Hypertension

Question 1

History needed?

Answer 1

Time of diagnosis
What were their initial readings (mild 140-159, moderate 1`60-179, severe > 180)
How well they responded to treatment - what they have had and why they changed
Complications - stroke, HF, PVD, renal failure

Potential secondary causes:

• phaeochromocytoma - paroxysmal sweating, palpitations and headache
• OSA
• Renal artery stenosis or CKD
• Aortic co-arctation
• adrenal tumors
• MEDS - COC, NSAIDs
• Pregnancy

Question 2

Other risk factors for vascular disease inc lifestyle

Answer 2

T2DM
Hyperlipidaemia
Family Hx or CAD or CVD

Lifestyle: obesity, low exercise, excessive alcohol, high salt

Question 3

Malignant Hypertension?

Answer 3

extremely high blood pressure that develops rapidly and causes some type of organ damage - presents with severe headache

Question 4

Examination

Answer 4

Cardiovascular disease (look for postural BP drop and BP in both arms) 
Signs of Cushing's (moonface, weight gain, purple striae, buffalo hump, proximal muscle loss) 
Radio-femoral delay = coarctation 
Fundoscopy - flame haemorrhages and cotton wool spots, AV nipping, exudates, papilledema

Question 5

Investigations

Answer 5

• UEC =any renal disease
• ECH = LVH or IHD
• CXR = exclude cardiomegaly, LVH, CHF
• Urine analysis =?proteinuria –> Urine ACR if positive
• HbA1C and Lipids
• Aldosterone/Renin ratio = to detect primary hyperaldosteronism i.e Conns (especially if hypokalaemic and not on diuretics) high PA:PRA ratio (plasma aldosterone:plasma renin activity) also renin secreting tumours
• 24h catecholamines for phaeo
• Serum cortisol if investigating Cushing’s/Decamethasone suppression test/ACTH stimulation test
• Renal artery dopplers
• Sleep study = ?OSA
• Ambulatory BP

Question 6

Management stratification

Answer 6

Depends upon RISK
- gender, age, ethnicity, BP, TC:HDL, Smoke, DM, Fam Hx

CVD risk < 5%

• lifestyle
• Discuss harms, benefits of statin
• further assess on 5-10 years

CVD risk 5-15%

• indivualised lifestyle advice
• commence BP lowering +/- statin
• further assessment 1-2 years

CVD risk > 15% and established CVD or BP 160/100

• intensive lifestyle advise
• BP lowering + statin + anti-platelet
• annual review

Target BP

• 140/90 if > 80 years or significant worry of fragility/hypotension
• 130/80 in most cases/high risk patients

Question 7

NP management

Answer 7

Diet - reduced salt, fats and sugars 
Physical activity - 30 min a day and green prescription 
Weight - BMI < 25 
Smoking cessation 
Alcohol  reduction

Question 8

P management

Answer 8

start on a low dose of one therapy followed by a low dose of a second therapy before up-titrating doses.

1. ACEi if < 55 years or DM versus CCB if > 55 years
2. Add other
3. Thiazide diuretic
4. beta blocker or spironolactone

ACEi can be swapped for ARB if SE (eg. cough)

CCB

• Felodipine, diltiazem, verapamil
• also useful if suffer from angina

BB

• metoprolol, bisoprolol, carvedilol
• useful in angina, HF, MI
• not very good anti-HTN and contrindicated in asthma, DM, heart vlock and PVD

NB: BPH - alpha blocker = doxazosin