Hypertension

Question 1

What is isolated systolic hypertension normally caused by? What are the increases in risks?

Answer 1

Often seen in >60yo due to stiffening of the large arteries. doubles the risk of MI, triples the risk of CVA

Question 2

What is malignant/accelerated phase hypertension? What are the signs? What are the symptoms? What can it precipitate?

Answer 2

refers to a rapid rise in BP leading to vascular damage.

Usually, there is severe hypertension (>180/110) and bilateral retinal haemorrhages and exudates, papilloedema may also be seen

Symptoms such as headache +/- visual disturbance

Can precipitate acute renal failure, heart failure, encephalopathy - hypertensive emergencies

Question 3

What is essential hypertension?

Answer 3

hypertension with a primary unknown cause

Question 4

What are the secondary causes of hypertension?

Answer 4

renal disease:
intrinsic renal disease - glomerulonephritis, polyarteritis nodosa, systemic sclerosis, chronic pyelonephritis, polycystic kidneys
renovascular disease: most frequently atheromatous, or rarely fibromuscular dysplasia

Endocrine disease: Cushing’s, Conn’s, phaeochromocytoma, acromegaly, hyperparathyroidism

Other: coarctation, pregnancy, steroids, MAOI, the Pill

Question 5

What is the treatment goal for hypertension?

Answer 5

<140/90 normally
<130/80 if diabetic
<150/90 if >80

Question 6

If a blood pressure reading is >140/90 in the clinic, how can a diagnosis of hypertension be confirmed?

Answer 6

Ambulatory blood pressure monitoring or home blood pressure monitoring

Question 7

When should antihypertensive therapy be started in a patient with stage 1 hypertension? What is stage 1 hypertension?

Answer 7

in patients <80yo with one of:
target organ damage
established cardiovascular disease
renal disease
diabetes
10-year cardiovascular risk of >20% (QRISK)

stage 1 HTN = clinic BP 140/90 - 160/110 and ABPM >135/85

Question 8

What is the first step in the management of hypertension?

Answer 8

lifestyle changes - smoking cessation, low-fat diet, reduce alcohol and salt intake, increase exercise, reduce weight if obese

Question 9

What is the first-line medication used for patients of Afro-Caribbean descent or >55yo? What is a contraindication?

Answer 9

Calcium channel blocker - nifedipine MR 30-60mg, amlodipine 5mg OD
Thiazide-like diuretic (indapamide) if CCB CI

CI to CCB: heart failure, at risk of heart failure, oedema

Question 10

What is the first-line medication in patients <55yo?

Answer 10

ACE inhibitor - lisinopril or enalapril
ARB (Candesartan) if ACE-i is CI

CI to ACE-i = cough

Question 11

Other than hypertensive medications, what should be considered in treating a hypertensive patient?

Answer 11

Statins

Aspirin if >55yo

Question 12

What is step 2 and step 3 of the anti-hypertensive medication pathway?

Answer 12

step 2: ACE-i/ARB + CCB

Step 3: ACE-i/ARB + CCB + thiazide-like diuretic

Question 13

What is the risk of a rapid decrease in blood pressure, especially in malignant hypertension?

Answer 13

cerebral autoregulation is poor so there is an increased risk of stroke - aim for a reduction over days not hours

Question 14

What are the signs of encephalopathy with hypertension?

Answer 14

headache, focal CNS signs, seizures, coma