Podcast
Questions and Answers
What is the recommended clinic blood pressure range that triggers the offer of ambulatory blood pressure monitoring (ABPM)?
What is the recommended clinic blood pressure range that triggers the offer of ambulatory blood pressure monitoring (ABPM)?
What is the target average blood pressure measurement for confirming hypertension using ABPM or HBPM?
What is the target average blood pressure measurement for confirming hypertension using ABPM or HBPM?
For individuals without previously diagnosed hypertension or renal disease, how often should blood pressure be measured?
For individuals without previously diagnosed hypertension or renal disease, how often should blood pressure be measured?
What should be done if hypertension is not diagnosed in a clinic visit?
What should be done if hypertension is not diagnosed in a clinic visit?
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What is the purpose of using a formal estimation of cardiovascular risk in people with hypertension?
What is the purpose of using a formal estimation of cardiovascular risk in people with hypertension?
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What equation represents the relationship between cardiac output, peripheral resistance, and blood pressure?
What equation represents the relationship between cardiac output, peripheral resistance, and blood pressure?
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Which of the following is NOT a risk factor associated with hypertension?
Which of the following is NOT a risk factor associated with hypertension?
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What percentage reduction in stroke incidence is associated with effective management of hypertension?
What percentage reduction in stroke incidence is associated with effective management of hypertension?
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When treating a patient with hypertension and no established cardiovascular disease (CVD), what type of prevention is applied?
When treating a patient with hypertension and no established cardiovascular disease (CVD), what type of prevention is applied?
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What can a 5 mmHg reduction in blood pressure reduce the risk of?
What can a 5 mmHg reduction in blood pressure reduce the risk of?
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Which factors are considered powerful predictors of absolute cardiovascular disease risk?
Which factors are considered powerful predictors of absolute cardiovascular disease risk?
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What is the effect of a 20 mmHg rise in systolic blood pressure on mortality rates?
What is the effect of a 20 mmHg rise in systolic blood pressure on mortality rates?
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What test should be performed to check for the presence of protein in the urine?
What test should be performed to check for the presence of protein in the urine?
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Which of these conditions is a direct cause of increased morbidity and mortality due to hypertension?
Which of these conditions is a direct cause of increased morbidity and mortality due to hypertension?
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Which of the following lifestyle modifications can help reduce blood pressure?
Which of the following lifestyle modifications can help reduce blood pressure?
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What should be done for a patient with severe hypertension but no immediate symptoms?
What should be done for a patient with severe hypertension but no immediate symptoms?
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What is advised regarding the consumption of caffeinated products?
What is advised regarding the consumption of caffeinated products?
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What does the initial assessment for patients with hypertension include?
What does the initial assessment for patients with hypertension include?
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Which of the following supplements should not be offered to reduce blood pressure?
Which of the following supplements should not be offered to reduce blood pressure?
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What should be encouraged for individuals who smoke?
What should be encouraged for individuals who smoke?
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When is antihypertensive drug treatment considered for a patient with severe hypertension?
When is antihypertensive drug treatment considered for a patient with severe hypertension?
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What is the primary focus in the discussion of hypertension?
What is the primary focus in the discussion of hypertension?
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Which measurement is crucial when diagnosing hypertension if the initial value is 140/90 mmHg or higher?
Which measurement is crucial when diagnosing hypertension if the initial value is 140/90 mmHg or higher?
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What should be checked for if pulse irregularity is present during blood pressure measurement?
What should be checked for if pulse irregularity is present during blood pressure measurement?
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Why is it important to consider the patient's environment when measuring blood pressure?
Why is it important to consider the patient's environment when measuring blood pressure?
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When should blood pressure be measured with the person standing for at least 1 minute?
When should blood pressure be measured with the person standing for at least 1 minute?
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What is the clinic blood pressure threshold for urgent referral to specialist assessment?
What is the clinic blood pressure threshold for urgent referral to specialist assessment?
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Which of the following symptoms requires an urgent referral for suspected phaeochromocytoma?
Which of the following symptoms requires an urgent referral for suspected phaeochromocytoma?
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In adults under 80 with persistent stage 1 hypertension, under which condition should antihypertensive treatment be discussed?
In adults under 80 with persistent stage 1 hypertension, under which condition should antihypertensive treatment be discussed?
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What medical history is considered as established cardiovascular disease?
What medical history is considered as established cardiovascular disease?
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For adults aged under 60 with stage 1 hypertension, what should be the estimated 10-year cardiovascular risk to consider antihypertensive therapy?
For adults aged under 60 with stage 1 hypertension, what should be the estimated 10-year cardiovascular risk to consider antihypertensive therapy?
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When is it appropriate to start antihypertensive drug treatment in frail individuals?
When is it appropriate to start antihypertensive drug treatment in frail individuals?
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What clinic blood pressure value dictates admission of individuals over 80 to antihypertensive treatment?
What clinic blood pressure value dictates admission of individuals over 80 to antihypertensive treatment?
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Which of the following is NOT a way to handle hypertension in adults?
Which of the following is NOT a way to handle hypertension in adults?
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Study Notes
Hypertension Overview
- Hypertension is not a disease but a condition defined by Cardiac Output x Peripheral resistance = blood pressure
- Normal, high, and low blood pressure values should be considered
- Hypertension is a risk factor for:
- Myocardial infarction (MI)
- Heart failure (HF)
- Stroke
- Chronic kidney disease (CKD)
- Peripheral vascular disease (PVD)
- If hypertension is detected a full cardiovascular risk assessment is required, not just managing the blood pressure.
- Patients with hypertension but no established CVD are treated with primary prevention rather than secondary prevention
Risk
- Effective management of hypertension results in:
- 35-40% reduction in stroke incidence
- 20-25% reduction in myocardial infarction
-
50% reduction in heart failure
- A rise in systolic blood pressure (SBP) of 20 mmHg doubles age-specific mortality rates for stroke, IHD, and other vascular diseases.
- A 5 mmHg reduction in blood pressure can reduce the risk of renal failure by 25%.
- Hypertension increases morbidity and mortality.
Definition
- Hypertension is not a disease; it's a condition of increased blood pressure
Type
- Primary (essential) hypertension is the focus of the lecture.
- Secondary hypertension is a result of an underlying cause.
Causes of Secondary Hypertension
-
Vascular:
- Renal artery stenosis
- Coarctation of aorta
-
Endocrine:
- Thyrotoxicosis
- Hyperaldosteronism
- Phaeochromocytoma
- Cushing's syndrome
-
Other:
- Obstructive sleep apnea.
-
Drug induced
-
Various symptoms may be associated with these causes. Details are provided in a table.
Diagnosis
- Patient Presentation: How patients present with hypertension.
-
Blood Pressure Measurement:
- Using correct equipment (manual or machines)
- Correct procedure for measurement.
- Standardize the environment
- Follow-up in clinic: Take a second measurement during the consultation. If different from the first, take a third measurement. Record the lower of the last two measurements.
- Ambulatory blood pressure monitoring (ABPM): Used if clinic blood pressure is between 140/90 and 180/120. This can confirm the diagnosis of hypertension.
- Home blood pressure monitoring (HBPM): Use if ABPM is not suitable or tolerated. Helps confirm diagnosis of hypertension
Diagnosing Hypertension
- Confirm diagnosis with:
- Clinic blood pressure of 140/90 mmHg or higher
- ABPM or HBPM daytime average of 135/85 mmHg.
- Measure clinic blood pressure every 5 years or more frequently if near 140/90mmhg
- Measure blood pressure at least annually in adults with type 2 diabetes without prior hypertension or kidney issues. Provide preventive lifestyle advice.
Assessing Cardiovascular Risk and Target Organ Damage
- Formal estimation of cardiovascular risk to discuss prognosis and healthcare options for patients with and without raised blood pressure (modifiable risk factors).
- For all hypertension patients offer:
- Urine sample for albumin/creatinine, hematuria estimation.
- Glycated hemoglobin (HbA1c), electrolytes, creatinine, estimated glomerular filtration rate (eGFR).
- Total cholesterol, high-density lipoprotein cholesterol.
- Eye examination (fundoscopy) for hypertensive retinopathy.
- 12-lead electrocardiogram (ECG).
Lifestyle Advice
- Offer lifestyle advice periodically to patients with suspected or confirmed hypertension.
- Assess diet and exercise patterns, encouraging healthy habits.
- Reduce alcohol intake in those with excessive consumption.
- Discourage excessive coffee/caffeine.
- Maintain a low sodium diet.
- Avoid calcium, magnesium and potassium supplements for blood pressure reduction.
- Help smokers to quit.
Urgent Cases
- For severe hypertension (180/120 mmHg or higher) but without symptoms perform investigations for target organ damage immediately.
- If target organ damage is detected, start antihypertensive drug treatment ASAP.
- If no target organ damage, repeat blood pressure measurement in seven days.
- Refer for specialist assessment of:
- Signs of retinal hemorrhage or papilloedema.
- Life-threatening symptoms (confusion, chest pain etc)
- Signs of acute kidney injury.
- Suspected phaeochromocytoma (severe labile or postural hypotension, headache, palpitations, etc.)
Definitions (important terms)
- Established Cardiovascular Disease: Past history of stroke, transient ischemic attack, heart attack, angina or narrowed peripheral arteries
Treatment of Hypertension
- Offer drug treatment in addition to lifestyle advice for adults with persistent stage 2 hypertension of any age. Use clinical judgement in frailty or multimorbidity cases
- Discuss treatment with adults under 80 with persistent stage 1 hypertension who have at least one condition/factor described below:
- Target organ damage
- Established Cardiovascular Disease
- Renal Disease.
- Diabetes
- Estimated 10-year cardiovascular risk of 10% or more
Treatment of Hypertension (continued)
- Consider antihypertensive drugs for those under 60 with stage 1 hypertension or estimated 10-year risk below 10%
- Consider drugs for those over 80 with blood pressure over 150/90 mmHg.
- Adults under 40 with hypertension may require secondary cause investigation and detailed long-term treatment risk/benefit assessment.
Blood Pressure Targets
- < Age 80:
- Clinic blood pressure < 140/90 mmHg
- ABPM/HBPM <135/85 mmHg
- ≥ Age 80:
- Clinic blood pressure < 150/90 mmHg
- ABPM/HBPM <145/85 mmHg
- Postural hypotension: consider baseline standing blood pressure.
- Consider frailty or multi-morbidity and use clinical judgment.
- In cases of CKD or Type 1 Diabetes, specific guidance should be consulted during targeted blood pressure management.
Blood Pressure Targets for Specific Conditions
- CKD and Diabetes: Aim for systolic blood pressure below 140 mmHg and diastolic below 90 mmHg or, for cases of an ACR of 70mg/mmol or higher, a systolic blood pressure below 130mmHg and a diastolic target below 80 mmHg.
- Type 1 diabetes: Intervention levels should be considered at or below 135/85mmHg. If the patient meets criteria of albuminuria or at least 2 criteria for metabolic syndrome, a lower target of 130/80 is recommended.
Prescribing Points
- For women of childbearing age with hypertension, consider prescribing treatment in line with pregnancy guidelines.
- Consider ethnicity (race) as a crucial consideration in tailoring hypertension management. Consult specific guidelines (e.g., British Guideline).
Choice of Antihypertensive Drugs
- Details for specific patient types is illustrated in table format.
- Follow the steps outlined for correct patient selection and drug choice.
Safe and Effective Medicine Use
- Benefit-risk assessment
- Drug licensing, indications, cautions, contraindications and dose.
- Side effects, renal/liver impairment, formulation, interactions.
- Evidence-based medicine
- Patient parameters (age, presenting complaint, past medical history, drug history).
- Drug interactions (pharmacodynamics and pharmacokinetics), concordance and compliance.
Drug Treatment
- Prescribing criteria for drug selection within a class.
- Contraindications and dose titrations.
- Drug interactions, adverse effect monitoring, and treatment plan management.
- Recommended reference resources (e.g. CKS Hypertension).
Follow Up
- Blood pressure rechecking frequency after starting drug treatment.
- Specific monitoring for thiazide-like diuretics, ACE inhibitors/ARBs, and CCBs.
Patient Perspective
- Considerations for patient compliance and concordance with treatment.
- Estimated non-adherence level of 50-80%.
- Importance of verbal advice, support materials, and clear communication about medication necessity and potential consequences of non-adherence.
- Importance of lifestyle modification and follow-up for optimal patient outcomes.
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Description
Test your knowledge on the recommended guidelines for diagnosing and managing hypertension. This quiz covers blood pressure measurement protocols, the use of ambulatory blood pressure monitoring, and the relationship between cardiovascular risk and hypertension treatment. Ideal for students and professionals in the healthcare field.
