Hypertension

Question 1

Stages of HTN

Answer 1

Stage I = 140/90 - 159/99 mmHg
Stage II = 160/100 - 179/119 mmHg
Stage III = sBD >/= 180mmHg or dBP >/= 120 mmHg

Malignant HTN = BP >/= 200/130 mmHg

Question 2

What needs to be investigated with stage III HTN?

Answer 2

Assess for target organ damage ASAP, refer same-day if:
= retinal haemorrhage/papilloedema
= life-threatening sx; new onset confusion, chest pain, signs of heart failure, AKI
= suspected phaeochromocytoma; postural hypotension, headache, palpitations, pallor, abdo pain, sweating

Question 3

HTN diagnosis

Answer 3

Repeat measurements:

• offer ambulatory BP monitoring (average 14 measurements/day)
• offer home BP monitoring (record daily x2 for 4-7 days)

Question 4

Ix for HTN

Answer 4

Review target organ damage

• proteinuria, estimated albumin:creatinine ratio
• HbA1c
• electrolytes
• creatinine
• eGFR
• total cholesterol
• fundoscopy
• ECG
• QRISK2 to assess cardiac risk

Question 5

Sx and signs

Answer 5

Typically asymptomatic, malignant HTN shows:
- headaches, N&V, blurred vision, seizures, visual field loss (scotoma)

Signs

• root cause; renal artery stenosis, coarctation of aorta
• S2, S4 loud

Question 6

Complications

Answer 6

No treatment leads to complications:

• heart failure
• retinopathy
• emboli
• peripheral vascular disease
• stroke
• coronary artery disease/MI

Question 7

Causes of HTN

Answer 7

90% estimated idiopathic
Renal
= renal failure, pyelonephritis, chronic glomerulonephritis, polycystic kidney disease, renal artery stenosis

Cardio
= coarctation of aorta, increased intramuscular volume

Endo
= congenital adrenal hyperplasia, acromegaly, phaeochromocytoma, hyperPTH, Conn’s, Cushing’s, hyperthyroidism, diabetes mellitus

Drugs
= OCP, corticosteroids, sympathomimetics

Pregnancy
= pre-eclampsia

Question 8

Mx of HTN (incl. side-effects)

Answer 8

1) Lifestyle modifications
- reduce alcohol intake, smoking cessation, wt loss, reduce salt intake

2) Antihypertensive drugs(+ side-effects)
- ACEi/ARB (increased creatinine, potassium levels and cough)
- CCB (ankle swelling, angiooedema)
- thiazides-like diuretics (decreased potassium levels, dry mouth)
- spironolactone/alpha or beta blockers (blockers cause dizziness)

*spironolactone > blockers when potassium levels are low

Question 9

Drug pathway for HTN

Answer 9

HTN II/<55 or not Afro-Cari.

1. ACEi/ARB
2. • CCB/thiazide
3. ACEi/ARB + CCB + thiazide
4. Seek expert advice, + low dose spironolactone/alpha or beta blockers

HTN I w/ diabetes/>55 or Afro-Cari.

1. CCB
2. • ACEi/ARB or thiazide
3. ACEi/ARB + CCB + thiazide
4. Seek expert advice, + low dose spironolactone/alpha or beta blockers

Question 10

A 48yo woman has been diagnosed with essential hypertension and commenced on treatment 3 months ago. She presents with a dry cough which has not been getting any better despite taking cough linctus and antibiotics. You assess the pt’s medication history. Which of the following is responsible for the pt’s symptoms?

A) amlodipine
B) lisinopril
C) bendeoflumethiazide
D) furosemide
E) atenolol

Answer 10

B) lisinopril

Question 11

A 48yo woman has been diagnosed with essential hypertension and commenced on treatment 3 months ago. She presents with a dry cough which has not been getting any better despite taking cough linctus and antibiotics. You assess the pt’s medication history. Which medication would you consider trying as the next line medication?

A) amlodipine
B) spironolactone
C) bendeoflumethiazide
D) furosemide
E) losartan

Answer 11

E) losartan

Question 12

A 57 yo man is reviewed in a hypertension clinic. His BP is 165/105mmHg despite standard doses of amlodipine, perindopril, do azo sin and bendroflumethiazide. Electrolytes and physical examination have been, and remain, normal. Which of the following would be your next stage management?

A) arrange for his medication to be given under direct observation
B) add spironolactone to his medication
C) arrange urinary catecholamine assays
D) request an adrenal CT scan
E) add verapamil to his medication

Answer 12

A) arrange for his medication to be given under direct observation

Question 13

A 47yo woman presents to clinic after being referred by her GP for consistently elevated BP. Her last reading was 147/93. The woman doesn’t report any symptoms but recently lost her job and attribute the elevated levels to stress. Her blood tests are as follows:
Sodium = 146 (135-145)
Potassium = 3.4 (3.5-5)
Random glucose = 7.7 (4.4-7.8)
Urea = 4 (2.5-7.8)

The next most appropriate investigation is:
A) CT scan
B) 24-hour ambulatory blood pressure
C) abdominal ultrasound scan
D) aldosterone-renin ratio
E) glucose tolerance test

Answer 13

B) 24-hour ambulatory blood pressure

Most appropriate to rule out essential hypertension, the deranged electrolytes are slight otherwise next would be exploring that