Hypertension

Question 1

Define Hypertension

Answer 1

Clinically
BP > 140/90 mmHg

Home/Ambulatory
BP>135/85 mmHg

Question 2

What are the causes of hypertension?

Answer 2

Essential Hypertension

• No identifiable cause
• Makes up 95% of hypertension cases.

Secondary hypertension  (ROPE) 
- Renal disease --> if patient's BP isn't coming down or the patient's BP is really high, investigate renal artery stenosis. 

• Obesity
• Pregnancy induced hypertension (pre-eclapmsia).
• Endocrine Disorders –> in particular Conn’s Syndrome (Primary Hyperaldosteronism).

> To identify Conn’s syndrome, order renin:aldosterone ratio for blood tests.

Specialist investigation should be considered if the patient is under 40 years old or if there is an underlying secondary cause.

Question 3

What are the potential complications that can arise from hypertension?

Answer 3

Hypertension promotes atherosclerosis
–> Ischaemic heart disease

Hypertension causes hyaline arteriosclerosis
> Hypertensive Nephropathy

> Hypertensive retinoapthy (features include papillodema, cotton wool, oedema and flame haemorrhages).

> Heart failure

> Cerebrovascular events e.g. stroke, intracerebral haemorrhage (Bouchard- Charcot aneurysms).

Question 4

What is the diagnostic process for hypertension?

What are the values for the different stages?

What investigations do you need to carry out to identify any end organ damage?

Answer 4

• NICE guideline recommends screening for hypertension every 5 years, more frequently for patients who have BP that is borderline hypertensive (140/90) and every year in patients with type 2 diabetes.
• If patients have a BP between 140/90 and 180/120, then a 24hour home/ambulatory reading is needed to identify hypertension.
• NICE recommends measuring the blood pressure on both arms –> this is to identify any difference between the right arm and the left arm, If significant difference (>15mmHg), then take the biggest reading.

Clinic
Stage 1: >140/90

Stage 2: 160/100

Stage 3: 180/120

Home/Ambulatory
- Stage 1: >135/85

Stage 2: ?150/95

Investigations for end organ damage?
- Urine albumin:creatinine ratio for proteinuria –> assess kidney function

• Urine dipstick test for haematuria –> assess kidney function
• Bloods for lipid profile, Hb1Ac and renal function (U&Es).
• Fundus examination to identify any features of hypertensive retinopathy
• ECG to detect any cardiac abnormalities

Question 5

How do you treat these patients? What is the management plan?

Answer 5

Lifestyle Advice

• Stop smoking
• Eat healthily –> reduce salt, caffeine, alcohol intake
• Exercise more

Medications
- A. - ACE inhibitor e.g ramipril (1.25mg OD, up to 10mg)
-B - beta blocker e..g bisoprolol (5mg OD, up to 20mg)
- C - calcium channel blocker e.g. amlodipine (5mg, up to 20mg OD)
- D- Thiazide like Diuretics e.g. Indapomide e.g. 2.5mg OD
ARB - angiotensin receptor blocker e.g. candesartan e.g. 8mg OD, upto 32mg

ARB is given instead of ACEinhibitors, in black people or those who dont tolerate ACEi due to its side-effects (e.g. chronic cough).

Medical management is offered to:
-All patients with Stage 2 hypertension

• Patients with stage 1 hypertension, who also have cardiovascular disease/kidney disease/end organ damage/diabetes

Step 1: A (<55, non-black) or C (>55, black)

Step 2: A+C, A+D, C+D

Step 3: A+C+D

Step 4 :A+C+D+another drug (which depends on the level of potassium levels).

<4.5mmol/L –> potassium sparing diuretic e.g. spironolactone

> 4.5mmol/L –> alpha blocker (e.g. doxazosin) or beta blocker (e.g. atenolol).

Question 6

What are the treatment targets?

Answer 6

Age <80 years

• Systolic target: < 140
• Diastolic target: <90

Age>80 years

• Systolic target <150
• Diastolic target< 90