Hypertension

Question 1

Define

Answer 1

• Systolic > 140 mm Hg and/or diastolic > 90 mm Hg measured on three separate occasions.
• Malignant Hypertension: BP > 200/130 mm Hg

Question 2

Epidemiology?

Answer 2

• VERY COMMON
• 10-20% of adults in the Western world
• Most important risk factor for premature death and CVD causing about 50% of all vascular deaths

Question 3

What’s the aetiology?

Answer 3

•	Primary
o	Essential or idiopathic hypertension 
o	Responsible for > 90% of cases
•	Secondary
o	Renal
•	Renal artery stenosis 
•	Chronic glomerulonephritis 
•	Chronic pyelonephritis 
•	Polycystic kidney disease 
•	Chronic renal failure
o	Endocrine
•	Cushing's syndrome 
•	Conn's syndrome 
•	Hyperparathyroidism
•	Phaeochromocytoma
•	Congenital adrenal hyperplasia 
•	Acromegaly
o	Cardiovascular
•	Coarctation of the aorta 
•	Increased intravascular volume 
o	Drugs
•	Sympathomimetics 
•	Corticosteroids
•	COCP
•	Cocaine
•	amphetamines
o	Pregnancy
•	Pre-eclampsia

Question 4

What are the presenting symptoms?

Answer 4

•	Often ASYMPTOMATIC
•	Symptoms of complications
•	Symptoms of the cause
•	Accelerated or Malignant Hypertension
o	Scotomas (visual field loss) 
o	Blurred vision 
o	Headache 
o	Seizures 
o	Nausea and vomiting 
o	Acute heart failure

Question 5

What are the risk factors?

Answer 5

• Age
• Family history of high blood pressure
• Unhealthy lifestyle habits (excess alcohol, dietary sodium, lack of exercise)
• African
• Before 55, men more likely but after 55, women more likely

Question 6

What are the signs?

Answer 6

• Blood pressure should be measured on 2-3 different occasions before diagnosing hypertension
• The lowest reading should be recorded
• Examination may reveal information about causes:
o Radiofemoral delay = coarctation of the aorta distal to the left subclavian artery
o Renal artery bruit = renal artery stenosis
o Fundoscopy to detect hypertensive retinopathy

Question 7

How do you classify hypertensive retinopathy?

Answer 7

i. Silver wiring
ii. As above + arteriovenous nipping
iii. As above + flame haemorrhages + cotton wood exudates
iv. As above + papilloedema

Question 8

What are the appropriate investigations?

Answer 8

• Bloods:
o U&Es
o Ca
o Fasting glucose
o Lipids
• Urine Dipstick
o Blood and protein (e.g. if glomerulonephritis)
• ECG
o May show signs of left ventricular hypertrophy or ischaemia
• Ambulatory blood pressure monitoring or home BP monitoring
o Excludes white coat hypertension
• Other investigations may be performed if a secondary cause of the hypertension is suspected (e.g. renal angiogram)
• Calculate CV risk and investigate for end-organ damage
• Patients under 40 with no risk factors should undergo further investigation for secondary causes of hypertension.

Question 9

How would you manage?

Answer 9

• Conservative
o Stop smoking
o Lose weight
o Reduce alcohol intake
o Reduce dietary sodium
• Investigate for secondary causes (mainly in young patients)
• Medical - treatment recommended if systolic > 160 mm Hg and/or diastolic > 100 mm Hg, or if evidence of end-organ damage. Multiple drug therapies often needed.

o ACE Inhibitors or Angiotensin Receptor Blockers - first line if:
• < 55 yrs
• Diabetic
• Heart failure
• Left ventricular dysfunction
o CCBs (dihyrdopyridines) - first line if:
• > 55 yrs
• Black
• NOTE: thiazide diuretics can be used if CCBs are not tolerated

2nd line - ACEi + CCB or ACEi + TTD

3rd line - ACEi + CCB + TTD

4th line - beta blocker, alpha blocker, spionolactone

Question 10

What is target BP?

Answer 10

o Non-Diabetic: < 140/90 mm Hg
o Diabetes: < 130/80 mm Hg
o Over 80: <150/90

Question 11

How would you manage acute malignant hypertension?

Answer 11

o IV beta-blocker (e.g. esmolol)
o Labetolol
o Hydralazine sodium nitroprusside
o CAUTION: avoid rapid lowering of blood pressure because it can cause cerebral infarction
• This is because the autoregulatory mechanisms within the brain for regulating blood flow will cause vasoconstriction of the vessels in the brain when blood pressure is very high
• Lowering the blood pressure too rapidly would mean that the autoregulatory mechanisms do not adapt to the drop in blood pressure and so the vessels remain constricted
• A rapid drop in blood pressure with constricted vessels will cause an infarction

Question 12

What are the possible complications?

Answer 12

• Heart failure
• Coronary artery disease
• Cerebrovascular accidents
• Peripheral vascular disease
• Emboli
• Hypertensive retinopathy
• Renal failure
• Hypertensive encephalopathy
• Posterior reversible encephalopathy syndrome (PRES)
• Malignant hypertension

Question 13

What’s the prognosis?

Answer 13

• Good prognosis if well controlled
• Uncontrolled hypertension is associated with increased mortality
• Treatment reduces incidence of renal damage, stroke and heart failure