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Haemodynamic Dysfunction
 
Haemodynamic Dysfunction
 

Essential Hypertension

 
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Overview

    • Classification

      Hypertension is defined as persistently elevated blood pressure, based on at least two readings over at least two visits.
    • Normal <120 / 80
    • Pre-hypertension 120 / 80 - 139 / 89
    • Stage I hypertension 140 / 90 - 159 / 99
    • Stage II hypertension >160 / 100

Pathogenesis

    • Causes of Hypertension

    • Primary

    • Primary (essential) hypertension: chronically elevated blood pressure of unknown aetiology (the most common cause of hypertension in the community)
    • Secondary

    • Chronic kidney disease
    • Renovascular - fibromuscular dysplasia, atherosclerosis
    • Endocrine - hyperthyroidism, hypothyroidism, Cushing’s syndrome, primary aldosteronism, phaeochromocytoma, hyperparathyroidism
    • Drugs - NSAIDs, amphetamines, glucocorticoids, fludrocortisone, erythropoietin, VEGF inhibitors, calcineurin inhibitors
    • Aortic coarctation
    • Obstructive sleep apnoea
    • Factitious

    • White coat hypertension: falsely elevated blood pressure may occur due to by anxiety in a healthcare setting, recent exercise or recent caffeine intake.
    • Recent exercise or caffeine intake

Manifestations

    • Complications of Hypertension

    • Cardiovascular - left ventricular hypertrophy, heart failure, ischaemic heart disease, peripheral vascular disease, arrhythmia
    • Cerebrovascular - ischaemic stroke, haemorrhagic stroke, posterior reversible encephalopathy syndrome
    • Hypertensive retinopathy
    • Hypertensive nephropathy
    • Erectile dysfunction

Management

    • Management Options

    • Non-Pharmacologic

    • Diet - low in salt
    • Exercise - increase incidental exercise and reduce sedentary time
    • Smoking cessation
    • Alcohol reduction
    • Pharmacologic

    • ACE inhibitors (ACEi) - captopril, ramipril, perindopril
    • Angiotensin II receptor blockers (ARBs) - candesartan, irbesartan
    • Calcium channel blockers (CCBs) - amlodipine
    • Thiazides - hydrochlorothiazide
    • Aldosterone antagonists - spironolactone
    • Alpha blockers - prazosin
    • Common Blood Pressure Targets

    • Most patients: ≤140/90
    • Diabetics: ≤130/80
  •  
    Cardiovascular Drugs
    • Pearls

    • Set realistic targets
    • Use non-pharmacologic and pharmacologic strategies
    • Titrate medications to the patient’s blood pressure and side effects, e.g. electrolytes / renal function (ACEi / ARBs), cough (ACEi), oedema (CCBs)
    • Titrate up to the maximum dose of an antihypertensive before adding an additional medication
    • If the patient’s blood pressure is not responding: consider white coat hypertension, non-adherence or secondary causes
 
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