Hypertension

Question 1

Definition of hypertension

Answer 1

Blood pressure of greater than 140/90mmHg

Question 2

Treatment parameters for hypertension

Answer 2

Most patients we aim to get under 160/100
Patients with a high risk of a coronary artery event (>20% in 10 years), diabetics and those with evidence of end organ damage require blood pressure under 140/90

Question 3

Definition of white coat hypertension.

Answer 3

When the patient has an elevated blood pressure in clinic, but a normal ambulatory blood pressure

Question 4

Management of white coat hypertension

Answer 4

No management - but these patient have an increased risk of developing hypertension in the future, and have an increased cardiovascular risk

Question 5

Definition of malignant hypertension

Answer 5

A rapid rise in blood pressure causing vascular damage

- more common in young, black patients

Question 6

Pathological hallmark of malignant hypertension

Answer 6

Fibroid necrosis

Question 7

Signs and symptoms of malignant hypertension

Answer 7

Headaches 
Visual disturbance 
Very severe hypertension: a systolic over 100, and/or a diastolic over 130
Bilateral retinal haemorrhages
Bilateral retinal exudates 
Papilloedema

Question 8

Why is urgent treatment of malignant hypertension required

Answer 8

Prevention of hypertensive emergencies such as AKIs, heart failure and encephalopathy

Question 9

Definition of primary hypertension

Answer 9

Hypertension with no known cause (95% of cases)

Question 10

Definition of secondary hypertension

Answer 10

Hypertension due to a known cause that can be treated - 5% of cases of hypertension

Question 11

Renal causes of secondary hypertension

Answer 11

Intrinsic renal disease
- glomerulonephritis 
- PAN
- systemic sclerosis 
- chronic pyelonephritis 
- polycystic kidney disease 
Renovascular disease
- atheromas (due to age, smoking or PVD)
- fibromuscular dysplasia

Question 12

Endocrine causes of secondary hypertension

Answer 12

Cushing/Conn’s syndrome
Pheochromocytoma
Acromegaly
Hyperparathyroidism

Question 13

Causes of secondary hypertension (excluding renal and endocrine causes)

Answer 13

Pregnancy
Aortic Coarctation 
Liquorice 
Drugs 
- amphetamines 
- cocaine 
- MDMA
- oral contraceptive pill
- steroids

Question 14

Four stages of hypertensive retinopathy

Answer 14

1) tortuous arteries with thick, shiny walls
2) AV nipping (narrowing where arteries cross veins)
3) flame haemorrhages and cotton-wool spots
4) papilloedema

Question 15

Signs and symptoms of secondary hypertension

Answer 15

Known renal disease
Radio-femoral delay
Weak femoral pulses
Renal bruits 
Palpable kidneys 
Cushingoid features 
Signs of end organ damage 
- left ventricular hypertrophy 
- retinopathy 
- proteinuria

Question 16

When should hypertension be treated

Answer 16

Confirm diagnosis
- home BP monitor readings/ambulatory BP monitoring
Treat if BP >160/100
If BP is >140/90, assess cardiovascular risk, check for diabetes and end-organ damage

Question 17

How to investigate for end-organ damage

Answer 17

ECG and echo - LVH
Urinalysis for blood and protein - AKI
Fundoscopy - retinopathy

Question 18

Assessment for the specific causes of secondary hypertension

Answer 18

Conn’s syndrome - U&Es for hypokalaemia
Primary hyperparathyroidism - calcium and PTH levels
Renal artery stenosis - renal USS or angiography
Pheochromocytoma - 24hr urinary adrenaline
Cushing’s syndrome - urinary free cortisol
Aortic coarctation - MRI of aorta
Renin and aldosterone levels

Question 19

What lifestyle changes are recommended for hypertension management

Answer 19

Smoking cessation 
Healthy diet (low salt and low fat)
Reduce alcohol intake 
Exercise 
Weight loss (if required)

Question 20

What medication is used to treat primary hypertension

Answer 20

Age <55 or diabetic
- ACE inhibitor/ARB
- then add CCB
Age >55 or black
- CCB
- then add ACE inhibitor/ARB
If further medication required you can add a Thiazides
Beyond this specialist help is needed (aspirin, alpha-blockers, beta-blockers)
Consider statins if hypercholesterolaemia

Question 21

Management of malignant hypertension

Answer 21

Bed rest
Calcium channel blocker or atenolol (unless encephalopathy or congestive cardiac failure)
Aim for a controlled drop in BP as cerebral autoregulation is poor (risk of stroke)