HYPERTENSION

Question 1

Define hypertension

Answer 1

Systolic > 140 mm Hg and/or diastolic > 90 mm Hg

Measured on three separate occasions.

Question 2

Define malignant hypertension

Answer 2

BP > 200/130 mm Hg

Question 3

Summarise the epidemiology of hypertension

Answer 3

• VERY COMMON

* 10-20% of adults in the Western world

Question 4

Explain the aetiology/risk factors of hypertension

Answer 4

PRIMARY
Essential or idiopathic hypertension = >90% of cases

SECONDARY
RENAL
•  Renal artery stenosis  
•  Chronic glomerulonephritis   
•  Chronic pyelonephritis  
•  Polycystic kidney disease  
•  Chronic renal failure 
ENDOCRINE
•  Diabetes mellitus  
•  Hyperthyroidism 
•  Cushing's syndrome  
•  Conn's syndrome  
•  Hyperparathyroidism 
•  Phaeochromocytoma 
•  Congenital adrenal hyperplasia   
•  Acromegaly 
CARDIOVASCULAR
•  Coarctation of the aorta  
•  Increased intravascular volume  
DRUGS
•  Sympathomimetics   
•  Corticosteroids 
•  COCP 
PREGNANCY
•  Pre-eclampsia

Question 5

Recognise the presenting symptoms of hypertension

Answer 5

• Often ASYMPTOMATIC
• Symptoms of complications
• Symptoms of the cause

Question 6

Recognise the presenting symptoms of MALIGNANT hypertension

Answer 6

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

Question 7

Recognise the signs of hypertension on physical examination

Answer 7

• Blood pressure should be measured on 2-3 different occasions before diagnosing hypertension
• The lowest reading should be recorded

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 8

Keith-Wagner Classification of Hypertensive Retinopathy

Answer 8

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

Question 9

Identify appropriate investigations for hypertension

Answer 9

BLOODS
o U&Es
o 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 - ABPM
o Excludes white coat hypertension

Other investigations may be performed if a secondary cause of the hypertension is suspected (e.g. renal angiogram)

Question 10

Generate a management plan for hypertension

Answer 10

CONSERVATIVE TREATMENT
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 - first line if:
• > 55 yrs
• Black
• NOTE: thiazide diuretics can be used if CCBs are not tolerated

o  Beta-Blockers  
Not preferred initial therapy  
May be considered in younger patients  
CAUTION: combining with thiazide diuretic may increase risk of developing  diabetes  
May increase risk of heart failure  

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

Question 11

What are the target BP measurements?

Answer 11

o NonJDiabetic: < 140/90 mm Hg
o Diabetes without proteinuria: < 130/80 mm Hg
o Diabetes WITH proteinuria: < 125/75 mm Hg

Question 12

What is the management for SEVERE hypertension?

Answer 12

o Atenolol

o Nifedipine

Question 13

What is the management for ACUTE MALIGNANT hypertension?

Answer 13

o IV beta-blocker (e.g. esmolol)
o Labetolol
o Hydralazine sodium nitroprusside

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 14

Identify the possible complications of hypertension

Answer 14

• 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 15

Summarise the prognosis for patients with hypertension

Answer 15

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