Essential Hypertension

Question 1

What is HTN

Answer 1

• High blood pressure - >140-159 / 90-99 mmHg

Question 2

How common is it

Answer 2

• V common - 20-30% adults (^ in black, elderly)

Question 3

Who gets it

Answer 3

• Anyone, but increased in African, elderly
• <65 year = M>F
• > 65 year = M

Question 4

What are the primary causes of essential HTN

Answer 4

95%
- Genetics - runs in families

• Foetal birth weight - low weight = increase risk –> foetal adaption to intrauterine undernutrition - long term changes
• Life style/ environment - obesity, smoking, alcohol, acute stress, Na/Salt diet, metabolic syndrome (DM, decrease HDL)

Question 5

What are some secondary causes

Answer 5

5% of cases - specific/treatable
- Congenital e.g. adrenal hyperplasia, aortic coarctation
- ACQUIRED
- RENAL - diabetic nephropathy, CKD, polycystic kidney
- ENDOCRINE - Conn’s, Cushing’s
- DRUGS - CC pill, NSAIDs, cyclosporine, steroids
- PREGNANCY - usually resolves -
NB preg-induced HTN + proteinuria = PRE-ECLAMPSIA

Question 6

What is the pathophysiology of HTN

Answer 6

• Changes in walls against resistance –> thicken + smaller radius
• Deposition Ca + collagen = loss compliance = more pronounced pressure wave
• LVH due to increase TPR –> increased afterload
• Renal vasc changes –> decrease renal perfusion + GFR = activation RAAS + further Na + H2O retention

Question 7

What are the symptoms of hTN

Answer 7

• Oft asymptomatic (unless accelerated)

- If sev e.g. malignant –> headache +/- visual disturbances

Question 8

What are the signs

Answer 8

• Elevated BP usually only sign

- radio-femoral delay in coarctation + renal bruits in reno-vascular disease

Question 9

What are the classifications of different BP levels

Answer 9

• Optimal = 120/80
• Normal = 120-129 / <85
• Pre HTN = 130-139 / 85-89

HTN
Grade 1 = 140-159 / 90-99
Grade 2 = 160-179 / 100-109
Grade 3 = >180 / >110

ISOLATED SYSTOLIC HTN
Grade 1 = 140-149 / <90
Grade 2 = >160 / <90

Question 10

What are the differential Dx

Answer 10

• Malignant (accelerated) HTN e.g. >200 / >130 mmHg accompanied by end-organ damage
• Phaechromocytoma - postural hypotension, headache, palpitations, sweating, pallor

Question 11

What investigations do you perform

Answer 11

• Look for end-organ damage –> ECG, Urinalysis
• Overall risk –> fasting glucose + cholesterol
• Exclude 2o causes –> U&E (decrease K in Conn), Ca2+ (increase in hyperparathyroidism)
• USS - renal artery stenosis

Question 12

What is the treatment for HTN

Answer 12

• Lifestyle advice

INITIAL CHOICE <55 + NON-BLACK

• A - ACEi - ramipril (or low budget ARB - losartan)
• (B) - B-Blocker if ACEi not tolerated (atenolol)

INITIAL CHOICES >55 OR BLACK

• C - Ca-channel blocker e.g. diltiazem
• D - thiazide-like diuretics (if CCB not suitable) - indapamide/ bendroflumethazide

2nd CHOICE
- A + C
3rd CHOICE
- A+C+D

Question 13

What are the treatment targets

Answer 13

\+80yrs = clinic <140/90mmHg 
<80yrs = clinic <150/90mmHg