Hypertension

Question 1

What is the definition of hypertension?

Answer 1

Systolic > 140 mm Hg and/or diastolic > 90 mm Hg measured on three separate occasions.

Malignant Hypertension: BP > 200/130 mm Hg

Question 2

What is the epidemiology of hypertension?

Answer 2

VERY COMMON

10-20% of adults in the Western world

Question 3

What is the aetiology of hypertension?

Answer 3

Primary

• Essential or idiopathic hypertension
• Responsible for > 90% of cases

Secondary

Renal

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

Endocrine

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

Cardiovascular

• Coarctation of the aorta
• Increased intravascular volume

Drugs

• Sympathomimetics
• Corticosteroids
• COCP

Pregnancy
- Pre-eclampsia

Question 4

What are the presenting symptoms of hypertension?

Answer 4

Often ASYMPTOMATIC

Symptoms of complications

Symptoms of the cause

Accelerated or Malignant Hypertension

• Scotomas (visual field loss)
• Blurred vision
• Headache
• Seizures
• Nausea and vomiting
• Acute heart failure

Question 5

What are the signs of hypertension upon physical examination?

Answer 5

Blood pressure should be measured on 2-3 different occasions before diagnosing hypertension

The lowest reading should be recorded

Examination may reveal information about causes:
- Radiofemoral delay = coarctation of the aorta distal to the left subclavian artery
- Renal artery bruit = renal artery stenosis
- Fundoscopy to detect hypertensive retinopathy
Keith-Wagner Classification of Hypertensive Retinopathy

Question 6

What are the sigs of hypertensive retinopathy

Answer 6

Silver Wiring

Arteriovenous nipping

Flame Haemorrhages, Cotton Wool Exudates and Papilloedema

Question 7

What are the appropriate investigations for hypertension?

Answer 7

Bloods:

• U&Es
• Glucose
• Lipids

Urine Dipstick
- Blood and protein (e.g. if glomerulonephritis)

ECG
- May show signs of left ventricular hypertrophy or ischaemia

Ambulatory blood pressure monitoring - Excludes white coat hypertension

Other investigations may be performed if a secondary cause of the hypertension is suspected (e.g. renal angiogram)

Question 8

What is the management plan for hypertension?

Answer 8

Conservative

• Stop smoking
• Lose weight
• Reduce alcohol intake
• Reduce dietary sodium

Investigate for secondary causes (mainly in young patients)

Medical - treatment recommended if systolic > 160 mm Hg and/or diastolic > 100 mm Hg, or if evidence of end-organ damage. Multiple drug therapies often needed.
A) ACE Inhibitors or Angiotensin Receptor Blockers - first line if:
- < 55 yrs
- Diabetic
- Heart failure
- Left ventricular dysfunction

B) CCBs - first line if:

• 55 yrs
• Black
• NOTE: thiazide diuretics can be used if CCBs are not tolerated

C) Beta-Blockers

• Not preferred initial therapy
• May be considered in younger patients
• CAUTION: combining with thiazide diuretic may increase risk of developing diabetes
• May increase risk of heart failure

Alpha-Blockers

• 4th line
• May be used in patients with prostate disease

Question 9

How is target BP decided?

Answer 9

Non-Diabetic: < 140/90 mm Hg

Diabetes without proteinuria: < 130/80 mm Hg

Diabetes WITH proteinuria: < 125/75 mm Hg

Question 10

How is severe hypertension managed?

Answer 10

Severe Hypertension Management (Diastolic > 140 mm Hg)

• Atenolol
• Nifedipine

Question 11

How is acute malignant hypertension managed?

Answer 11

IV beta-blocker (e.g. esmolol)

Labetolol

Hydralazine sodium nitroprusside

CAUTION: avoid rapid lowering of blood pressure because it can cause cerebral infarction

• This is because the autoregulatory mechanisms within the brain for regulating blood flow will cause vasoconstriction of the vessels in the brain when blood pressure is very high
• Lowering the blood pressure too rapidly would mean that the autoregulatory mechanisms do not adapt to the drop in blood pressure and so the vessels remain constricted
• A rapid drop in blood pressure with constricted vessels will cause an infarction

Question 12

What are the possible complications of hypertension?

Answer 12

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 13

What is the prognosis for patients with hypertension?

Answer 13

Good prognosis if well controlled

Uncontrolled hypertension is associated with increased mortality

Treatment reduces incidence of renal damage, stroke and heart failure