HYPERTENSIONHYPERTENSION

Lesley AshbyLesley Ashby

DEFINITIONDEFINITION NICE define hypertension as NICE define hypertension as

persistent raised blood pressure persistent raised blood pressure above 140/90 mmHg above 140/90 mmHg

95% have essential hypertension 95% have essential hypertension 5% due to secondary cause5% due to secondary cause Screening very important as Screening very important as

common, often asymptomatic and common, often asymptomatic and has serious complicationshas serious complications

ESSENTIAL HYPERTENSIONESSENTIAL HYPERTENSION Hypertension without a demonstrable Hypertension without a demonstrable

cause and is a diagnosis of exclusioncause and is a diagnosis of exclusion Affects 20% middle aged populationAffects 20% middle aged population 97% treated and supervised by GP97% treated and supervised by GP Target BP in non diabetics 140/90Target BP in non diabetics 140/90 Type 2 diabetics <140/80 unless Type 2 diabetics <140/80 unless

microalbuminuria <135/75microalbuminuria <135/75 Type 1 diabetics <135/85 unless Type 1 diabetics <135/85 unless

nephropathy <130/80nephropathy <130/80

CATEGORYCATEGORY SYSTOLIC BLOOD SYSTOLIC BLOOD PRESSURE (MMHG)PRESSURE (MMHG)

DIASTOLIC BLOOD DIASTOLIC BLOOD PRESSURE (MMHG)PRESSURE (MMHG)

OptimalOptimal < 120< 120 < 80< 80

NormalNormal < 130< 130 < 85< 85

High normalHigh normal 130-139130-139 85-8985-89

HypertensionHypertension      

mild (grade 1)mild (grade 1) 140-159140-159 90-9990-99

moderate (grade 2)moderate (grade 2) 160-179160-179 100-109100-109

severe (grade 3)severe (grade 3) >= 180>= 180 >= 110>= 110

Isolated Systolic Isolated Systolic HypertensionHypertension

     

grade 1grade 1 > 140-159> 140-159 < 90< 90

grade 2grade 2 >= 160>= 160 < 90< 90

AetiologyAetiology Genetic factors Genetic factors Dietary factors: Dietary factors:

– High saltHigh salt– Low calciumLow calcium– High caffeineHigh caffeine

Oral contraceptives Oral contraceptives Hormone replacement therapy Hormone replacement therapy Role of the sympathetic nervous Role of the sympathetic nervous

system system Role of the kidney, in particular Role of the kidney, in particular

vasopressin vasopressin

Assessment of BPAssessment of BP Never diagnose HTN on one single Never diagnose HTN on one single

reading.reading. If possible repeat at end of consultationIf possible repeat at end of consultation Need 3 elevated readings at monthly Need 3 elevated readings at monthly

intervals unless patient has severe HTNintervals unless patient has severe HTN Home monitoring or ambulatory BP Home monitoring or ambulatory BP

measurements not recommendedmeasurements not recommended

Refer or not to refer??Refer or not to refer?? Refer immediately if signsRefer immediately if signs

– Accelerated HTN eg >180/110, Accelerated HTN eg >180/110, papilloedema +/- retinal heamorrhagepapilloedema +/- retinal heamorrhage

– Suspected phaeochromocytomaSuspected phaeochromocytoma Consider if:Consider if:

– Unusual signs and symptomsUnusual signs and symptoms– Suspected secondary causeSuspected secondary cause– Symptoms of postural hypotensionSymptoms of postural hypotension– Management depends critically on Management depends critically on

accurate estimation of BPaccurate estimation of BP

Routine investigationsRoutine investigations

Cardiovascular risk stratificationCardiovascular risk stratification Urine strip for protein and blood Urine strip for protein and blood U&E U&E Fasting blood glucose Fasting blood glucose Fasting lipidsFasting lipids 12-lead ECG12-lead ECG

Conservative TreatmentConservative Treatment

Diet and exerciseDiet and exercise Reduce caffeine intakeReduce caffeine intake Reduce salt intakeReduce salt intake Offer smokers cessation adviceOffer smokers cessation advice Make patients aware of local Make patients aware of local

initiatives to help lifestyle etcinitiatives to help lifestyle etc

Medical TreatmentMedical Treatment

Beta BlockersBeta Blockers Evidence suggests less effective than Evidence suggests less effective than

other groups at reducing cardiovascular other groups at reducing cardiovascular risk and diabetesrisk and diabetes

Maybe useful in:Maybe useful in:– Women of child bearing ageWomen of child bearing age– Evidence of raised sympathetic driveEvidence of raised sympathetic drive– Intolerance to other meds such as ACE IIntolerance to other meds such as ACE I

If already taking and need second drug If already taking and need second drug add calcium channel antagonist add calcium channel antagonist

Don’t withdraw if taking for other reasons Don’t withdraw if taking for other reasons eg AF, Post MIeg AF, Post MI

Continuing treatmentContinuing treatment

Advise patient long term treatmentAdvise patient long term treatment If low cardiovascular risk and have If low cardiovascular risk and have

good control can be offered trial good control can be offered trial reduction but need followup.reduction but need followup.

Patient support groups availablePatient support groups available Annual review if well controlledAnnual review if well controlled

Secondary hypertensionSecondary hypertension 5% of all hypertensive patients5% of all hypertensive patients Suspect in those <35 yearsSuspect in those <35 years Obvious history or examination to Obvious history or examination to

suggest secondary causesuggest secondary cause Maybe due to :Maybe due to :

– Renal causesRenal causes– Endocrine diseaseEndocrine disease– Pregnancy Pregnancy – Miscellaneous including drugsMiscellaneous including drugs

Renal CausesRenal Causes Parenchymal disease:Parenchymal disease:

– chronic renal failure of any kind chronic renal failure of any kind – glomerulonephritis glomerulonephritis – chronic pyelonephritis chronic pyelonephritis – analgesic nephropathy analgesic nephropathy – diabetic nephropathy diabetic nephropathy – polycystic disease polycystic disease – tumours e.g. Wilm's tumourtumours e.g. Wilm's tumour

Arterial disease:Arterial disease:– renal artery atherosclerosis / stenosis renal artery atherosclerosis / stenosis – renal artery embolism renal artery embolism – fibromuscular dysplasia fibromuscular dysplasia – polyarteritis nodosa polyarteritis nodosa

Endocrine and metabolic Endocrine and metabolic causescauses

Cushing's syndrome Cushing's syndrome Conn's syndrome Conn's syndrome Phaeochromocytoma Phaeochromocytoma Acromegaly Acromegaly Diabetes mellitus Diabetes mellitus Hyperparathyroidism Hyperparathyroidism Enzyme defects - such as congenital Enzyme defects - such as congenital

adrenal hyperplasia adrenal hyperplasia Familial hyperaldosteronism type 1 Familial hyperaldosteronism type 1 Apparent mineralocorticoid excessApparent mineralocorticoid excess

Drugs Drugs Oestrogen-containing oral contraceptives Oestrogen-containing oral contraceptives NSAID's NSAID's Corticosteroids Corticosteroids Cyclosporin A Cyclosporin A Carbenoxalone and liquorice-containing Carbenoxalone and liquorice-containing

substances substances Erythropoietin Erythropoietin Ergotamine Ergotamine Monoamine oxidase inhibitors - with Monoamine oxidase inhibitors - with

tyramine-containing foods e.g. cheese tyramine-containing foods e.g. cheese Sympathomimetics e.g Sympathomimetics e.g

phenylpropanolamine, ephedrinephenylpropanolamine, ephedrine

OthersOthers

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

PHAEOCHROMOCYTOMAPHAEOCHROMOCYTOMA Arise from chromaffin cells mainly in Arise from chromaffin cells mainly in

adrenal medulla adrenal medulla Paragangliomas mainly at carotid Paragangliomas mainly at carotid

bifurcationbifurcation 0.1-0.2% all cases of hypertension0.1-0.2% all cases of hypertension Most secrete adrenaline and Most secrete adrenaline and

noradrenaline, some dopamine and noradrenaline, some dopamine and rarely ACTHrarely ACTH

10% Rule10% Rule 10% are extra-adrenal 10% are extra-adrenal 10% are bilateral, increasing to 70% 10% are bilateral, increasing to 70%

in familial cases in familial cases 10% are malignant, but the risk of 10% are malignant, but the risk of

malignancy in women is three fold malignancy in women is three fold that in men that in men

10% are multiple 10% are multiple 10% occur in children, but 25-30% of 10% occur in children, but 25-30% of

children have extra-adrenal and/or children have extra-adrenal and/or bilateral tumours bilateral tumours

Symptoms and signsSymptoms and signs HypertensionHypertension Headache Headache Palpitations Palpitations Tachycardia Tachycardia Sweating Sweating Anxiety Anxiety Panic attacks Panic attacks Tremor Tremor Nausea and vomiting Nausea and vomiting FeverFever

Be Suspicious…Be Suspicious… Hypertensive with orthostatic Hypertensive with orthostatic

hypotension and tachycardia hypotension and tachycardia Hypertensive whose symptoms Hypertensive whose symptoms

respond poorly to anti-hypertensive respond poorly to anti-hypertensive treatment treatment

Patient whose blood pressure Patient whose blood pressure fluctuates widely fluctuates widely

Hypertensive with cafe au lait spotsHypertensive with cafe au lait spots

Take Home MessagesTake Home Messages Never diagnose on single readingNever diagnose on single reading Be suspicious of secondary causes in Be suspicious of secondary causes in

<35 years<35 years Don’t panic about which drug group Don’t panic about which drug group

to use as most important thing is to to use as most important thing is to lower the BPlower the BP

In most cases you have time to be In most cases you have time to be sure of the diagnosissure of the diagnosis