HYPERTENSION

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HYPERTENSION

• Lesley Ashby

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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

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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 lt140/80 unless microalbuminuria
  lt135/75
• Type 1 diabetics lt135/85 unless nephropathy
  lt130/80

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CATEGORY SYSTOLIC BLOOD PRESSURE (MMHG) DIASTOLIC BLOOD PRESSURE (MMHG)
Optimal lt 120 lt 80
Normal lt 130 lt 85
High normal 130-139 85-89
Hypertension    
mild (grade 1) 140-159 90-99
moderate (grade 2) 160-179 100-109
severe (grade 3) gt 180 gt 110
Isolated Systolic Hypertension    
grade 1 gt 140-159 lt 90
grade 2 gt 160 lt 90
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Aetiology

• Genetic factors
• Dietary factors
• High salt
• Low calcium
• High caffeine
• Oral contraceptives
• Hormone replacement therapy
• Role of the sympathetic nervous system
• Role of the kidney, in particular vasopressin

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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??

• Refer immediately if signs
• Accelerated HTN eg gt180/110, 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

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Routine investigations

• Cardiovascular risk stratification
• Urine strip for protein and blood
• UE
• Fasting blood glucose
• Fasting lipids
• 12-lead ECG

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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

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Medical Treatment
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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
• Dont withdraw if taking for other reasons eg AF,
  Post MI

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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

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Secondary hypertension

• 5 of all hypertensive patients
• Suspect in those lt35 years
• Obvious history or examination to suggest
  secondary cause
• Maybe due to
• Renal causes
• Endocrine disease
• Pregnancy
• Miscellaneous including drugs

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Renal Causes

• Parenchymal disease
• chronic renal failure of any kind
• glomerulonephritis
• chronic pyelonephritis
• analgesic nephropathy
• diabetic nephropathy
• polycystic disease
• tumours e.g. Wilm's tumour
• Arterial disease
• renal artery atherosclerosis / stenosis
• renal artery embolism
• fibromuscular dysplasia
• polyarteritis nodosa

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Endocrine and metabolic causes

• 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

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Drugs

• Oestrogen-containing oral contraceptives
• NSAID's
• Corticosteroids
• Cyclosporin A
• Carbenoxalone and liquorice-containing substances
  
• Erythropoietin
• Ergotamine
• Monoamine oxidase inhibitors - with
  tyramine-containing foods e.g. cheese
• Sympathomimetics e.g phenylpropanolamine,
  ephedrine

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Others

• Coarctation of the aorta
• Polycythaemia rubra vera
• Porphyria during acute attacks
• Lead poisoning during acute attacks

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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

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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

• Hypertension
• Headache
• Palpitations
• Tachycardia
• Sweating
• Anxiety
• Panic attacks
• Tremor
• Nausea and vomiting
• Fever

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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

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Take Home Messages

• Never diagnose on single reading
• Be suspicious of secondary causes in lt35 years
• Dont 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