Hypertension

Question 1

Phaeocromocytoma

Answer 1

Tumour of the adrenal gland

Paroxysmal secretion of catecholamines results in hypertension, palpitations, sweating, headache and anxiety

Question 2

What is the value for hypertension?

Answer 2

140/90

Question 3

Aetiological Classification

Answer 3

Primary - No obvious cause

Secondary - Underlying disease implicated

Question 4

Clinicopathological Classification

Answer 4

Benign

Malignant

Question 5

Factors contributing to primary hypertension

Answer 5

Genetics
Salt intake 
Protein intake
RAAS 
Sympathetic activity

Question 6

Causes of secondary hypertension

Answer 6

Renal disease 
Obstructive Sleep Apnoea
Endocrine disease 
Aortic disease - e.g. coarctation of the aorta 
Renal artery stenosis 
Drug therapy - including corticosteroids

Question 7

Renal causes of secondary hypertension

Answer 7

Any renal disease, especially renal artery stenosis and diabetic renal disease
Reduced renal blood flow -> excess renin release -> salt and water overload -> hypertension

Question 8

Endocrine causes of secondary hypertension

Answer 8

Adrenal gland hyperfunction/tumours
Conn’s syndrome (excess aldosterone)
Cushing’s syndrome (excess corticosteroid)
Phaeochromocytoma (excess noradrenaline)

Question 9

What is benign hypertension?

Answer 9

Asymptomatic hypertension

Question 10

What are the complications of benign hypertension?

Answer 10

Left ventricular hypertrophy 
Congestive cardiac failure 
Increased atheroma 
Increased aneurysm rupture (aortic dissection, Berry aneurysms) 
Renal disease

Question 11

What is malignant hypertension?

Answer 11

Serious, life threatening in short term
Diastolic pressure >130-140
Developed from being primary or secondary hypertension, or rarely de novo

Question 12

What are the complications of malignant hypertension?

Answer 12

Cerebral oedema
Acute renal failure
Acute heart failure
Headache and cerebral haemorrhage

Question 13

If clinic BP is 140/90 mmHg, what is the next step of diagnosis?

Answer 13

Ambulatory blood pressure

Question 14

When using ABPM to confirm hypertension, how often should measurements be taken?

Answer 14

At least two per hour during the patients normal waking hours (usually 14 per day)

Question 15

When using HBPM to confirm hypertension, how often should measurements be taken?

Answer 15

Two consecutive seated measurement, 1 minuted apart
BP recorded x2 daily for at least 4 days, but preferably 7
Discard first day measurement and average the rest

Question 16

Define Stage 1 Hypertension

Answer 16

Cinic BP =>140/90mmHg
AND
ABPM or HBPM daytime average =>135/85mmHg

Question 17

Define Stage 2 Hypertension

Answer 17

Clinic BP =>160/100mmHg
AND
ABPM or HBPM daytime average =>150/95

Question 18

Define Severe Hypertension

Answer 18

Clinic systolic BP => 180mmHg
OR
Clinic diastolic BP => 110mmHg

Question 19

Risk Factors for End Organ Damage

Answer 19

AGE 
Left ventricular hypertrophy 
Creatinine raised 
Albuminuria/microabuminuria 
Retinopathy
Established vascular disease

Question 20

Target BP with drug treatment

Answer 20

Clinic BP
80y/o

White Coat Effect (ABPM/HBPM BP)
80y/o

Question 21

Hypertension Management - Lifestyle Interventions

Answer 21

Diet = reduce sodium and caffeine intake
Weight reduction and increased exercise
Reduce alcohol consumption
Quit smoking

Question 22

How much does BP drop for every kg lost?

Answer 22

1mmHg

Question 23

Which classes of drugs can be used as anti-hypertensives?

Answer 23

Thiazide diuretics
ACE inhibitors/ARBs
Calcium channel blockers 
Beta blockers 
Spironolactone 
Alpha blockers

Question 24

Which anti-hypertensive is ideally suited in a patient who also has angina?

Answer 24

Beta blockers 
(or calcium channel blockers)

Question 25

Which anti-hypertensives are ideally suited in a patient who also has CCF?

Answer 25

ACE inhibitors

Beta blockers

Question 26

Which anti-hypertensive is ideally suited in a patient who also has diabetic nephropathy?

Answer 26

ACE inhibitors/ARBs

Question 27

Which anti-hypertensive is ideally suited, with caution, in a patient who also has prostatism?

Answer 27

Alpha blockers

Question 28

Which anti-hypertensive is ideally suited in elderly patients?

Answer 28

Thiazide diuretics

Question 29

Antihypertensive Drug Treatment = Step 1 for

Answer 29

ACE inhibitor or low cost ARB

Question 30

Antihypertensive Drug Treatment = Step 1 for >55y/o or person of Afro-Carribean family origin

Answer 30

Calcium channel blocker

can use thiazide-like diuretic if CCB not tolerated

Question 31

Why might a CCB not be tolerated?

Answer 31

Oedema
Evidence of heart failure
High risk of heart failure

Question 32

Antihypertensive Drug Treatment = Step 2

Answer 32

ACE inhibitor (or low cost ARB)
\+ CCB (or thiazide-like diuretic if CCB not tolerated)

Question 33

Antihypertensive Drug Treatment = Step 3

Answer 33

Review medication to ensure optimal or best tolerated dosage

ACE inhibitor (or low cost ARB) + CCB + Thiazide-like diuretic

Question 34

Antihypertensive Drug Treatment = Step 4

Answer 34

A + C + D
Consider further diuretic treatment, spironolactone, alpha blocker or beta blocker
Seek expert advice

Question 35

What are the advantages to combination therapy?

Answer 35

Fewer side effects than mono therapy

Gives a greater reduction in BP than mono therapy

Question 36

What factors might explain resistant hypertension?

Answer 36

Non-concordance 
White Coat Effect
Pseudo-hypertension
Lifestyle factors 
Drug interactions 
Secondary hypertension 
True resistance

Question 37

What is the most effective treatment for resistant hypertension?

Answer 37

Spironolactone

Question 38

How should spironolactone be given?

Answer 38

Start low go slow

Caution in diabetes and low GFR

Question 39

In young women, what may ACE inhibitors be replaced with, and why?

Answer 39

Beta Blockers

Risk of foetal toxicity