Hypertension

Question 1

What are some signs/symptoms of extremely high hypertension (>200/120)

Answer 1

headaches
visual disturbance
seizures

Question 2

Listen some renal, endocrine and other causes of secondary hypertension

Answer 2

Renal: glomerulonephritis, chronic pyelonephritis, APKD, renal artery stenosis

Endocrine: hyperaldosteronism, phaeochromocytoma, Cushing’s, congenital adrenal hyperplasia, acromegaly

Other: glucocorticoids, NSAIDs, pregnancy, coarctation of the aorta, COCP

Question 3

How do you assess a patient with newly-diagnosed HTN for end-organ damage

Answer 3

Fundoscopy, to check hypertensive retinopathy

Urine dipstick and U&Es, check for renal disease

ECG, to check for left ventricular hypertrophy or ischaemic heart disease

Question 4

Gold standard Ix for hypertension

Answer 4

24h blood pressure monitoring

Question 5

Drugs used to treat HTN, including MoA and side-effects

Answer 5

1. ACE-I: inhibits conversion of angiotensin l to angiotensin ll –> angiontensin ll stops triggering adrenal glands from releasing aldosterone and pituitary gland from releasing ADH –> less sodium retained –> less water retained. Main SEs are cough, angioedema and hyperkalaemia. ACE-I are the first-line tx in patients <55 year old and T2DM.
2. CCB: block voltage-gated calcium channels, relaxing vascular smooth muscle and force of myocardial contractions. Main SEs are ankle swelling, flushing and headache. First line in older patients and afro-caribbeans.
3. Thiazide-type diurtectics: inhibit sodium absorption at beginning of DCT. Thiazide is a weak ass diuretic. Main SEs are hyponatraemia, hypokalaemia.
4. A2RB: Block effects of angiotensin ll at AT1 receptor. Main SE is hyperkalaemia. Used when Pt cannot tolerate ACE-l.

Question 6

Pt with newly dx HTN is started on ACE-I - what is an impt thing to do?

Answer 6

Check renal function 2-3 weeks after

Question 7

Which HTN drug must be avoided in pregnant women?

Answer 7

ACE-I

Question 8

Pt comes in with new raised BP of 180/120mmHg - what do you do next?

Answer 8

1. Admit for specialist assessment if signs of retinal haemorrhage/papilloedema/chest pain/HF/AKI
2. Refer if phaeochromocytoma is suspected
3. Urgent Ix for end-organ damage
4. If no end-organ damage, repeat BP measurement in 7 days

Question 9

When do you decide to offer drug therapy for HTN?

Answer 9

If Stage 1 (ABPM >135/85mmHg): treat if <80y.o. and signs of organ damage/cardiovascular disease/renal disease/T2DM

If Stage 2 (ABPM > 150/95mmHg): offer tx regardless of age

Question 10

patients of black African or African–Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider:

Answer 10

an angiotensin receptor blocker in preference to an ACE inhibitor

Question 11

What are 4th line drugs to treat resistant HTN?

Answer 11

if potassium < 4.5 mmol/l add low-dose spironolactone
if potassium > 4.5 mmol/l add an alpha- or beta-blocker

Question 12

When might you suspect phaeochromocytoma (adrenal gland tumour in the medulla that secretes excessive adrenaline) in a Pt with newly-diagnosed HTN?

Answer 12

If the pt also has:
postural hypotension
headache
palpitations
pallor
diaphoresis (sweating)