Hypertension

Question 1

What is the definition of hypertension?

Answer 1

Stage 1 hypertension - BP in surgery/clinic is ≥140/90 mm Hg and ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) is ≥135/85 mm Hg.

Stage 2 hypertension - BP in surgery/clinic is ≥160/100 mm Hg and ABPM or HBPM is ≥150/95 mm Hg.

Severe hypertension - BP in surgery/clinic is ≥180/110 mm Hg or higher

Question 2

What are the causes of hypertension?

Answer 2

Most common – Primary Essential Hypertension

Others - Coarctation of aorta, Cushing’s, Conns, Pheochromocytoma, Acromegaly, Hyperparathyroidism, Hyperthyroidism, Pregnancy, Renal Failure, Steroids, Cocaine, OCP

Question 3

What will you find on a history taking of hypertension?

Answer 3

Symptoms:
Normally Asymptotic
May have headaches in Acute/Extreme hypertension

Risk Factors:
Cardiovascular Risk Factors
Endocrinopathy
Renal Problems

Specific questions to ask in a history taking:
Indications of secondary hypertension - <40 years, Rapid onset, Resistant hypertension
If acutely high BP think malignant hypertension (>180/120) and immediately refer to hospital
Assess for end organ damage:
Cardiovascular: Heart failure
Cerebrovascular: Previous TIA/Stroke
Renal: CKD
Retinal: Visual Loss/Problems or Headache

Question 4

What will you find on examination of a patient with hypertension?

Answer 4

End of the bed:
May be overweight (risk factor)
Look for stigmata of endocrinopathy
Hands:
Tendon xanthoma (risk factor)
Weak pulses – Peripheral vascular disease (risk factor)
Neck:
Palpable thyroid gland
Carotid bruits - may indicate carotid artery stenosis and warrant further duplex imaging
Face:
Examination of optic fundi - Papilledema, Hypertensive retinopathy (retinal haemorrhages, micro aneurysms, cotton-wool spots)
Corneal arcus, Xanthalasma (risk factor)
Chest:
Look for signs of heart failure – Pulmonary crackles at lung bases, Gallop Rhythm
Abdomen:
Renal Bruit - renal artery stenosis
Enlarged kidneys - Tumours or CKD
Feel for an AAA - Hypertension is a risk factor
Legs:
Absent, weak, or delayed femoral pulses or Radio femoral delay suggest coarctation of the aorta#
Weak pulses – Peripheral vascular disease (risk factor)

Question 5

What investigations will you order in hypertension?

Answer 5

Bedside Tests:
ABPM – 24 ambulatory blood pressure monitoring offered to all patients with BP > 140/90 to rule out white coat hypertension
Urinalysis - Looking for signs out renal end organ damage e.g. Proteinuria or Haematuria
ECG - Looking for signs of end organ damage to the heart e.g. LVH or coronary artery disease
Calculate BMI
Capillary Glucose - Assess Cardiovascular Risk factors

Bloods:
Lipids - Assess Cardiovascular Risk factors
U&E – To look for underlying renal damage either caused by or causing the hypertension. K+ abnormalities can indicate endocrine causes
Ca2+ - Raised in any underlying hyperparathyroidism causing the hypertension
FBC - to look for any anaemia
BNP - Looking for heart failure

Imaging:
CXR - To look for Heart failure
Echo - To look for end organ damage to the heart
Renal Ultrasound - Looking for any underlying renal artery stenosis causing the hypertension
MRI of aorta - To look for any other underlying coarctation of the aorta that may be causing the hypertension, only if other indications

Special Tests: Ordered when secondary cause suspected and will depend on suspected cause
Coarctation of aorta
Cushing’s – Dexamethasone suppression test
Conns – Renin/Aldosterone levels
Pheochromocytoma – 24-hour urinary metanephrines
Acromegaly - Serum insulin-like growth factor 1
Hyperparathyroidism – Serum Calcium Levels and PTH
Hyperthyroidism – TFT’s
Pregnancy – Pregnancy Test

Question 6

What is the treatment of hypertension?

Answer 6

Treat everyone with BP >160/100
Treat anyone with BP >140/90 with: Target organ damage, Cardiovascular disease, Renal disease, Diabetes, A QRISK2 score of >20%
Aim for a BP <140/90 or <130/80 in diabetics with end organ damage. And Aim to reduce BP slowly, rapid reduction can be fatal. Treatment may take 4-8 weeks to take effect
Remember People with BP >140/90 should be confirmed hypertensive with home BP monitoring

Lifestyle:
Reduce Cardiovascular Risk Factors
Low Salt Diet

Medication:
>55 or Black skin: 1st Line - Ca2+ channel blocker (Thiazide diuretic if CI)
<55 or Renal Failure: 1st Line - Ace inhibitor (ARB if CI)
2nd line – ACE inhibitor + Ca2+ channel blocker
3rd Line- Add a thiazide diuretic
4th Line – Consider referral and check compliance. Add Spironolactone/Beta Blocker/Alpha Blocker