HTN + Hypotension

Question 1

What is accelerated/ malignant HTN?

• Syx
• Mx

Answer 1

Acute increase >220/120mmHg

Syx: headache, retinal haemorrhage, papilloedema +/- end-organ damage e.g. encephalopathy, CV, renal damage

Mx

• urgent (same day) assessment.
• IV drugs (nitroprusside, labetalol, CCB) - reduce BP slowly by 25% over 24-48hrs
• Phentolamine if phaeochromocytoma crisis
• Arterial line for continuous BP monitoring

HTN emergency = HTN with papilledema, new confusion, HF, AKI, phaeochromocytoma
HTN ‘urgency’ = severe HTN w/NO damage to organs

Question 2

Dx of HTN + stages

Answer 2

x2 BP readings: both clinic + home with value > or = 140/90mmHg

Stage 1 = >140/90mmHg (ABPM: >135/85)

Stage 2 = >160/100mmHg (ABPM: >150/95)

Stage 3 = >180/110mmHg

Question 3

Ix for HTN to assess target organ damage + assess CV risk

Answer 3

1. URINE ANALYSIS: Urine dip + albumin:creatinine
2. BLOODS: HbA1C, UE, cholesterol
   - AssessCVD
   - Exclude secondary causes
3. Fundoscopy
   - hypertensive retinopathy, eye damage, papilloedema
4. 12-lead ECG
5. QRISK

Special Tests

• Renal US/arteriography - renal artery stenosis
• Urine metadrenalines - Pheochromocytomas
• Renin aldosterone ratio

Question 4

BP targets

Answer 4

• < 140/90mmHg
• < 150/90mmHg if over 80y (due to frailty)
• < 130/80mmHg if DM (lower threshold due to having higher CVD risk), stroke, CKD

Question 5

Indication for antihypertensives

Answer 5

Stage 2 regardless of age

Stage 1 <80y +

• end organ damage
• CVD, renal disease, DM
• QRISK >10%

Question 6

Mx + Antihypertensive stepwise Rx

Answer 6

Lifestyles: diet, exercise, wt loss, reduce caffeine, alcohol

1st line:
DM - ACEi
African, Caribbean - CCB or (ARB if DM)
<55y - ACEi
>55y - CCB

2nd + 3rd line add additional drug

• CCB or TLD or ARB/ACEi
• avoid ACEi in African Caribbean

4th line/resistant HTN

• consider referral
• spironolactone = K <4.5
• bb or ab = K >4.5

Pregnancy HTN
- labetalol or methyldopa

Question 7

Iatrogenic HTN - what is it? causes?

Answer 7

Definition = HTN causes by medication. It is important to take a thorough hx to rule out other secondary causes

Drug induced:

• Alcohol
• cocaine
• ciclosporins
• COCP
• Steroids
• NSAIDS
• Antidepressant

RF

• Chronic pain
• Alcohol/substance abuser
• Organ transplant recipient
• Comorbidities such as asthma, COPD

Question 8

What is hypotension + types

Answer 8

Hypotension defined as < 90/60mmHg and may cause syx such as dizziness, light headedness.

Orthostatic/postural, hypovolaemic shock, cardiogenic shock

Question 9

Orthostatic/postural hypotension

• causes
• syx
• dx
• mx

Answer 9

Causes

• Hypovolaemia: dehydration (vomiting, diarrhoea, fever), blood loss
• Medication: nitrates, diuretics, anti-hypertensives, BB, sildenafil, anti-psyhcotics
• Disease: Addison’s, Hypopituitarism/low ACTH, Autonomic neuropathy, Idiopathic

syx

• Asyx
• Light-headedness
• Weakness
• Dizziness
• Blurred vision
• Syncope/LOC

Dx

• record BP with pt lying/sitting for 5mins and then stand for 3mins
• Dx = drop of >20mmHg (systolic) or >10mmHg (diastolic) after standing for 3 mins

mx

• Advice: lie down if feeling faint, stand slowly
• inc water + salt intake
• review meds
• 1st line: fludrocortisone (corticosteroid) - promotes Na retention
• 2nd line: Midodrine or ephedrine

Question 10

SIgns + Mx of hypovolaemic + cardiogenic shock

Answer 10

Signs: tachycardia, reduced BP, reduced U/O, raised JVP, poor tissur turgor

• ABCDE
• Oxygen
• IV normal saline
• Keep warm
• Seek senior help
• Monitor
• Identify cause