hypertension

Question 1

Eric attended surgery last month because he had been suffering from persistent headaches and fatigue for the previous three weeks. your colleague found his blood pressure to be high and started him on bendroflumethiazide. Eric is otherwise well apart from being overweight and requiring treatment- venlafaxine- for depression. he has attended for blood tests and is coming to see you to fe the results which are normal apart from borderline low potassium.

Answer 1

-

Question 2

what might be the cause of Erics high blood pressure?

Answer 2

screening should be
-limited to
early onset < 30 years and no RF
-hypertension resistant to 3 drugs
-malignant hypertension
-specific features e.g phaeochromocytoma

Question 3

what might hypokalaemia give you clues to?

Answer 3

• spontaneous hypokalaemia or in response to thiazides, might suggest hyperaldosteronism

Question 4

You measure his blood pressure and it is again high at 215/115 mmHg but apparently he stopped his treatment after the tablets ran out?

given his particularly high blood pressure is there any specific part of Eric you want to examine?

Answer 4

-high blood pressure is not an emergency unless
there is evidence of immediate damage
- papilloedema
- acute kidney injury
-acute stroke
-acute coronary syndrome
-aortic dissection

Question 5

Your examination gives nothing to worry about but you decide to change treatment to atenolol 50mg
daily and remind Eric of the importance of taking his tablets regularly. He is to come back to see the
nurse next week. When he does he complains that he had been feeling dizzy and that he had checked
his blood pressure with a mate’s machine in the pub and it had only been 148/64mmHg.

is this the size of response you might expect from the full (50mg) dose of atenolol?

Answer 5

BP response depends in part on starting pressure but in moderate hypertension expected reductions with full dose of any single drug
- systolic 8-10 mmHg
- diastolic 4-6 mmHg

Question 6

Eric asks whether he might have that
“white coat” disorder with high blood pressure only when he
sees the doctor.

05 How might you investigate Eric’s home
blood pressure further?

Answer 6

• clinic/surgery measures
• unattended automated office BP
• home self measurement*
• ambulatory blood pressure measurement*
• different threshold/target

Question 7

When you next see Eric his blood pressure by the means you elected was 150/101mmHg

Q6 What threshold would you consider Eric
needing drug treatment?

Answer 7

For patients
- at low CVD risk 160/100 mmHg
- at high CVD risk 140/90 mmHg
( these are clinic thresholds)

Question 8

Q7 Is Eric unlucky to develop high blood
pressure at his age?

Answer 8

in the middle

Question 9

You put Eric back on the atenolol and ask to see him for review in one month. When he comes to see
you his blood pressure is lower at 138/92mmHg but he complains that he is not feeling any better.

Q8 Will blood pressure lowering drugs make
Eric feel better?

Answer 9

-by and large hypertension is symptom free
-the only symptomatic benefit of treatment is a reduction in headache
– this is of importance if a patient has, or perceives that they have side-effects

so no

Question 10

Q9 How far do you want to lower Eric’s blood
pressure?

Answer 10

target ( average clinic)
- routine <140/90 mmHg
- previous stroke < 130/80 mmHg
- Heavy proteinuria <130/80 mmHg
- CKD AND diabetes <130/80 mmHg
- older patients <150/90 mmHg

therefore the answer is routine <140/90 mmHg

Question 11

Q10 How many drugs is it likely to take?

Answer 11

patients with controlled BP are prescribed the following

• 1 drug- 39%

Question 12

You have a bit of a pep talk with Eric and encourage him to continue with his atenolol. Three days
later he returns deeply unhappy with his treatment. It transpires that he is having problems with
potency and he thinks his blood pressure treatment is making it worse. He asks a number of
searching questions mainly about whether such treatment is really necessary.

Q11 What type of illness is Eric’s high blood
pressure likely to cause?

Answer 12

-stroke
-dementia
-myocardial infarction
-heart failure
-renal failure
-peripheral vascular disease

Question 13

Q12 On average by how much might high
blood pressure shorten Eric’s life?

Answer 13

with untreated hypertension:

50 yr male
-5 yr loss of life
-7 years loss of life disease free

5o yr female
- 5 yrs loss of life
- 6.5 years loss of disease free life

Question 14

Q13 How much benefit will he get from blood
pressure lowering treatment?

Answer 14

average gain
- increase in life expectancy in 6 years
-reduction in stroke 40%
-reduction in MI 35%

Question 15

Q14 Are some people “designed” to run with
higher pressures or does blood pressure
lowering help everyone?

Question 16

You change Eric to doxazosin starting at 2mg daily and increasing in steps to 8mg daily and advise
him that this drug is not known to have any effect on erectile function. When you next se Eric he is
still grumpy. He may not be having as much trouble with his erections but is still feeling exhausted.
He asks whether he could stop treatment or at least try a different drug

Q15 Are there any changes in lifestyle by
which Eric might lower his blood pressure
without drug treatment?

Answer 16

weight loss-
1st 6kg = 8-10 mmHg

salt restriction -
moderate= 4 mmHg

exercise-
3 hours/ week = 8mmHg

alcohol-
reduction 6 to 3 units per night = 7mmHg

Question 17

Q16 What are the main types of blood
pressure lowering drugs?

Answer 17

B blockers
reduce renin release/ cardiac contractility

Diuretics-
reduce circulating sodium

Ace inhibitors/ ARBs-
block formation/action of angiotensin

Calcium channel blockers
- non rate limiting
-rate limiting
- -mainly vasodilators

Question 18

Q17 Are there any other factors which might
be contributing to Eric’s high blood pressure?

Answer 18

drugs with increase blood pressure:
- non steroidal anti inflammatory drugs
- SNRIs e.g venlafaxine
- corticosteroids
-oestrogen containing oral contraceptives
- stimulants e.g methylphenidate
- anti- anxiety drugs e.g gabapentin
-anti- TNFs

not taking tablets
change in lifestyle- increased in weight or new drugs
-progression of underlying cause- patients with resistant or progressive high blood pressure more likely to have secondary hypertension

Question 19

At last on a combination of amlodipine and candesartan Eric is reasonably comfortable and has
acceptable blood pressure control

Q18 How long will Eric need to take treatment
for?

Answer 19

Early studies showed:
-Treatment withdrawal led to a rebound in blood pressure
-Treatment of pre- hypertension did not prevent later development of hypertension

therefore treatment needed lifelong

Question 20

Q19 How often do you want to re-check Eric’s
blood pressure?
how do you check if Erics taking his meds?

Answer 20

checking concordance
- ask him
-check prescribing log
- spot check of urine
– mass spec analysis detects non/polar concordance
- improving concordance
-simplifying regimen

Question 21

Q20 Are there any circumstances in which
blood pressure lowering should be withheld?

Answer 21

during general anaesthesia hypotension can be a problem and some antihypertensives block attempts to increase BP therefore ACE inhibitors ARBs temporarily stopped