JC10 (Medicine) - Hypertension Flashcards by Max Kam

Etiologies of Hypertension

Essential hypertension (95%):
→ Environmental: high salt intake, heavy alcohol consumption, obesity, lack of exercise, IUGR
→ Genetics

Secondary hypertension (5%): distinct, identifiable cause

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Pathogenesis of hypertension

Mechanism: complex interplay between neurohormonal mechanisms

Young patients: predominantly ↑SN and ↑RAAS activities → ↑SVR ↑CO
Elderly patients: predominantly arterial degeneration → ↑SVR

Chronic hypertension causes target organ damage (TOD) in heart, brain, kidneys, vessels

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3 methods of BP monitoring/ diagnosis

Office BP: Average of three readings, risk of masked HTN and White-coat hypertension

Home BP monitoring (HBPM): better adherence and correlation with prognosis

Ambulatory BP monitoring (ABPM): better accuracy and correlation with prognosis

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Diagnosis of white-coat hypertension, masked hypertension and true hypertension

High office BP but normal ABPM/HBPM - white coat hypertension
High office BP and high ABPM/HBPM - True hypertension
Normal office BP but high ABPM/HBPM - Masked Hypertension

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Cut-off BP for hypertension stages

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Diagnosis of true hypertension

□ Hypertensive crisis, i.e. >180/120
□ Evidence of Target organ damage (TOD) + High BP (≥160/100)
□ High office BP (≥130/80) confirmed by HBPM/ABPM

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Presentation of hypertension

□ Asymptomatic (incidental finding)
□ ↑BP: headache, dizziness, palpitations, easy fatigability, impotence
□ HTN vascular disease: epistaxis, haematuria, blurring of vision, episodes of weakness/dizziness, angina, dyspnoea
□ S/S of 2o cause

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Risk factors of cardiovascular disease

Previous history of CVD

HTN

Low HDL-C <1 mmol/L

Smoking

Age: ≥45y (M) or ≥55y (F)

Premature CHD in first degree relatives

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Outline history taking questions for hypertension

□ Age: consider 2oHTN <35y or >55y
□ Duration of HTN and previous BP levels
□ Family Hx of HTN: essential HTN
□ Other risk factors: smoking, DM, lipid disorders, FHx of early CVD deaths
□ Lifestyle: diet, physical activity, family status, work

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Outline physical exams for hypertension

□ BP/P: bilateral arms, supine and standing
□ BMI and waist circumference
□ CVS: standard + palpation/auscultation of all peripheral arteries
□ Fundus

Target organ damage (see pic)

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First-line investigations for hypertension

Blood:
→ RFT and electrolytes: baseline renal function test, r/o renal parenchymal disease,
→ Hormone: hyperAldosteronmism and hyperPTH
→ Lipid profile for dyslipidemia
→ Serum fasting glucose: r/o DM
→ ± serum urate: baseline and look for hyperuricaemia

Urinalysis: haematuria (r/o renal disease), UACR (albuminuria)

ECG: LVH, MI, cardiac failure, heart block

Echocardiogram: for LVH

Calculation of 10y CVD risk

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Causes of secondary hypertension

Aetiology: DANCER
□ Drugs
□ Apnoea
□ Neurological: ↑ICP, stress, others
□ Coarctation of aorta

□ Endocrine:
→ Thyroid: hyperthyroidism, hypothyroidism
→ Adrenals: Cushing’s, Conn’s, phaeochromocytoma
→ Parathyroid: hyperparathyroidism
→ Others: pre-eclampsia, acromegaly

□ Renal:
→ Renal vascular: renal artery stenosis (RAS)
→ Renal parenchymal: GN, polycystic kidney, kidney failure

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List drugs that can cause secondary hypertension

SN-related/ psychiatric: caffeine, amphetamines/ cocaine, levodopa, MAOI, antidepressants, decongestants

Fluid retention: OCP, anabolic steroids, mineralocorticoids, corticosteroids

Immunosuppressants (cyclosporine)

NSAIDs, COX-2 inhibitors

Alcohol, nicotine

Anti-cancer: chemotherapy, angiogenesis inhibitor, TKIs

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Indicators of secondary hypertension

General:
→ Age of onset: <30y or diastolic HTN for ≥65y
→ Severity: accelerated or malignant HTN, disproportionate TOD for degree of HTN
→ Course: abrupt onset, drug-resistant or exacerbation of previously controlled HTN

Specific:

Unprovoked or excessive hypoK (thiazide diuretics use)
Renal HTN: palpable kidney, renal bruit, abnormal urinalysis
Endocrine: S/S of phaeochromocytoma, unexplained hypoK, signs of Cushing’s sundrome
Coarctation: radiofemoral delay

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primary aldosteronism and secondary hypertension

Clinical features
Indications for screening
Screening tests

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Renal artery stenosis and secondary HTN

Clinical features
Indications for screening
Screening tests

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Renal parenchymal disease and secondary HTN

Clinical features
Indications for screening
Screening tests

OSA and secondary hypertension

Clinical features
Indications for screening
Screening tests

Coarctation of aorta and secondary HTN

Clinical features
Indications for screening
Screening tests

Pheochromocytoma and secondary HTN

Clinical features
Indications for screening
Screening tests

Cushing’s disease and secondary HTN

Clinical features
Indications for screening
Screening tests

List all major target organs damaged by Hypertension

Vessels: Aorta, carotid arteries, peripheral arteries, coronary arteries… etc

Heart: Ventricles, Coronary arteries

Kidneys: renal vessels, tubules

Brain: Cerebral vessels, cerebral edema

Retina

List cardiovascular damage caused by hypertension

List renal and retinal damage caused by hypertension

Renal: Hypertensive nephrosclerosis, Hypertensive nephropathy

Retina: Hypertensive retinopathy, central retinal vein occlusion and blindness

List cerebral damages caused by hypertension

TIA due to carotid atherosclerosis Stroke due to small vessel hyalinosis or intracerebral haemorrhage from microaneurysms HT encephalopathy due to cerebral edema

Stages of hypertensive retinopathy

Treatment options for hypertension

Treatment options for hypertension ***

Lifestyle modifications: - Weight reduction - Diet: Low sodium, Low fat, High fruit/ vegetables, High K, DASH diet - Exercise: 30min/day - Alcohol: moderation ≤2 (M) or ≤1 (F) drinks/day Medical therapy: Change dose/ combination therapy accordingly - First line: ACEI/ARB, CCB, thiazide diuretic (+/- BB) - Second line: Alpha blocker, Aldosterone antagonist or vasodilator - Adjunctive drugs: Aspirin (lower CVD risk), Statins (hyperlipidemia) - Substitute drugs: Methyldopa, hydralazine for pregnancy; Loop diuretics for CKD Compelling indications: DM, CKD, CAD, LV dysfunction, Ischemic stroke

Resistant HTN - Definition - Diagnosis

Definition: - Poor HTN control under 3 antihypertensive with 1 diuretic - HTN only controlled by ≥4 drugs ``` Diagnosis: Exclude pseudoresistance: → Adherence → Timing of drugs → Home and ambulatory BP → Exclude secondary hypertension → Identify confounding factors: diet, obesity, drugs ```

Resistant HTN - Treatment

Increase dosage of existing therapy Use second-line drugs: Aldosterone blockers, Loop diuretics Alter combination of therapy

Malignant hypertension - Clinical features

ABCDEF: - Azotemia - BP ≥220/120 - Cardiac failure - Distress - Encephalopathy - Fundus Clinical presentation: ↑BP + rapidly progressive TOD □ Retina: papilloedema, retinal haemorrhages and exudates □ HTN encephalopathy: severe headache, vomiting, visual disturbances, transient paralyses, convulsions, stupor and coma □ Heart: acute LV failure □ Kidneys: acute RF with oliguria, proteinuria

Malignant hypertension - Mechanism

Mechanism: accelerated microvascular damage including □ Fibrinoid necrosis in small vessel wall □ Intravascular thrombosis

Differentiate hypertensive emergency with hypertensive urgency

Hypertensive emergency (i.e. with TOD) - BP >180/120 + worsening/new TOD - Indication for acute BP control - e.g. aortic dissection, pheochromocytoma, eclampsia Hypertensive urgency (i.e. no TOD) - Malignant HTN without TOD - HT with grade III or IV retinal changes - e.g. Hypertension with pre-op/ perioperative bleeding, Hypertension complicated by pregnancy, AMI, unstable angina - e.g. Catecholamine excess or sympathomimetic overdose

First-line investigations for malignant hypertension

Ix: - CBC, - L/RFT, - cardiac enzymes, - aPTT/PT, - CXR, ECG, - urine RBC/albumin Confirm BP twice, BP/P Q1H Intra-arterial BP monitoring

Treatment of malignant hypertension | - HTN emergency and HTN urgency

HTN emergency: - IV Labetalol - Sodium nitroprusside - Hydralazine - Phentolamine HTN urgency: - Oral antihypertensive: ACBD

Specific treatment for malignant hypertension associated with following conditions Acute Pulmonary edema Angina/ AMI Aortic dissection

Acute pulmonary edema: Nitroprusside/nitroglycerin + loop diuretic Angina/AMI: Nitroglycerin, nitroprusside, labetalol, calcium channel blocker Aortic dissection: Labetalol/propranolol IV + nitroprusside

Treatment of malignant hypertension during pregnancy

IV hydralazine, nicardipine, labetalol

Advantages and disadvantages of ABPM and HBPM

ABCDE acronym for cause of HTN

Investigations for target organ damage due to hypertension

Indications for emergency BP reduction with IV treatments