Essential and Secondary Hypertension (CVS)

Question 1

Define Hypertension (incl by number)

Answer 1

Persistently elevated arterial blood pressure
NICE says:
A clinic reading that is persistently >=140/90mmHg and 24 hrABPM/HBPM is >= 135/85mmHg
The ABPM is what confirms the diagnosis

Question 2

Describe essential hypertension

Answer 2

Most common type (~90%)
No identifiable cause
Often linked to lifestyle factors

Question 3

Describe secondary hypertension, give examples of causes

Answer 3

This type of hypertension is caused by an underlying medical condition such as kidney disease, thyroid problems, or sleep apnea
~10% of all cases

Question 4

What are the risk factors of hypertension?

Answer 4

Age, Obesity, Lack of physical exercise, High salt diet, alcohol, race - black, diabetes

Question 5

How common is hypertension?

Answer 5

Over a quarter of people in UK have it

Question 6

What are the causes of hypertension (brief)

Answer 6

Primary HTN - no identifiable cause
Secondary HTN - Renal disease, Endocrine disorders, other causes

Question 7

What are the renal causes of secondary hypertension?

Answer 7

• CKD e.g. due to Glomerulonephritis
• Chronic pyelonephritis
• Adult PCKD
• Renal artery stenosis

Question 8

What are the endocrine causes of secondary hypertension?

Answer 8

• Primary hyperaldosteronism
• Phaeochromocytoma
• Cushing’s syndrome
• Liddle’s syndrome
• CAH
• Acromegaly

Question 9

What are the other causes of secondary hypertension (not renal/endo)

Answer 9

GCCs, NSAIDs, combined oral contraceptive pill
Pregnancy, coarctation of the aorta

Question 10

Most common cause of secondary hypertension?

Answer 10

Renal disease

Question 11

What is the formula for BP?

Answer 11

BP = CO x TPR
HR x SV - affected by preload and contractility
TPR - vasodilation/constriction

Question 12

What is the aetiology of primary hypertension (development)?

Answer 12

We don’t know the fundamental cause of it however there are suggested mechanisms e.g. increased/dysregulated RAAS and incr SNS
Overall, it is the result of reduced elasticity of large arteries due to elastin degradation, age related and atherosclerotic related calcification etc.

Question 13

How is hypertension diagnosed incl its stages?

Answer 13

First, clinic reading is persistently >=140/90.
Then offer ABPM (or HBPM if intolerant to ABPM)
If <135/85 - no hypertension but monitor
If >=135/85 - Stage 1
If >=150/95 - Stage 2

Question 14

What is the pathophysiology of hypertension (effects of it)?

Answer 14

Causes endothelial damage -> Atherosclerosis
Left vent hypertrophy
Damage to organs such as renal, cerebral, retinal

Question 15

What are the clinical features of hypertension?

Answer 15

Usually asymptomatic
If very raised (>200/129mmHg) pts may experience headaches, visual disturbance, seizures

Question 16

What are the investigations for hypertension?

Answer 16

24 hr BP monitor (ABPM) or HBPM if ABPM not tolerated/decline
Below is assessment for end organ damage

Fundoscopy - hypertensive retinopathy
Urine dip - renal disease e.g. if haematuria/proteinuria
ECG - LVHT or IHD
U + E blood test - renal disease
HbA1c blood - DM
Lipids blood - hyperlipidemia

Question 17

What is the lifestyle management of hypertension?

Answer 17

Modifiable risk factors:
Weight loss, healthy diet (reduce salt/saturated fat), reduce alcohol and caffeine, reduce stress, stop smoking, exercise

Question 18

What are the indications to treat for hypertension?

Answer 18

Indications to treat are:

Stage 1 pts who are below 80 AND have CVS disease, renal disease, diabetes or 10 year CVS risk > 10%

All stage 2 patients

Question 19

What are the steps for hypertension management?

Answer 19

Step 1 = if under 55yrs OR diabetes, ACEi (if not tolerated e.g. cough, switch to ARB). If above 55 OR african descent, CCB

Step 2 = if step 1 failed, combine ACEi and CCB
Step 3 = Add thiazide diuretic e.g. indapamide
Step 4 = This is resistant hypertension. Either add a 4th drug or seek specialist advice.

Question 20

What are the two different first line medical treatment for hypertension?

Answer 20

• Below 55 and end organ damage OR has diabetes - ACEi
• Above 55 or african descent - CCB

Question 21

What is the management of resistant hypertension?

Answer 21

This is step 4.
Either
Add a fourth drug - if blood K is <4.5mmol/L then add spironolactone. If less - increase thiazide diuretic dose.
OR
Seek specialist advice
If step 4 fails, should be referred to a specialist

Question 22

Features of ACEi in hypertension treatment

Answer 22

Age< 55 years.
This is less effective in black people so CCB is given instead
AVOID in pregnancy
Can cause a cough, then may be given ARB. Both can cause hyperkalaemia
-pril

Question 23

A2RB indication to use in hypertension?

Answer 23

If ACEi is not tolerated usually due to cough side effect
-sartan

Question 24

CCB indication in hypertension?

Answer 24

If above 55 yrs or african caribbean descent
- dipine

Question 25

Complications of Hypertension?

Answer 25

Incr risk of morbidity/mortality from all causes
CAD
Heart failure
Renal failure
Stroke
Peripheral vascular disease
Hyoertensive retinopathy
Hypertensive nephropathy
CVD (particularly if high systolic)