high blood pressure, above 180/120, with retinal haemorrhages or papilloedema.
what examination do those with blood pressure over 180/120 require
fundoscopy examination
what are the intravenous options in a hypertensive emergency
Sodium nitroprusside
Labetalol
Glyceryl trinitrate
Nicardipine
Diagnosing Hypertension;
1.2.2 If blood pressure measured in the clinic is 140/90 mmHg or higher:
Take a second measurement during the consultation.
If the second measurement is substantially different from the first, take a third measurement. Record the lower of the last 2 measurements as the clinic blood pressure. [2019]
1.2.3 If clinic blood pressure is between 140/90 mmHg and 180/120 mmHg, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.
1.2.4 If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) to confirm the diagnosis of hypertension. [2019]
what do we investigate for cardiovascular risk
● Renal profile (U&E, eGFR)
● HbA1c
● Lipid profile
● Urine albumin:creatinine ratio
what does average BP of 152/96 mean - category wise
stage 2 hypertension
what is the management strategy for someone with stage 2 hypertension and no end organ damage
antihypertensive and lifestyle advice
if someone is 50 yrs old, white british and doesn’t have type 2 diabetes, what is the first line medication
either an ACE or ARB
what is second line in a 50yr old white, non diabetic
CCB and a thiazide like diuretic
what does not feature at all in the recommended treatment of hypertension
furosemide
what is refractory hypertension defined as
the inability to achieve blood pressure control despite maximum tolerated doses of at least five antihypertensive medications, including a diuretic
how is a hypertensive emergency differentiated from a hypertensive urgency
the fact that the patient exhibits signs and symptoms of end-organ dysfunction
what symptoms would you ask about to screen for a hypertensive emergency
▪ Focal neurological symptoms such as agitation, delirium, stupor, seizures, or visual disturbances and headache – Signs of intracranial bleed
▪ Vomiting, headache, agitation, delirium – Signs of raised intracranial pressure
▪ Visual disturbance – Sign of raised intracranial pressure or hypertensive retinopathy
▪ Chest pain – Sign of myocardial ischaemia or aortic dissection
▪ Back pain – Sign of aortic dissection
▪ Shortness of breath – Sign of pulmonary oedema
If the urine dipstick had demonstrated blood / protein was present, does that suggest that hypertension had caused damage to the kidneys, or that the kidneys are diseased and causing the high blood pressure
both are correct - blood pressure and the kidneys are very closely linked
how does long standing high BP damage the kidney
by damaging the glomeruli, making them lead, and therefore allowing protein into the urine
what pathologies of the kidney cause hypertension
IgA nephropathy
how does IgA nephropathy cause hypertension
IgA antibodies accumulate in the kidney causing inflammation, affecting the ability of the kidney to filter the blood. inflammation allows blood and protein to leak through the glomeruli into the urine, and a damaged kidney cannot remove excess fluid and produce urine, so the BP rises
for an MI to be diagnosed what criteria does the patient need to have
at least two out of the three:
- chest pain
- evidence of ischaemia on ECG
- biochemical evidence - raised troponin
give examples of four drugs that can cause a hypertensive emergency
amphetamines
cocaine
MOAI
recent discontinuation of antihypertensive agents
in a hypertensive urgency, how quickly should the blood pressure be reduced in this scenario?
hours to days
what is primary hyperaldosteronism due to
an adrenal cause of increased aldosterone secretion: either a benign adenoma of the adrenal glands (Conn’s syndrome 1/3 of cases); or bilaterally enlarged adrenal glands (adrenal hyperplasia 2/3 of cases). Renin levels remain appropriately low because they are not being triggered for release, due to low blood pressure.
what is secondary hyperaldosteronism due to
a cause outside of the adrenal glands, and results in excessive stimulation of the Renin-Angiotensin-Aldosterone System (RAAS) pathway, with high renin levels triggering high aldosterone production. Causes include reduced blood flow to the kidneys (renal artery stenosis, fibromuscular dysplasia), reduced cardiac output (congestive cardiac failure), and reduced circulating volume (cirrhosis with ascites).
what is the treatment for hyperaldosteronism and hypertension as a result
spironolactone and salt restriction
need something that works on the RAAS system
what medication can contribute to suddenly developing pulmonary oedema
ramipril
what kidney issue is linked to pulmonary oedema
bilateral renal artery stenosis
A 56-year-old patient who was newly started on Ramipril is found to have a potassium level of 6 (normal range 3.5 - 5.3) on routine blood monitoring in hospital.
What is the single most important investigation to perform next?
ECG
An ECG is the only investigation from the list above that will alter your management steps. With a potassium of 6 if there is evidence of ECG changes, calcium gluconate would also be required to stabilise the myocardium to prevent arrhythmias occurring whilst the potassium level is bought down. If the ECG is normal, then this additional treatment is not required. If a potassium level is >6.5 calcium gluconate should be administered regardless of ECG findings.
what is the standard treatment of hyperkalaemia
insulin-dextrose infusion to drive potassium into cells, along with salbutamol
A 67-year-old woman has a blood pressure of 167/84 on routine GP review. She is already taking Amlodipine 10mg orally daily and Ramipril 5mg orally daily. What medication change would you make?
increase rampiril to 10mg a day
The maximum daily dose of Ramipril is 10mg OD.
A 44-year-old man attends clinic for the results of his investigations into his hypertension. His aldosterone level is high along with his renin level.
Which medication would you want to avoid, pending further investigations?
Lisinopril
These blood results demonstrate secondary hyperaldosteronism, and so ACE-I should be avoided until renal artery stenosis has been excluded as the cause for this to avoid precipitating severe renal failure.
The same would go for angiotensin receptor blockers, but that was not given as an option.§
A 24-year-old 25/40 primigravida attends antenatal clinic with high blood pressure (165/85). Her BP at booking was 120/65. She feels well in herself. What is first investigation to perform?
Urine dipstick
The presence of proteinuria would require obstetrician-led care and careful monitoring to prevent eclampsia from occurring.
A 33-year-old lady with uncontrolled secondary hypertension is found with a dense R hemiparesis. A CT scan performed in ED confirms a L sided intracerebral haemorrhage. Her BP is currently 140/90. What is your immediate management?
Urgent discussion with neurosurgeons
Definitive management for this patient would require neurosurgical intervention and close monitoring in a neuro-ITU setting, so the advice of the neurosurgical team should be sought urgently.
