Hypertension

Question 1

Definition of hypertension

Answer 1

Persistently elevated BP >140/90 mmHg

Question 2

Describe the correlation between cardiovascular risk and BP

Answer 2

CVD risk doubles for every 20 mmHg increase in systolic and 10 mmHg increase in diastolic BP

Question 3

Describe the pathophysiology of hypertension

Answer 3

• BP is product of cardiac output and systemic vascular resistance with genetic and environmental factors
• increases in CO or resistance or both causes hypertension

Results:
- imbalance in naturesis
- overactive renin in RAAS system —> salt and water retention
- decreased vascular bio-sensitivity
- vascular tone increased (due to overactive renin, SNS and alpha-adrenoreceptors)
- activation of endothelins (vasoconstrictor + growth factor) can increase vascular wall thickness by vascular remodelling

Question 4

Describe primary hypertension

Answer 4

Primary hypertension has no identifiable cause and is associated with several risk factors

Question 5

Describe secondary hypertension

Answer 5

Secondary hypertension is a result of an underlying condition with a known mechanism, eg.
- endocrine eg. Hyperaldosteronism
- vascular eg. Coarctation of aorta
- renal eg. Renal artery stenosis
- drug induced eg. NSAIDs
- other

Question 6

What is the course of action for patients with normal BP measurements?

Answer 6

• screen in another 5 years
• consider drug treatment if super high risk

Question 7

What is the course of action for patients with BP measurements of 140/90-149/90 mmHg?

Answer 7

• do ambulatory BP readings
• offer lifestyle advice
• discuss possibility of drug treatment

Question 8

What is the course of action for patients with BP readings of 150/95+ mmHg?

Answer 8

• do ambulatory BP readings
• offer lifestyle advice
• commence drug treatment
• annual review

Question 9

What is the course of action for patients with BP readings of 180/120mmHg?

Answer 9

• assess for target organ damage
• start drug treatment immediately
• repeat BP reading in 7 days
• refer for specialist review if symptomatic/target organ compromise

Question 10

What are relevant things to do in the patient examination in the context of hypertension?

Answer 10

• BP (both arms, 2+ readings on 2+ occasions = use average)
• BMI
• cardiac + resp + bruits
• thyroid
• abdominal
• palpation of lower extremities for oedema + pulses
• ophthalmoscope
• neuro exam + mental status exam

Question 11

What investigations would you do for a hypertensive patient?

Answer 11

• metabolic panel + lipids
• eGFR + creatinine
• FBC
• urinalysis
• ECG

Question 12

What is the target BP measurements for hypertensive patients?

Answer 12

• 18-65 years = 130/70-79 mmHg
• 65+ = 130-139 mmHg

Question 13

What lifestyle modifications can be employed for hypertensive patients?

Answer 13

• education
• sodium retention
• dietary changes (DASH diet)
• weight loss to a BMI of 25 kg/m2
• increased physical activity
• limited alcohol consumption
• smoking cessation

Question 14

When should drug therapy be commenced in hypertension?

Answer 14

• immediately if patient has or is at high risk of renal/CVD
• Stage 1 (140-159/90-99 mmHg): commence after 3-6 months if not controlled by lifestyle changes
• Stage 2 (160-179/100-109 mmHg): immediate (aim for control within 3 moths)
• Stage 3 (180/110 mmHg): immediate (aim for control with 3 months)

Question 15

Describe the NICE guidelines for hypertension prescribing

Answer 15

Check notes for diagram