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hypertension:persistently raised arterial blood pressure. It increases the…
hypertension:persistently raised arterial blood pressure. It increases the risk of a number of conditions, including heart failure, coronary artery disease, stroke, chronic kidney disease, peripheral arterial disease, and vascular dementia.
Definition
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Secondary hypertension
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underlying cause- Renal, endocrine, vascular disorder, or the use of certain drugs
Diagnosis
- Systollic BP≥ 140mmhg and/or
- Diastollic ≥ 90mmHg
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Classes
Stage 2-Clinic blood pressure of 160/100 mmHg or higher but less than 180/120 mmHg and subsequent ABPM daytime average or HBPM average blood pressure of 150/95 mmHg or higher.
Stage 3-clinic systolic blood pressure of 180 mmHg or higher or clinic diastolic blood pressure of 120 mmHg or higher.
Stage 1-clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ABPM daytime average or HBPM average blood pressure ranging from 135/85 mmHg to 149/94 mmHg.
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Masked hypertension- BP normal in clinic, but raised outside clinic
Risk Factors
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Sex — 65 years and below- women tend to have a lower blood pressure than men. Between 65 to 74 years of age, women tend to have a higher blood pressure.
Ethnicity — people of Black African and Black Caribbean origin are more likely to be diagnosed with hypertension.
Genetic factors — research on twins suggest that up to 40% of variability in blood pressure may be explained by genetic factors.
Social deprivation — people from the most deprived areas in England are 30% more likely to have hypertension than those from the least deprived.
Lifestyle — smoking, excessive alcohol consumption, excess dietary salt, obesity, and lack of physical activity are associated with hypertension.
Anxiety and emotional stress — can raise blood pressure due to increased adrenaline and cortisol levels
Assessment
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Symptoms of postural hypotension: measure BP supine or seated. Measure after one minute of standing. If difference of 20mmhg, repeat.
- measure BP both arms using apt cuff size. If difference more than 15mmhg, recheck. 2. If the difference remains the same, measure the arm with the higher reading.
In Clinic BP 140/90mmhg or higher, take a second, if large difference take a third time, and record last two
If BP between 140/90 and 180/120mmhg, offer ABPM, if not tolerated HMBP
HMBP 2 consecutive measurements a minute apart. BP taken bd morning and night.Recorded for at least 4 days preferably 7 days.
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Investigations
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Electrolytes, creatinine, and estimated glomerular filtration rate (to test for chronic kidney disease).
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Arrange for a 12-lead electrocardiograph to be performed (to assess cardiac function and detect left ventricular hypertrophy).
Consider the need for specialist investigations in people with signs and symptoms suggesting target organ damage or a secondary cause of hypertension.
Treatment
Lifestyle advice-weight, diet, caffeine, sodium intake, alcohol
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Stage 2 hypertension- lifestyle advice and anti hypertensive treatment. Clinical judgement in frailty
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Step 1- age 55 and over/Black African or African–Caribbean family origin (any age)- CCB Age ˂ 55 and not Black African or African-Caribbean origin, and hypertension with T2DM- ACE or ARB
Step 2- age 55 and over/Black African or African–Caribbean family origin (any age)- CCB +ACEi or ARB or thiazide-like diuretic Age ˂ 55 and not Black African or African-Caribbean origin, and hypertension with T2DM- ACE or ARB + CCB or thiazide-like diuretic
Step 3 – All - ACEi or ARB2,3 + CCB + thiazide-like diuretic
Step 4- Consider seeking expert advice or adding a: low-dose spironolactone if blood potassium level is ≤4.5 mmol/l or alpha-blocker or beta-blocker if blood potassium level is >4.5 mmol/l
Referral
same day referral to specialist if evidence of Signs of retinal haemorrhage and/or papilloedema (accelerated hypertension).
Life-threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.: