Essential, Secondary & Malignant Hypertension

Question 1

What is essential hypertension?

Answer 1

Hypertension without a secondary cause, accounts for 90% cases.

Question 2

What are the ‘ROPED’ causes of secondary hypertension?

Answer 2

• R - renal disease
• O - obesity
• P - pregnancy-induced or pre-eclampsia
• E - endocrine
• D - drugs (alcohol, steroids, liquorice)

Question 3

What characterizes accelerated/malignant hypertension?

Answer 3

Rapid increase in BP ≥180/120mmHg

Question 4

What are common risk factors for hypertension?

Answer 4

• Increasing age (if <65 years - male > female)
• Ethnicity - Black African/Caribbean
• Lifestyle factors (smoking, alcohol, high salt intake, obesity, sedentary)

Question 5

What are red flags for malignant hypertension?

Answer 5

• Headache
• Visual disturbance
• Seizures
• Nausea and vomiting

Question 6

What is the clinic blood pressure reading indicating hypertension and need for ABPM/HBPM?

Answer 6

140/90 to 180/20

Question 7

What is the purpose of using 24-hour ambulatory blood pressure monitoring (ABPM)?

Answer 7

To rule out ‘white-coat syndrome’ as a cause of elevated clinic blood pressure

Question 8

What is the QRISK3 score used for?

Answer 8

To assess the % risk that a patient will have a stroke or MI in the next 10 years.
Score >10% indicates statin.

Question 9

Investigating for end-organ damage in newly diagnosed hypertension?

Answer 9

urinary ACR & urinalysis - proteinuria, haematuria
bloods - HbA1c, renal function, lipids
fundoscopy - hypertensive retinopathy
ECG - left ventricular hypertrophy

Question 10

What are the stages of hypertension based on clinic reading and associated HBPM?

Answer 10

• Stage 1 HT: >140/90 & >135/85
• Stage 2 HT: >160/100 & >150/90
• Stage 3 HT: >180/120

Question 11

What are the components of conservative management for hypertension?

Answer 11

• Healthy diet
• Reduce caffeine
• Reduce salt
• Increase physical activity
• Smoking cessation
• Reduce alcohol consumption

Question 12

What first-line medications are recommended for patients <55 years or with Type II Diabetes Mellitus?

Answer 12

ACE inhibitor or ARB

Question 13

What is the recommended first-line medication for patients >55 years or Black African?

Answer 13

Calcium channel blocker (CCB)

Question 14

NICE stepwise approach to hypertension management?

Answer 14

1. ACEi/ARB or CCB
2. ACEi + CCB or ACEi + TLD or CCB + TLD
3. ACEi + CCB + TLD
4. ACEi + CCB + TLD + (spironolactone or alpha-blocker)

Question 15

Indications for spironolactone or alpha-blockers in hypertension management?

Answer 15

Spironolactone if serum potassium <=4.5
If >4.5 use an alpha blocker (e.g. doxazosin)

Question 16

What is the target blood pressure for patients <80 years and >80 years?

Answer 16

<140/<90 and <150/<90

Question 17

What is a hypertensive emergency characterized by?

Answer 17

Extremely high BP >180/120 with retinal haemorrhages or papilloedema

Question 18

What are the indications for same day specialist assessment in malignant hypertension?

Answer 18

• signs of retinal haemorrhage and/or papilloedema
• life-threatening symptoms such as new confusion, chest pain, signs of HF, signs of AKI

Question 19

What is specialist management for malignant hypertension?

Answer 19

Aim: reduce BP gradually over 24-48hrs (reduced too quickly -> organ hypoperfusion and ischaemia!!)

IV antihypertensives.
Continuous BP monitoring using arterial line.

Question 20

What are common complications of hypertension?

Answer 20

• Stroke
• Vascular dementia
• Hypertensive retinopathy
• Coronary artery disease
• Peripheral vascular disease
• Cardiac arrhythmias
• Heart failure
• Chronic kidney disease (CKD)