Systemic hypertension

Question 1

Define hypertension

Answer 1

BP equal or greater than 140/90

Question 2

What is the diagnostic criteria for orthostatic hypertension?

Answer 2

A drop in either, after standing for three minutes:

• SBP of 20+ mmHg
• DBP of 10+ mmHg

Question 3

List five causes of hypertension

Answer 3

• Essential hypertension: Unknown cause
• Secondary hypertension:
  
  • Renal artery stenosis, renal parenchymal disease ^eg. ADPKD
  • Conn’s syndrome, Phaechromocytoma, Hyperthyroidism, Cushing’s syndrome, Acromegaly
  • Coarctation of aorta, pregnancy, exogenous steroids, MAOi (tyramine)

Question 4

How is hypertension diagnosed?

Answer 4

• Initial BP ≥140/90 mmHg is offered Ambulatory BP monitoring (ABPM)
  
  • Home BP monitoring can also be used.
• HTN if both:
  
  • Clinic BP is ≥140/90 mmHg
  • Daytime average ABPM is ≥135/85 mmHg

Question 5

Describe the stages of hypertension

Answer 5

1. Clinic BP 140/90+, and Daytime average ABPM 135/85+
2. Clinic BP 160/100+, and Daytime average ABPM 150/95+
3. [Severe] Clinic SBP 180+, or Clinic DBP 110+

Question 6

Provide three examples of target organ damage in hypertension

Answer 6

• Blood vessel: Atherosclerosis, aneurysm, aortic dissection
• CKD: Haematuria, uraemia, proteinaemia
• Heart failure: Pulmonary oedema, MI, LV hypertrophy
• CVA: Haemorrhage/infarction, seizures, vascular dementia
• Hypertensive retinopathy

Question 7

Request three investigations whilst awaiting ABPM/HBPM results for hypertension?

Answer 7

Investigations for target organ damage:

• Urinalysis: protein, ACR, haematuria
• Bloods: glucose, electrolytes, creatinine, eGFR, total and HDL cholesterol
• Fundoscopy: hypertensive retinopathy
• 12-lead ECG: LV hypertrophy
• QRISK2

Question 8

Which patients should be referred to specialist care on the same day?

Answer 8

• Accelerated HTN: BP >180/110 with papilloedema and/or retinal haemorrhage
• Phaechromocytoma: HTN, headaches, palpitations, pallor, sweating, postural hypotension

Question 9

Outline the classification of hypertensive retinopathy

Answer 9

1. Tortuous arteries with increased reflectiveness (silver wiring)
2. Grade I + AV nipping
3. Grade II + Flame haemorrhages and cotton wool spots
4. Grade III + Papilloedema (blurred optic disc margin)

Question 10

Give four lifestyle modifications for the management of hypertension

Answer 10

• Low salt diet
• Low alcohol and caffeine intake
• Smoking cessation
• Exercise; weight control
• Minimise stress.

Question 11

What are the indications for starting antihypertensives?

Answer 11

• Stage 1 HTN if <80yr with any of:
  
  • Target organ damage
  • CVD
  • Renal disease
  • Diabetes
  • 10-year CVD risk ≥10%:
• Stage 2 HTN for any age

Question 12

Outline the choice of antihypertensives and BP targets

Answer 12