hypertension

Question 1

define hypertension

Answer 1

high blood pressure

Question 2

aetiology

Answer 2

primary : unknown
secondary
accelerated/malignant 
white coat 
masked - clinic different to home/ABPM

Question 3

aetiology of secondary hypertension

Answer 3

kidney disease - glomerulonephritis, diabetic nephropathy, renal cell carcinoma
vascular disease - renal artery stenosis, coarctation of aorta
endocrine disease - primary hyperaldosteronism, cushing’s, acromegaly
drugs - corticosteroids, venlafaxine, alcohol

connective tissue disorder
obstructive sleep apnoea
gestational hypertension
pre-eclampsia

Question 4

outcome of untreated hypertension

Answer 4

brain : stroke (ischaemic/haemorrhagic)
vascular dementia
heart : CAD, PVD, cardiac arrythmias, heart failure, heart attack
eye : hypertensive retinopathy
kidneys : chronic kidney disease

Question 5

treatment

Answer 5

lifestyle changes - healthy diet, exercise, reducing dietary salt intake, caffeine consumption, alcohol consumption, smoking cessation

medical - stepwise approach

Question 6

stages of hypertension

Answer 6

stage 1 = >140/90mmHg (clinic), >135/85 (ABPM/HBPM)

stage 2 = >160/100mmHg , >150/95

stage 3 = >180/120mmHg , —

Question 7

bedside investigations

Answer 7

urinalysis
urine albumin creatinine ratio (uACR) - albuminuria suggests end-organ damage
ECG

Question 8

lab investigations

Answer 8

urea and electrolytes
HbA1c - indicates blood glucose conc over previous 3mnths - high suggests diabetes
lipid profile - useful for assessing CVS disease risk

Question 9

what tool can be used for assessing CVS disease risk

Answer 9

QRISK3

Question 10

target BP for patients <80years

Answer 10

clinic = <140/90mmHg

ABPM/HBPM = 135/85mmHg

Question 11

target BP for patients aged >80 years

Answer 11

clinic = 150/90mmHg

ABPM/HBPM = <145/85mmHg

Question 12

medical management for stage 1

Answer 12

discuss anti-hypertensive drug therapy w/ patients <80 years who have 1 or more of … CVS disease, kidney disease, or estimated 10yr risk of CVS disease

consider anti-hypertensive drug therapy in patients…
aged >80yrs with clinic BP >150/90mmHg
aged <60yrs with estimated 10yr risk of CVS disease

Question 13

medical management for stage 2&3

Answer 13

offer anti-hypertensive drug therapy to all patients (NICE guidelines)

stepwise approach, min of 4wks to determine combination of drugs/drug have been successful at reducing BP or not

Question 14

step 1 of stepwise approach

Answer 14

patients aged <55yrs not of black african/caribbean descent : offer ACE inhibitor (ramipril), if not tolerated offer angiotensin-ii receptor blocker such as losartan

patients >55yrs and of black african/caribbean descent : offer CCB such as amlodipine

Question 15

step 2 of stepwise approach

Answer 15

patients already taking ACE inhibitor or ARB offer CCB or a thiazide-type diuretic such as indapamide

patients already taking CCB : offer ACE inhibitor or a thiazide-type diuretic such as indapamide
if ACE not tolerated offer ARB

Question 16

ARBs preferred in what ethnicity of patient

Answer 16

Black African

African-Caribbean descent

Question 17

step 3 of stepwise approach

Answer 17

offer combo of ACE inhibitor or ARB plus CCB and thiazide-type diuretic

Question 18

step 4 of stepwise approach

Answer 18

resistant HTN
options depend upon serum potassium

serum K+ <4.5mmol/l : offer low-dose spironolactone
serum K+ of >4.5mmol/L : offer an alpha blocker such as doxazosin or a BB such as atenolol

referred for specialist assessment if remain hypertensive despite 4 anti-hypertensive drug therapies

Question 19

treatment during pregnancy

Answer 19

chronic : referral to specialist

NICE guidelines