Hypertension

Question 1

Define Hypertension?

Answer 1

Systolic > 140 mm Hg and/or diastolic > 90 mm Hg measured on three separate occasions

Question 2

Define Malignant Hypertension?

Answer 2

BP > 200/130 mm Hg

Question 3

What is the primary aetiology of Hypertension?

Answer 3

Essential or idiopathic hypertension

Responsible for > 90% of cases

Question 4

What are the secondary causes of Hypertension?

Answer 4

Renal Causes
Endocrine Causes
Cardiovascular Causes 
Drugs
Pregnancy

Question 5

What are the Renal Causes of Hypertension?

Answer 5

Renal Artery Stenosis 
Chronic Glomerulonephritis 
Chronic Pyelonephritis 
Polycystic Kidney Disease 
Chronic Renal Failure

Question 6

What are the Endocrine Causes of Hypertension?

Answer 6

Diabetes Mellitus 
Hyperthyroidism 
Cushing's Syndrome 
Conn's Syndrome 
Hyperparathyroidism
Phaeochromocytoma
Congenital Adrenal Hyperplasia
Acromegaly

Question 7

What are the Cardiovascular causes of Hypertension?

Answer 7

Coarctation of the aorta

Increased intravascular volume

Question 8

What drugs can cause Hypertension?

Answer 8

Sympathomimetics
Corticosteroids
COCP

Question 9

How can Pregnancy cause Hypertension?

Answer 9

Pre-eclampsia

Question 10

What are the presenting symptoms of Hypertension?

Answer 10

Often Asymptomatic
Symptoms of Complications
Symptoms of the cause

Question 11

What are the presenting symptoms of Accelerated or Malignant Hypertension?

Answer 11

Scotomas (visual field loss)
Blurred Vision
Headache 
Seizures 
Nausea and Vomiting 
Acute Heart Failure

Question 12

What are the signs of Hypertension on examination?

Answer 12

BP should be measured on 2-3 different occasions before diagnosing Hypertension
The lowest reading may be recorded

Question 13

How can Examination reveal information about the causes of Hypertension?

Answer 13

Radiofemoral delay = Coarctation of the aorta distal to the left subclavian artery
Renal Artery Bruit = Renal Artery Stenosis
Fundoscopy to detect hypertensive retinopathy

Question 14

What is Keith-Wagner Classification of Hypertensive Retinopathy?

Answer 14

I - Silver wiring
II - As above + arteriovenous nipping
III - As above + flame haemorrhages + cotton wood exudates
IV - As above + papilloedema

Question 15

What bloods would you do for Hypertension?

Answer 15

U&Es
Glucose
Lipids

Question 16

What would you look for on a Urine Dipstick in Hypertension?

Answer 16

Blood and Protein (e.g. if glomerulonephritis)

Question 17

What would you look for on a ECG for Hypertension?

Answer 17

May show signs of Left Ventricular Hypertrophy or ischaemia

Question 18

Why might you do an Ambulatory BP monitoring?

Answer 18

Excludes white coat hypertension

Question 19

Why might we do other investigations?

Answer 19

If a secondary cause of the Hypertension is suspected

Question 20

What is the conservative management plan for Hypertension?

Answer 20

Stop smoking 
Lose weight
Reduce alcohol intake 
Reduce Dietary Sodium 
Investigate for secondary causes (mainly in young patients)

Question 21

When is medical treatment needed for Hypertension?

Answer 21

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

Question 22

What are the different lines of drug treatment we can do for Hypertension?

Answer 22

ACE inhibitors or ARB blockers
CCBs
Beta-Blockers
Alpha-Blockers

Question 23

When are ACE inhibitors/ ARB receptor blockers first line treatment for Hypertension?

Answer 23

< 55 years
Diabetic
Heart Failure
Left Ventricular Dysfunction

Question 24

When are CCBs first line treatment for Hypertension?

Answer 24

> 55 yrs

Black

Question 25

What can be used if CCBs are not tolerated for Hypertension treatment?

Answer 25

Thiazide Diuretics

Question 26

What are the characteristics of Beta-Blocker usage for Hypertension treatment?

Answer 26

Not preferred initial therapy May be considered in younger patients Combining with thiazide diuretic may increasing risk of developing diabetes May increase risk of heart failure

Question 27

What are the characteristics of Alpha-Blocker usage for Hypertension treatment?

Answer 27

4th line | May be used in patients with prostate disease

Question 28

What is the target BP in a non-Diabetic patient with Hypertension?

Answer 28

< 140/90 mm Hg

Question 29

What is the target BP in a diabetic patient without proteinuria and with Hypertension?

Answer 29

< 130/80 mm Hg

Question 30

What is the target BP in a diabetic patient with proteinuria and with Hypertension?

Answer 30

< 125/75 mm Hg

Question 31

What drugs would we use in the treatment of Severe Hypertension Management (Diastolic > 140 mm Hg)?

Answer 31

Atenolol | Nifedipine

Question 32

What is management of Acute Malignant Hypertension?

Answer 32

IV beta-blocker (e.g. esmolol) Labetolol Hydralazine Sodium Nitroprusside

Question 33

Why should we be careful of rapid lowering of BP in Acute Malignant Hypertension management?

Answer 33

Can Cause Cerebral Infarction

Question 34

Why can rapid lowering of BP cause Cerebral Infarction?

Answer 34

The autoregulatory mechanisms within the brain for regulating blood flow will cause vasoconstriction of the vessels in the brain when BP is very high Lowering the BP too rapidly will mean the autoregulatory mechanisms don't adapt to the drop in BP and so the vessels remain constricted A rapid drop in BP with constricted vessels will cause an infarction

Question 35

What are the possible complications of Hypertension?

Answer 35

``` 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 36

What is the prognosis for patients with Hypertension?

Answer 36

Good prognosis if well controlled Uncontrolled hypertension if associated with increased mortality Treatment reduces incidence of renal damage, stroke and heart failure