Hypertension

Question 1

Define Hypertension

Answer 1

Sustained SBP > 140 mm Hg +/or DBP > 90 mm Hg measured on 3 separate occasions

Question 2

Define Malignant Hypertension

Answer 2

Severe increase in BP >, 180/120 mmHg (often > 220/120 mmHg) with signs of retinal haemorrhage +/or papilloedema

Question 3

Describe the aetiology of Hypertension

Answer 3

Primary/ Essential= 90% Idiopathic

Secondary= 10% has underlying cause

Question 4

List 5 systems/ states with their respective causes of secondary hypertension

Answer 4

Renal: glomerulonephritis, RAS, PKD, chronic pyelonephritis, CKD
Endocrine: DM, Cushings, Conns, phaeochromocytoma, hyperthyroidism, CAH, acromegaly
CVS: aortic coarctation, high intravascular volume
Drugs: sympathomimetics, corticosteroids, OCP
Pregnancy: pre eclampsia

Question 5

Describe the epidemiology of hypertension

Answer 5

> 25% of UK adults

Question 6

How does hypertension present?

Answer 6

Often asymptomatic
Symptoms of complications
Symptoms of the cause

Question 7

Give 6 features of malignant hypertension presentation

Answer 7

Scotomas (visual field loss)
Blurred vision
Severe headaches
Seizures
N + V
Acute heart failure

Question 8

How is hypertension diagnosed?

Answer 8

Record BP on 3 separate occasions
Record lowest reading
If 140/90 - 180/120, offer ABPM.

Question 9

Which 3 signs may present in a hypertensive patient, suggesting the cause?

Answer 9

Radiofemoral delay = coarctation of the aorta
Renal artery bruit = renal artery stenosis
Fundoscopy = hypertensive retinopathy

Question 10

Describe the Keith-Wagner Classification of Hypertensive Retinopathy

Answer 10

i. Silver wiring
ii. As above + arteriovenous nipping
iii. As above + flame haemorrhages + cotton wool exudates
iv. As above + papilloedema

Question 11

List the appropriate investigations for hypertension

Answer 11

Bloods (FBC, U+E’s, Lipids, Glucose)
Urine dipstick (blood + protein for renal causes)
ABPM (exclude white coat HTN)
ECG (LV hypertrophy)

Question 12

Describe 4 strategies in conservative management of hypertension

Answer 12

Stop smoking
Lose weight
Reduce alcohol intake
Reduce dietary sodium

Question 13

What is the mnemonic for medical treatments for hypertension? Give examples

Answer 13

CAT AB
CCB: Amlodipine
ACEi: Ramipril
Thiazide diuretic: Bendroflumethiazide
A/B blockers: Doxazosin/ Atenolol

Question 14

What is the first line pharmacological treatment of hypertension?

Answer 14

If <55, Diabetic, HF or LV dysfunction: ACEi or ARB

If >55/ Black: CCB

Question 15

What are the target BP’s aimed for with treatment?

Answer 15

<140/90 non diabetic + < 80
<130/80 diabetic
<125/75 diabetic with proteinuria

Question 16

Name 2 drugs used to treat malignant hypertension

Answer 16

Atenolol

Nifedipine

Question 17

What is used for Malignant Hypertension treatment with encephalopathy?

Answer 17

IV BB e.g. Labetalol
or
IV Na nitroprusside

Question 18

Why must you avoid rapid lowering of blood pressure when treating acute malignant hypertension?

Answer 18

Can cause cerebral infarction
Autoregulatory mechanisms in brain for regulating blood flow will cause vasoconstriction of vessels in brain when BP is very high
Lowering BP too rapidly would mean autoregulatory mechanisms do not adapt to the drop in BP + so the vessels remain constricted
Rapid drop in BP with constricted vessels will cause an infarction

Question 19

List 10 possible complications of hypertension

Answer 19

Heart failure  
CAD
Cerebrovascular accidents  
PVD
Lacunar brain haemorrhages
Emboli  
Renal failure
Hypertensive retinopathy  
Hypertensive encephalopathy  
Malignant HTN

Question 20

Describe the prognosis of a patient with hypertension

Answer 20

Good if well controlled.

Uncontrolled, increases risk of stroke 3x, MI 6x + renal + heart failure.

Question 21

What is papilloedema?

Answer 21

Optic disc swelling due to raised ICP

Sharp optic disc edge is NOT visible