Hypertension

Question 1

A 64-year-old black man presents for a check-up. He denies past medical problems, but has been told that his blood pressure was a little high. He has no complaints, takes no medications, tries to adhere to a healthy diet, and rarely exercises. He reports that over the previous 5 years he has gained 6.8 kg (15 lb). Review of systems is otherwise non-contributory. Physical examination is notable for obesity and blood pressure 172/86 mmHg. The remainder of the examination is unremarkable.

Impression/DDx/Goals

Answer 1

Provisional/Differential
Essential HTN, given asymptomatic BP >140/90 (as per Australian heart foundation guidelines) with no symptoms.

Consider other causes of high blood pressure, rule out secondary causes:
o White coat HTN
o Pheochromocytoma (would expect highly elevated BP)
o Arteriosclerosis
o OSA* given obesity
o CKD/ renal failure
o Hyper/hypothyroidism

Goals:

• manage hypertension, aim for BP within heart foundation guidelines
• adequately manage other cardiovascular risk factors

Question 2

HTN: History

Answer 2

History:

• Sx/complications; headache, visual changes, leg swelling, palpitations, dyspnoea
• Past med/Fam: heart disease, HTN, diabetes, renal disease
• medications (HTN, other heart meds)
• SNAP, readiness for change (if relevant)

Question 3

HTN: Examination

Answer 3

Examination:

• general: height, weight, waist circumference, BMI
• cardiovascular examination
  
  • peripheral stigmata of CVD
  • radial pulse
  • BP
  • Praecordial assessment: murmurs, apex beat
• endocrine examination (diabetes)
  
  • retinopathy, leg ulcers, peripheral neuropathy, acanthosis nigricans

Question 4

HTN: Investigations

Answer 4

Investigations:

• Bedside: BP, consider ECG, uACR
• Bloods: UEC (for formal eGFR, check every 1-2 yrs in high risk patients), lipids panel
• further imaging: not required at this state

Question 5

HTN: Management

Answer 5

Management would be as per existing Heart Foundation Guidelines

• Non-pharm:
  
  • lifestyle mods (trial for 3 mnths)
• Pharm
  
  • Monotherapy (ACEi, ARBs, CCBs, etc)`
  • Dual therapy
  • Triple therapy
• Review/referral/safety-netting
  - review 3-monthly
  - to present to ED if LOC, headache, visual changes (malignant HTN)
• Long-term
  - regular review
  - screen for complications (kidneys, eyes)

Question 6

Anti-hypertensive medications

Answer 6

ACEi

ARBs

CCBs:
Block L-type voltage-gated calcium channels of smooth muscle cells
Dihydro = mainly vasodilation
Non-dihydro = mainly cardiac, lower contractility and HR

• Dihydro: Nifedipine, amlodipine
• Non-dihydro: verapamil, diltiazem

Diuretics

Centrally acting
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