Hypertension

Question 1

Define Hypertension

Answer 1

SBP >140 and/or diastolic >90 measured on 3 separate occasions

Question 2

Define malignant hypertension

Answer 2

> 200/130

Question 3

Aetiology of hypertension

Answer 3

Primary: essential/idiopathic (90%)

Secondary:
Renal (RAS | glomerulonephritis | pyelonephritis | PKD | renal failure)

Endocrine (DM | Cushing’s | Conn’s | HyperPTH | phaeo | congenital adrenal hyperplasia | acromegaly)

Drugs ( sympathomimetics | corticosteroids | OCP)

Cardiovascular (aortic coarctation | Increased intravascular volume)

Pregnancy

Question 4

Risk factors for Hypertension

Answer 4

Obesity 
Aerobic exercise < 3x a week
Alcohol intake 
Metabolic syndromes
DM 
Black ancestry 
>60 
FMHx CAD 
Sleep apnoea
High sodium intake

Question 5

Epidemiology of Hypertension

Answer 5

Very common - estimated 1 billion
12-20% adults in the Western world
Incidence increases with age

Question 6

Symptoms of Hypertension

Answer 6

Asymptomatic, unless there is another condition

Question 7

Symptoms of malignancy hypertension

Answer 7

Scotomas (visual field loss)
Blurred vision
Headache
Seizures
Nausea + vomiting 
Acute heart failure

Question 8

Signs of Hypertension on examination

Answer 8

Retinopathy on fundoscopy 
S4 
Sensory or motor deficit 
BP high on 3 different occasions
Heaves
Bruits

Question 9

What are the stages of hypertensive retinopathy

Answer 9

Grade I - silver wiring
Grade II - Silver wiring + AV nipping
Grade III - Flame haemorrhages (± cotton wool spots)
Grade IV - papilloedema

Question 10

Investigations for Hypertension

Answer 10

BP x3 (sitting + standing) in BOTH arms
=> Ambulatory blood pressure monitoring

Calculate QRISK2 score for CVS risk
Investigations for cause: U+Es (renal function, Conn’s)
Glucose
FBC (polycythaemia)
Urinalysis
ECG (LVH signs: deep S wave V2, tall R wave V5 | Inverted T waves)

Question 11

Management for Hypertension

Answer 11

Conservative: stop smoking, weight loss, reduce alcohol and dietary sodium intake

Treat secondary causes

<55 of non-Afro-Caribbean

1. ACEi / ARB
2. ACEi/ARB + CCB
3. ACEi/ARB + CCB + TLD
4. K+ >4.5: Beta blocker / alpha blocker
5. K+ <4.5: spironolactone

> 55 and Afro-Caribbean

1. CCB
2. CCB + ACEi/ARB
3. ACEi/ARB + CCB + TLD
4. K+ >4.5: Beta blocker / alpha blocker
5. K+ <4.5: spironolactone

Diabetic: ACEi first line

Question 12

Management for severe hypertension

Answer 12

Atenolol or nifedipine

Question 13

Management for acute malignant hypertension

Answer 13

IV labetalol (beta blocker) or hydralazine sodium nitroprusside (more effective) + urgent referral

Question 14

Complications of Hypertension

Answer 14

Congestive heart failure 
Retinopathy 
MI 
CAD 
CVA 
Peripheral vascular disease
Emboli - stroke, PE
Renal failure 
Encephalopathy

Question 15

Prognosis for hypertension

Answer 15

Good if BP is controlled
Uncontrolled - increased mortality (6x stroke risk, 3x cardiac death risk)
Major risk factor for cardiac, vascular, renal and cerebrovascular disease