Hypertension

Question 1

Hypertension: Definition

Answer 1

Hypertension= Clinical BP >140/90, with ambulatory home BP >135/80

Question 2

Hypertension: Aetiology

Answer 2

• Primary, without cause (most common-90%)
• Secondary causes (“ROPED” mneumonic):
  
  • R- Renal Disease (most common secondary cause)
  • O- Obesity
  • P- Pregnancy-induced HTN or Pre-eclampsia
  • E- Endocrine
  • D- Drugs (eg. alcohol, steroids, NSAIDs, oestrogen and liquorice)

Question 3

Hypertension: Symptoms

Answer 3

• asymptomatic unless it is very high
  
  • headaches
  • visual disturbance
  • seizures

Question 4

Hypertension: Epidemiology and Risk Factors (edit)

Answer 4

• It is higher in men than in women before 60 years of age, but equal after this point.
• Hypertension is a major risk factor for myocardial infarction (MI), stroke and chronic kidney disease (CKD).

Question 5

Hypertension: Diagnosis

Answer 5

• If clinic BP ≥ 140/90 mmHg, ABPM or HBPM ≥ 135/80 mmHg to confirm the diagnosis (except in Stage 3 hypertension, in which immediate treatment is initiated), to exclude “white coat syndrome”.
  
  • “white coat syndrome”= ≥ 20/10 mmHg difference between clinic BP and ABPM/HBPM

Ambulatory blood pressure monitoring (ABPM) - first line

• at least 2 measurements an hour during the person’s usual waking hours (eg. 8am - 10pm)
• use the average value of at least 14 measurements
• can also use 24 hour ABPM

Home blood pressure monitoring (HBPM) - second line

• for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated
• BP should be recorded twice daily, ideally in the morning and evening
• BP should be recorded for at least 4 days, ideally for 7 days
• discard the measurements taken on the first day and use the average value of all the remaining measurements

Question 6

Hypertension: Screening

Answer 6

• Measure BP every 5 years in healthy patients
• Measure BP more often in borderline patients
• Measure BP every year in T2DM patients
• All newly diagnosed patients should be screened for end-organ damage

Question 7

Hypertension: Staging

Answer 7

Stage 1: Clinic BP ≥140/90 and ABPM/HBPM ≥135/85
Stage 2: Clinic BP ≥160/100 and ABPM/HBPM ≥150/95
Stage 3: Clinic BP ≥180/120

Question 8

Hypertension: Complications

Answer 8

Hypertension is a leading risk factor for end-organ damage, which can cause serious health conditions:

• Heart diseases: Ischaemic Heart diseases- Coronary heart disease ??, myocardial infarction, acs LV hypertrophy, heart failure
• Brain diseases: cerebrovascular accident (Stroke or intracranial haemorrhage) and cerebral lacunae, vascular dementia
• Kidney damage: hypertensive nephropathy, Proteinuria, renal failure, and acute kidney injury
• Eye damage: hypertensive Retinopathy
• Blood vessel damage: Atherosclerotic change, stenoses, and aneurysms, peripheral arterial disease, aortic dissection and aortic aneurysms

Question 9

Hypertension: Investigations

Answer 9

Investigate for secondary causes and end-organ damage:

• Observations
• Blood pressure
  
  • measure blood pressure in both arms, and if the difference is more than 15 mmHg, use the highest BP reading
• Urinalysis
  
  • Proteinuria or haematuriasuggest renal disease
• Urinary protein/albumin:creatinine ratio(uPCR)
• ECG - for cardiac abnormalities, includingleft ventricular hypertrophy
• Direct ophthalmoscopy - Fundus examinationfor hypertensive retinopathy

• FBC
• U&Es
  
  • Hypokalaemia and hypernatraemiasuggest Conn’s syndrome
• Fasting glucose
• Cholesterol(CVS risk)
• HbA1c

• eGFR
  
  • Reduced eGFRsuggest renal disease
• Ambulatory BP monitoring(ABPM or HBPM)
• Renal USS
• Endocrine tests(e.g. aldosterone: renin ratio, if indicated)
• Urinealbumin:creatinine ratioforproteinuriaanddipstickformicroscopic haematuria to assess for kidney damage
• QRISK score to estimate the percentage risk that a patient will have a stroke or myocardial infarction in thenext 10 years. When the result isabove 10%, they should beoffereda statin, initiallyatorvastatin20mgat night.

Question 10

Hypertension: Management

Answer 10

• Lifestyle adviceincludes a healthy diet, stopping smoking, reducing alcohol, caffeine and salt intake and taking regular exercise.
• Stage 3 HTN should be referred to specialist management

Medications used in management are:

• A–ACE inhibitor (e.g.,ramipril) or Angiotensin IIreceptorblocker (ARBs) (e.g.,candesartan)
  
  • use ARB if Black African/Caribbean or cannot tolerate ACEi (ie. dry cough)
  • do not use ACE and ARB together
• B–Beta blocker (e.g.,bisoprolol)
• C–Calcium channel blocker (e.g.,amlodipine)
• D– Thiazide-likediuretic (e.g.,indapamide)
  
  • Use Thiazide-like diuretics if patient cannot tolerate CCBs (ie. ankle oedema)
• Monitor U+Es:
  
  • Thiazide-like diureticscan cause hypokalaemia
  • potassium-sparing diuretic (eg. spironolactone) can cause kyperkalaemia
  • ACEi can cause hyperkalaemia
• Step 1: A if under 55 or any age T2DM or C if over 55 or Black African/Caribbean
• Step 2:A+C orA+DorC+D.
• Step 3:A+C+D
• Step 4:A+C+D+fourth agent, depending on serum K+ levels. Refer for specialist management
• Check for adherence at each step

Step 4 depends on theserum potassiumlevel:

• Less than or equal to 4.5 mmol/L- potassium-sparing diuretic (eg. spironolactone)
• More than 4.5 mmol/L- alpha blocker(e.g.,doxazosin) or abeta blocker (e.g.,atenolol)

Treatment Targets:
- Under 80yrs= <140/90
- Over 80yrs= <150/90

Question 11

Hypertensive Emergency: Definition

Answer 11

BP >180/120 with signs of papilloedema and/or retinal haemorrhage.

Question 11

Hypertensive Emergency

Answer 11

• same day referral
• investigate secondary cause and end-organ damage
• close monitoring while BP is controlled
• medications (guided by specialist)
• • IV - Sodium nitroprusside
• Labetalol
• Glyceryl trinitrate
• Nicardipine