Hypertension

Hypertension is a serious community disorder and the most common condition requiring long-term

drug therapy.It is a silent killer because most people with hypertension are asymptomatic and unaware of their problem.Epidemiological studies have demonstrated the association between hypertension and stroke, coronary heart disease, kidney disease, heart failure and atrial fibrillation. Treatment may be lifelong, hence the need for careful work-up.

• Target organs (including some specific examples) that can be damaged by hypertension include the

heart (failure, LVH, ischaemic disease), the kidney (kidney insufficiency), the retina (retinopathy), the blood vessels (peripheral vascular disease, aortic dissection) and the brain (cerebrovascular disease).

Isolated systolic hypertension is that of ≥ 140 mmHg in the presence of a diastolic pressure <90 mmHg.
Category Systolic Diastolic
Normal <120 <80
High normal 120–139 80–89
Grade 1 hypertension (mild) 140–159 90–99
Grade 2 hypertension
(moderate)
160–179 100–109
Grade 3 hypertension (severe) ≥180 ≥110
Isolated systolic hypertension ≥140 <90

Clinical features	Likely cause
Abdominal systolic bruit	Kidney artery stenosis
Proteinuria, haematuria, casts	Glomerulonephritis
Bilateral kidney masses with or without haematuria	Polycystic disease
History of claudication and delayed femoral pulse	Coarctation of the aorta
Progressive nocturia, weakness	Primary aldosteronism (check serum potassium)
Paroxysmal hypertension with headache, pallor, sweating, palpitations	Phaeochromocytoma
truncal obesity with pigmented striae	Cushing's syndrome

Factors associated with the prognosis are age,smoking , diabetes , dyslipidemia ,family history, obesity,CRP,brain heart kidney eye vascular complications,target organ damage ( echo LVH, Urine MA/EGFR,angio/opthalmo evidence , socio economic , ethnic factors, sedentary life, alcohol.

Conn's syndrome: clinical features Weakness due to hypokalaemia Polyuria and polydypsia Na ↑, K ↓, alkalosis Aldosterone ↑ (serum and urine) Plasma renin ↓

Phaeochromocytoma: clinical features Paroxysms or spells of: hypertension headache (throbbing) sweating palpitations pallor/skin blanching rising sensation of tightness in upper chest and throat (angina can occur) Investigation: 24 hour urinary free catecholamines ↑ (VMA)

FH,MXH –OCP,HRT, Nasal decongests, NSAID , Steroids ,salt ,alcohol

G/A , BP Standing and sitting , PL RR O2 , H/W/BMI/Waist circumference

 Pallor cyanosis, dyspnea temperature Face Plathora, Alcohol abuse, Hyper LIP

Neck- Carotid bruit , Thyroid

Heart -HS,M, Added , Peripheral pulse , Apex ---  Chest - Crepts , wheeze ,

ABD- EPIGASTRIC BRUIT, H/S,

 Fundy HE, EXU, AVN,PAPD

Investigations - U FOR Cast, Cell, Protein, GLC,

RBS , FBC , RFT , LFT, SE, LP , SC, EGFR, S uric acid, ECG, Albumin/Creatinin ratio

SPC test- Atherosclerotic kidney artery stenosis – Dropler USS, ECHO, Carotid USS, Micro albuminuria, 24 hour proteinuria,  Fundoscopy.

Non pharmacological and pharmacological ……4-6 weeks take to act ADTC----- if end organ damage start drug straight away . some times for aboriginal

Systolic (mm Hg)	Diastolic (mm Hg)	Action/recommended follow-up *
< 120	< 80	Recheck in 2 years.
120 - 139	80 - 89	Recheck in 1 year - lifestyle advice.
140 - 159	90 - 99	* Confirm within 2 months - lifestyle advice.
160 - 179	100 - 109	* Evaluate or refer within 1 month - lifestyle advice.
≥ 180	≥ 110	* Further evaluate and refer within 1 week (or immediately depending on clinical situation). If blood pressure has been confirmed at ≥ 180 mm Hg systolic and/or ≥ 110 diastolic mm Hg (after multiple readings and excluding ‘white coat’ hypertension), drug treatment should be commenced.

Ambulatory blood pressure monitoring may distinguish from established from transient hypertension .Measurement of BP at home 

 SNAPS – caffeine no , salt no , MX OSA for 3 months

Start ACEI lower dose X rew 6 WK to 3 M ( take to work ) Ramipril ( 2.5 mg bd)

Still high add HCT if old or Nifidipin if 40- 50

Start lowest dose and allow 6- 12 weeks to work

Then increase one

If high BP record  BP twice a day for 1/52 home meter

Keep < 140/90 or < 120/ 80 if proteinuria

If 180 / 110 or 180/70  ( gap) treat straight away or aboriginal or proteinuria 

Say Cant go hospital --- Explain --à Still give antihypertensives and rew tomorrow

Aboriginal -  not sure come back so start drug

ACEI or ARB

How much you drop BP – DBP about 10 systolic about 20-30

Manage risk factures -  

dermatology

Author & Editor

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