Hypertension

Question 1

What is Hypertension?

Answer 1

High blood pressure - BP above 140 | 90 mmHg in clinic or 135 | 85 mmHg with ambulatory/home readings.

Question 2

Types of Hypertension (2).

Answer 2

1. Essential/Primary (95%) - no cause.

2. Secondary - ROPE causes : consider if patient below age of 40.

Question 3

Aetiology of Secondary Hypertension (4).

Answer 3

ROPE :-

1. R - Renal Disease (commonest) - Renal Artery Stenosis.
2. O - Obesity.
3. P - PIH or PET.
4. E - Endocrine - mainly Conn’s (Primary Hyperaldosteronsim) - Renin : Aldosterone Ratio Blood Test.

Question 4

What is NICE’s recommendation on Hypertension screening?

Answer 4

BP screening every 5 years - more often for borderline/Type II Diabetes patients.

Question 5

Diagnosis of Hypertension (3).

Answer 5

1. If between clinic BP of 140 | 90 and 180 | 120, 24 Hour Ambulatory/Home Readings to confirm diagnosis.
2. Measure BP in both arms - if difference is more than 15mmHg, use higher pressure to diagnose.
3. End-Organ Damage Investigations.

Question 6

What is White Coat Effect/Syndrome?

Answer 6

A more than 20 | 10 mmHg difference in BP between clinic and ambulatory/home readings.

Question 7

Stages of Hypertension (3).

Answer 7

1. Stage I - Clinic > 140 | 90 or Ambulatory > 135 | 85.
2. Stage II - Clinic > 160 | 100 or Ambulatory > 150 | 95.
3. Stage III - Clinic > 180 | 120.

Question 8

End-Organ Damage Investigations (4).

Answer 8

1. Urine ACRAT (Proteinuria) and Dipstick (Microscopic Haematuria) - KIDNEY.
2. Bloods : HbA1C, Renal Function, Lipids.
3. Fundoscopy : Hypertensive Retinopathy.
4. ECG : Cardiac Abnormalities e.g. LV Hypertrophy.

Question 9

Management of Hypertension (3).

Answer 9

1. Lifestyle Management.
2. 4 Step Medical Management.
3. Specialist Advice.

Question 10

Indications of Medical Management of Hypertension (2).

Answer 10

1. Stage II Hypertension.

2. Stage I Hypertension + Age < 80 + Q-Risk > 10% or End-Organ Damage.

Question 11

Management Algorithm of Hypertension (4).

Answer 11

1A. Age < 55 or Type II DM = A.
1B. Age > 55 + No Type II DM or Black + No Type II DM = C.
2. A + C or D.
3. A + C + D.
4. A + C + D + Other.

Question 12

What medications are used in Steps 1-3? (4)

Answer 12

1. A : ACE Inhibitor e.g. Ramipril.
2. A : ARB : Angiotensin II Receptor Blocker e.g. Candesartan.
3. C : DHP Calcium Channel Blocker e.g. Amlodipine.
4. D : Thiazide-Like Diuretic e.g. Indapamide.

Question 13

What medications can be used in Step 4?

Answer 13

1. If serum Potassium < /= 4.5 : Potassium-sparing Diuretic e.g. Spironolactone.
2. If serum Potassium > 4.5 : a-Blocker e.g. Doxazosin or B-blocker e.g. Atenolol.

Question 14

Treatment Targets (4).

Answer 14

1. Age < 80 : 140 | 90.
2. Age > 80 : 150 | 90.
3. Type II Diabetes = Same.
4. Type I Diabetes - 135 | 85 usually but if albuminuria or 2+ features of metabolic syndrome - 130 | 80.

Question 15

Complications of Hypertension (5).

Answer 15

1. Ischaemic Heart Disease.
2. Cerebrovascular Accident.
3. Hypertensive Retinopathy.
4. Hypertensive Nephropathy.
5. Heart Failure.

Question 16

Dietary Lifestyle Advice of Hypertension.

Answer 16

Low Salt Diet (<6g/day vs 8-12g/day).

Question 17

Malignant Hypertension.

Answer 17

1. Admit for Specialist Assessment if signs of retinal haemorrhage or papilloedema or life-threatening symptoms e.g. new-onset confusion, chest pain, heart failure, AKI.
2. Urgent Investigations for End-Organ Damage.
3. Controlled Drop to 160 | 100 over at least 24 hours (risk of ischaemic stroke) with oral CCBs.

Question 18

ABPM Procedure (2).

Answer 18

1. 2 measurements per hour during usual awake time.

2. Average of at least 14 measurements.

Question 19

HBPM Procedure (3).

Answer 19

1. 2 consecutive measurements 1 minute apart for each BP reading.
2. 2x daily for at least 4 days.
3. Remove Day 1 and use average of remaining days.

Question 20

Renal Causes of Hypertension (4).

Answer 20

1. Glomerulonephritis.
2. Pyelonephritis.
3. ADPKD.
4. Renal Artery Stenosis.

Question 21

Endocrine Causes of Hypertension (6).

Answer 21

1. Conn’s (Primary Hyperaldosteronism) Syndrome.
2. Cushing’s Syndrome.
3. Phaeochromocytoma.
4. Liddle’s Syndrome.
5. CAH (11-B-Hydroxylase) Deficiency.
6. Acromegaly.

Question 22

Drug Causes of Hypertension (5).

Answer 22

1. Steroids.
2. MAO Inhibitors.
3. COCP.
4. NSAIDs.
5. Leflunomide.

Question 23

Give 4 causes of Hypokalaemia with Hypertension.

Answer 23

1. Cushing’s syndrome.
2. Conn’s Syndrome.
3. Liddle’s Syndrome.
4. 11-B-Hydroxylase Deficiency.

Question 24

What effects does hypertension have on vascular health?

Answer 24

1. Accelerates atherosclerosis.

2. Accelerates arteriosclerosis.

Question 25

What is arteriosclerosis?

What are the 2 types of arteriosclerosis?

Answer 25

Hardening of an artery or arteriole - lowered compliance of arterial tree; contributes to increase in SBP and alters tissue autoregulation and narrowing of lumen - progressive chronic ischaemia.

• Hyaline Arteriosclerosis.
• Hyperplastic Arteriosclerosis.

Question 26

Pathophysiology of Hyaline Arteriosclerosis.

Answer 26

Gradual change in artery : smooth muscle cells in the media are replaced by collagen and deposition of plasma proteins - hyaline change.

Question 27

Pathophysiology of Hyperplastic Arteriosclerosis.

Answer 27

Very high SBP causes fibrinoid necrosis in the vessel wall - proliferation of intimal cells, significantly narrowing vessel lumen = ‘onion-skin’ appearance.