11. Hypertension

Question 1

What are the NICE/BHS values for stage 1, 2 and 3 hypertension?

What is malignant hypertension?

What is postural hypotension?

Answer 1

Stage 1: 140/90 and ABPM 135/85
Stage 2: 160/100 and ABPM 150/95
Stage 3: Systolic > 180 or diastolic >110
If stage 1 or 2 don’t start tx without 24hr BP first

BP > 180/110 AND signs of papilloedema (optic disc swelling) or retinal haemorrages. Medical emg BUT mustn’t bring BP down too fast.

Measure BP seated/supine. Stand pt for 1 min. Systolic drops by > 20mmHg or diastolic by 10mmHg.

Question 2

What is ABPM?

Briefly review how you would take a history for HT.

Answer 2

24h monitoring. Machine: take BP 3 x an hour during day and hourly at night. BP should dip a night; if not, worse prognosis. Home monitoring may be acceptable alternative.

PC. HPC: ask about pregnancy and pill. Ever had a BP check at work/for work e.g. HGV? PMH: diabetes, CVA, MI, renal disease (looking for signs of end organ damage). FH: cause and age of death, specifically ask about MI and CVA, parents and siblings. SH: smoking, alcohol, salt, dairy, 5 a day, exercise, caffeine, snoring. Systems review: CDV - angina, claudication (pain/cramping in lower leg - angina of calf muscle), exercise tolerance, erectile function. Females - pregnancy plans/contraception (be careful of meds you give).

Question 3

How would you examine a pt for HT?

What Ix would you do?

What are some causes of HT?

What are some 2^o causes?

Answer 3

Measure BP in both arms (highest = true BP). APBM before starting tx. Look for end organ damage (eyes, proteinuria). Look for 2^o causes (Cushings, Conn’s, coarctation, renal artery stenosis).

ABPM, urinalysis, U+Es, lipids, fundi, ECG, wt, 2^o care: ECHO, urinary CATS, renin/aldo ratio, renal/liver ultrasound.

Artifact: wrong cuff size, white coat
Essential (dx of exclusion): genetic, environmental (city living, alcohol, obesity, salt, lack of exercise, OSA)

Phaeochromocytoma (neuroendocrine tumor of medulla of adrenal glands), Cushing’s (signs and symptoms due to prolonged cortisol exposure), OSA, obesity, Conn’s (Primary aldosteronism), renal disease, renal artery stenosis, drugs (OC, steroids, recreational).

Question 4

What end organ damage can HT cause?

How are stage 1, 2 and 3 HT managed?

What drugs are used to treat HT (3 classes)?

Answer 4

Heart: MI, CCF. Brain: CVA. Kidney: nephrosclerosis, accelerates other forms of kidney disease. Depends on ethnicity. Legs (claudication). Erectile function.

Stage 1: access cardiovascular risk (if target organ damage or 20% risk give drugs), life style intervention.
Stage 2: check with ABPM, drugs and lifestyle.
Stage 3: treat now

• *DRUGS: ACD²
  1) ACE-I/ARBs:** check pregnancy plans, < 55 yo, not as monotherapy in Africans/Caribbeans
• *2) CCBS:** > 55 yo, African/Caribbeans, caution if worried about heart failure or oedema
• *3) Diuretics**
• *4) Diuretics** - increase dose or add 2nd e.g. spironolactone (but hyperkalaemia risk)

Question 5

What is the target BP for someone:

a) <80 yo
b) >80 yo
c) End organ damage, diabetic or renal disease

What are some other BP drugs aside from the 3 main classes?

What surgical treatments could be offered?

Answer 5

a) 140/90
b) 150/90
c) 130/80

Spironolactone (aldosterone antagonist), α-blockers (e.g. doxazosin, alfuzosin), β-blockers (e.g. propanolol, atenolol), centrally acting; moxonidine, renin inhibitors. NB pregnancy: labetolol, methyl dopa? nifedipine (CCB)?

Renal denervation: renal artery wall nerves ablated by applying radiofrequency pulses/ultrasound to renal arteries causing reduction of sympathetic afferent and efferent activity to the kidney and BP can be decreased. AV fistula: abnormal connection/passageway between an artery and a vein, decreases peripheral resistance and BP.