Hypertension

Question 1

What is hypertension?

Answer 1

High blood pressure

Question 2

What are the two types of hypertension?

Answer 2

Primary and secondary

Question 3

What is primary hypertension?

Answer 3

AKA essential hypertension, accounting for 95% of hypertension

Occurs on its own without secondary cause

Question 4

What are the causes of secondary hypertension?

Answer 4

THINK ROPE

Renal
Obesity
Pregnancy induced hypertension / pre-eclampsia
Endocrine

Question 5

Why does hypertension occur?

Answer 5

Reduced elasticity of large arteries, due to age-related and atherosclerosis-related calcification, and degradation of arterial elastin.

Question 6

What is more important - raised systolic pressure or raised diastolic pressure?

Answer 6

Raised systolic pressure is more important than raised diastolic pressure as a risk factor for cardiovascular and renal disease.

Question 7

What are the complications of hypertension?

Answer 7

Ischaemic heart disease
Cerebrovascular accident (i.e. stroke or haemorrhage)
Hypertensive retinopathy
Hypertensive nephropathy
Heart failure

Question 8

According to NICE guidelines, what blood pressure reading can diagnose hypertension?

Answer 8

Clinical - 140/90

Ambulatory or home readings - 135/85

Question 9

What patients should have 24H ambulatory blood pressure to confirm diagnosis?

Answer 9

Patients with a clinic blood pressure between 140/90 mmHg and 180/120 mmHg

Question 10

What is white coat syndrome?

Answer 10

Having your blood pressure taken by a doctor or nurse often results in a higher reading.

Question 11

When would you suspect white coat syndrome?

Answer 11

More than a 20/10 mmHg difference in blood pressure between clinic and ambulatory or home readings.

Question 12

What is stage one hypertension?

Answer 12

Clinical: >140/90

Ambulatory/home: >135/85

Question 13

What is stage two hypertension?

Answer 13

Clinical: >160/100

Ambulatory/home: >150/95

Question 14

What is stage 3 hypertension? Malignant hypertension

Answer 14

> 180/120

Question 15

When can ARBs be used?

Answer 15

In place of an ACE inhibitor if the person does not tolerate ACE inhibitors (commonly due to a dry cough) or the patient is black of African or African-Caribbean descent. ACE inhibitors and ARBs are not used together.

Question 16

Initial management

Answer 16

Establish a diagnosis.

Investigate for possible causes and end organ damage.

Advise on lifestyle. This includes recommending a healthy diet, stopping smoking, reducing alcohol, caffeine and salt intake and taking regular exercise.

Question 17

Who is medical management of hypertension offered to?

Answer 17

All patients with stage 2 hypertension

All patients under 80 years old with stage 1 hypertension that also have a Q-risk score of 10% or more, diabetes, renal disease, cardiovascular disease or end organ damage.

Question 18

Step one medical management of hypertension

Answer 18

Aged less than 55 and non-black use ACE inhibitor - eg ramipril.

Aged over 55 or black of African or African-Caribbean descent use calcium channel blocker - eg amlodipine.

Question 19

Step two medical management of hypertension

Answer 19

ACE inhibitor + calcium channel blocker.

If black then use an ARB instead of A.

Question 20

Step three medical management of hypertension

Answer 20

ACE inhibitor + calcium channel blocker + Diuretic

Question 21

Step four medical management of hypertension

Answer 21

ACE inhibitor + calcium channel blocker + Diuretic + another med

Seek specialist advice if the blood pressure remains uncontrolled despite treatment at step 4.

Question 22

What medicine is given at stage 4 and what does it depend on?

Answer 22

Depends on serum potassium level

If the serum potassium is ≤ 4.5 mmol/l consider a potassium sparing diuretic such as spironolactone.

If the serum potassium is >4.5 mmol/l consider an alpha blocker (e.g. doxazosin) or a beta blocker (e.g. atenolol).

Question 23

What medications increase the risk of hyperkalaemia?

Answer 23

ACE inhibitors
Thiazide like diuretics

For this reason it is important to monitor U+Es regularly when using ACE inhibitors and all diuretics.

Question 24

What is the treatment target in under 80s?

Answer 24

Systolic Target: <140
Diastolic Target: <90

Question 25

What is the treatment target in over80s?

Answer 25

Systolic Target: <150
Diastolic Target: <90

Question 26

What is malignant hypertension?

Answer 26

Severe elevation of arterial blood pressure, resulting in end-organ damage.

Question 27

Malignant hypertension stats.

Answer 27

Blood pressure ≥180 mm Hg systolic and ≥120 mm Hg diastolic

Question 28

Malignant hypertension complications

Answer 28

Evidence of end-organ damage
Papilloedema and/or retinal haemorrhages
New-onset confusion (encephalophathy)
Seizure
Chest pain
Signs of heart failure
Acute kidney injury

Question 29

Malignant hypertension management

Answer 29

Guidelines in treatment suggest aiming for controlled drop in blood pressure, to around 160/100mmHg over at least 24 hours.

Question 30

What can cause an uncontrolled drop in malignant hypertension?

Answer 30

Ischaemic stroke due to poor cerebral autoregulation and perfusion.

Question 31

First line treatment in malignant hypertension

Answer 31

Oral medication is preferred to IV, unless there is encephalopathy, heart failure or aortic dissection.

Oral calcium channel blockers such as amlodipine or nifedipine are often used first line.

Question 32

When would you suspect secondary hypertension?

Answer 32

Younger patients with few comorbidities.
Severe hypertension or hypertension resistant to treatment
New hypertension in patients with previously stable or low readings.
Hypertension with associated symptoms or electrolyte disturbances