Hypertension

Question 1

What is the practical definition of hypertension?

Answer 1

When treatment does more good than harm.

Question 2

What is the clinical definition of hypertension?

Answer 2

SBP over 140 and/or diastolic over 85 mmHg, measured on three separate occasions.

Question 3

What is malignant hypertension?

Answer 3

BP over 200/130 mmHg.

Question 4

What is the aetiology of hypertension?

Answer 4

• Idiopathic in most
• RENAL: renal artery stenosis, chronic glomerulonephritis, pyelonephritis, polycystic kidney disease, CKD
• ENDOCRINE: diabetes, hyperthyroid, Cushing’s, Conn’s, hyperparathyroidism, phaeochromocytoma, congenital adrenal hyperplasia, acromegaly
• CARDIOVASCULAR: aortic coarctation (narrowing)
• DRUGS: sympathomimetics, corticosteroids, OCP
• PREGNANCY: pre-eclampsia

Question 5

What is the pathophysiology of hypertension?

Answer 5

Small vessels respond to hypertension with fibrotic intimal thickening of arteries, reduplication of elastic lamina and smooth muscle hypertrophy. There is also endothelial dysfunction leading to atherosclerosis and eventual thrombosis in small vessels. Associated with end-organ damage in advanced hypertension.

Question 6

What is essential hypertension?

Answer 6

Hypertension with no known aetiology – idiopathic. You must exclude secondary causes before labelling as essential hypertension.

Question 7

What are the grades of hypertension?

Answer 7

• Grade 1: mild; 140-159 and 90-99
• Grade 2: moderate; 160-179 and 100-109
• Grade 3: severe; over 180 and over 110

Question 8

What are the signs and symptoms of hypertension?

Answer 8

• Loud S2, S4
• Malignant or accelerated: scotomas (visual field loss), headache, seizures, N&V, acute heart failure
• End-organ damage e.g., kidneys and eyes are commonly affected

Question 9

What are the investigations for hypertension?

Answer 9

Focuses on ruling out causes: U&Es, glucose, lipids, urine dipstick, ECG. Indicated in young patients, malignant hypertension, or poor response to treatment.

Question 10

How is ‘white coat’ hypertension mitigated?

Answer 10

Ambulatory BP monitoring – measured throughout day

Question 11

How is hypertension conservatively managed? (x5)

Answer 11

Weight reduction and exercise. Stop smoking. Reduce alcohol. Reduce dietary Na+.

Question 12

How is hypertension medically managed?

Answer 12

.

Question 13

How is malignant hypertension treated? (x2)

Answer 13

IV beta-blocker such as labetalol, or hydralazine sodium nitroprusside.

Question 14

What is the problem with antihypertensive medication?

Answer 14

Hypertension does not have symptoms until it is too late to manage. As such, patients are at risk of becoming non-compliant because their reported effects are usually only side-effects of the medication e.g., CCBs can worsen peripheral oedema.

Question 15

What are the risks of beta-blocker use in hypertension management?

Answer 15

Used with thiazide diuretic increases patient risk of developing diabetes. Beta blockers also increase heart failure risk.

Question 16

How can you overcome non-compliance?

Answer 16

Multiple antihypertensives, each at less-than-standard doses, increases efficacy of treatment while reducing risk of adverse effects.

Question 17

Intensive versus standard treatment?

Answer 17

Intensive treatment in patients with heart disease leads to decreased mortality when compared with standard treatment.

Question 18

What are the target BPs in management: Non-diabetic? Diabetes without proteinuria? Diabetes with proteinuria?

Answer 18

Less than 140/85, 130/80, and 125/75, respectively.

Question 19

What are the complications of hypertension?

Answer 19

Heart failure, ACS, peripheral vascular disease, emboli, retinopathy, renal failure, hypertensive encephalopathy, posterior reversible encephalopathy syndrome (PRES)