Hypertension

Question 1

What are the systolic and diastolic measurements for prehypertension?

Answer 1

Systolic: 130-139
Diastolic: 85-89

Question 2

What is isolated systolic hypertension?

Answer 2

Systolic = >140 mmHg
Diastolic - <90 mmHg
- Less serious than full HTN, more serious in the elderly
- 1st line treatment = lifestyle modifications

Question 3

What are the systolic and diastolic measurements for hypotension? What is orthostatic hypotension?

Answer 3

Systolic: <90 mmHg
Diastolic: <60 mmHg
Orthostatic hypotension: systolic BP decreases on standing by >20 mmHg or diastolic BP decreases by>10 mmHg

Question 4

What are the main symptoms of hypotension?

Answer 4

CNS: dizziness, impaired cognition, lethargy + fatigue, visual disturbances
Muscle: paracervical (upper back) ache, general fatigue
Heart: angina (hypoperfusion of heart)

Question 5

What is hypertension? By how much does it increase risk of stroke and cardiac death?

Answer 5

HTN = systolic is persistently >140 mmHg and diastolic is persistently >90 mmHg

6 fold increase in stroke and 3 fold increase in cardiac death

Question 6

How does chronic HTN affect the heart?

Answer 6

LV thickens, myocardial fibres undergo hypertrophy = increase pressure in systole
Concentric hypertrophy = stroke volume decreased = tachycardia for normal cardiac output
Poor blood supply = ischaemic damage

Question 7

How can HTN affect the eyes?

Answer 7

HTN retinopathy
There is arteriolar narrowing and abnormalities –> can result in sight loss
Microaneurysms, blot + flame haemorrhages, cotton wool spots and swelling of the optic nerve

Question 8

What is primary HTN? What % of HTN cases does it account for?

Answer 8

HTN where there is no obvious cause

Accounts for 90-95% of all HTN cases

Question 9

What is secondary HTN? What % of HTN cases does it account for?

Answer 9

Accounts for ~5% of HTN cases
HTN where there is an obvious cause such as:
- coarctation of the aorta
- renal/renovascular disease
- hypo/hyperthyroidism + parathyroidism
- endocrine disease –> phaeochromocytoma, Cushing’s syndrome, Conn’s syndrome, acromegaly etc
- iatrogenic –> hormonal/oral contraceptives, NSAIDs

Question 10

What are the 3 main causes of HTN?

Answer 10

1. Impaired production of NO - excess vasoconstriction, increased SVR
2. Elevated renin release (possible kidney damage)
3. Reduced ANP release –> salt dependent HTN and water retention –> increased blood volume = increased BP –> stretching of atria = reduced ANP

Question 11

What is stage 1 and stage 2 HTN?

Answer 11

Stage 1 = 140/90+
- only offer treatment if accompanied by organ damage

Stage 2 = 160/100+
- always offer treatment

Question 12

What is Step 1 of HTN treatment according to NICE?

Answer 12

<55: ACE-I or ARB –> Not both

>55 or Afro-Caribb: CCB or thiazide-like diuretic

Question 13

What is Step 2 of HTN treatment according to NICE?

Answer 13

CCB with an ACE-I or ARB
If CCB not suitable –> thiazide-like diuretic
Afro-Caribb: ARB preferred with CCB over ACE

Question 14

What is Step 3 of HTN treatment according to NICE?

Answer 14

Three drug combination: ACE-I/ARB with CCB and thiazide-like diuretic

Question 15

What is Step 4 of HTN treatment according to NICE?

Answer 15

BP remains high after 3 drug combination = resistant HTN

Add 4th antihypertensive/seek expert advice

Question 16

Why are beta blockers not used as part of 1st line treatment for HTN? When might BBs be used?

Answer 16

BBs associated with increased risk of diabetes
Used when:
- ACE-I/ARB intolerance
- woman of child-bearing age
- increased sympathetic drive

Question 17

If beta blocker therapy for HTN requires a second drug, what should be used?

Answer 17

CCB NOT a thiazide-like diuretic