Hypertension

Question 1

What is the pathophysiology of hypertension?

Question 2

What is primary hypertension and its risk factors?

Answer 2

• Primary/essential hypertension which is when there is no single disease causing hypertension.
  Non-modifiable: Age, biological sex, race and genetics
  Modifiable risk factors: Diet (high salt), physical activity, obesity, alcohol and stress.

Question 3

What are some secondary causes of hypertension?

Answer 3

Renal - Renal artery stenosis, APKD, glomerulonephritis, chronic pyelonephrtitis
Endocrine - Primary hyperaldosteronism, phaechromocytoma, Cushing’s syndrome, Liddle’s syndrome, congenital adrenal hyperplasia, acromegaly
Other - Steroids, NSAIDs, pregnancy, coarctation of the aorta, combined OCP

Question 4

What are the signs and symptoms of hypertension?

Answer 4

Doesn’t typically cause symptoms unless very high eg, >200/120. This then may cause headaches, visual disturbances and seziures

Question 5

What are the different grades of hyper tension?

Answer 5

Grade 1: Systolic of 140-159 and/or diastolic of 90/99.
Grade 2: Systolic of 160-179 and/or a diastolic of 100-109
Grade 3: Systolic of 180+ and/or a diastolic of 110+

Question 6

What are the in-office and ambulatory BP values that are classed as hypertension?

Answer 6

Office: 140+/90+
Ambulatory: 135+/85+

Question 7

What are the investigations for hypertension?

Answer 7

• 24 hour blood pressure monitoring (for diagnosis)
• Take blood pressure in both arms
• U&Es: Look for renal disease or damage
• HbA1c
• Lipids
• ECG
• Urine dipstick

Question 8

What do you do if BP is over 180/120?

Answer 8

• Admit for specialist assessment (signs of retinal haemorrhage/papilloedema
• Assess for end organ damage: ACR, ECG

Question 9

When should you treat hypertension?

Answer 9

• Stage 1 hypertension if under age 80 AND signs of end organ damage, renal disease or high 10 year cardiovascular risk (>10%)
• Stage 2+ hypertension

Question 10

What is the target BP for a patient under 65 and over 65

Answer 10

Under 65 - systolic of 130. Unless they have CKD then aim for less than 140.
Over 65 - Systolic of 130-139.
Diastolic in both is 70-79

Question 11

What are some of the lifestyle modifications for the management of hypertension

Answer 11

Education around the risks of hyper tension and the importance of control.
Sodium reduction,
DASH diet,
Weight loss aiming for a BMI of around 25.
Increased physical activity,
Limiting alcohol consumption,
Smoking cessation

Question 12

Explain the pharmacological treatment of hypertension in patients who are type 2 diabetic or patients of under 55 years old who are not of black ethnicity

Answer 12

Step 1. ACEi or ARB.
Step 2. Add a CCB or thiazide-like diuretic.
Step 3. ACEi/ARB + CCB + Thiazide-like diuretic.
Step 4. Confirm resistant hypertension. Referral or add spironolactone if K+ <4.5 or alpha/BB if K+ >4.5

Question 13

Explain the pharmacological treatment of hypertension in patients >55 years or patients of black ethnicity

Answer 13

Step 1. Calcium channel blocker,
Step 2. Add ACEi/ARB or thiazide-like diuretic.
Step 3. CCB + ACEi/ARB + Thiazide like diuretic.
Step 4. Confirm resistant hypertension. Referral or add spironolactone if K+ <4.5 or alpha/BB if K+ >4.5

Question 14

Describe features of an isolated systolic hypertension

Answer 14

• Common in elderly
• Treat like normal hypertension

Question 15

What are some causes of hypertension and hypokalaemia?

Answer 15

• Cushing’s syndrome,
• Conn’s syndrome,
• Liddle’s syndrome
• 11-beta hydroxylase deficiency (not 21 hydroxylase deficiency)

Question 16

What is the definition of hypertension in pregnancy?

Answer 16

BP > 140/90 or an increase in systolic BP of 30mmHg or diastolic of 15mmHg.

Question 17

What are important investigations for hypertension in pregnancy and the first line treatment?

Answer 17

Investigations - Proteinuria (urine dip and ACR)
Treatment - Labetalol or nifedipine and hydralazine if asthmatic