Case 8- Hypertension

Question 1

Causes of secondary hypertension

Answer 1

ROPE
Renal- renal artery stenosis
Others- coarctation, obstructive sleep apnoea, excessive liquorice, corticosteroids, OCP, cocaine, amphetamines
Pregnancy- pre eclampsia/ pregnancy induced
Endocrine- primary hyperaldosteronism, primary hyperparathyroidism, pheochromocytoma, hypercotisolism, acromegaly, hyperthyroidism, congenital adrenal hyperplasia

NB- the secondary causes aren’t HTN that has just happened on its own (eg. essential HTN)

Question 2

What other investigations should be carried out on a newly diagnosed hypertensive patient?

Answer 2

Random finger BM
Fundoscopy
Urine dipstick- protein and haematuria
UE- kidney function, HBA1c, lipid profile
ECG
QRISK score- if no previous cardiovascular disease (inc. TIA)

Question 3

HTN treatment targets for under 80 years

Answer 3

Less than 140/90 (5 less if at home)

Question 4

HTN targets for patients over 80 years

Answer 4

Less than 150/90 (5 less if at home)

Question 5

Hypertensive urgency

Answer 5

BP raised but no target organ damage
Can still have symptoms (headache, SOB, epistaxis, anxiety)
180/110

Question 6

Hypertensive emergency (malignant hypertension)

Answer 6

When BP so high it damages target organs and Sx (retinal haemorrhage, papilloedema, (chest pain, SOB, back pain, numbness and weakness, visual changes, difficulty speaking, cerebral oedema) p)- refer for same day specialist assessment
Usually 180/120 (can be lower)
IV medication (labetolol, nitroglycerin, amlodipine)

Question 7

Diagnosing HTN

Answer 7

Clinic BP of 140/90 measured on at least 2 occasions or HBPM/ ABPM of 135/85

NB- see passmed flow chart for when to initiate treatment

Question 8

Stages of HTN (home monitoring)

Answer 8

1) >135/85

2) >150/95

3) >180/110

Isolated systolic HTN also

Question 9

HTN treatment

Answer 9

Stage 2- treat at any age
Stage 1- if below 80, only treat if one of the following is present;
-target organ damage
-renal disease
-established CVD
-DM
-QRISK >10%

Under 55- ACE-I or ARB
Over 55/ Afro-Caribbean- CCB

NB- unless background of DM type 2 in which first line would be ACE-I or ARB

Question 10

Angiotensin 2 effects

Answer 10

Increased sympathetic activity of the ANS
Increased NA Cl reabsorption, K H excretion and H20 retention
Increased aldosterone secretion
Increased ADH secretion
Increased systemic arteriolar vasoconstriction

Question 11

ARB’s

Answer 11

Losartan, candesartan

Question 12

Calcium channel blockers

Answer 12

Dihydropiridines- amlodipine, nifedipine

Non-dihydropiridines- verapamil, diltiazem

Question 13

Management of phaeochromocytoma

Answer 13

Alpha blockade (phenoxybenzamine) then beta blockade (propranolol)
Then surgery (adrenalectomy)

Question 14

HTN in black patients

Answer 14

ARB’s are preferable to ACE-i if they need to be given