Medically Fit For Exams
Medically Fit For Exams

Hypertension

Definition

  • Raised blood pressure
    • Stage 1: >140/90 mmHg clinic reading AND >135/85 average ambulatory reading
    • Stage 2: >160/100mmHg clinic AND >150/95 average ambulatory
    • Stage 3: >180mmHg systolic clinic reading OR >110mmHg diastolic clinic reading
  • Can be primary (idiopathic) or secondary
  • Can be malignant – fast progressing to end-organ damage

 

Risk factors

  • Obesity
  • Sedentary lifestyle
  • Poor diet/high fat/high salt
  • Alcohol intake
  • Atherosclerosis
  • Black/SE Asian ethnicity
  • Smoker
  • Male
  • High anxiety/stress
  • Low birth weight
  • Family history

 

Differential diagnoses(/causes)

  • White coat syndrome
  • Pregnancy
  • Anxiety/stress
  • Recent exercise
  • Orthostatic hypertension
  • Renal disease
  • Hyperthyroidism
  • Cushing’s disease

 

Epidemiology

  • 30% of general population
  • Increased chance with advancing age
  • 40-45% of black adults

 

Aetiology

  • Majority of cases are idiopathic (primary, with no clear discernible cause)
  • Contributory factors: see differential diagnoses
    • Changes to RAAS system – including high salt intake, slight kidney dysfunction
  • Secondary: as a result of another pathology
    • Endocrine disease
      • Hyperthyroid
      • Phaeochromocytoma
      • Cushing’s disease
    • Renal disease – most common cause of secondary hypertension
      • Diabetic nephropathy
      • Glomerulonephritis
      • Polycystic kidney disease
    • Pregnancy
      • Pre-eclampsia (also: protein in urine and ankle swelling)
    • Congenital cardiovascular disorder – eg coarctation
    • Drugs can increase blood pressure
      • NSAIDS (nephrotoxic)
      • Oral contraceptives
      • Steroids
      • Vasopressin (ADH)

 

Clinical features

  • Usually symptomless
  • Atherosclerosis
  • Chronic hypertension and malignant hypertension can cause end organ damage
    • Kidneys are susceptible – cycle of doom
    • Heart failure
    • Retinopathy
    • Headaches
    • Stroke
    • Acute coronary syndrome from atherosclerosis

 

 

Pathophysiology

  • Hypertrophy and thickening of tunica media
  • Thickening of elastic lamina
  • Fibroelastic thickening of intima
  • Reduction in size of lumen
  • Reduction in elasticity
  • Hyaline deposition in vessel wall (hyaline arteriosclerosis)
  • Peripheral vessel narrowing
  • Atheroma formation – atherosclerosis
  • In accelerated/malignant hypertension:
    • Fibrinoid necrosis of vessel wall; necrotic tunica media infiltrated by fibrin – much reduced elasticity and narrowing of vessel

Investigations

  • Ambulatory/home BP monitoring
  • Blood lipids
  • U&Es if concerned about kidney function

 

Management

  • Non-pharmacological
    • Reduced fat and salt intake
    • Exercise
    • Weight loss
    • Stress reduction
    • Mediterranean type diet
  • Pharmacological treatment
    • A – ACE inhibitors (eg ramipril), and angiotensin 2 receptor blockers (eg lorsartan)
    • B – beta blockers (eg atenolol)
    • C – calcium channel blockers (eg verapamil)
    • D – diuretics (eg furosemide)
  • If <55yo and white
    • Start with A
    • Then add C and D
    • Then A, C and D
    • Then B + extra D
  • If >55yo or black
    • Start with C
    • Then add A or D
    • Then A, C and D
    • Then add B, maybe alpha blockers and more D

 

Prognosis

  • Hypertension contributes to many other life-threatening conditions:
    • Atherosclerosis and acute coronary syndrome
    • Chronic kidney disease
    • Stroke
    • Vascular damage
  • Damage to vision
Hypertension.docx
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