Hypertension

>140/90 mmHg ABPM or on 3 occasions

Classification:
- By cause
o Primary (essential idiopathic)
o Secondary
Renal (renal parenchymal disease, pyelonephritis,
glomerulonephritis, polycystic kidneys)
Endocrine (pheochromocytoma, Cushings,
hyperthyroid/parathyroid, Conns, hypercalcemia)
Pregnancy (due to increase in blood volume, heart rate and
PVR monitor closely for pre-eclampsia)
Drugs (Steroids, MAOI, lithium, NSAIDs, cocaine, oesterogen,
amphetamines, alcohol, decongestants)
Vascular (aortic coarctation, renal artery stenosis)

- By severity
o Sustained hypertension (confirm within 2 months)
o Isolated systolic hypertension: (>140 S, D <90) common x2
MI risk, x3 CVA risk
o Accelerated hypertension: Recent increase on top of previous
hptn + fundoscopy changes WITHOUT papilloedema (reassess in 1-7
days)
o Malignant hypertension: Rapid rise in BP (>200/130) -
headaches, confusion, seizures, visual changes bilateral retinal
changes + papilloedema. Causes fibrinoid necrosis, renal (high
creatinine)/cardiac failures, hypertensive encephalopathy
Presentation:
- Majority asymptomatic, universal screening required
- Hypertensive encephalopathy: altered mental status, headache,
seizures, visual disturbances, retinopathy, papilloedema
- Hypertensive retinopathy:

Grad Definition Image

e
I Silver wiring
and vascular
tortuosities

II I + AV
nipping
(irregular
tight
constrictions
)
 III II + retinal
oedema,
flame
haemorrhag
es, cotton-
wool spots

IV III + macular
star, optic
disc oedema
(papilloedem
a)

- Renal: oliguria, palpable kidneys

- Vascular: radiofemoral delay, renal bruit
- Endocrine:
o Pheochromocytoma: Headaches, palpitations, tremors,
diaphoresis, nausea, weight loss, constipation, anxiety, abdo-pain,
hypertension, diabetes, pallor, fever, ileus
o Cushings: Central obesity, proximal wasting, moon face, striae,
dry skin, easy bruising, poor wound healing, infections,
hypertension, depression
o Hyperthyroidism: Weight loss, high temp, HR, tremor, agitation,
hyperreflexia, exophthalmos, thyroid bruit, soft thyroid swelling.
o Conns: Spontaneous unprovoked hyperkalemia, refractory hptn,
weakness, abdo distension
o Drug abuse: Euphoric, agitation, hallucinations, track marks,
tachyarrhythmias, hyperthermia, tremors,
 - Other cardiovascular risk factors: Family history, obesity,
dyslipidemia, male, age, high salt intake, smoking, sedentary lifestyle
Actions:
- Assess CV risk fasting lipids
- Look for end organ damage
- Consider 24 hour ambulatory monitoring if unclear, borderline, end-organ
damage despite treatment.
- Exclude secondary causes U&E, Ca2+, 24 hour urine cortisol etc
- End organ damage assessment echo (LV hypertrophy), renal US, contrast
- CT (coarctation)

Management:
Lifestyle modification:
1. Exercise:
a. Regular exercise reduces SBP by 4mmHg on average
b. Review required before start for pts with grade III+, poorly
controlled diabetes, angina, other acute illness
2. Smoking cessation: reduces overall CV risk, 3-5 minute brief intervention,
pharmacotherapy
3. Diet control:
a. Reduce salt to 4gms/day (4-5mmHg drop SBP)
b. Fruit and vegetable intake
c. Increase dietary K+ for non-renal pts (4-8 mmHg drop SBP)
4. Weight reduction:
a. 1mmHg SBP drop/% body weight lost (6-10 mmHg drop with 10kg)
b. Aim for waist circumference <94cm male, <80cm female
5. Limit alcohol consumption

Anti-hypertensive therapy:
Whom to medicate?
- Usually treated with other CVD risk factors
- Medicate all patients over grade III
- Medicate all patients with end organ damage
- >180/110 mmHg pts need immediate antihypertensive therapy
- Isolated systolic hptn + widened pulse pressure (>160 S, <70 D)
- Low threshold in indigenous pts
Whom to medicate:
Follow up:
Common Antihypertensives and Dosages

Class Generic Name Trade Dosage Notes

Name(s)
ACE Inhibitor Preindopril Coversyl 5 10 mg Cough
arginine daily
Angiotensin II Irbesartan Avapro 150-300 mg
receptor daily
antagonist
Ca2+ channel Amlodipine Nordip 2.5 10 mg
antagonist daily
(dihydropyridi
ne)
Ca2+ channel Verapamil Anpec 120-240 mg Avoid with
blocker (non- daily beta blocker
dihydropyridi Heart block
ne)
Beta blocker Atenolol Noten 25 100 mg Avoid with
daily verapamil
heart block
Thiazide Hydrochlorothia Dithiazide 12.5 25 mg
diuretic zide daily
Alpha-2 Clonidine Catapres 50 300 mg Ortho-hypo,
agonist daily somnolence
Methyldopa Hydopa 125 500 Depression,
mg daily anxiety
Used in
pregnancy
hptn with
hydralazine

Other considerations:
- Commence antihypertensive therapy 1-2 weeks post-stroke (ACEIs, ARBs,
thiazide diuretics most effective post-stroke)
- CCF ACEIs and beta blockers+diuretics most effective in prevention,
consider spironolactone
Counselling points:
- DBP reduction of 5mmHg reduces 5 year stroke risk by 40%
- Hptn is the most common cause of heart failure, control reduces risk
- Reinforce lifestyle modification as major part of treatment