Confirming a diagnosis of hypertension

Question 1

White-coat hypertension

Answer 1

is defined as a difference of more than 20(systolic)/10(diastolic) mmHg between clinic and daytime out-of-clinic BP measurements.

Occurs in:

• 9 – 16% of the general population
• 55% of people with mild HTN
• 10% of people with severe HTN.

‒ A significant risk for future hypertension

‒ Consider ABU every 2 years

Question 2

Masked hypertension

Answer 2

Also referred to as isolated ambulatory HTN.

Occurs when out-of-clinic BP readings are higher than measurements taken in the clinic

• is the opposite of white-coat HTN

Affects 10 – 17% of the general population.

Can be picked up in Hx or ABU

Cardiovascular events occur approximately twice as often in people with masked hypertension as people with sustained HTN.

Should be suspected in people with;

• high-normal clinic BP measurement
• pts with normal clinic BP measurement and asymptomatic organ damage
• high total cardiovascular risk

Question 3

Home BP measuring

Answer 3

is an acceptable alternative to ambulatory monitoring if;

• pt cannot tolerate 24-hour monitoring
• a practice does not have access to ABU equipment

Gives a more accurate assessment of the likelihood of end organ damage occurring, compared to office-based measurements alone.

Home measurements should be taken (by the pt) in a quiet room while seated, with back and arm support.

Two consecutive measurements should be taken in the morning and the evening for at least four days.

The measurements taken on the first day are disregarded, and the average measurement calculated from the remaining results

Donot measure the BP during the WE; pts are more relaxed

Make sure the pt gets the right cuff isze

Question 4

Ambulatory monitoring of BP ( ABU)

Answer 4

is the gold standard for confirming a diagnosis

• only at ACH, not MMH Aucklan

Should ideally be offered to pts with a clinic BP of ≥140/90 mmHg, where availability and cost allow.

More sensitive predictor of cardiovascular risk than clinic BP in patients in primary care.

24Hr ambulatory monitoring provides half hourly BP measurements during the day and hourly measurements at night.

It is an ideal method for primary care clinicians to detect white-coat or masked HTN.

Can also provide additional information about secondary causes of HTN, e.g. elevated night-time BP, which may suggest OSA, and increased renal and cardiovascular risk.

Question 5

Consider ABU if:

Answer 5

suspected white coat HTN.

suspected nocturnal HTN in sleep apnoea, DM, or CRD.

marked variability of clinic and home BP measurements.

autonomic, postprandial, postural, or drug-induced hypotension.

Question 6

Hypertensive urgency

Answer 6

is a severe blood pressure elevation (> 180/110 mmHg) that is:

• not immediately life‑threatening.
• sometimes associated with symptoms (e.g., headache, vision disturbance).
• without evidence of target organ damage.

Question 7

Hypertensive emergency

Answer 7

High BP (often > 180/110 mmHg) associated with acute target organ damage or dysfunction:

• Heart failure
• Acute PE
• Acute MI
• Aortic aneurysm
• Acute renal failure (evidence of proteinuria or haematuria)
• Major neurological changes
• Hypertensive encephalopathy
• Flame-shaped haemorrhages on fundoscopy
• Cerebral infarction
• Haemorrhagic stroke

Question 8

Symptoms of secondary hypertension

Answer 8

OSA – obesity, snoring, daytime sleepiness, Epworth Sleepiness Score ≥ 10

Hypokalaemia – muscle weakness, cramps, hypotonia

Hypothyroidism – tiredness, weight gain, bradycardia

Hyperthyroidism – sensitivity to heat, weight loss, tachycardia

Cushing syndrome – central obesity, skin pigmentation, round flushed face

Pheochromocytoma – frequent headache, sweating, palpitation

Question 9

Medications and substances associated with HTN, intolerance to any antihypertensive medication, and non‑adherence.

Answer 9

Medications:

• NSAIDs
• Stimulants (dexamphetamine, modafinil)
• Oestrogen‑containing contraceptives and menopause hormone therapy (MHT)
• Corticosteroids
• Serotonin‑norepinephrine reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs)
• Clozapine
• Bupropion
• Decongestants
• Diet pills e.g., duromine

Substances:

• Excessive alcohol consumption
• Liquorice
• Caffeine pills and products
• Energy drinks and guarana
• Cocaine and amphetamine