Hypertension

Question 1

What are the different stages of HTN using clinical measurements?

Answer 1

Stage 1 - => 140/90
Stage 2 - => 160/100
Stage 3 - => 180 systolic or =>120 diastolic
Isolated systolic => 160
Accelerated HT >= 180/120

Question 2

What are the different stages of HTN using ABPM?

Answer 2

=>135/85 is stage 1
=> 150/95 is stage 2

Question 3

What are the common aetiologies of HTN?

Answer 3

90% cases are essential or idiopathic
10% of cases are secondary HTN

Question 4

What are the main categories of secondary HTN?
What factors might fit into each category?

Answer 4

RECN
Renal - dec blood flow or parenchymal disease - renal artery stenosis, diabetic nephropathy, glomerulonephritis
Endocrine - hyperaldosteronism, pheochromocytoma, neuroblastoma.
Cardiovascular - coarcatation of the aorta, increased CO
Neurologica - sleep apnoea, increased ICP.
Other: pre-eclampsia, MAOi, oral contraceptives.

Question 5

When might a hypertension patient require referall to a specialist?

Answer 5

If under 40yrs old and suspect a secondary cause of HTN
If severe blood pressure (stage 3 or higher) or suspect organ damage.

Question 6

What causes of HTN are amenable to surgery?

Answer 6

Cushing syndrome - pituitary tumour leads to increased cortisol production
Primary hyperaldosteronism due to suprarenal cortical tumour
Polycystic kidney disease
Coartcation of the aorta.

Question 7

Give a basic overview of the physiology that underpins HTN

Answer 7

BP = CO*SVR
Any factors that increase CO or SVR will increase blood pressure
Key parameters to consider: contractility, HR, preload, intravascular volume (Na+ and water retention)

Question 8

Define HTN

Answer 8

Persistent elevation of BP in systemic arterial circulation
140/90 or above
Based on at least two reading on separate occasions

Question 9

What are some consequences of HTN on the blood vessels?

Answer 9

Hyperplastic arteriosclerosis - ‘onion skinning’ prolif SM, BM.
Hyaline arteriolosclerosis - deposition of hyaline material in walls
Cerebrovascular haemorrhage - degnerate elastic laminae + SM, microaneurysm and rupture, particularly small blood vessels.
Aortic dissection - risk of rupture and haemorrhage

Question 10

What are some modifiable risk factors for HTN?

Answer 10

Smoking
Obesity/poor diet
Alcohol
Stimulant drugs (cocaine + caffeine)
Sedentary lifestyle
Stress

Question 11

What are some non-modifiable risk factors for HTN?

Answer 11

Age inc - loss elasticity, NO dec, endothelin inc
Ethnicity - African-Caribbean and South Asian descent are at inc risk of high ABP (food high in salt)
Family history - shared genetic or lifestyle risk factors.

Question 12

What is the purpose of a QRISK3 score?

Answer 12

Calculate the estimate CVD risk within the next ten years for people aged 25 to 84yrs
Considered demographics, social history, pMH and current health status.

Question 13

What investigations should be carried out to asses the risk of complication in a person diagnosed with HTN?

Answer 13

Blood glucose - risk T2D
Fundoscopy
ECG - left ventricular hypertrophy or ischemia
U&Es, urine dipstick - kidney function
Serum lipids - atherosclerosis

Question 14

What are the key complications of HTN?

Answer 14

Ischemic heart disease - angina and ACS
Cerebrovascular disease - stroke or intracranial haemorrhage
Vascular disease - PAD, aortic dissection, aortic aneurysm
Hypertensive retinopathy
Hypertensive nephropathy
Vascular dementia
Left ventricular hypertrophy
Heart failure

Question 15

What retinal abnormalities are seen in HTN and how does this relate to their grade?

Answer 15

1 - silver wiring of arteries - inc torosity causes increased effectiveness
2 - AV nipping - high pressure arteries occlude nearby veins
3- flame shaped haemorrhages as small capillaries burst, soft cotton wool exudates (ischemia or nerve fibre)
4 - papilloedema - optic disk swelling increased hydrostatic pressure and increased permeability of blood vessel walls

Question 16

What are the key ECG changes seen in HTN?

Answer 16

Left ventricular hypertrophy - inc amplitude in 1, AvL, V5, V6
Left atrial enlargement - wide and notched P wave called a P mitral, seen in leads 2,3 AvF.

Question 17

What is the process of diagnosing HTN?

Answer 17

Measure the BP in both arms, repeat if more than 15mmHg diff.
For true diagnosis must repeat on different days
If 140/90 in clinic offer ABPM to confirm
If clinic 180/120 consider same day referall if retinal damage or life threatening symptoms, if no serious signs or complications require more investigations and give treatment immediately.

Question 18

What is the non-pharmacological management for HTN?

Answer 18

Weight reduction - aim for BMI below 25kg/m2
Low fat and saturated fat diet
Low salt diet
Limited alcohol consumption
Increased fruit and vegetable consumption
Reduced cardiovascular risk by stopping smoking and increasing oily fish consumption.

Question 19

In what condition are ACEi contraindicated?

Answer 19

Renal artery stenosis - prevention of RAAS may decrease renal blood flow leading to AKI

Question 20

What electrolyte abnormality can A2RB and ACEi cause?

Answer 20

Hyperkalemia

Question 21

What are the different thresholds for intervention in a hypertensive patient?

Answer 21

Pre-HTN = lifestyle advice
Stage 1 = treat is under80yrs, organ damage, CVD, renal disease, DM, cardio risk>20%, consider in over80yrs
Stage 2 = all patients offered treatment
Stage 3 = treat immediately.

Question 22

What bloods should be taken from a patient with essential HTN?

Answer 22

U&Es - kidney damage, Na+ level, creatinine
LFTs - risk of non-alcohol liver disease sue to HTN
Lipid profile and total cholesterol/TG
Blood glucose
Cortisol test /catecholamine test
Troponin C

Question 23

What cardiovascular system medication is associated with peripheral oedema as a side effect?

Answer 23

Calcium channel blockers

Question 24

How does the QRISK3 score of a HTN patient influence their management?

Answer 24

If score above 10% should be offered a statin, initially atorvastatin 20mg at night.

Question 25

What are the different classes of medication that can be used as an anti-hypertensive?
Give an example of each class

Answer 25

ACE inhibitor - ramipril
Beta blocker - bisoprolol
Calcium channel blocker - amlodipine
Thiazide like diuretic - indapamide
ARB - candesartan

Question 26

In the treatment of HTN when might an ARB be used instead of an ACEi?

Answer 26

Recommended ARB in Black African or African-Caribbean family origin
If not tolerate ACEi (typically because of a dry cough).

Question 27

What is the decision process for medical management in HTN for step 1 treatment ?

Answer 27

If T2D or Under55yrs (not African) - offer ACEi or ARB as the first line.

If Age55yrs over or Black African or African-Caribbean family origin - offer a CCB.

Question 28

What is stage 2 and stage 3 for treatment of HTN?

Answer 28

Stage 2: add additional drug so now taking ACEi/ARB and CCD OR continue as stage one and add a thiazide diuretic
Stage 3: Should not be taking all of ACEi/ARB and CCB and thiazide diuretic.

Question 29

What is the stage for management of HTN?

Answer 29

Dependent on serum potassium.
If higher than 4.5mmol/L offer alpha blocker or beta blocker
If less than or equal to 4.5mmol/L offer potassium-sparing diuretic

Question 30

What anti-hypertensive drugs require U&E monitoring?

Answer 30

ACEi
Potassium sparing diuretics
Thiazide like diuretics

Question 31

What are the treatment targets for HTN patients?

Answer 31

Under 80yrs S<140 D<90
Over 80 S<180 D<90

Question 32

What classifies as a hypertensive emergency and how should you treat it?

Answer 32

Accelerated/malignant = 180/120 or above with retinal haemorrhages or papilloedema
Same-day referral - fundoscopy exam - also required if confused, HF< ACS or AKI.
Closely monitor blood pressure
IV - sodium nitroprusside, Labetalol, GTN, Nicardipine.