Hypertension

Question 1

Define

Answer 1

DEFINITION: systolic > 140 mm Hg and/or diastolic > 90 mm Hg measured on three separate occasions.

Malignant Hypertension: BP > 200/130 mm Hg

Question 2

Epidemiology

Answer 2

VERY COMMON

10-20% of adults in the Western world

Question 3

Causes

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

Symptoms

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

Signs

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

Question 6

Investigation

Answer 6

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 7

Management

Answer 7

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.

ACE Inhibitors or Angiotensin Receptor Blockers - first line if:

< 55 yrs

Diabetic

Heart failure

Left ventricular dysfunction

CCBs - first line if:

> 55 yrs

Black

NOTE: thiazide diuretics can be used if CCBs are not tolerated

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 8

Prognosis

Answer 8

Good prognosis if well controlled

Uncontrolled hypertension is associated with increased mortality

Treatment reduces incidence of renal damage, stroke and heart failure

Question 9

Complication

Answer 9

Heart failure

Coronary artery disease

Cerebrovascular accidents

Peripheral vascular disease

Emboli

Hypertensive retinopathy

Renal failure

Hypertensive encephalopathy

Posterior reversible encephalopathy syndrome (PRES)

Malignant hypertension