Hypertension

Question 1

What are some DDs for High Bp?

Answer 1

Primary HTN- no identified cause- 95% of cases

Secondary htn: claear cause.
1. Renal: parenchymal disease- e.g. Chronic atrophic pyelonephritis, chronic glomerulonephritis, renal artery stenosis, renin producing tumors, 1o Na+ retention.
2. Endocrine:
Acromegaly, hypo+ hyperthyroidism, hypercalcaemia, adrenal cortex disorders (Cushings, Conn syndrome, congenital adrenal hyperplasia, adrenal medulla disorders e.g. Phaeochromocytoma.

3. Vascular disease- aorta coarcation
4. Other: htn of pregnancy, carcinoid syndrome.
5. Increased intravawcular volume- polycythaemia
6. Drugs: alcohol, oral contraceptives, monoamine oxidase inhibitors, glucocorticoids.
7. Psychogenic- Stress.

Question 2

Categories of HTN:

Answer 2

Clinic Blood pressure. ABPM/HBPM
Stage 1- >140/90mmHg. >135/85mmHg
Stage 2->160/100mmHg. >150/95 mmHg

Severe. >180mmHg systolic or >110mmHg diastolic

Question 3

What might hypertensive patients present with?

Answer 3

Dizziness, wt loss.. Tremor, hair loss, feeling cold.
Paroxysmal palpitations, sweating, headaches, collapse: may indicate phaeochromocytoma.

Complications of htn:
Dyspnoea, orthopnoea or ankle oedema: indicating cardiac failure.
Chest pain: ishaemic heart disease
Unilateral weakness or visual distirbance - cerebrovascular disease.

Question 4

PMHx of HTN

Answer 4

PMHx- recurrent UTIs- esp in childhood–> chronic pyelonephritis– common cause of renal F.
Hx of asthma: chronic corticosteroid use? Cushings??
Thyroid surgery in past
Evidence of peripheral vascular diasease - leg ulceration or prev vascular surgery- underlying renovaacular disease?

Question 5

Drug, family and social hx

Answer 5

Analgesics?
Aspirin, Nsaids- possible cause of renal disease.
Liquorice- mineralocorticoid excess.

Fhx:
1o htn.
2o- adult polycystic kidney disease,- autosomal dominant assc w/ htn, rebal f and cerebrovascular disease.
Phaeochromocytoma- as part of multiple endocrine neoplasia- assc w/ medullary carcinoma of thyroid and hyperparathyroidism.

Shx: smoking and Xs alcohol intake.

Question 6

How many stages are there?

Answer 6

Stage 1 and 2 and severe ha.

Stages 1&2 require both clinic and ambulatory blood pressure monitoring (ABPM) or home- HBPM.

Question 7

In what diseases is HTN considered a risk factor?

Answer 7

CVA, 
MI
Cardiac Failure
Renal F
Peripheral vascular disease.

Question 8

What are the different types of htn and what might be the 2o causes?

Answer 8

Primary hypertension- 95%

Secondary

Question 9

What findings would you have in different examinations when Hypertensive?

Answer 9

Cardiovascular: pulses- 1. Rate- tacchys or bradys may indicate underlying thyroid disease.

2. Rhythm: AF may occur as a result of hypertensive heart disease
3. Symmetry: compare pulses, radio- radial delay- coarcation sign + abnormally weak foot pulses.

❗️weak/absent peripheral pulses along with cold extremities- PVD
Jugular venous pressure may be elevated in congestive HF- complication of HTN.

Displaced apex in LVF due to dikatation of LV.

Mitral regurg may occur 2o to dilatation og valve ring due otomorrow LV dilation.

Coarcation: bruits may be heard over scapula and systolic murmur may be heard below the L Clavicle. Maybalso be an S4.

Resp- bilateral basal crepitations- pulm oedema

GI: hepatomegaly and ascites in congestive HF. AAA must be looked for cz its a generalised atheroscletoric manifestation.

Limbs: peripheral oedema- congestive HF or renal disease.

Remember to always look for signs of: thyroid disease, cushings, acromegaly and renal impairment.

Question 10

What are the eeatures of hypertensive retinopathy?

Answer 10

Grade
I- narrowing of arteriole lumen- silver wiring effect
II- sclerosis of adventitia and thickening of muscular wall of arteries leads to compression of underlying veins and AV nipping.
III- rupture of small vessels- Haemorrhages and exudates.
IV- papilloedema + signs I-IV.

Question 11

How would you investigate 2o causes of HTN with bloods?

Answer 11

1. Serum electrolytes: Low K+ -> Cushings or Conns syndrome
   High K+: 1o renal disease,
   ⬆️ serum and creatinine-> 1o renal diease.
2. Urinary catecholamines and metabolites (VMA) : phaeochromocytoma
3. CXR, cardiomegaly, rib notching-> aortic coarcation- check contrast enhanced CT or MRI.
4. Radiofemorql delay-> coarcation
5. CT angiogram: Renovascular disease

Question 12

Investigatioms of HTN??

Answer 12

🔹Ambulatory BP monitoring: 24hrs in pts with suspected HTn.
Also usedto establish eficacy in home tx.

🔹Home BP monitoring: alternative ambulatory: taken 2 daily with pt sitting.

Bedside investigations:
🔶Bloods: many are on diuretics so risk of hypokalaemia or hyponatraemia. + exclude renal causes.
FBc: polycythaemia. Macrocytosis: hypothyroidism. Anaemia due to CKD.
Blood glucose:DM or seen in Cushings.
TFTs
Blood lipid profile: IHD.

Urinalysis: haematuria or proteinuria- underlying renal disease-

ECG: may be evidence of LVH. Is there evidence of old MI? Or rhythm disturbance- AF.
CXR: look for: enlarged LV- as an enlarged cardiac shadow. Cardiothoracic ratio should be 1:2. Coarcation? Rib notching…

ECHO: (USS heart) 🔹LVH- not bigger chamber size, just more muscular- diastolic
dysx.
🔹Poor LV function
🔹Enlarged L atrium (2o to increased end diastolic pressures in ventricles)
Show any ventricular wall abnormalities- old MI?

Question 13

What are the ECG signs of LVH?

Answer 13

Tall R waves in lead V6 >25mm
Deep S wave in V2
R wave in V5 + S wave in V2
Invreted T waves in lateral leads. I, AVL, V5, V6.

In severe LVF: might be L axis deviation + ST changes- “strain”.

Question 14

Investigations to exclude 2o HTN:

Answer 14

Renal parenchymal disease–> 1. 24h creatinne clearance: ⬇️
24 h protein excretion :⬆️ (they leak) . renal USS- bilateral small kidneys. Renal biopsy- sometimes.

REnal Artery Stenosis- Renal UsS- assymetrical kidneys
Radionucleotide studies using DTPA:⬇️ uptake on affected side- this effect is highlighted when administrating an ACE inhibiotr.
Renal angiography or MRI angiography.

Phaeochromocytoma: 24h urine catecholamines- ⬆️ VMa (rare use)
CT abdo: tumor often big. MIBG scan (meta-iodpbemzylguanine) to identift any extra adrenal tumors.

1 hyperaldosteronism: aldosterone: renin ratio- may be 2o to bilateral hyperplasia or a single adenoma: Conns syndrome.

Cushings: 24h urinary free cortisol- ⬆️
Dexamethasone supression test:
low dose 48 hr test initially, high dose test to rule out ectopic source of ACTH (adrenocorticotrophic H)
9:00-24:00 blood cortisol: Reveals loss of cicardian rhytm in Cushings.
Adrenal Ct: adrenal tumor?
Pituitary MRI scan: enlarged pituitary.
CXR: oat cell carcinoma of broncus (ectopic ACTH)