Hypertension

Question 1

What is the definition of hypertension?

Answer 1

Persistently elevated blood pressure over 140/90

Question 2

What is the pathophysiology of hypertensions

Answer 2

Varies different genetic and environmental factors result in:
- Defects in renal sodium homeostasis resulting in salt and water retention which increases ECF volume, increases cardiac output.
- Functional vasoconstriction increases vascular reactivity which increases TPR
- Defects in vascular smooth muscle increases the vascular wall thickness which increases TPR

Question 3

What is primary hypertension and the risk factors?

Answer 3

Also known as essential/idiopathic. It accounts for 90% of hypertension. No identifiable cause but several risk factors:
Non-modifiable: Age, biological sex, race and genetics
Modifiable risk factors: Diet (high salt), physical activity, obesity, alcohol and stress.

Question 4

What are the causes of secondary hypertension?

Answer 4

• Endocrine: Cushing’s, thyroid disorders, hyperaldosteronism, phaeochromocytoma
• Vascular: Coarctation of the aorta.
• Renal: Renal artery stenosis, renal parenchymal disease.
• Drug: NSAIDs, herbal medicines, cocaine, exogenous steroid use.
• Other: obstructive sleep apnoea

Question 5

What are some of the practical investigations for a patient with primary and secondary hypertension?

Answer 5

• Metabolic and lipid panels,
• Renal function (eGFR and creatinine)
• FBC
• Urinalysis (looking to detect end organ damage)
• ECG
• Secondary hypertension (when BP is hard to control) - Echo/carotid doppler, sleep study, pheochromocytoma screen, TFTs, plasma renin/aldosterone and renal artery imaging

Question 6

What is involved in the physical assesment of hypertension?

Answer 6

• BP on both arms or ambulatory BP measurements,
• BMI,
• Cardiovascular and respiratory exam,
• Auscultation for carotid, femoral and renal bruits,
• Examination of thyroid,
• Abdo exam,
• Optic fundi exam (looking for end organ damage)
• Neurological exam and cognitive status exam

Question 7

What are the different grades of hyper tension?

Answer 7

• Grade 1: Systolic of 140-159 and/or diastolic of 90/99.
• Grade 2: Systolic of 160-179 and/or a diastolic of 100-109
• Grade 3: Systolic of 180+ and/or a diastolic of 110+

Question 8

What are the in-office and ambulatory BP values that are classed as hypertension?

Answer 8

Office: 140+/90+
Ambulatory: 135+/85+

Question 9

What is the target BP for a patient under 65 and over 65

Answer 9

Under 65 - systolic of 130. Unless they have CKD then aim for less than 140.
Over 65 - Systolic of 130-139.
Diastolic in both is 70-79

Question 10

What are some of the lifestyle modifications for the management of hypertension

Answer 10

• Education around the risks of hyper tension and the importance of control.
• Sodium reduction,
• DASH diet,
• Weight loss aiming for a BMI of around 25.
• Increased physical activity,
• Limiting alcohol consumption,
• Smoking cessation

Question 11

Explain the pharmacological treatment of hypertension in patients who are type 2 diabetic or patients of under 55 years old who are not of black ethnicity

Answer 11

Step 1. ACEi or ARB.
Step 2. Add a CCB or thiazide-like diuretic.
Step 3. ACEi/ARB + CCB + Thiazide-like diuretic.
Step 4. Confirm resistant hypertension. Referral or add spironolactone if K+ <4.5 or alpha/BB if K+ >4.5

Question 12

Explain the pharmacological treatment of hypertension in patients >55 years or patients of black ethnicity

Answer 12

Step 1. Calcium channel blocker,
Step 2. Add ACEi/ARB or thiazide-like diuretic.
Step 3. CCB + ACEi/ARB + Thiazide like diuretic.
Step 4. Confirm resistant hypertension. Referral or add spironolactone if K+ <4.5 or alpha/BB if K+ >4.5

Question 13

What are some potential management devices which could potentially be used for hypertension?>

Answer 13

• Renal artery denervation.
• Baroreflex activation therapy