Hypertension Flashcards
What is the definition of hypertension
Essential hypertension:
Systolic BP >/= 140mmHg
Diastolic BP >/= 90 mmHg
But rely over a set of reading over time (e.g. ambulatory readings etc)
Malignant hypertension:
200/130 mmHg
Describe the aetiology/RFs for hypertension
Hypertension can be primary (95%) or secondary.
`Causes of secondary hypertension:
- Renal - renal artery stenosis, glomerulonephritis, pyelonephritis, polycystic kidney disease, chronic renal failure
- Endocrine - T2DM, hyperthyroidism, Cushings, Conns, hyperparathyroidism, phaeochromocytoma, CAH, acromegaly
- Cardiovascular - aortic coarctation, raised intravascular volume
- Drugs - sympathomimetics, corticosteroids, oral contraceptive pill,
- Pregnancy - pre-eclampsia
(RECDP)
Other RFs = obesity, high alcohol intake, low exercise, age, black ancestry, family history, sleep apnoea
Describe the epidemiology of hypertension
Very common - 10-20% adults in western world
What may people with hypertension present with?
Often asymptomatic
Symptoms of the complications (see later)
Symptoms of the cause
Accelerated/Malignant hypertension - scotomas (visual field loss), blurred vision, headache, seizures, nausea/vomiting, acute heart failure, papilloedema. Requires URGENT treatment
What are the hypertensive emergencies
Acute kidney injury, heart failure, encephalopathy.
These may all be precipitated by malignant hypertension
Weak femoral pulses may indicate?
Aortic coarctation
What must be done in the physical examination for hypertension?
Measure BP 2/3 times before diagnosing - write lowest reading.
May be a loud second/fourth heart sound
Examine for:
Radiofemoral delay - aortic coarctation
Renal artery bruit - renal artery stenosis
Examine for end organ damage - e.g. fundoscopy for retinopathy
On examination of retinopathy for end-organ damage, describe the Keith-Wagner classification of retinopathy
Stages:
- Silver wiring
- As above + arteriovenous nipping
- As above + flame haemorrhages + cotton wool exudates
- As above + papilloedema
What are the first investigations to order?
- ECG - may show signs of LV hypertrophy or ischaemia
- Metabolic panel with estimated GFR - may show renal insufficiency, hyperglycaemia, hypokalaemia, hyperuricaemia, hypercalcaemia
- Lipid panel - high LDL, low HDL, high triglycerides
- Urinalysis - proteinuria
- Hb - anaemia/polycythaemia indicates secondary cause or complication
- TSH
- Ambulatory BP monitoring
What is the management plan for hypertension
General conservative management plan:
Stop smoking, lose weight, reduce alcohol intake, reduce dietary sodium. Investigate for secondary causes
ACEi / ARB (e.g. ramipril / losartan) first line if:
- < 55 years
- Diabetic
- HF
- LV dysfunction
CCB (e.g. amlodipine) first line if:
- > 55 years
- Black
- Can use thiazide diuretics (e.g. bendrofluamethiazide) if CCB not tolerated -
Beta blockers (e.g. atenolol)-
- Not ideal initial therapy
- May be used in younger patients
- Try to avoid combining beta blockers and thiazides as this may increase risk of diabetes
- May increase risk of HF
Alpha blockers (e.g. doxazosin):
- Fourth line agent
- May be useful in patients with prostatism
When should hypertension treatment be administered?
If systolic >/= 160mmHg
If diastolic >/= 100mmHg
Or if evidence of end-organ damage
What are the target BPs once treatment has commenced?
Non diabetic : <140/85
Diabetic without proteinuria : <130/80
Diabetic with proteinuria : <125/75
Which 2 drugs may be given if there is severe hypertension (diastolic > 140mmHg)
Nifedipine or atenolol
If there is acute malignant hypertension, what is given
IV beta blocker, labetolol or hydrazine sodium nitroprusside. Rapid lowering of BP may cause cerebral infarction
What are the complications of hypertension
- HF
- CAD / MI
- PVD
- Emboli
- Retinopathy
- Renal failure
Other complications include hypertensive encephalopathy, posterior reversible encephalopathy syndrome (PRES), malignant hypertension
