Hypertension

Question 1

Define systemic hypertension?

Answer 1

Persistent high arterial BP of >140/90 mmHg.

Question 2

Describe the pathophysiology of hypertension?

Answer 2

Combo of genetics and environment contribute.

• Defects in renal sodium homeostasis leads to inadequate sodium excretion and water retention. This causes an increase in plasma and ECF volume, increasing CO.
• Functional vasoconstriction occurs. Increased plasma and ECF cause increased naturetic hormone release, and increased vascular reactivity.
• Defects in vascular SM growth and structure lead to increased vascular wall thickness.
• Increased vascular reactivity + increased wall thickness leads to increased total peripheral resistance.
• Increased CO and TPR lead to hypertension!

Question 3

What is the prevalence of hypertension?

Answer 3

45% worldwide.

Question 4

What is the relationship between blood pressure and risk of CV disease?

Answer 4

Risk of CV disease double for every 20mmHg increase in systolic pressure.
Risk of CV disease doubles for every 10mmHg increase in diastolic pressure.

Question 5

What is ‘high normal’ BP?

Answer 5

130-139/85-89 mmHg

Question 6

What is Grade 1 hypertension?

Answer 6

140-159/90-99 mmHg

Question 7

What is Grade 2 hypertension?

Answer 7

160-179/100-109 mmHg

Question 8

What is Grade 3 hypertension?

Answer 8

> 180/>110 mmHg

Question 9

What is isolated systolic hypertension?

Answer 9

> 140/<90 mmHg.

Question 10

Who normally gets isolated systolic hypertension?

Answer 10

Elderly people are their blood vessels are stiffer.

Question 11

What % of hypertension patients have primary hypertension?

Answer 11

90%

Question 12

What is primary hypertension?

Answer 12

No identifiable cause, but many risk factors.

Question 13

List non-modifiable risk factors of primary hypertension?

Answer 13

• age
• gender (More males <50, but equal males and females after menopause)
• ethnicity (more common in afro carribeans)
• genetic factors.

Question 14

List modifable risk factors for primary hypertension?

Answer 14

• poor diet (high fat, high salt)
• low physical activity
• obesity
• excess alcohol
• stress.

Question 15

What % of hypertension cases are secondary hypertension?

Answer 15

5-10%

Question 16

What is secondary hypertension?

Answer 16

Hypertension secondary to another medical condition.

Question 17

List endocrine causes of secondary hypertension?

Answer 17

• Hyperaldosteronism: excess aldosterone from adenoma so greater salt and water retention.
• Phaechromocytoma: excess catecholamines.
• Hyperthyroid: Systolic hypertenson.
• Hypothyroid: Diastolic hypertension.
• Cushings: due to excess cortisol.

Question 18

What vascular causes are there of secondary hypertension?

Answer 18

Co-arctation of the aorta.

Question 19

What Renal causes of secondary hypertension are there?

Answer 19

• Renal artery stenosis

- Renal parenchymal disease.

Question 20

What other causes of secondary hypertension are there?

Answer 20

Obstructive sleep aponea.

Question 21

What drugs can cause secondary hypertension?

Answer 21

• NSAID’s like ibuprofen
• Herbel remedies
• Cocaine as it mimics the sympathetic NS.
• Exogenous steroid use.

Question 22

What are the consequences of uncontrolled hypertension?

Answer 22

• Retinopathy
• PVD
• TIA or stroke
• Renal failure
• LV hypertrophy, coronary heart disease, or heart failure.

Question 23

How do patients usually present with hypertension?

Answer 23

Normally asymptomatic and is an incidental finding.

If severe, may have headaches or visual disturbance.

Question 24

How do we diagnose hypertension ‘in office’?

Answer 24

Hypertension of over 140/90mmHg on 2 or more readings 5 minutes apart, on 2 separate visits.

Question 25

How do we diagnose hypertension 'at home'?

Answer 25

Average hypertension of 135/85 mmHg

Question 26

How can we monitor someones BP at home?

Answer 26

- Use a portable measurement device where they wear a BP cuff and the device takes their BP every 20-30 minutes though out the day, and every 2 hours overnight. Useful as we can classify someone as a 'dipper' or 'non-dipper'. Annoying for patient having to wear the cuff. - Do 2+ readings twice a day over 4-7 days.

Question 27

What is the significance of someone being a 'dipper' or 'non-dipper'?

Answer 27

A dipper means you drop your BP by >10% at night. | If you don't dip, you have a higher CV risk.

Question 28

Once someone is diagnosed with hypertension, what must we assess?

Answer 28

- Assess CV risk - Assess any end organ damage or associated complications (CKD, PVD, CVA, IHD) - Assess if it could be secondary hypertension, especially if <40 years old.

Question 29

Why can liquorice affect BP?

Answer 29

Has weak mineralocorticoid activity so promotes salt n water reabsorption.

Question 30

How would we examine a hypertension patient (physical exam)?

Answer 30

- BP on both arms - Weight and BMI - Xanthalsma, oedema, rashes. - Assess pulses - Chuck for murmurs - Check for renal masses - Any vascular bruits (carotids, kidneys) - Fundoscopy for eye assessment

Question 31

How would we investigate a hypertension patient?

Answer 31

- Glucose/Hba1c: To check for diabetes/diabetic control - Lipid profile: To see if they need statin treatment. - TFT's - LFT's - U&E's, urine dipstick, albumin:creatinine ratio, proteins in urine: Assess renal function.

Question 32

What additional tests could be done in specialist clinic for hypertension patients?

Answer 32

- renin and aldosterone: Rule out hyperaldosteronism. - 24h urine catecholeamines: Rule out phaechromocytoma. - echo: Assess any LV hypertrophy. - Renal ultrasound or MRA (angiogram): Check renal artery stenosis.

Question 33

How do we assess CV risk in hypertension patients?

Answer 33

Sign guidelines reccomend ASSIGN score. | Based on BP category, presence of end-organ damage, presence of diabetes, CV or renal disease.

Question 34

What would an ASSIGN score of >20 indicate?

Answer 34

20% chance of CVD over next ten years.

Question 35

What lifestyle measures can be take to reduce hypertension?

Answer 35

- Lose weight (can decrease SBP by 20 mmHg) - Exercise (can decrease SBP by 10 mmHg) - Reduce sodium intake - Reduce alcohol intake - DASH diet - Smoking cessation.

Question 36

What device based therapies are available for hypertension treatment?

Answer 36

- Renal denervation | - Baroreceptor stimulation

Question 37

What would be the order of drug treatment for patients <55 years old?

Answer 37

- ACEi/ARB - Ca channel blocker - Diuretic - B-blocker

Question 38

What would be the order of drug treatment in patients >55 years or black?

Answer 38

- Calcium channel blockers - ACEi/ARB - Diuretic - B-blocker

Question 39

Give examples of drugs used in hypertension treatment?

Answer 39

- ACEi: Captopril - ARB: Losartan - Calcium channel blocker: Amlodipine - Diuretic: - Loop: frusemide - Thiazide: Bendrofluothiazide - K+ sparring: Spironolactone.

Question 40

What is the target BP for hypertension?

Answer 40

Wan <140/90mmHg | Ideally try get <130/80 mmHg if patient can tolerate it.

Question 41

How do we treat 'high normal' BP?

Answer 41

Lifestyle advice | May consider drugs in patients with high CAD risk.

Question 42

How do we treat grade 1 hypertension?

Answer 42

Lifestyle advice Immediate drug is high CAD risk or patients with renal disease. Drug treatment in low risk patients after 3-6 months lifestyle advice.

Question 43

How do we treat grade2/3 hypertension?

Answer 43

Lifestyle advice Immediate drug treatment in all patients Aim for BP control within 3 months.