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Hypertension

Hypertension is defined as a BP > 140/90mmHg in clinic or > 135/85mmHg with 24hr ABPM/at home


The risk factors for it can be categorised into if they're non-modifiable or modifiable:

  • Non-modifiable - 65+, FHx, Afro-Caribbean

  • Modifiable - Obese, Lack of exercise, Smoking, Alcohol, Stress


Usually asymptomatic and diagnosed during regular checks.


Classification

Primary HTN - Most common type (95%), and is when there's no identifiable cause.


Secondary HTN - This is when there's an identifiable cause. The most common cause here is Renal disease (overactivation of the RAAS). The other less common causes include:

  • Endocrine - Cushing’s (high cortisol), Conns (high aldosterone), Phaeochromocytoma, Acromegaly

  • Pre-eclampsia

  • Drugs - Steroids, COCP, NSAIDs


Malignant HTN - Severe, rapid rise in BP > 180/120mmHg leading to end-organ damage. Presents with evidence of end-organ damage e.g. papilloedema, retinal haemorrhages, new confusion, seizure, HF, AKI.


White-coat HTN - High BP during consultations (normal ABPM)


Masked HTN - High BP on ABPM (normal during consultations)


Staging

Investigations

If clinic reading > 140/90mmHg, a 24hr ABPM is needed to confirm the diagnosis.


The investigations done are mainly to check for end-organ damage:

  • Bloods - Glucose, U+E’s, Lipid profile

  • Urine dip and Albumin:Creatinine Ratio (ACR) - haematuria and proteinuria

  • Fundoscopy - hypertensive retinopathy

  • ECG - LV hypertrophy


Management

Lifestyle changes - Smoking cessation, Reduce alcohol and caffeine, Exercise, Diet, Reduce stress


N.B. These lifestyle changes tend to be the only management needed for patients with Stage 1 HTN.


Medication ladder for those < 55 year olds: ACTS

  • ACEi/ARB

  • CCB (DHP)

  • Thiazide diuretic - Thiazide-like diuretics, such as indapamide, are preferred to the conventional drugs like bendroflumethiazide

  • Spironolactone (use alpha/beta blocker if K > 4.5)


Medication ladder for those > 55 years OR African/Caribbean: CATS

  • CCB (DHP)

  • ACEi/ARB

  • Thiazide diuretic - Thiazide-like diuretics, such as indapamide, are preferred to the conventional drugs like bendroflumethiazide

  • Spironolactone (use alpha/beta blocker if K > 4.5)


If Diabetic, the patient should be started on an ACEi/ARB (regardless of age/ethnicity).


N.B. ARB can be used instead of ACEi if patient can’t tolerate it e.g. due to cough.

N.B. Young black men have a poor response to ACEi and B-blockers as they are salt-conservers by background, and therefore resistant to renin manipulation.


Complications

  • Heart:

    • IHD - Accelerates atherosclerosis in coronary arteries

    • HF - LV has to work harder against the increased systemic pressure, so undergoes compensatory hypertrophy. Eventually, the hypertrophied LV decompensates and fails → Left HF

  • Brain:

    • Stroke - Accelerates atherosclerosis

    • Haemorrhage - Rupture of tiny berry aneurysms → SAH

    • Vascular Dementia

  • Kidney:

    • CKD - Hypertensive nephropathy - Progressive arteriosclerosis in renal arteries, causing renal ischaemia = Tubular atrophy, Interstitial Fibrosis, and Glomerular sclerosis. USS will show small, fibrotic kidneys.

  • Eye:

    • Hypertensive Retinopathy - Flame haemorrhages, cotton-wool spots, yellow hard exudates, and papilloedema



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