Hypertension

Question 1

What are the stages of hypertension?

Answer 1

Stage 1:
Clinic reading of >140/90
24hr ambulatory reading of >135/85

Stage 2:
Clinic reading of >160/100
24hr ambulatory reading of >150/95

Stage 3 (severe hypertension):
Clinic reading of >180/120

Question 2

What are the secondary causes of hypertension?

Answer 2

Renal disease such as:
Glomerulonephritis
Pyelonephritis
Adult polycystic kidney disease
Renal artery stenosis

Majority of endocrine disorders such as:
Primary hyperaldosteronism
Phaeochromocytoma
Cushing's syndrome
Liddle's syndrome
Congenital adrenal hyperplasia
Acromegaly

Drug causes:
Steroids
Monoamine oxidase inhibitors
Combined oral contraceptive pill 
NSAIDs
leflunomide (a DMARD)

Other causes include:
Pregnancy
Coarctation of the aorta

Question 3

What investigations for end organ damage should a newly diagnosed hypertension patient have?

Answer 3

Bloods - HbA1c, renal function and lipids

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

Fundus examination - for hypertensive retinopathy

ECG - for cardiac abnormalities

Question 4

What medication is given to hypertensive patient?

Answer 4

A - ACE inhibitor e.g. ramipril 1.25mg to 10mg OD
B - Beta blocker e.g. bisoprolol 5mg to 20mg OD
C - Calcium channel blocker e.g. amlodipine 5mg to 10mg OD
D - Thiazide-like diuretics e.g. indapamide 2.5mg OD
ARB - e.g. candesartan 8mg to 32mg OD

Use ARB instead if ACE inhibitor causing dry cough or if patient is black

Question 5

What group of patients are offered hypertension medication?

Answer 5

All patients with stage 2 hypertension

All patients <80 years old with stage 1 hypertension that also have QRISK score of 10% or more, diabetes, renal disease, cardiovascular disease or end organ damage

Question 6

What are the steps for hypertension medication?

Answer 6

Step 1:
If <55 years old = A
If >55 years old or black of African-carribbean descent = C

Step 2:
A+C or A+D or C+D
If black, use an ARB instead of A

Step 3:
A+C+D

Step 4:
A+C+D+additional

Additional include:
If K+ <=4.5, add low dose spironolactone
If K+ >4.5, add alpha- or beta-blocker

Question 7

What lifestyle advice should be given to patient with hypertension?

Answer 7

Low salt diet
Reduce caffeine intake
Stop smoking
Reduce alcohol intake
Balanced diet with fruit and veg
Exercise
Lose weight

Question 8

What bloods need to be monitored when using ACE inhibitors and diuretics?

Answer 8

U&Es as ACE inhibitors can cause hyperkalaemia and thiazide diuretics can cause hypokalaemia

Question 9

What are some of the causes of hypokalaemia associated with hypertension?

Answer 9

Cushing’s syndrome
Conn’s syndrome (primary hyperaldosteronism)
Liddle’s syndrome
11-beta hydroxylase deficiency

Question 10

What are some of the causes of hypokalaemia NOT with hypertension?

Answer 10

Diuretics
GI loss e.g. diarrhoea and vomiting
Type 1 and type 2 renal tubular acidosis (type 4 is associated with HYPERkalaemia)
Bartter's syndrome
Gitelman syndrome

Question 11

What is the management for hypertension in patients with Diabetes?

Answer 11

1st line = ACE inhibitors as they have renoprotective effects in diabetes

African-caribbean patients should be given ACE inhibitor with thiazide diuretic or calcium channel blocker