Hypertension

Question 1

Define the stages of hypertension (1/2/severe)

Answer 1

Stage 1 hypertension: Clinic blood pressure (BP) is 140/90 mmHg or higher and subsequent ambulatory BP monitoring (ABPM) daytime average or home BP monitoring (HBPM) average BP is 135/85 mmHg or higher.

Stage 2 hypertension: Clinic BP is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average BP is 150/95 mmHg or higher.

Severe hypertension: Clinic systolic BP is 180 mmHg or higher or clinic diastolic BP is 110 mmHg or higher.

Question 2

Usual symptoms of hypertension?

Answer 2

Usually Asymptomatic

1. Nil or headache
2. Sweating, headache, palpitations and anxiety may point to phaeochromocytoma.
3. Muscle weakness or tetany may point to hyperaldosteronism

Question 3

What conditions should we ask in history for CVS risk of hypertensive patient

Answer 3

In particular TIA, stroke, diabetes, previous renal disease, smoking and cholesterol, NSAIDS excess.

Past History of angina, CCF, palpitations, syncope and valvular heart disease

Family history should look for hypertension, premature coronary disease and polycystic kidney disease.

Drug history should be taken including any prior anti-hypertensive therapy and details of previous drug intolerances. Non-compliance is sometimes an issue.

Question 4

Hypertension - what are some examples of secondary causes we can look for

Answer 4

Cushing’s syndrome,

enlarged kidneys (PCK disease),

renal bruits,

radio-femoral delay (coarctation).

Question 5

6 Investigations can do for hypertension

Answer 5

Test for the presence of protein in the urine by sending a urine sample for estimation of the albumin: creatinine ratio and test for haematuria using a reagent strip.

• Blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol.
• Bloods may suggest secondary cause (low potassium, high Na: hyperaldosteronism).
• Examine the fundi for the presence of hypertensive retinopathy.
• Arrange for a 12-lead electrocardiograph to be performed.
• Consider echocardiography if suggestion of LVH, valve disease or LVSD or diastolic
  dysfunction.

Question 6

In who with stage 1 hypertension should we treat?

Answer 6

In those with stage 1 hypertension under the age of 80, treatment should be offered in those with evidence of target organ damage, those with established cardiovascular disease, patients with renal impairment, diabetes and patients with a 10-year risk ≥ 20%

Question 7

In who with stage 2 hypertension should we treat

Answer 7

In those with stage 2 hypertension, of any age, treatment should be offered.

Question 8

Target blood pressure for:

low->mod risk patients.

Diabetes/ stroke/ tia/ IHD/ CKD

People >< 80 years old

All patients diastolic (exc diabetes)

CKD with overt proteinuria

Answer 8

Target blood pressure is < 140 mmHg systolic in patients at low-moderate risk.

In diabetes, previous stroke/TIA, IHD and in patients with CKD, target blood pressure is ideally < 130/80.

In elderly hypertensives less than 80 years old with systolic > 160 mmHg, target is 140-150 mmHg although < 140 mmHg is reasonable if tolerated.
In those over 80 years, systolic target is 140-150 mmHg.

For all patients the diastolic target is < 90 mmHg except in diabetes where the target is < 85 mmHg.

In patients with CKD and overt proteinuria, systolic < 130 mmHg should be considered.

Question 9

Non Pharma treatment for hypertension

Answer 9

1. Weight reduction if body mass index > 25 kg/m2. Each kg weight loss yields a BP reduction of 3/2 mmHg.
2. Moderate salt intake (can reduce BP by 8/5 mmHg). Minimise alcohol intake. Aerobic exercise. Smoking cessation (to reduce cardiovascular risk).

Question 10

What is hypertensive crisis and what 2 states can patients present with

Answer 10

A hypertensive crisis is an increase in blood pressure, which if sustained over the next few hours, will lead to irreversible end-organ damage (encephalopathy, LV failure, aortic dissection, unstable angina, renal failure).

Emergency vs Urgency

Question 11

Emergency vs urgency hypertensive crisis?

Answer 11

Patients can present with an emergency (high BP associated with a critical event: encephalopathy, pulmonary oedema, acute kidney injury, myocardial ischaemia).

An urgency (high BP without a critical illness, but may include ‘malignant hypertension’: associated with grade 3/4 hypertensive retinopathy).

Question 12

What is the aim for therapy against hypertensive crisis

Answer 12

The aim of therapy is to reduce the diastolic BP to 110 mmHg in 3 - 12 hours (emergency) or 24 hours (urgency).

Question 13

Hypertensive crisis management (IV meds to give?)

Answer 13

1. Sodium nitroprusside
2. Labetalol
3. GTN (1 - 10 mg/hr)
4. Esmolol acts within 60 seconds, with a duration of action of 10 - 20 minutes.
   Typically, the drug is given as a 0·5 - 1 mg/kg loading dose over 1 minute, followed by an infusion starting at 50 μg/kg/min and increasing up to 300 μg/kg/min as necessary.

Question 14

Hypertensive ‘urgency’ definition + aim of treatment?

Answer 14

evere blood pressure elevation that will cause damage within days.

Diastolic is usually > 130 mmHg and retinal changes will be apparent. The aim should be to reduce BP gradually to a diastolic of 100 mmHg over 48 - 72 hours using an oral regime

Question 15

Hypertensive emergency -> what oral treatment is recommended (+ most effective treatment regimen)

Answer 15

For oral treatment, any of the following drugs may be used:

amlodipine 5 - 10 mg OD,
diltiazem 120 - 300 mg daily,

lisinopril 5 mg OD, etc.

A combination of a ACEI and calcium antagonist is effective and well tolerated.

Local expertise advises that the safest and most effective treatment regimen for the majority of patients is nifedipine 20mg MR BD plus amlodipine 10 mg OD for three days, continuing with Amlodipine 10 mg OD thereafter.

Question 16

classic triad of symptoms in patients with a phaeochromocytoma?

Answer 16

episodic headache, sweating, and tachycardia although most patients will not have all three

Question 17

Phaeo most classic sign

Answer 17

Sustained or paroxysmal hypertension is the most common sign of phaeochromocytoma

Question 18

Diagnosis of phaeo (there’s a couple tests)

Answer 18

The diagnosis is typically confirmed by measurements of urinary and plasma fractionated metanephrines and catecholamines.

A 24 hour urine collection is the main test.

A CT or MRI scan of the abdomen and pelvis may detect adrenal tumours. A MIBG scan can detect tumours not detected by CT or MRI but the diagnosis is still considered likely.

Question 19

Once a phaeochromocytoma is diagnosed, all patients should undergo a resection. Pending surgery, control of hypertension is combined … (+ describe full regimen, types of drug/ specific)

Answer 19

…alpha- and beta-adrenergic blockade. Phenoxybenzamine is most commonly used.

The initial dose is 10 mg once or twice daily, and the dose is increased by 10 to 20 mg in divided doses every two to three days as neededto control blood pressure and spells.

The final dose of phenoxybenzamine is typically between 20 and 100 mg daily. If not tolerated, the calcium channel blocker nicardipine can be used.

After adequate alpha-adrenergic blockade has been achieved, beta-adrenergic blockade is initiated, which typically occurs two to three days preoperatively. The beta-adrenergic blocker should never be started first.