Hypertension

Question 1

Define:

Answer 1

SBP >140 mmHg and DBP >90mmHg on three separate occasions.

Malignant hypertension >200/130 mmHg

Question 2

Aetiology:

Answer 2

Primary (essential)- treat the hypertension as the cause is idiopathic.

Secondary - treat the cause: can be renal, endocrine, cardiovascular, pre-eclampsia or drug cause

Isolated systolic hypertension - 50% of cases in the >60s . Due to atherosclerosis

Malignant hypertension - usually presents with bilateral retinal haemorrahges

Question 3

Renal causes of hypertension:

Answer 3

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

Question 4

Endocrine causes of hypertension

Answer 4

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

Question 5

Cardiovascular causes of hypertension:

Answer 5

• Coarctation of the aorta

* Increased intravascular volume

Question 6

Drug causes of hypertension:

Answer 6

• Sympathomimetics
• Corticosteroids
• COCP

Question 7

Risk factors:

Answer 7

obesity 
high sodium intake 
high alcohol 
inactivity 
family history 
age

Question 8

Epidemiology:

Answer 8

very common

10-20 % of the world

Question 9

symptoms:

Answer 9

usually asymptomatic

may have symptoms of the cause or complications

Malignant :
scotomas (visual field losses), blurred vision, headaches, seizures, nausea and vomiting and acute heart failure.

Question 10

Signs:

Answer 10

must have an elevated BP on three separate occasions. Record the lowest reading

signs of the causes:
radiofemoral delay (coarctation)
renal bruits (renal artery stenosis)
palpable kidneys 
signs of cushings or phaecytochroma 
LVH
proteinuria 
retinopathy (fundoscopy will show silver wiring, cotton wool spots, papilloedema, arteriovenous nipping and flame haemorrhages)

Question 11

investigations:

Answer 11

Bloods:

• U+E’s
• Glucose
• Lipids
• renin
• aldosterone

Urine:

• urine dipstick for protein or blood
• 24hr urine for catecholamines

ECG (look for signs of LVH)

Ambulatory BP

Question 12

management:

Answer 12

if <55 yrs (ACEi or ARB) but if >55 or afrocarribean (CCB or thiazide diuretic)

Step 2: ACEi and CCB or thiazide

Step 3: ACEi and CCB and thiazide

Step 4: add another diuretic or alpha/beta blocker

First line management is to modify lifestyle (stop smoking, lose weight, reduce sodium and alcohol)

If >140mmHg DBP (atenolol + nifedipine)

Question 13

Complications:

Answer 13

• 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 14

Prognosis:

Answer 14

good if managed.

poor mortality if unmanaged

50% of vascular deaths