Hypertension

Question 1

What is normal ambulatory BP reading?

Answer 1

< 135/85 during the day

< 120/75 at night

Question 2

Classify normal, mild, moderate, severe HTN

Answer 2

Normal: <140/90

Mild: <160/100

Moderate: <180/110

Severe: ≥180/110

Question 3

5 main complications of HTN? (i.e. end-organ damage)

Answer 3

Cardiovascular (LVH, HF, MI)

Cerebrovascular

Peripheral vascular

Renovascular (hypertensive nephropathy)

Hypertensive retinopathy

Question 4

Things to ask in “A” (associated/contributing factors)? - 5

(i.e. causes of secondary HTN)

Answer 4

Symptoms of secondary HTN

Phaeo: paroxysmal sweating, flushing, palpitations, headache

OSA: day time sleepiness, snoring

Acromegaly: change the ring / clothe size

Ask if they have RAS, Coartation (aorta) or Adrenal tumour (e.g. primary hyper-aldosteronism), Cushing’s

Question 5

Things to ask about in pricMcp?

Answer 5

Non-pharm: low-salt diet, exercise, weight loss, (CPAP for OSA), ETOH consumption

Pharm: medications

Question 6

What is your approach to investigating Hypertension?

Answer 6

Confirm dx

• ABP

Ivx for secondary causes/associations:

• Associations: HBA1C, cholesterol, serum glucose
• Conn’s: EUC for K+/Na+, ARR (look for high aldo:renin ratio)
• Cushing’s: morning urinary cortisol or 24 hour urinary cortisol
• Phaeo: urinary metanephrines, serum catecholamine
• OSA: collateral history, sleep study
• RAS: renal artery doppler / CT angiogram - if intractable HTN

Look for complications

• ECG (LVH, IHD), TTE (LV wall thickness, chamber size, diastolic function), CXR (cardiomegaly) - CVD
• EUC, urine for protein (UACR/UPCR) - RVD
• CTB - microvascular disease / previous stroke - Cerebrovascular
• ABPI +/- arterial doppler if ABPI abnormal (<0.8 or >1.4) - PVD

Question 7

Non-pharmacological Mx of Hypertension and what are their effectiveness? (5)

Answer 7

Say non-pharm Mx is crucial as they can reduce BP significantly - I will educate the patient on this, as well as complications associated with HTN

Weight reduction: 1 kg loss = 2 mmHg reduction in BP

Exercise: 30min, 5/week → BP reduction by 3-5 mmHg

Diet: salt reduction to 90mmol/day → ≥ 5mmHg reduction

Alcohol: reduction to 2 stds/day (men) or 1 std/day (women) → 5 mmHg reduction

Others include: Avoiding caffeine, Liquorice, CPAP for OSA

Question 8

What are the Goals of Mx? (what are you going to say to examiners)

Answer 8

The best BP for this patient is the lowest one that he/she can tolerate. I would weight up against the risk of falls.

The guidelines suggest that the target should be: 1) <125/75 (proteinuric), 2) <130/80 (if high risk - IHD, DM, CKD, CVA), 3) 140/90 (population).

Question 9

What is your approach to managing this patient with uncontrolled HTN despite 3-4 drugs?

Answer 9

Confirm adherence - if poor, what is the reason? Is it related to the…

• side Fx (consider switching/dose reduction)
• pill burden (combination regime)
• simply forget (phone reminders, single-dose regimen)
• Due to lack of understanding of controlling the BP (educate)

If there is no adherence issue

• Non-pharmacological Mx
• Investigate for secondary causes of HTN

Question 10

Side effects of ACEi/ARB? (4)

Answer 10

Hypotension (1st dose, postural)

Cough

Hyper-K

Angioedema

Question 11

Side effects of Thiazides? (4)

Answer 11

Gout

Hypercholesterolaemia

Hyperglycaemia

Thrombocytopaenia

Question 12

Side effects of beta-blockers? (4)

Answer 12

Bradycardia

Postural Hypotension

Exacerbates Raynaud’s / Cold hands/feets

Depression

Question 13

Side effects of CCBs? (3)

Answer 13

Headaches

Peripheral oedema

Flushing

Question 14

Patient with PVD on beta-blocker - thoughts?

Answer 14

Can exacerbate intermittent claudication. Consider switching if possible (it is a relative contraindication)

Question 15

Patient with diabetes on beta-blocker - thoughts?

Answer 15

Increased risk of hypoglycaemia unawareness due to blunted tachycardic effects

Question 16

Safe anti-hypertensives in pregnancy? (3)

Answer 16

Methydopa

Hydralazine

Labetolol

Severe HTN - use IV Hydralazine

Question 17

What are the features of hypertensive retinopathy? (mild-mod-sev)

Answer 17

Mild: Arteriolar narrowing, AV nipping, copper/silver wiring

Moderate: blot/dot/flame haemorrhages, cotton wool spots, microaneurysms, exudates

Severe: papilloedema

Question 18

Minoxidil 4 side effects

Answer 18

It is one of the most potent anti-hypertensive, used in resistant HTN

Side effects are…

Na/Water retention

Ankle oedema

Pericardial effusion (rare)

Hypertrichosis