Hypertension

Question 1

What is Hypertension?

Answer 1

A blood pressure above which there is a significant health risk, and treatment has a significant impact on health

Question 2

How should HTN be diagnosed?

Answer 2

If clinic reading >140/90 offer ABP

Question 3

Describe ABPM

Answer 3

2 measurements/hr, average reading used

Question 4

What is Stage 1 HTN?

Answer 4

Clinic BP >140/90

ABPM >135/85

Question 5

What is Stage 2 HTN?

Answer 5

Clinic BP >160/100

ABPM >150/95

Question 6

What is Severe HTN?

Answer 6

Clinic BP >180 OR DBP >110

Question 7

What should be done upon diagnosing Severe HTN?

Answer 7

Immediately start antihypertensives w/o waiting for ABPM

Question 8

How are the causes of HTN classified?

Answer 8

Essential (95%)

Secondary

Question 9

What are the common secondary causes of HTN?

Answer 9

Adrenal cortical diseases (Conn's, Cushing's, Acromegaly)
Renal artery stenosis
CKD
Phaeochromocytoma
Coarctation of the aorta
Neurogenic
Pregnancy

Question 10

How does HTN due to Phaeochromocytoma present?

Answer 10

HTN initially paroxysmal
Sweating
Pallor
Palpitations

Question 11

What is Benign HTN?

Answer 11

Gradual elevation of BP over years

Question 12

What is the pathological consequence of benign HTN?

Answer 12

Gradual hypertrophy of arterial media
Reduces capacity to expand
Increases fragility

Question 13

What is Malignant HTN?

Answer 13

Rapid, sustained increase in BP

Question 14

What is the pathological consequence of malignant HTN?

Answer 14

Intimal proliferation, reduced luminal size
No blood flow through small vessels
Tissue necrosis

Question 15

What is the mortality of malignant HTN?

Answer 15

20% at 1yr

Question 16

How is malignant HTN diagnosed?

Answer 16

SBP >200 OR DBP >120 AND bilateral retinal haemorrhages/exudates

Question 17

What effect does HTN have on the heart?

Answer 17

LV hypertrophy, eventual LHF

Question 18

What effect does HTN have on the aorta?

Answer 18

Predisposes to AAAs & Aortic dissections

Question 19

What effect does HTN have on the brain?

Answer 19

Intracerebral haemorrhage due to vessel rupture

Question 20

What effect does HTN have on the kidney?

Answer 20

CKD due to progressive nephron ischaemia & glomerular destruction

Question 21

What effect does HTN have on the eyes?

Answer 21

Hypertensive retinopathy

Question 22

What investigations are appropriate in suspected HTN?

Answer 22

Assess for signs of malignant HTN/secondary sx
Urine dip
ECG, Echo
U&Es, eGFR
Renal artery doppler
HbA1c, lipids etc.

Question 23

How can Phaeochromocytoma be diagnosed?

Answer 23

3x 24hr urine collections for free metadrenaline & normetadrenaline

Question 24

How should HTN be managed?

Answer 24

Lifestyle interventions

Drug treatment

Question 25

When should medications be started for HTN?

Answer 25

All with Stage 2
Stage 1 if under 80 and 1 of:
-10yr risk >20%
-Comorbidities (renal disease, CVD, end organ damage)

Question 26

What are the therapeutic BP targets?

Answer 26

Clinic BP <140/90 (150/90 if >80yrs)

ABPM <135/85 (145/85 if >80yrs)

Question 27

What are the 1st line medications in HTN?

Answer 27

ACEI if <55 and non-black (high renin)

CCB if >55 or black (low renin)

Question 28

What are the main side effects of ACEIs?

Answer 28

Hyperkalaemia
1st dose HTN (give at night)
Worsened renal funcn (renoprotective in DM)

Question 29

When are ACEIs contraindicated?

Answer 29

Renal artery stenosis

Question 30

What CCBs are used in HTN?

Answer 30

Dihydropyridines (amlodipine, nifedapine)

Question 31

What are the main side effects of CCBs?

Answer 31

Peripheral oedema
Postural HTN
Reflex tachycardia

Question 32

What is the 2nd line therapy for HTN?

Answer 32

Combined ACEI & CCB

Question 33

What is the 3rd line therapy for HTN?

Answer 33

Loop diuretic

Question 34

What therapy is available for resistant HTN?

Answer 34

Spironolactone (K+ <4.5)
Bendroflumethiazide (K+ >4.5)
Alpha/beta blockers