Cardiovascular: Essential Hypertension

Question 1

what is essential hypertension?

Answer 1

Essential hypertension is high blood pressure that doesn’t have a known secondary cause.

It’s also referred to as primary hypertension.

Question 2

what is the blood pressure range for stage one hypertension?

Answer 2

clinic blood pressure:140/90 mmHg.

Ambulatory/home reading: average or at least 135/85 mmHg.

Question 3

what is the blood pressure range for stage two hypertension?

Answer 3

clinic blood pressure:>160/100mmHg

Ambulatory/home reading: average or at least
>150/95mmHg

Question 4

what is the blood pressure range for severe/stage three hypertension?

Answer 4

clinic blood pressure:>180/120mmHg

Question 5

what are some risk factors for hypertension?

Answer 5

• increasing age
• male
• black African / Caribbean ethnicity
• smoking
• excessive alcohol
• excess dietary salt
• obesity
• lack of physical activity
• anxiety and emotional. stress

Question 6

what are some clinical features of hypertension

Answer 6

NB: patients usually asymptomatic except when there is accelerated hypertension which may present as:

• headaches
• dizziness
• blurred vision
• nausea
• palpitations
• SOB

Question 7

what investigations would you conduct to diagnose hypertension?

Answer 7

The diagnosis should be confirmed with ambulatory blood pressure monitoring (ABPM), or home blood pressure monitoring (HBPM) if ABPM is not tolerated.

Question 8

what advise should you give a patient when explaining how to monitor their blood pressure at home? (with reference to suspected hypertension)

Answer 8

• two consecutive measurements taken with the pt sat down
• BP taken twice daily (2 in the morning, 2 in the evening)
• BP measuring continues for at least 4 days, ideally 7 days

Question 9

when diagnosing hypertension, besides blood pressure, what other investigations might you consider?

Answer 9

NICE recommend all patients with a new diagnosis should 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

Question 10

what is the first line treatment for hypertension?

Answer 10

Step 1: A/ARB or C

Aged less than 55 and non-black use ACEI. Aged over 55 or black of African or African-Caribbean descent use CCB.

Question 11

if first line treatment fails for hypertension, what is the second line?

Answer 11

Step 2: A/ARB + C.

Alternatively A/ARB + D or C + D.

ACEI and CCB, or ACEI and Thiazide-like diuretic (e.g. indapamide 2.5mg once daily)

nb: If black then use an ARB instead of A. Angiotensin Receptor Blockers are used instead of ACEI when they can’t be tolerated (e.g. cough) - they should not be used together.

Question 12

if hypertension is not controlled by both an ACEI and CCB together, what is the third line treatment?

Answer 12

Step 3: A/ARB + C + D

Question 13

what are some complications of hypertension if left untreated?

Answer 13

Ischaemic heart disease
Cerebrovascular accident (i.e. stroke or haemorrhage)
Hypertensive retinopathy
Hypertensive nephropathy
Heart failure

Question 14

what are secondary causes of hypertension?

Answer 14

ROPE:

R – Renal disease. This is the most common cause of secondary hypertension. If the blood pressure is very high or does not respond to treatment consider renal artery stenosis.

O – Obesity

P – Pregnancy induced hypertension / pre-eclampsia

E – Endocrine. Most endocrine conditions can cause hypertension but primarily consider hyperaldosteronism (“Conns syndrome”) as this may represent 2.5% of new hypertension. A simple test for this is a renin:aldosterone ratio blood test.

Question 15

what is pre-eclampsia?

Answer 15

Pre-eclampsia is a condition that causes high blood pressure during pregnancy and after labour.

Question 16

if hypertension is not controlled by both an ACEI, CCB and a Diuretic together, what is the fourth line treatment?

Answer 16

Step 4: A + C + D + additional (see below)

if the serum potassium is less than or equal to 4.5 mmol/l consider a potassium sparing diuretic such as spironolactone.

If the serum potassium is more than 4.5 mmol/l consider an alpha blocker - blood vessels and bladder (e.g. doxazosin) or a beta blocker - heart and lungs (e.g. atenolol).