Case 8 - Hypertension

Question 1

What is the stepwise therapy in hypertension for a patient <55 years?

Answer 1

1) ace inhibitor
2) ace inhibitor + calcium channel blocker
3) ace inhibitor + calcium channel blocker + thiazide diuretic
4) K+ <4.5 add spironolactone
K+ >4.5 add higher dose thiazide like treatment
5) if further diuretic therapy not tolerated or ineffective consider alpha/beta blocker

Question 2

What is the stepwise therapy of hypertension in patients over the age of 55?

Answer 2

1) calcium channel blocker
2) ace inhibitor + calcium channel blocker
3) ace inhibitor + calcium channel blocker + thiazide diuretic
4) K+ <4.5 add spironolactone
K+ >4.5 add higher dose thiazide like treatment
5) if further diuretic therapy not tolerated or ineffective consider alpha/beta blocker

Question 3

What is the stepwise therapy of hypertension in patients of Afro-Caribbean origin

Answer 3

1) calcium channel blocker
2) ace inhibitor + calcium channel blocker
3) ace inhibitor + calcium channel blocker + thiazide diuretic
4) K+ <4.5 add spironolactone
K+ >4.5 add higher dose thiazide like treatment
5) if further diuretic therapy not tolerated or ineffective consider alpha/beta blocker

Question 4

How do blood pressure targets differ for patients under and over the age of 80

Answer 4

Age < 80 : clinic BP 140/90, ABPM 135/85

Age > 80: clinic BP 150/90, ABPM 145/85

Question 5

What is the first line treatment for gestational hypertension?

Answer 5

Oral labetalol

Use oral nifedipine in patients with asthma or where beta blocker is contradicted

Question 6

What medical conditions associated with hypertension and hypokalaemia (low potassium)?

Answer 6

Cushing syndrome
Conn’s syndrome (primary aldosteronism)
Liddle’s syndrome
11-beta hydroxylase deificiency

Question 7

What is malignant hypertension?

Answer 7

When hypertension is so high (>180/120), that it damages target organs (brain, kidney, heart)

Question 8

What are the causes of secondary hypertension?

Answer 8

Cushings disease
Conns syndrome (aldosterone secreting tumour)
Pheochromacytoma (adrenaline/noradrenaline releasing tumour)
Diabetic nephropathy
Coarction of the aorta
Renal artery stenosis

Question 9

Which antihypertensives are safe during pregnancy?

Answer 9

Labetalol
Nifedipine
Methyl dopa

Question 10

What are the different stages of hypertension?

Answer 10

Grade 1 (Mild) : 140-159 / 90-99 (>135/90 for ABPM/HBPM)
Grade 2 (Moderate) : 160-179 / 100-109 (>150/90 for ABPM/HBPM)
Grade 3 (Severe) : >180 / >110

Question 11

Which type of blood pressure drug can cause ankle swelling as a side effect?

Answer 11

Calcium channel blocker

Question 12

Which type of blood pressure drug can cause hyponatremia as a side effect?

Answer 12

Thiazide diuretics

Question 13

Which class of hypertension drugs can cause hyperkalaemia as a side effect?

Answer 13

Aldosterone antagonists

Question 14

How do you diagnose hypertension?

Answer 14

Measure BP in both arms, if difference is more than 20, repeat measurements. If it remains more than 20, take BP readings from arm with higher reading

Take 2nd measurement if higher than 140/90. If 2nd measurement is significantly different, take a third. Record the lower of the last 2 measurements as clinic BP

If clinic BP is higher than 140/90, offer ABPM (or HBPM if unable to tolerate)

Use ABPM to take the average value of at least 14 measurements taken during waking hours to confirm hypertension

Use HBPM to take BP twice daily morning and evening for 7 days. Use average of measurements to take diagnosis

Question 15

What is a hypertensive emergency?

Answer 15

BP > 180 systolic or 120 diastolic
Causing end organ damage to kidneys, heart or brain

Symptoms include: chest pain, SOB, back pain, numbness, weakness, visual change or difficulty speaking

Question 16

How is a hypertensive emergency treated?

Answer 16

IV hypertensive meds:
Vasodilator - nitroglycerine
Beta blocker - labetalol
Calcium channel blocker?

Aim for normal BP within 24-48 hours

Question 17

What drugs can cause secondary hypertension?

Answer 17

Oral contraceptives
NSAIDS
Cocaine
Antidepressants

Question 18

What exams and investigations can you do to check potential for potential end organ damage in a patient with hypertension?

Answer 18

Eyes - Fundoscopy
Kidney - U&E, eGFR, urine dipstick
Brain - neurological exam
Heart - ECG

Question 19

What is the difference between hypertensive urgency and hypertensive emergency?

Answer 19

Urgency - BP > 180/120 with no evidence of end organ damage

Emergency - BP >180/120 with evidence of end organ damage

Question 20

What are the ECG changes which suggest left ventricular hypertrophy?

Answer 20

Large R wave

T wave inversion

Question 21

What lifestyle factors is high blood pressure caused by?

Answer 21

Being overweight 
Being stressed 
Eating too much salt
Excessive alcohol 
Too much caffeine 
Smoking 
Not enough exercise

Question 22

When would you refer to a patient to specialist to look for secondary causes regarding high BP

Answer 22

If patient is under 40

If BP is unable to be controlled under 4 drugs

Question 23

What is the cut off for stage 1 and stage 2 hypertension?

Answer 23

Stage 1 >= 135/85

Stage 2 >= 150/95

Question 24

When would you medically treat a patient with stage 1 hypertension?

Answer 24

If under 80 and with any of the following:

• end organ damage
• established cardiovascular disease
• renal disease
• diabetes
• QRISK >20%