Hypertension

Question 1

Degrees of hypertension.

Answer 1

Stage 1

Stage 2

Severe

Question 2

Stage 1 hypertension

Answer 2

Clinic 140/90 or higher

Ambulatory or home BP of 135/85 or higher

Question 3

Stage 2 hypertension

Answer 3

Clinic 160/100 or higher

Ambulatory or home 150/95 or higher

Question 4

Severe hypertension

Answer 4

Clinic 180 mmHg or higher, or a clinic diastolic blood pressure of 120 mmHg or higher.

This is called malignant hypertension

Refer for same-day specialist assessment if the person has:

A clinic blood pressure of 180/120 mmHg and higher with:

Signs of retinal haemorrhage and/or papilloedema (accelerated hypertension) or

Life-threatening symptoms, such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury.

Question 5

When should ambulatory monitoring of BP be offered?

Answer 5

When BP is over 140/90

Question 6

Explain ambulatory BP.

Answer 6

Discontinuously measures BP over 24 hours.
Most commonly every 20-30 minutes during waking hours and every 30-60 minutes during sleep.

Question 7

Symptoms of hypertension.

Answer 7

Usually asymptomatic.

Can have a headache.

Rarely have epistaxis, visual disturbances and dizziness.

Question 8

What does hypertension with sweating, headache and anxiety suggest?

Answer 8

Phaeochromocytoma

Question 9

What does hypertension with muscle weakness and tetany suggest?

Answer 9

Hyperaldosteronism

Question 10

What increases the CVS risk along with hypertension?

Answer 10

TIA, stroke, diabetes, previous renal disease, smoking, cholesterol and NSAIDs excess.

History of angina, CCF, palpitations, syncope and valvular heart disease.

FH of hypertension, premature coronary disease and PCK (polycystic kidney disease)

Drug history of any prior anti-hypertensive therapy and details of drug intolerances.

Question 11

Physical examination of hypertension.

Answer 11

Look for secondary causes such as Cushing’s syndrome, enlarged kidneys in PCK, renal bruits and radio-femoral delay (coarctation).

Out of office BP

Asymptomatic organ damage of eyes, kidneys and heart

ECG

Estimation of total cardiovascular risk.

Question 12

Investigations of hypertension.

Answer 12

Presence of protein in urine

Albumin:creatinine ratio

Haematuria

Plasma glucose, electrolytes, creatinine, eGFR, cholesterol, HDL cholesterol.

Fundoscopy

ECG

Consider echocardiography if suggestion of LVH, valve disease or LVSD or diastolic dysfunction.

Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage

Bloods for HbA1c, renal function and lipids

Fundus examination for hypertensive retinopathy

ECG for cardiac abnormalities

Question 13

While waiting for confirmation of hypertension, what should be assessed?

Answer 13

Cardiovascular risk by QRISK or jbs3risk.

Question 14

Which patients should receive treatment when diagnosed with stage 1 hypertension?

Answer 14

Evidence of target organ damage

Established cardiovascular disease

Renal impairment

Diabetes

10 year risk >10%

Question 15

Which patients should receive treatment in stage 2 hypertension?

Answer 15

Any age

Any person

Question 16

Give examples of drugs that can raise BP.

Answer 16

Alcohol

Stimulants

COCP

NSAIDs

Corticosteroids

Calcineurin inhibitors

VEGFi

Antidepressants

Question 17

What is the target BP in low-moderate risk?

Answer 17

< 140 mmHg

Question 18

What is the target BP in diabetes, previous stroke/TIA and CKD?

Answer 18

< 130/80

Question 19

What is the target BP in elderly less than 80 with systolic > 160?

Answer 19

140-150 mmHg but if less is tolerated aim for that.

Question 20

Target BP in over 80 yo.

Answer 20

Less than 150/90.

If less is tolerated then shoot, however be careful.

Question 21

What is the diastolic target BP?

Answer 21

< 90 mmHg

Unless diabetic < 85 mmHg.

Question 22

Non-pharma treatment of hypertension.

Answer 22

Weight reduction if BMI > 25

Moderate salt intake

Minimise alcohol intake

Aerobic exercise

Smoking cessation.

Question 23

Who should receive pharmacological treatment?

Answer 23

Question 24

Treatment algorithm of hypertension.

Answer 24

1st Offer an ACE inhibitor or an ARB (do not combine) to adults

• type 2 diabetes and are of any age or family origin
• are aged under 55 but not of black African or African–Caribbean family origin.

1st CCB to adults

• aged 55 or over and do not have type 2 diabetes or
• of black African or African–Caribbean family origin and do not have type 2 diabetes.

2 - If ACE/ARB is not enough in step 1 add…
a CCB or
a thiazide-like diuretic.

2 - If CCB is not enough in step 1 add…
an ACE inhibitor or
an ARB or
a thiazide-like diuretic.

Question 25

Step 3 treatment of hypertension.

Answer 25

First off review maximal tolerated dose and discuss adherence.

If hypertension is still not controlled in step 2 add…

an ACE inhibitor or ARB and

a CCB and

a thiazide-like diuretic

Question 26

Step 4 treatment of hypertension.

Answer 26

This is called resistant hypertension.

Confirm ambulatory hypertension, discuss adherence and assess for postural hypotension.

If still not enough add…

spironolactone (<4.5 K+) or alpha or beta-blocker (>4.5 K+) to existing treatment.

Question 27

Causes of secondary hypertension.

Answer 27

Divided into renal, neural, vascular and endocrine.

Glomerulonephritis, polyarteritis nodosa, systemic sclerosis, PCK, renal artery stenosis.

Cushings, hyperaldosteronism, phaeochromocytoma, acromegaly, hyperparathyroidism, hyperthyroidism

Coarctation, pregnancy, liquorice, drugs.

Question 28

What is white coat hypertension?

Answer 28

Elevated in clinic BP.

Should not be treated but has a risk of developing into hypertension.

Question 29

How is hypertensive retinopathy graded?

Answer 29

1 - Tortuous arteries with thick shiny walls

2 - AV nipping

3 - flame hamorrhages, cotton-wool spots and fibrin exudate.

4 - Papilloedema

Question 30

What is an hypertensive crisis?

Answer 30

Increase in BP sustained over the next few hours that leads to irreversible end-organ damage.

Question 31

Give examples of end organ damage in hypertensive crisis.

Answer 31

Encephalopathy

LV failure

Aortic dissection

Unstable angina

Renal failure

Question 32

What are emergency hypertensive crises?

Answer 32

High BP with a critical event such as encephalopathy, pulmonary oedema, AKI or myocardial ischaemia.

Question 33

What are urgency hypertensive crises?

Answer 33

High BP without critical illness.

It may include malignant hypertension associated with grade 3/4 hypertensive retinopathy.

Question 34

What is the aim of emergency hypertensive crisis?

Answer 34

Reduce diastolic BP to 110 mmHg in 3-12 hours.

Question 35

What is the aim of urgency hypertensive crisis?

Answer 35

Reduce diastolic BP to 110 mmHg in 24 hours.

Question 36

Treatment in hypertensive emergency.

Answer 36

IV to start:

1 - Sodium nitroprusside

2 - Labetalol

3 - GTN (1-10 mg/hr)

4 - Esmolol which acts within 60 seconds and a duration of 10-20 minutes. Drug is usually given 0.5-1mg/kg loading dose over 1 minute and then 50mcg/kg/min increasing up to 300mch/kg/min as necessary.

Question 37

Treatment of hypertensive urgency.

Answer 37

An oral regime to reduce diastolic to 100-110 over 48-72 hours.

Amlodipine 5-10 mg OD or diltiazem 120-300mg OD, or lisonopril 5 mg OD etc…

A combination of ACEi and calcium antagonist is effective and well tolertaed.

Most effective treatment in majority of patients is nifedipine 20 mg MR BD and amlodipine 10 mg OD for three days and then continue with amlodipine 10 mg OD thereafter.

Question 38

Classic triad of symptoms in phaeochromocytoma.

Answer 38

Headache

Sweating

Tachycardia

Sustain or paroxysmal hypertension.

Question 39

Diagnosis of phaeochromocytoma.

Answer 39

Urinary and plasma fractionated metanephrines and catecholamines.

24 hour urine collection is the main test.

CT or MRI scan of the abdomen and pelvis for adrenal tumours.

MIBG scan if tumours are not detected by CT/MRI.

Question 40

Treatment of phaeochromocytoma.

Answer 40

All should undergo resection.

While waiting for surgery they should be started on alpha blockers (if not tolerated then CCB nicardipine can be used) of phenoxybenzamine 10 mg OD/BD and then increased to 20mg to control BP and increasingly. Last phenoxybenzamine dose is usually around 20-100 mg.

After adequate alpha blockade has been achieved, beta-blockade should be initiated. This usually occurs two to three days before operation. Beta-blocker should never be started first.

Question 41

Diagnosis of primary adolsteronism.

Answer 41

Low serum potassium and high/normal sodium.

In up to 50% however the potassium is normal.

Aldosterone:renin ratio is measured in the morning.

Renin should be low or undetectable and plasma aldosterone very high.

Ratio is usually >20-30.

Adrenal CT should be done as well.

Question 42

Secondary causes of hypertension.

Answer 42

R – Renal disease. This is the most common cause of secondary hypertension. If the blood pressure is very high or does not respond to treatment consider renal artery stenosis.

O – Obesity

P – Pregnancy induced hypertension / pre-eclampsia

E – Endocrine. Most endocrine conditions can cause hypertension but primarily consider hyperaldosteronism (“Conns syndrome”) as this may represent 2.5% of new hypertension. A simple test for this is a renin:aldosterone ratio blood test.