Download hypertension - Bridgend VTS

HYPERTENSION
Lesley Ashby
DEFINITION
NICE define hypertension as persistent
raised blood pressure above 140/90
mmHg
 95% have essential hypertension
 5% due to secondary cause
 Screening very important as common,
often asymptomatic and has serious
complications

ESSENTIAL HYPERTENSION
Hypertension without a demonstrable
cause and is a diagnosis of exclusion
 Affects 20% middle aged population
 97% treated and supervised by GP
 Target BP in non diabetics 140/90
 Type 2 diabetics <140/80 unless
microalbuminuria <135/75
 Type 1 diabetics <135/85 unless
nephropathy <130/80
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CATEGORY
SYSTOLIC BLOOD
PRESSURE (MMHG)
DIASTOLIC BLOOD
PRESSURE (MMHG)
Optimal
< 120
< 80
Normal
< 130
< 85
High normal
130-139
85-89
mild (grade 1)
140-159
90-99
moderate (grade 2)
160-179
100-109
severe (grade 3)
>= 180
>= 110
grade 1
> 140-159
< 90
grade 2
>= 160
< 90
Hypertension
Isolated Systolic
Hypertension
Aetiology
Genetic factors
 Dietary factors:
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– High salt
– Low calcium
– High caffeine
Oral contraceptives
 Hormone replacement therapy
 Role of the sympathetic nervous system
 Role of the kidney, in particular
vasopressin

Assessment of BP
Never diagnose HTN on one single
reading.
 If possible repeat at end of consultation
 Need 3 elevated readings at monthly
intervals unless patient has severe HTN
 Home monitoring or ambulatory BP
measurements not recommended
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Refer or not to refer??
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Refer immediately if signs
– Accelerated HTN eg >180/110, papilloedema
+/- retinal heamorrhage
– Suspected phaeochromocytoma

Consider if:
– Unusual signs and symptoms
– Suspected secondary cause
– Symptoms of postural hypotension
– Management depends critically on accurate
estimation of BP
Routine investigations
Cardiovascular risk stratification
 Urine strip for protein and blood
 U&E
 Fasting blood glucose
 Fasting lipids
 12-lead ECG

Conservative Treatment
Diet and exercise
 Reduce caffeine intake
 Reduce salt intake
 Offer smokers cessation advice
 Make patients aware of local initiatives to
help lifestyle etc

Medical Treatment
Beta Blockers
Evidence suggests less effective than other
groups at reducing cardiovascular risk and
diabetes
 Maybe useful in:

– Women of child bearing age
– Evidence of raised sympathetic drive
– Intolerance to other meds such as ACE I
If already taking and need second drug add
calcium channel antagonist
 Don’t withdraw if taking for other reasons eg AF,
Post MI

Continuing treatment
Advise patient long term treatment
 If low cardiovascular risk and have good
control can be offered trial reduction but
need followup.
 Patient support groups available
 Annual review if well controlled

Secondary hypertension
5% of all hypertensive patients
 Suspect in those <35 years
 Obvious history or examination to suggest
secondary cause
 Maybe due to :

– Renal causes
– Endocrine disease
– Pregnancy
– Miscellaneous including drugs
Renal Causes
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Parenchymal disease:
–
–
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–
–
–
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chronic renal failure of any kind
glomerulonephritis
chronic pyelonephritis
analgesic nephropathy
diabetic nephropathy
polycystic disease
tumours e.g. Wilm's tumour
–
–
–
–
renal artery atherosclerosis / stenosis
renal artery embolism
fibromuscular dysplasia
polyarteritis nodosa
Arterial disease:
Endocrine and metabolic causes
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Cushing's syndrome
Conn's syndrome
Phaeochromocytoma
Acromegaly
Diabetes mellitus
Hyperparathyroidism
Enzyme defects - such as congenital adrenal
hyperplasia
Familial hyperaldosteronism type 1
Apparent mineralocorticoid excess
Drugs
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Oestrogen-containing oral contraceptives
NSAID's
Corticosteroids
Cyclosporin A
Carbenoxalone and liquorice-containing
substances
Erythropoietin
Ergotamine
Monoamine oxidase inhibitors - with tyraminecontaining foods e.g. cheese
Sympathomimetics e.g phenylpropanolamine,
ephedrine
Others
Coarctation of the aorta
 Polycythaemia rubra vera
 Porphyria during acute attacks
 Lead poisoning during acute attacks

PHAEOCHROMOCYTOMA
Arise from chromaffin cells mainly in
adrenal medulla
 Paragangliomas mainly at carotid
bifurcation
 0.1-0.2% all cases of hypertension
 Most secrete adrenaline and
noradrenaline, some dopamine and rarely
ACTH

10% Rule
10% are extra-adrenal
 10% are bilateral, increasing to 70% in
familial cases
 10% are malignant, but the risk of
malignancy in women is three fold that in
men
 10% are multiple
 10% occur in children, but 25-30% of
children have extra-adrenal and/or
bilateral tumours
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Symptoms and signs
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Hypertension
Headache
Palpitations
Tachycardia
Sweating
Anxiety
Panic attacks
Tremor
Nausea and vomiting
Fever
Be Suspicious…
Hypertensive with orthostatic hypotension
and tachycardia
 Hypertensive whose symptoms respond
poorly to anti-hypertensive treatment
 Patient whose blood pressure fluctuates
widely
 Hypertensive with cafe au lait spots

Take Home Messages
Never diagnose on single reading
 Be suspicious of secondary causes in <35
years
 Don’t panic about which drug group to use
as most important thing is to lower the BP
 In most cases you have time to be sure of
the diagnosis
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