HTN

Question 1

What is refractory HTN

Answer 1

BP >140/90 despite max dosage of 2 drugs for 3-4 months

Question 2

Main areas of target organ damage in HTN

Answer 2

Heart: Heart failure, LVH, Ischemic disease
Kidney: Renal insufficiency
Retina: Retinopathy
Blood vessels: Peripheral vascular disease, aortic dissection
Brain: Cerebrovascular disease

Question 3

Risk Factors for CVD?

Answer 3

Levels of systolic and diastolic BP
Men >55
Women >65
Smokers
DM
Dyslipidemia
FHx premature CVD 102 in males, >88 in women
C-reactive protein >1mg/dl

Also:
Excessive alcohol intake
Sedentary lifestyle
High-risk socioeconomic groups
High-risk ethnic groups

Question 4

How can HTN be confirmed, based on BP readings?

Answer 4

Initial high BP readings must be confirmed with at least 2 more high readings over 3 months

Question 5

Factors that can artificially raise BP

Answer 5

Apprehension - patient should be made to feel relaxed, and be seated for at least 5 minutes prior to taking BP

Caffeine - avoid caffeine for 4-6 hours before measurement

Smoking - avoid smoking for 2 hours before measurement

Eating - should not have eated for 30 mins before measurement

Question 6

When is ambulatory BP monitoring indicated?

Answer 6

Not for everyone

For patients with fluctuating BP, borderline HTN, or refractory HTN

Question 7

Causes of secondary HTN

Answer 7

Kidneys:
Glomerulonephritis
Reflux nephropathy
Renal artery stenosis
Other renovascular disease
DM

Endocrine:
Primary aldosteronism
Cushing Syndrome
Phaeochromocytoma (neuroendocrine cancer of medulla and adrenal glands)
Oral contraceptives
Other endocrine factors

Coarctation of aorta
Immune disorders - polarteriris nodosa
Drugs: NSAIDs, corticosteroids
Pregnancy

Question 8

Abdominal systolic bruit suggestive of

Answer 8

Secondary cause: renal artery stenosis

Question 9

Proteinuria, hematuria, casts are suggestive of

Answer 9

Glomerulonephritis

Question 10

Bilateral kidney masses, with or without hematuria are suggestive of

Answer 10

Polycystic disease

Question 11

Hx of claudication and delayed femoral pulse are suggestive of

Answer 11

Coarctation of the aorta

Question 12

Progressive nocturia, weakness are suggestive of

Answer 12

Primary aldosteronism (check serum K+)

Question 13

Paroxysmal HTN with headache, palor, sweating and palpitations are suggestive of

Answer 13

Phaeochromocytoma

Question 14

Suggested follow up for normal BP reading

Answer 14

2 years

Question 15

Suggested follow up for pre-HTN reading

120-139 / 80-89

Answer 15

1 year, with lifestyle advice

Question 16

Suggested follow up for mild HTN (140-159 / 90-99)

Answer 16

Confirm diagnosis over the next 2 months with repeated readings. Give lifestyle advice

Question 17

Suggested follow up for moderate HTN (160-179 / 100-109)

Answer 17

Evaluate or refer within 1 month - Give lifestyle advice

Question 18

Suggested follow up for severe HTN >180 / >110

Answer 18

Further evaluate and refer within 1 week (or immediately, depending on clinical situation)

If BP is confirmed to be consistently this high, and ‘white coat’ HTN is excluded, drug treatment should be initiated as first-line

Question 19

Findings on physical examination - HTN

Answer 19

ECG: May show LVH or old infarction

Echo: if suspecting HF (only if other CV risk factors)

Metabolic panel with estimated GFR: look for renal insufficiency. Unprovoked hypokalemia may suggest hyperaldosteronism.

Plasma renin measures - low renin suggests hyperaldosteronism

Lipid profile: Gain insight into CV risk

FBC with Hb: Anemia accompanies chronic renal failure. Polycythemia is seen in phaeochromocytoma

Urinalysis: Increased urine albumin indicates end-organ damage of kidneys

TFTs / TSH - for hypo or hyperthyroidism

Fundoscopy: Assess for retinopathy (in severe HTN)

Carotid and femoral US: may show abnormal intima media thickness

Question 20

What are the features of the 4 grades of Hypertensive Retinopathy

Answer 20

Grade 1: Tortuous looking arterioles

Grade 2: Arteriovenous nipping (crossing over)

Grade 3: Arteriovenous nipping of tortuous looking vessels, PLUS Flame-shaped hemorrhages, and soft cotton-wool exudates

Grade 4: Papillodema