Hypertension

Question 1

Define hypertension

Answer 1

DEFINITION: systolic > 140 mm Hg and/or diastolic > 90 mm Hg measured on three separate occasions.

Malignant Hypertension: BP > 200/130 mm Hg

Question 2

Summarise the epidemiology of hypertension

Answer 2

VERY COMMON

10-20% of adults in the Western world

Question 3

Aetiology/risk factors of hypertension

Answer 3

Primary

• Essential or idiopathic hypertension
• Responsible for > 90% of cases

Secondary
-Renal

Endocrine

Cardiovascular

Drugs

Pregnancy

Question 4

Renal

Answer 4

Renal artery stenosis

Chronic glomerulonephritis

Chronic pyelonephritis

Polycystic kidney disease

Chronic renal failure

Question 5

Endocrine

Answer 5

Diabetes mellitus

Hyperthyroidism

Cushing’s syndrome

Conn’s syndrome

Hyperparathyroidism

Phaeochromocytoma

Congenital adrenal hyperplasia

Acromegaly

Question 6

Cardiovascular

Answer 6

Coarctation of the aorta

Increased intravascular volume

Question 7

Drugs

Answer 7

Sympathomimetics

Corticosteroids

COCP

Question 8

Pregnancy

Answer 8

Pre-eclampsia

Question 9

Recognise the presenting symptoms of hypertension

Answer 9

Often ASYMPTOMATIC

Accelerated or Malignant Hypertension:

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

Question 10

Recognise the signs of hypertension on physical examination

Answer 10

Radiofemoral delay = coarctation of the aorta distal to the left subclavian artery

Renal artery bruit = renal artery stenosis

Fundoscopy to detect hypertensive retinopathy

Question 11

Keith-Wagner Classification of Hypertensive Retinopathy

Answer 11

Silver wiring

As above + arteriovenous nipping

As above + flame haemorrhages + cotton wood exudates

As above + papilloedema

Question 12

Identify appropriate investigations for hypertension

Answer 12

Bloods
Urine Dipstick
ECG
Ambulatory blood pressure monitoring

Question 13

Bloods

Answer 13

U&Es

Glucose

Lipids

Question 14

Urine Dipstick

Answer 14

Blood and protein (e.g. if glomerulonephritis)

Question 15

ECG

Answer 15

May show signs of left ventricular hypertrophy or ischaemia

Question 16

Ambulatory blood pressure monitoring

Answer 16

Excludes white coat hypertension

Question 17

Management plan for hypertension

Conservative

Answer 17

Stop smoking

Lose weight

Reduce alcohol intake

Reduce dietary sodium

Question 18

Management plan for hypertension

Medical

Answer 18

treatment recommended if systolic > 160 mm Hg and/or diastolic > 100 mm Hg, or if evidence of end-organ damage. Multiple drug therapies often needed.

Question 19

ACE Inhibitors or Angiotensin Receptor Blockers

Answer 19

first line if:

< 55 yrs

Diabetic

Heart failure

Left ventricular dysfunction

Question 20

CCBs

Answer 20

first line if:

> 55 yrs

Black

NOTE: thiazide diuretics can be used if CCBs are not tolerated

Question 21

Beta-Blockers

Answer 21

Not preferred initial therapy

May be considered in younger patients

CAUTION: combining with thiazide diuretic may increase risk of developing diabetes

May increase risk of heart failure

Question 22

Alpha-Blockers

Answer 22

4th line

May be used in patients with prostate disease

Question 23

Target BP

Answer 23

Non-Diabetic: < 140/90 mm Hg

Diabetes without proteinuria: < 130/80 mm Hg

Diabetes WITH proteinuria: < 125/75 mm Hg

Question 24

Severe Hypertension Management

Answer 24

Atenolol

Nifedipine

Question 25

Acute Malignant Hypertension Management:

Answer 25

IV beta-blocker (e.g. esmolol)

Labetolol

Hydralazine sodium nitroprusside

Question 26

Identify the possible complications of hypertension

Answer 26

Heart failure

Coronary artery disease

Cerebrovascular accidents

Peripheral vascular disease

Emboli

Hypertensive retinopathy

Renal failure

Hypertensive encephalopathy

Posterior reversible encephalopathy syndrome (PRES)

Malignant hypertension

Question 27

Summarise the prognosis for patients with hypertension

Answer 27

Good prognosis if well controlled

Uncontrolled hypertension associated with increased mortality

Treatment reduces incidence of renal damage, stroke and heart failure