Hypertension

Question 1

Define HTN

Answer 1

• Persistent elavation of BP
• >140/90 in clinic
• >135/85 with ABPM

Question 2

HTN is the most important risk factor for?

Answer 2

• premature death
• CVD

Question 3

What are the causes of HTN?

Answer 3

• Primary (essential) HTN - 95%
• Secondary HTN
• Malignant HTN
• White-coat HTN - high in clinic but normal in ABPM

Question 4

What are the common causes of Secondary HTN?

*use ROPE +Meds

Answer 4

• Renal disease (most common)
  
  • Intrinsic renal disease
    
    • CKD
    • Glomerulonephritis
  • Vascular
    
    • Renal artery stenosis
• Obesity
• Pregnancy
• Endocrine
  
  • Cushing’s
  • primary aldosteronism
  • Phaeochromocytoma
  • Acromegaly
• Meds
  
  • glucocorticoids, COCP, SSRIs, NSAIDs, EPO
• Coarctation of aorta in children

Question 5

What is malignant (accelerated phase) HTN?

Answer 5

• Rapid rise in BP causing vascular damage

Question 6

What are the hallmark signs of malignant HTN?

Answer 6

• Fibrinoid necrosis
• systolic >200, diastolic >130
• bilateral retinal haemorrhages
• exudates

Question 7

What are the sx for malignant HTN?

Answer 7

• headache
• visual disturbances

Question 8

What Ix would you have for HTN?

Answer 8

Bedside

• Observations
• Blood pressure
• Urinalysis
• Urinary protein creatinine ratio (uPCR)
• ECG
• Direct ophthalmoscopy

Bloods

• FBC
• U&Es
• Fasting glucose
• Cholesterol (CVS risk)
• HbA1c

Special tests

• Ambulatory BP monitoring (ABPM or HBPM)
• Renal USS
• Endocrine tests (e.g. aldosterone: renin ratio, if indicated)
• echo if LVH, valve disease, LVSD or diastolic dysfunction

Question 9

What are the Cx of HTN?

Answer 9

• IHD
• HF
• Stroke
• Retinopathy
• Nephropathy

Question 11

What are the features of hypertensive retinopathy?

Answer 11

• Flame haemorrhage
• Cotton wool spots
• Hard exudates
• Papilloedema

Question 12

What is the grading for hypertensive retinopathy?

Answer 12

Keith-Wagener Barker (KWB) grades

• Grade 1: Generalised arteriolar narrowing (silver wiring).
• Grade 2: Focal narrowing and arteriovenous nipping.
• Grade 3: Retinal haemorrhages, cotton wool spots (retinal nerve fibre layer micro-infarcts leading to exudation of axoplasmic materials).
• Grade 4: Papilloedema

Question 13

What device would you use to measure BP?

Answer 13

• sphygmomanometer

Question 15

What are the stages of HTN?

Answer 15

Question 16

What are the sx and signs of HTN?

Answer 16

Sx

• Palpitations
• Angina
• Headaches
• Blurred vision
• New neurology (e.g. limb weakness, paraesthesia)

Signs

• New neurology (e.g. limb weakness, paraesthesia)
• Retinopathy
• Cardiomegaly
• Arrhythmias
• Proteinuria

Question 17

What pt should you exclude underlying causes in HTN like presentation?

Answer 17

• Age < 40 years
• Reduced eGFR (suggestive of renal disease)
• Proteinuria or haematuria (suggestive of renal disease)
• Hypokalaemia and hypernatraemia (suggestive of Conn’s syndrome)
• Hypertension that is sudden onset, variable or worsening.

Question 18

How would you diagnosed HTN?

Answer 18

1. Clinic BP 140/90. Confirm with ABPM or
   
   • 2 measurements/hr on APBM during waking time. Average reading is used.
2. HBPM
   
   • ​​ two measurements a day (morning & evening) over a period of 4-7 days
   • reading of first day discarded. The other days will be used for average.

Question 19

What is the white coat HTN?

Answer 19

• discrepancy of > 20/10 mmHg between clinic and average ABPM/HBPM

Question 21

Describe the target BPs for 3 major categories.

Answer 21

1. Pt c low-moderate risk: <140
2. DM, Stroke/TIA, IHD, CKD: <130/80
3. >80: 140-150

All Diastolic BP target: <90

Except DM: <85

Question 22

What are the non pharmalogical mx for HTN?

Answer 22

• If BMI >25, weight reduction
  
  • every 1kg loss = 2mmHg drop
• Moderate salt intake
• Discourage excessive caffeine and alcohol
• offer smoking cessation advice

Question 23

What is the pharmacological mx for HTN?

Answer 23

Question 24

When should pt with stage 3 HTN be reffered for same day specialist assessment?

Answer 24

• New onset confusion
• Chest pain
• Signs of heart failure (e.g. shortness of breath, fluid overload)
• Acute kidney injury
• Papilloedema
• Retinal haemorrhage
• suspected phaeochromocytoma

Question 26

What is Hypertensive emergency?

Answer 26

• High BP resulting in irreversible end organ damage
• Eg: (encephalopathy, LV failure, Aortic dissection, Unstable angina, renal failure)

Question 27

How can HE present?

Answer 27

• Emergency
  
  • High BP + critical illness (encephalopathy, pulmonary oedema, AKI, MI)
• Urgency
  
  • High BP w/o critical illness

Question 28

What is Malignant HTN?

Answer 28

• BP >180/120 with signs of papilloedema and/or retinal haemorrhage

Question 29

How would you mx Hypertensive Emergencies?

Answer 29

• IV Nitroprusside (a nitric oxide releasing drug)
• labetalol
• glyceryl trinitrate infusions (1-10mg/hr)
• Esmolol
  
  • 0.5-1mg/kg loading dose over 1 min
  • 50ug/kg/min inc to 300ug/kg/min of infusion

Question 30

What is Hypertensive urgency?

Answer 30

• Severe BP elevation that will cause damage within days
• diastolic BP >130 + retinal changes

Question 31

How would you mx Hypertensive urgency?

Answer 31

• Amlodipine: 5-10mg OD
• Diltiazem: 120-300mg daily
• Lisinopril: 5mg OD

Question 32

What is the typical triad of Phaeochromocytoma?

Answer 32

• Sustained/paroxysmal HTN (most common)
• Headache
• Sweating
• Tachycardia