Hypertension

Question 1

Define hypertension and its stages

Answer 1

BP >140/90 on 3 separate occasions

1: Clinic BP ≥140/90 mmHg AND ABPM / HBPM average BP ≥135/85 mmHg

2: Clinic BP ≥160/100 mmHg AND ABPM / HBPM average BP ≥150/95 mmHg

Severe: Clinic systolic BP ≥180 mmHg OR clinic diastolic BP ≥ 110mmHg

Question 2

Aetiology of Hypertension

Answer 2

Primary: essential/idiopathic (90%)

Secondary:
Renal: Renal artery stenosis, chronic glomerulonephritis/pyelonephritis, PCKD, chronic renal failure
Endocrine: DM, Cushing’s, Conn’s, phaeochromocytoma, congenital adrenal hyperplasia, hyperPTH
Cardiovascular: aortic coarctation
Drugs: sympathomimetics, steroids, OCP
Pregnancy, pre-eclampsia

Question 3

Risk factors for hypertension

Answer 3

Obesity
Sedentary lifestyle (<3 aerobic exercise a week)
Black/Afro-Caribbean
DM
Alcohol
Smoking
Metabolic syndrome
FHx
High sodium intake, low fruit and vegetable
>60 years old

Question 4

Symptoms and signs of hypertension

Answer 4

Asymptomatic
May present with complications: headache, visual changes, dyspnoea, chest pain

Obs: HTN
Fundoscopy: retinopathy, papilloedema
Cardiac: S4, heave, bruits
Neuro: sensory or motor deficit

Question 5

Investigations for hypertension

Answer 5

Clinic BP, standing and sitting
Ambulatory blood pressure monitoring >140/90
ECG: may show signs of hypertrophy
Urinalysis: ?renal disease

U&Es: ?renal disease, Conn’s
Glucose
Lipid profile
TFTs
FBC: ?polycythaemia
LFTs: ?end-organ damage

Question 6

What necessitates admission for hypertension

Answer 6

Severe (>180/110)
Retinal haemorrhage
Papilloedema
Confusion
AKI
Chest pain

Question 7

Management for hypertension (Stable)

Answer 7

Conservative: stop smoking | maintain weight | reduce alcohol intake | reduce dietary sodium

Medical
Stage 1: treat if under <80yo + end-organ damage, CVD, renal disease, diabetes, QRisk >10%)
<55yo
1. ACEi or ARB
2. ACEi + CCB OR TLD
3. ACEi/ARB + CCB + TLD
4. Low-dose spironolactone OR beta-blocker

> 55yo OR Afro-Caribbean
1. CCB or thiazide-like diuretic
2. CCB + TLD OR ARB
3. ACEi/ARB + CCB + TLD
4. Low-dose spironolactone OR beta-blocker

+ statin (20mg primary prevention, 80mg secondary prevention)

Question 8

What are the considerations for anti-hypertensive medications

Answer 8

ARBs are preferred to ACEis in Afro-Caribbeans
ACEi should be given to patients with diabetes who have microalbuminaemia BUT Afro-Caribbean → ARB

Question 9

How is BP monitored in HTN and what is the target

Answer 9

Monitor U&Es before ACEi (ACEi), and during treatment (ACEi/ARB)
Increase up to 30% in creatinine is acceptable (U&Es in 2w)
Increase K+ up to 5.5mmol is acceptable (stop ACEi/ARB if >5.5)
no thiazides in CKD 4, 5 (eGFR <30), DM, gout, dyslipidaemia, SLE

<80: CBP <140/90 | ABPM <135/85
>80: CBP <150/90 | ABPM <145/85

Question 10

What is malignant hypertension and how is it treated

Answer 10

Malignant hypertension = BP >200/130mmHg
IV labetalol + urgent referral for specialist care

Question 11

Complications of hypertension

Answer 11

Congestive Heart failure, Coronary artery disease, MI, Peripheral vascular disease
Hypertensive retinopathy
CVA, Hypertensive encephalopathy
Emboli
Renal failure
Posterior reversible encephalopathy syndrome (PRES)
Malignant hypertension

Question 12

Prognosis for hypertension

Answer 12

Good if the BP is controlled
Uncontrolled hypertension is associated with increased mortality (6x stroke risk, 3x cardiac death risk)
Major risk factor for development of cardiac, vascular, renal and cerebrovascular disease, morbidity and mortality

Question 13

What are the stages of hypertensive retinopathy

Answer 13

Grade I: Silver wiring

Grade II: AV nipping

Grade III: Flame haemorrhages | May see cotton wool spots (ischaemia)

Grade IV: Papilloedema (blurring of optic disc edge)