Hypertension (1)

Question 1

What is it defined as?

What are its risk factors?

Answer 1

➊ BP > 140/90mmHg in clinic or > 135/85mmHg with 24hr ABPM/at home

➋ • Non-modifiable - 65+, FHx, Afro-Caribbean
• Modifiable - Obese, Lack of exercise, Smoking, Alcohol, Stress

Question 2

Complications:
How does it affect the Heart?

How does it affect the Brain?

How does it affect the Kidney?
→ What will be seen on USS?

How does it affect the Eye?

Answer 2

➊ • IHD - Accelerates atherosclerosis in coronary arteries
• HF - LV has to work harder against the increased systemic pressure, so undergoes compensatory hypertrophy. Eventually, the Hypertrophied LV decompensates and fails → LHF

➋ • Stroke - Accelerates atherosclerosis
• Haemorrhage - Rupture of tiny Berry aneurysms → SAH
• Vascular Dementia

➌ CKD - Hypertensive nephropathy - Progressive arteriosclerosis in renal arteries, causing renal ischaemia = Tubular atrophy, Interstitial Fibrosis, and Glomerular sclerosis
→ Small, fibrotic kidneys

➍ Hypertensive Retinopathy - Flame haemorrhages, cotton-wool spots, yellow hard exudates, and papilloedema

Question 3

Classification:
What is the most common type?

What is Secondary HTN?
→ What is its most common cause?
→ What are the other causes?

What is Malignant HTN?
→ How does it present?

What’s the difference between White-coat and Masked HTN?

Answer 3

➊ Primary (95%) - No identifiable cause

➋ When there’s an identifiable cause
→ Renal disease - Overactivation of the RAAS
→ • Pre-eclampsia
• Endocrine - Cushing’s (high cortisol), Conns (high aldosterone), Phaeochromocytoma, Acromegaly
• Drugs - Steroids, COCP, NSAIDs

➌ Severe, rapid rise in BP > 180/120mmHg leading to end-organ damage
→ Evidence of end-organ damage e.g. papilloedema, retinal haemorrhages, new confusion, seizure, HF, AKI

➍ • White coat - HTN during consultations (normal ABPM)
• Masked - Normal during consultations (HTN on ABPM)

Question 4

What are the 3 stages?

How does it present?

How is it diagnosed?

How is it investigated?

Answer 4

➊ • Stage 1 - Clinic > 140/90mmHg, 24hr ABPM > 135/85mmHg
• Stage 2 - Clinic > 160/100mmHg, 24hr ABPM > 150/95mmHg
• Stage 3 - Clinic > 180/120mmHg

➋ Usually asymptomatic and diagnosed during regular checks

➌ If clinic reading > 140/90mmHg, a 24hr ABPM is used to confirm diagnosis

➍ Check for end-organ damage:
• Bloods - Glucose, U+E’s, Lipid profile
• Urine dip and ACR - haematuria and proteinuria
• Fundoscopy - hypertensive retinopathy
• ECG - LV hypertrophy

Question 5

Management:
What are the lifestyle changes to make?

What is the drug ladder for those < 55 yrs?

What is the drug ladder for those > 55 yrs OR Black?

What’s the first drug given if Diabetic?

Answer 5

➊ • Smoking cessation
• Reduce alcohol and caffeine
• Exercise
• Diet
• Reduce stress

N.B. Tends to be the only management for pts with Stage 1 HTN pts

➋ ACTS:
• ACEi/ARB
• CCB (DHP)
• Thiazide diuretic
• Spironolactone (Increase thiazide dose instead if K > 4.5)

➌ CATS:
• CCB (DHP)
• ACEi/ARB
• Thiazide diuretic
• Spironolactone (Increase thiazide dose instead if K > 4.5)

➍ ACEi/ARB (regadless of age/ethnicity)
‣ Start with ARB if also black

N.B. ARB can be used instead of ACEi if pt can’t tolerate it e.g. due to cough