Hypertension

Question 1

Define hypertension

Answer 1

DEFINITION: systolic > 140 mm Hg and/or diastolic > 90 mm Hg measured on three separate occasions.

Malignant Hypertension: BP > 200/130 mm Hg

Question 2

Summarise the epidemiology of hypertension

Answer 2

• VERY COMMON

* 10-20% of adults in the Western world

Question 3

Aetiology of HTN?

Answer 3

Primary htn = Essential htn. Idiopathic. 90% of cases.

Secondary htn causes;

• Renal; renal artery stenosis
• Endocrine; acromgegaly, dm, cah
• CVS;
• Pregnancy; preeclampsia
• Drugs; corticosteroids, cocp

Question 4

Renal causes of htn?

Answer 4

• Renal artery stenosis
• Chronic glomerulonephritis
• Chronic pyelonephritis
• Polycystic kidney disease
• Chronic renal failure

Question 5

Endocrine of htn?

Answer 5

• Diabetes mellitus

• Cushing’s syndrome
• Conn’s syndrome
• Congenital adrenal hyperplasia
• Hyperthyroidism
• Hyperparathyroidism
• Phaeochromocytoma
• Acromegaly

Question 6

CVS and drugs causing htn?

Answer 6

○ Cardiovascular
• Coarctation of the aorta
• Increased intravascular volume

○ Drugs
• Sympathomimetics
• Corticosteroids
• COCP

Question 7

Recognise the presenting symptoms of hypertension

Answer 7

• Often ASYMPTOMATIC
• Symptoms of complications
• Symptoms of the cause/ rfs
- retinopathy

uncommon;
headache
visual changes
dyspneoa - laboured breathing
chest pain

Question 8

Recognise the signs of hypertension on physical examination

Answer 8

• BP > 140/90
- Blood pressure should be measured on 2-3 different occasions before diagnosing hypertension
• The lowest reading should be recorded

Extreme;
• Examination may reveal information about causes:
○ Radiofemoral delay = coarctation of the aorta distal to the left subclavian
artery
○ Renal artery bruit = renal artery stenosis
○ Fundoscopy to detect hypertensive retinopathy

Keith-Wagner Classification of Hypertensive Retinopathy

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

Question 9

Symptoms of Accelerated or Malignant Hypertension

Answer 9

○ Scotomas (visual field loss)
○ Blurred vision
○ Headache
○ Seizures
○ Nausea and vomiting
○ Acute heart failure

Question 10

Risk factors of HTN?

Answer 10

Obesity
Age >60
Aerobic exercise <3 days pw
Moderate-high alcohol intake
DM
Black
FH
Sleep apnoea

Weak links;
High salt intake
Low fruit n veg intake
dysipidaemia

Question 11

Investigations for HTN?

Answer 11

Bloods
TSH
eGFR

Lipids;
may show high LDL, low HDL, or high triglycerides

Hb;
Anaemia accompanies chronic renal failure. Polycythaemia may be seen with phaeochromocytoma.

Metabolic profile; may show renal insufficiency, hyperglycaemia, hypokalaemia, hyperuricaemia, or hypercalcaemia

ECG;
may show evidence of LVH or old infarction

Urine Dipstick
○ Blood and protein (e.g. if glomerulonephritis)

Question 12

Generate a management plan for hypertension

Answer 12

• Conservative
○ Stop smoking
○ Lose weight - physical activity
○ Reduce alcohol intake
○ Reduce dietary sodium 

• Medical - treatment recommended if systolic > 160 mm Hg and/or diastolic > 100.

○ ACE Inhibitors or Angiotensin Receptor Blockers - first line if:
• younger than 55 yrs
• Diabetic
• Heart failure
• Left ventricular dysfunction

○ CCBs - first line if:
• > 55 yrs
• Black

2nd line:
ACEi/ARB + CCB or Thiazide
CCB + ACEi/ARB or Thiazide

3rd line
ACEi/ARB + CCB + Thiazide

• 4th line
○ Alpha-Blockers
• May be used in patients with prostate disease

• CAUTION: combining BB with thiazide diuretic may increase risk of developing diabetes
• May increase risk of heart failure

Question 13

What is the target range for BP in HTN?

Answer 13

Target BP
○ Non-Diabetic: < 140/90 mm Hg
ambulatory reading: < 135/85

○ Diabetes without proteinuria: < 130/80 mm Hg
○ Diabetes WITH proteinuria: < 125/75 mm Hg

Question 14

How does one manage severe htn?

How does one manage Acute Malignant Hypertension?

Answer 14

Severe Hypertension Management (Diastolic > 140 mm Hg)
○ Atenolol
○ Nifedipine - Dhp CCB

• Acute Malignant Hypertension Management:
○ IV beta-blocker (e.g. esmolol)
○ Labetolol
○ Hydralazine sodium nitroprusside
○ CAUTION: avoid rapid lowering of blood pressure because it can cause cerebral infarction

Question 15

Identify the possible complications of hypertension

Answer 15

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