Hypertension

Question 1

What is hypertension a risk factor for?

Answer 1

Cerebral haemorrhage, atheroma, renal failure, sudden cardiac death.

Question 2

What populations have higher and lower incidences of hypertension?

Answer 2

Higher in black populations, lower in south pacific.

Question 3

What are the aetiological classifications of hypertension?

Answer 3

Primary (unknown cause) and secondary (known cause).

Question 4

What are the clinicopathological classifications of hypertension?

Answer 4

Benign (often primary), malignant (often secondary, extreme).

Question 5

Blood flow in what organ is important in determining blood pressure?

Answer 5

Kidneys.

Question 6

What are the contributing factors to primary hypertension?

Answer 6

Genetic factors, salt intake, protein intake, RAAS, sympathetic activity.

Question 7

What are the types of diseases that can cause secondary hypertension?

Answer 7

Renal disease, endocrine disease, aortic disease, renal artery stenosis, drug therapy (steroids).

Question 8

How can renal disease cause hypertension?

Answer 8

Can cause reduced renal blood flow leading to excess renin release and salt and water overload.

Question 9

Give some endocrine causes of hypertension.

Answer 9

Adrenal gland hyperfunction, adrenal gland tumours, Conn’s syndrome (excess aldosterone), Cushing’s syndrome (excess corticosteroid), phaeochromocytoma (adrenal gland tumour, excess noradrenaline).

Question 10

What is coarctation of the aorta and can it cause hypertension?

Answer 10

Congenital narrowing of segments of the aorta, yes.

Question 11

Over time, what can benign hypertension cause?

Answer 11

LVH, congestive cardiac failure, atheroma, aneurysm rupture (aortic dissection, Berry aneurysms), renal disease.

Question 12

What can LVH cause in the heart?

Answer 12

Poor myocardial perfusion, increased susceptibility to arrhythmias, interstitial fibrosis (cells less able to communicate with each other), micro-infarcts, diastolic dysfunction, cardiac failure.

Question 13

What is the relation between hypertension and aortic dissection?

Answer 13

Increases risk.

Question 14

What microvascular injury does hypertension cause in the kidneys and eyes?

Answer 14

Thickening of media (smooth muscle). Hyaline arteriosclerosis (plasma proteins forced into vessel wall, thickening of vessels).

Question 15

At what diastolic pressure would hypertension be considered malignant?

Answer 15

When diastolic pressure is greater than 130-140.

Question 16

What are the complications of malignant hypertension?

Answer 16

Cerebral oedema (seen as papilloedema [swelling of optic disk]), acute renal failure, acute heart failure, headache and cerebral haemorrhage, blood vessels show fibrinoid necrosis and endarteritis proliferans of their walls.

Question 17

What is pre-eclampsia?

Answer 17

Hypertension and proteinuria.

Question 18

What are the recommendations for measuring blood pressure?

Answer 18

Use a relaxed, temperate setting with the person quiet and seated.

Question 19

When will automated blood pressure cuffs not work?

Answer 19

If pulse rate is irregular.

Question 20

What are the definitions of stage 1, stage 2 and stage 3 hypertension?

Answer 20

Stage 1: clinic 140/90, daytime average 135/85.
Stage 2: clinic 160/100, daytime average 150/95.
Stage 3: clinic systolic 180mmHg or diastolic 110mmHg.

Question 21

What tests should you offer for all patients with hypertension?

Answer 21

Test urine for protein; take blood to measure glucose, electrolytes, creatinine, estimated glomerular filtration rate and cholesterol; examine fundi for hypertensive retinopathy; arrange a 12 lead ECG.

Question 22

What are the signs of end organ damage in hypertension?

Answer 22

LVH, creatinine raised, albuminuria/microalbuminuria, retinopathy.

Question 23

What is hypertensive retinopathy?

Answer 23

When the artery thickens and contricts a vein in the eye. Can include haemorrhage, hard exudates and a blurred disk.

Question 24

How would LVH and heart strain show up in an ECG?

Answer 24

ST depression.

Question 25

What are the target blood pressures for under 80s and over 80s?

Answer 25

Under 80s: 140/90. Over 80s: 150/90.

Question 26

Can intracranial tumour and fibromuscular dysplagia cause secondary hypertension?

Answer 26

Yes.

Question 27

What is the reduction in blood pressure when someone loses a kilogram of weight?

Answer 27

1mmHg.

Question 28

What kind of diet can help reduce blood pressure?

Answer 28

A no added salt diet.

Question 29

What are the generic drugs for the treatment of hypertension?

Answer 29

Thiazide diuretics, calcium channel blockers, beta blockers, spironolactone.

Question 30

Why do you use calcium channel blockers in elderly people first line for hypertension?

Answer 30

They have low renin.

Question 31

What are the causes of resistant hypertension?

Answer 31

White coat effect, pseudo-hypertension (walls of arteries stiffer), lifestyle factors, drug interactions, secondary hypertension, true resistance.

Question 32

What is the most effective treatment for resistant hypertension?

Answer 32

Spironolactone.

Question 33

What rise should you tolerate when prescribing spironolactone?

Answer 33

25% rise in potassium and creatinine.

Question 34

What is the drug treatment ladder for under 55 year old hypertensives?

Answer 34

ACEI/ARB (B-blocker if fertile female) -> those plus calcium antagonist -> diuretic -> spironolactone

Question 35

What is the drug treatment ladder for over 55 year old hypertensives?

Answer 35

Same as under 55 but swap ACEIs and calcium antagonists.

Question 36

What ethnicity do ACEIs not work on?

Answer 36

Afrocarribeans.