Hypertension - Case Studies

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  • Created by: LBCW0502
  • Created on: 22-01-19 11:54
What are the hypertension reference ranges?
BP > 120/80 mmHg indicates no hypertension. BP > 140/90 mmHg indicates borderline hypertension. BP > 150/90 mmHg (hypertension treated by GP). BP > 160/100 mmHg and BP > 180/120 mmHg (drug treatment)
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Describe features of clinical BP checks
2 or 3 readings on each occasion and take average. Repeated monthly for 3 months. Persistent values above 140/90 mmHg indicates hypertension (old method)
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Describe features of initial clinic BP measurement
If BP > 140/90 mmHg, refer to either ambulatory BP monitor (AMBP) or home BP monitoring (HBPM). BP > 125/85 mmHg indicates hypertension
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Describe features of ABPM (1)
24 hours BP monitor. Readings every 30 mins throughout day and hourly overnight. Average of daytime readings used to assess BP. Hypertension if BP >135/85 mmHg. Will reduce number of patients with white coat hypertension being treated
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Describe features of ABPM (2)
Important to know when patient sleeps (BP falls during sleep)
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Describe what the data would should for a patient with white coat hypertension on the ABPM
Initially high, decreases to normal over time
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Describe features of home BP monitoring
Patients loaned a calibrated BP machine. Take readings twice daily for 7 days and record results. Discard first days results and calculate average of all other readings. Hypertension if BP > 135/85
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What is Stage 1 hypertension?
Clinical BP is 140/90 mmHg or higher and ABPM or HBPM average is 135/85 mmHg or higher
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What is Stage 2 hypertension?
Clinical BP 160/100 mmHg is or higher and ABPM or HBPM daytime average is 150/85 mmHg or higher
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What is severe hypertension?
Clinic BP is 180 mmHg or higher or clinical diastolic BP is 110 mmHg or higher
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Describe the epidemiology of hypertension (1)
Common in UK population. Influenced by age/lifestyle factors. 25% of adult population in UK have hypertension. 50% of those over 60 years have hypertension. With ageing population, prevalence of hypertension/requirements for treatment will increase
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Describe the epidemiology of hypertension (2)
16 million people in the UK have hypertension (6 million not diagnosed). Responsible for 14% deaths in men/12% in women. High systolic/diastolic BP (accelerated atherosclerosis, affects fibrinolysis, increases risk of stroke, MI, renal dysfunction
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Describe the epidemiology of hypertension (3)
HBP increases risk of coronary heart disease by 2-3 times. 75% under diagnosed and 66% under-treated
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Describe the epidemiology of hypertension (4)
People think hypertension if associated with stress and headaches
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Describe the epidemiology of hypertension (5)
Increased afterload, thickening of cardiac muscle, high risk of developing heart failure, higher myocardial oxygen demand, weaken blood vessels (head, kidneys), can accelerate with deposition of cholesterol (stroke, MI etc.)
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Which patient group is the target group for hypertension?
Elderly patients
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What needs to be assessed in a patient with hypertension? (1)
Investigate: renal function, thyroid function, cholesterol levels, liver function, fasting glucose/HbA1c, urine protein/glucose, ECG (LVH)
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What needs to be assessed in a patient with hypertension? (2)
Lifestyle - smoker, BMI/abdominal obesity, alcohol intake, diet (fruit/veg, salt intake, oily fish, saturated fats), physical activity, family history
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How can the lifestyle modifications reduce systolic BP?
Weight loss (- 5-20 mmHg per 10 kg weight loss). DASH-type diet (- 8-14 mmHg). Reduced salt intake (- 2-8 mmHg). Physical activity (- 4-9 mmHg). Moderation of alcohol intake (- 2-4 mmHg)
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State features of lifestyle issues
Goal setting, motivation, encouragement, support services, smoking cessation, dietician, local gym/exercises classes, weight management programmes
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What do the NICE guidelines state about BP treatment thresholds?
160/100 mmHg or more unless high CV risk then treat if BP persistently > 140/90 mmHg
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What is considered as high CV risk?
CVD risk > 20% (CHD risk > 15%), established CV disease, target organ damage, or diabetes
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Describe features of target organ damage
Heart (LV hypertrophy, angina, heart failure). Brain (stroke, transient ischaemic attack). Chronic kidney disease, peripheral arterial disease. Retinopathy
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What is the QRISK score?
Gives an % of how likely a person will experience a heart attack or stroke within the next 10 years based on factors (e.g. smoking, diseases, cholesterol levels, BP etc.)
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Summarise the antihypertensive drug treatment (1)
For patients aged <55 years pathway - ACE inhibitor or angiotensin II receptor blocker - ACE inhibitor/angiotensin II receptor blocker + calcium channel blocker or diuretic - combination
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Summarise the antihypertensive drug treatment (2)
Aged >55 years or Black/African/Caribbean origin of any age pathway - calcium channel blocker or thiazide like diuretic - ACE inhibitor/angiotensin II receptor blocker + calcium channel blocker or diuretic - combination
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What is used to treat resistant hypertension?
A + C + D + consider further diuretic or alpha/beta blocker (consider seeking expert advice)
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Describe the beliefs about BP lowering treatment
Beliefs about necessity of prescribed treatment (doesn't work, BP fine, too late to treat). Concerns about dependence and long term effects (label, don't like taking medicines, don't want to be dependent, feel worse)
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When monitoring drug treatment, what is the aim for target BP?
140/90 mmHg in people <80 yrs. 150/90 mmHg in people 80+ yrs
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What needs to be monitored for ACE inhibitors?
BP, serum creatinine/eGFR, serum potassium/sodium (vasodilators - headaches/flushing for a few days)
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What needs to be monitored for calcium channel blockers?
BP and HR
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What needs to be monitored for diuretics?
BP, serum creatinine/eGFR, serum electrolytes (K+, Mg2+, Na+), uric acid (for thiazides)
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What is monitored for beta blockers?
BP, HR
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What causes an ACE induced cough?
Build up of bradykinins (Sartan – don’t cause build-up of bradykinin, alternative)
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Which type of medication can contribute to increased BP?
NSAIDs
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Describe features of ethnicity and hypertension (1)
Increased prevalence in people of Black/African/Caribbean family origin. Higher stroke incidence as a result. Earlier onset, not common in 30s/40s. Respond less well to renin-angiotensin system blockers (low renin levels)
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Describe features of ethnicity and hypertension (2)
Often resistant to treatment and require multiple therapies
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ACE inhibitors in Black people increases the risk of what?
Angiodema - use low cost ARB instead, candesartan, monitor renal function, reviews
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What is oedma?
Swelling in ankles and feet due to build up of fluid
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Describe features of resistant hypertension
Affects 500,000 in the UK. Older with co-morbidities/high CV risk. Low dose spironolactone (4th) effectively reduces BP (but no data), cautions - gynaecomastia, hyperkalaemia, renal dysfunction
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What are the alternatives to spironolactone?
High dose thiazide like diuretic, alpha blockers, beta blockers
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Describe features of white coat hypertension
When HCP takes BP but BP is normal outside healthcare setting. ABPM/HBPM confirm white coat effect. Individuals with white coat hypertension may be at higher risk of developing hypertension in the future - need regular reassessment
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What is the target average of BP reading for people with white coat hypertension?
ABPM/HBPM target average of: >135/85 mmHg in people <80 yrs. >145/85 mmHg in people 80+ yrs
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What are some of the reasons for non-adherence?
Belief that body can heal itself. Feel fine. Side effects/inconvenience
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Other cards in this set

Card 2

Front

Describe features of clinical BP checks

Back

2 or 3 readings on each occasion and take average. Repeated monthly for 3 months. Persistent values above 140/90 mmHg indicates hypertension (old method)

Card 3

Front

Describe features of initial clinic BP measurement

Back

Preview of the front of card 3

Card 4

Front

Describe features of ABPM (1)

Back

Preview of the front of card 4

Card 5

Front

Describe features of ABPM (2)

Back

Preview of the front of card 5
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