Hypertension (HTN)

Question 1

Definition of HTN

Answer 1

• Stage 1: Clinic BP >140/90 or HBPM ≥135/85
• Stage 2: Clinic BP >160/100 or HBPM ≥150/95
• Severe: Clinic BP >180/110
• Malignant: BP >180/110 + papilloedema and/or retinal haemorrhage
• Isolated SHT: SBP ≥140, DBP <90

Question 2

Aetiology of HTN (PREDICTION)

Answer 2

• Prediction
  
  • Primary: 95%
  • Renal: RAS, GN, APKD, PAN
  • Endo: ↑T4, Cushing’s, phaeo, acromegaly, Conn’s
  • Drugs: cocaine, NSAIDs, OCP
  • ICP ↑
  • CoA
  • Toxaemia of Pregnancy (PET)
  • Increased viscosity
  • Overload with fluid
  • Neurogenic: diffuse axonal injury, spinal section

Question 3

Aetiological Clues

Answer 3

• ↑HR: Thyrotoxicosis
• RF-delay: CoA
• Renal bruits: RAS
• Palpable kidneys: APKD
• Paroxysmal headache, tachycardia, sweating, palpitations, labile or postural hypotension: Pheochromocytoma

Question 4

Signs and Symptoms of HTN

Answer 4

• Signs/symptoms include BP >140/90 mmHg and retinopathy.
• Risk factors include obesity, low exercise, high alcohol intake, metabolic syndrome, diabetes, black ancestry, age >60 years, FHx of HTN or CAD and sleep apnoea.

Question 5

Investigation of HTN

Answer 5

• 12-lead ECG
  
  • May show evidence of LVH or old infarction
• Fasting metabolic panel
  
  • May show renal insufficiency
  • Hyperglycaemia
  • Hypokalaemia
  • Hyperuricaemia
  • Hypercalcaemia
• Fasting lipid panel
  
  • High LDL
  • Low HDL
  • High triglycerides
• Urinalysis
  
  • Proteinuria
• Hb
  
  • Anaemia
  • Polycythaemia
• TSH
  
  • High or low if thyroid dysfunction
• Fundoscopy
  
  • Hypertensive retinopathy

Question 6

Management of HTN

Answer 6

• Lifestyle modifications (i.e. smoking cessation, dietary modification, increased exercise)
• CV risk management with statins
• NB - In diabetic patients always start with ACE-I

Question 7

Complications of HTN

Answer 7

• CAD
• CVA
• LCH
• CHF
• Retinopathy
• PVD
• CKD
• Aortic dissection
• Malignant HTN

Question 8

Treatment Targets

Answer 8

• < 80 years - Clinic BP 140/90 or HBPM 135/85
• ≥ 80 years - Clinic BP 150/90 or HBPM 145/85
• T1DM - Clinic BP 135/85 unless albuminuria or 2 or more features of metabolic syndrome in which case 130/80
• T2DM - Clinic BP 140/90 for <80 years and 150/90 for >80 years. SIGN recommend clinic BP 130/80.

Question 9

Secondary Causes

Answer 9

• Renal
  
  • GN
  • Pyelonephritis
  • APKD
  • Renal artery stenosis
• Endocrine
  
  • Phaeochromocytoma
  • Cushing’s syndrome
  • Conn’s syndrome
  • Thyroid dysfunction
  • Hypoparathyroidism
  • Liddle’s syndrome
  • Congenital adrenal hyperplasia
  • Acromegaly
• Drugs
  
  • Steroids
  • Monoamine oxidase inhibitors
  • COCP
  • NSAIDs
  • Leflunomide
• Other
  
  • Pregnancy
  • Coarctation of the aorta
  • Obstructive sleep apnoea