Hypertension

Question 1

How would you define stage 1 hypertension?

Answer 1

> 140/90 or home monitoring blood pressure is an average of 135/85mmHg or higher.

Question 2

How would you define stage 2 hypertension?

Answer 2

> 160/100 or home monitoring blood pressure is an average of 150/95mmHg or higher

Question 3

How would you define severe hypertension?

Answer 3

Clinica systolic BP is 180mmHg or higher and diastolic BP is 110mmHg or higher.

Question 4

When should treatment be commenced immediately in hypertension?

Answer 4

If the patient has severe hypertension

Question 5

What symptoms might you find in a hypertensive patient?

Answer 5

1) Nil or headache
2) Sweating, headache, palpitations and anxiety may point towards a phaeochromocytoma
3) Muscle weakness or tetany may point towards hyperaldosteronism

Question 6

What additional investigations would you like to carry out for a hypertensive patient?

Answer 6

1) Urine analysis: dipstick to look for blood and protein. Albumin: creatinine ratio.
2) Blood analysis: U+E, glucose, lipids.
3) ECG
4) Opthalmoscopy to look for hypertensive retinopathy
5) Consider Echo to look at cardiac health.

Question 7

When should pharmacological management be offered to hypertensive patients?

Answer 7

In patients who have stage 2 hypertension.

Or stage 1 hypertension with end organ damage

Or stage 1 hypertension under the age of 80y/o

Question 8

What lifestyle advice can be given to a hypertensive patient?

Answer 8

1) Weight loss

2) Reduce salt intake

Question 9

How would you define a hypertensive emergency?

Answer 9

A patient who presents with an increase in blood pressure that if sustained over the next few hours will lead to irreversible end-organ damage.

Question 10

What is hypertensive urgency?

Answer 10

Patients with hypertension without a critical illness but may include malignant hypertension which is associated with a grade 3/grade 4 hypertensive retinopathy.

Question 11

What would the treatment target be in patients with hypertensive emergency and urgency?

Answer 11

Emergency - reduce the blood pressure to a diastolic pressure of 110mmHg in 3-12 hours

Urgency - reduce the blood pressure to a diastolic pressure of 100mmHg in 48-72 hours with an oral regime.

Question 12

How would you treat a hypertensive emergency?

Answer 12

1) IV Sodium nitroprusside
2) IV labetalol
3) GTN - 1-10mg/hr
4) Esmolol

Question 13

How would you treat hypertensive urgency?

Answer 13

A combination of an ACEi and CCB is effective and well tolerated.

best treatment option is Nifedipine 20mg BD and Amplodipine 10mg OD for three days with just Amlodipine after this.

Question 14

What is the classic triad of symptoms in a patient with a phaeochromocytoma?

Answer 14

Headaches, sweating and tachycardia

Question 15

How would you diagnose a phaeochromocytoma?

Answer 15

Urinary and plasma fractionated metenephrines and catecholamines.

You can also do an abdomen and pelvis CT or MRI to look for adrenal tumours.

Question 16

How would you manage a patient with a phaeochromocytoma?

Answer 16

Alpha and beta adrenergic blockade. Phenoxybenzamine is commonly used.

Once alpha blockade has been achieved you start a beta blocker usually around 3 days before the surgery.

Question 17

How would you diagnose Cushings syndrome?

Answer 17

This can be done via a clinical diagnosis alongside hyperglycaemia.

The excreted cortisol levels in the urine will be 3x above the level of normal

Diagnosis can be confirmed with a dexamethasone suppression test. Adrenal CT is indicated to look for a tumour.

Question 18

When would you suspect primary aldosteronism as the underlying cause of hypertension?

Answer 18

If the patient was suffering with tetany.

Bloods would show hypokalaemia and hypernatraemia or potentially a normal sodium level.

Aldosterone: renin ratio should be measured in the morning.