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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
  • 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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