Hypertension

Question 1

Define Hypertension

Answer 1

Sustained SBP >140 mmHg +/or DBP >90 mmHg measured on 3 separate occasions

Question 2

Define Malignant Hypertension

Answer 2

Severe increase in BP >,180/120 mmHg (often >220/120 mmHg) with signs of retinal haemorrhage +/or papilloedema

Question 3

Describe the aetiology of Hypertension

Answer 3

Primary/ Essential= 90% Idiopathic
Secondary= 10% has underlying cause

Question 4

List 5 systems/ states with their respective causes of secondary hypertension

Answer 4

Renal: glomerulonephritis, RAS, PKD, chronic pyelonephritis, CKD
Endocrine: DM, Cushings, Conns, phaeochromocytoma, hyperthyroidism, CAH, acromegaly
CVS: aortic coarctation, high intravascular volume
Drugs: sympathomimetics, corticosteroids, OCP
Pregnancy: pre eclampsia

Question 5

Describe the epidemiology of hypertension

Answer 5

> 25% of UK adults

Question 6

How does hypertension present?

Answer 6

Often asymptomatic
Sx of complications
Sx of the cause

Question 7

Give 6 features of malignant hypertension presentation

Answer 7

Scotomas (visual field loss)
Blurred vision
Severe headaches
Seizures
N + V
Acute heart failure

Question 8

How is hypertension diagnosed?

Answer 8

Record BP on 3 separate occasions
Record lowest reading
If >140/90 offer ABPM.

Question 9

Which 3 signs may present in a hypertensive patient, suggesting the cause?

Answer 9

Radiofemoral delay = coarctation of the aorta
Renal artery bruit = renal artery stenosis
Fundoscopy = hypertensive retinopathy

Question 10

Describe the Keith-Wagner Classification of Hypertensive Retinopathy

Answer 10

i. Silver wiring
ii. As above + arteriovenous nipping
iii. As above + flame haemorrhages + cotton wool exudates
iv. As above + papilloedema

Question 11

List the appropriate investigations for hypertension

Answer 11

Bloods (FBC, U+E’s, Lipids, Glucose)
Urine dipstick (blood + protein for renal causes)
ABPM (exclude white coat HTN)
ECG (LV hypertrophy)

Question 12

Describe 5 strategies in conservative management of hypertension

Answer 12

Stop smoking
Lose weight
Reduce alcohol intake
Reduce salt <6g/day
Reduce caffeine

Question 13

What are the stages of hypertension?

Answer 13

1. Clinic BP >140/90 + ABPM >135/85
2. Clinic BP >160/100 + ABPM >150/95
3. Clinic SBP >180 or DBP >120

Question 14

How should a patient with an average BP of >135/85 be managed?

Answer 14

Treat if <80y and any of the following:
* Target organ damage
* Established cardiovascular disease
* Renal disease
* Diabetes
* 10y cardiovascular risk >,10%

Question 15

How should stage 2 hypertension be managed?

Answer 15

Treat all patients regardless of age

Question 16

What is the first line pharmacological treatment of hypertension?

Answer 16

If <55, Diabetic, HF or LV dysfunction: ACEi or ARB
If >55/ Black: CCB

Question 17

What is second line treatment of hypertension?

Answer 17

If taking ACEi/ ARB: Add a CCB or a thiazide-like diuretic
If taking CCB: Add ACEi/ARB or a thiazide like diuretic

Question 18

What is the second line treatment for hypertension in black African/ afro-caribbean patients?

Answer 18

ARB (in preference to ACEi)

Question 19

What is the third line treatment for hypertension?

Answer 19

If taking ACEi/ ARB + CCB: add thiazide-like diuretic
If taking ACEi/ARB + thiazide-like diuretic: add CCB

Question 20

What must be done if persistent hypertension despite triple therapy?

Answer 20

Confirm elevated BP with ABPM
Assess for postural hypotension
Discuss adherence
Measure K+

Question 21

What is the fourth line management of hypertension?

Answer 21

K+ <4.5: add low dose spironolactone
K+ >4.5: add alpha or beta blocker

Question 22

How should patients with persistent hypertension despite quadruple therapy be managed?

Answer 22

Refer to specialist

Question 23

What are the target BP’s aimed for with treatment?

Answer 23

<80y: clinic <140/90, ABPM <135/85
>80y: clinic <150/90, ABPM <145/85

Question 24

Which medication used in treatment of hypertension can impair glucose tolerance? (more freq hyperglycaemia)

Answer 24

Thiazides

Question 25

Name 2 drugs used to treat malignant hypertension

Answer 25

Atenolol | Nifedipine

Question 26

What is used for Malignant Hypertension treatment with encephalopathy?

Answer 26

IV BB e.g. Labetalol or IV Na nitroprusside

Question 27

Why must you avoid rapid lowering of blood pressure when treating acute malignant hypertension?

Answer 27

Can cause cerebral infarction Autoregulatory mechanisms in brain for regulating blood flow will cause vasoconstriction of vessels in brain when BP is very high Lowering BP too rapidly would mean autoregulatory mechanisms do not adapt to the drop in BP + so the vessels remain constricted Rapid drop in BP with constricted vessels will cause an infarction

Question 28

List 10 possible complications of hypertension

Answer 28

``` Heart failure CAD Cerebrovascular accidents PVD Lacunar brain haemorrhages Emboli Renal failure Hypertensive retinopathy Hypertensive encephalopathy Malignant HTN ```

Question 29

Describe the prognosis of a patient with hypertension

Answer 29

Good if well controlled. | Uncontrolled, increases risk of stroke 3x, MI 6x + renal + heart failure.

Question 30

What is papilloedema?

Answer 30

Optic disc swelling due to raised ICP | Sharp optic disc edge is NOT visible

Question 31

What is the most common cause of refractory hypertension?

Answer 31

Primary hyperaldosteronism (most common aetiology: Bilateral adrenal hyperplasia)

Question 32

What is the first investigation for primary hyperaldosteronism?

Answer 32

Aldosterone:Renin ratio High Aldosterone relative to renin indicates inappropriate secretion of aldosterone, resulting in Na retention + subsequent HTN