HYPERTENSION Lesley Ashby

DEFINITION NICE define hypertension as persistent raised blood pressure above 140/90 mmHg NICE define hypertension as persistent raised blood pressure above 140/90 mmHg 95% have essential hypertension 95% have essential hypertension 5% due to secondary cause 5% due to secondary cause Screening very important as common, often asymptomatic and has serious complications Screening very important as common, often asymptomatic and has serious complications

ESSENTIAL HYPERTENSION Hypertension without a demonstrable cause and is a diagnosis of exclusion Hypertension without a demonstrable cause and is a diagnosis of exclusion Affects 20% middle aged population Affects 20% middle aged population 97% treated and supervised by GP 97% treated and supervised by GP Target BP in non diabetics 140/90 Target BP in non diabetics 140/90 Type 2 diabetics <140/80 unless microalbuminuria <135/75 Type 2 diabetics <140/80 unless microalbuminuria <135/75 Type 1 diabetics <135/85 unless nephropathy <130/80 Type 1 diabetics <135/85 unless nephropathy <130/80

CATEGORY SYSTOLIC BLOOD PRESSURE (MMHG) DIASTOLIC BLOOD PRESSURE (MMHG) Optimal < 120 < 80 Normal < 130 < 85 High normal Hypertension mild (grade 1) moderate (grade 2) severe (grade 3) >= 180 >= 110 Isolated Systolic Hypertension grade 1 > < 90 grade 2 >= 160 < 90

Aetiology Genetic factors Genetic factors Dietary factors: Dietary factors: –High salt –Low calcium –High caffeine Oral contraceptives Oral contraceptives Hormone replacement therapy Hormone replacement therapy Role of the sympathetic nervous system Role of the sympathetic nervous system Role of the kidney, in particular vasopressin Role of the kidney, in particular vasopressin

Assessment of BP Never diagnose HTN on one single reading. Never diagnose HTN on one single reading. If possible repeat at end of consultation If possible repeat at end of consultation Need 3 elevated readings at monthly intervals unless patient has severe HTN Need 3 elevated readings at monthly intervals unless patient has severe HTN Home monitoring or ambulatory BP measurements not recommended Home monitoring or ambulatory BP measurements not recommended

Refer or not to refer?? Refer immediately if signs Refer immediately if signs –Accelerated HTN eg >180/110, papilloedema +/- retinal heamorrhage –Suspected phaeochromocytoma Consider if: Consider if: –Unusual signs and symptoms –Suspected secondary cause –Symptoms of postural hypotension –Management depends critically on accurate estimation of BP

Routine investigations Cardiovascular risk stratification Cardiovascular 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 lipids Fasting lipids 12-lead ECG 12-lead ECG

Conservative Treatment Diet and exercise Diet and exercise Reduce caffeine intake Reduce caffeine intake Reduce salt intake Reduce salt intake Offer smokers cessation advice Offer smokers cessation advice Make patients aware of local initiatives to help lifestyle etc Make patients aware of local initiatives to help lifestyle etc

Medical Treatment

Beta Blockers Evidence suggests less effective than other groups at reducing cardiovascular risk and diabetes Evidence suggests less effective than other groups at reducing cardiovascular risk and diabetes Maybe useful in: Maybe useful in: –Women of child bearing age –Evidence of raised sympathetic drive –Intolerance to other meds such as ACE I If already taking and need second drug add calcium channel antagonist If already taking and need second drug add calcium channel antagonist Don’t withdraw if taking for other reasons eg AF, Post MI Don’t withdraw if taking for other reasons eg AF, Post MI

Continuing treatment Advise patient long term treatment Advise patient long term treatment If low cardiovascular risk and have good control can be offered trial reduction but need followup. If low cardiovascular risk and have good control can be offered trial reduction but need followup. Patient support groups available Patient support groups available Annual review if well controlled Annual review if well controlled

Secondary hypertension 5% of all hypertensive patients 5% of all hypertensive patients Suspect in those <35 years Suspect in those <35 years Obvious history or examination to suggest secondary cause Obvious history or examination to suggest secondary cause Maybe due to : Maybe due to : –Renal causes –Endocrine disease –Pregnancy –Miscellaneous including drugs

Renal Causes Parenchymal disease: Parenchymal disease: –chronic renal failure of any kind –glomerulonephritis –chronic pyelonephritis –analgesic nephropathy –diabetic nephropathy –polycystic disease –tumours e.g. Wilm's tumour Arterial disease: Arterial disease: –renal artery atherosclerosis / stenosis –renal artery embolism –fibromuscular dysplasia –polyarteritis nodosa

Endocrine and metabolic causes 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 adrenal hyperplasia Enzyme defects - such as congenital adrenal hyperplasia Familial hyperaldosteronism type 1 Familial hyperaldosteronism type 1 Apparent mineralocorticoid excess Apparent mineralocorticoid excess

Drugs Oestrogen-containing oral contraceptives Oestrogen-containing oral contraceptives NSAID's NSAID's Corticosteroids Corticosteroids Cyclosporin A Cyclosporin A Carbenoxalone and liquorice-containing substances Carbenoxalone and liquorice-containing substances Erythropoietin Erythropoietin Ergotamine Ergotamine Monoamine oxidase inhibitors - with tyramine- containing foods e.g. cheese Monoamine oxidase inhibitors - with tyramine- containing foods e.g. cheese Sympathomimetics e.g phenylpropanolamine, ephedrine Sympathomimetics e.g phenylpropanolamine, ephedrine

Others 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

PHAEOCHROMOCYTOMA Arise from chromaffin cells mainly in adrenal medulla Arise from chromaffin cells mainly in adrenal medulla Paragangliomas mainly at carotid bifurcation Paragangliomas mainly at carotid bifurcation % all cases of hypertension % all cases of hypertension Most secrete adrenaline and noradrenaline, some dopamine and rarely ACTH Most secrete adrenaline and noradrenaline, some dopamine and rarely ACTH

10% Rule 10% are extra-adrenal 10% are extra-adrenal 10% are bilateral, increasing to 70% in familial cases 10% are bilateral, increasing to 70% in familial cases 10% are malignant, but the risk of malignancy in women is three fold that in men 10% are malignant, but the risk of malignancy in women is three fold that in men 10% are multiple 10% are multiple 10% occur in children, but 25-30% of children have extra-adrenal and/or bilateral tumours 10% occur in children, but 25-30% of children have extra-adrenal and/or bilateral tumours

Symptoms and signs Hypertension Hypertension Headache Headache Palpitations Palpitations Tachycardia Tachycardia Sweating Sweating Anxiety Anxiety Panic attacks Panic attacks Tremor Tremor Nausea and vomiting Nausea and vomiting Fever Fever

Be Suspicious… Hypertensive with orthostatic hypotension and tachycardia Hypertensive with orthostatic hypotension and tachycardia Hypertensive whose symptoms respond poorly to anti-hypertensive treatment Hypertensive whose symptoms respond poorly to anti-hypertensive treatment Patient whose blood pressure fluctuates widely Patient whose blood pressure fluctuates widely Hypertensive with cafe au lait spots Hypertensive with cafe au lait spots

Take Home Messages Never diagnose on single reading Never diagnose on single reading Be suspicious of secondary causes in <35 years Be suspicious of secondary causes in <35 years Don’t panic about which drug group to use as most important thing is to lower the BP Don’t panic about which drug group to use as most important thing is to lower the BP In most cases you have time to be sure of the diagnosis In most cases you have time to be sure of the diagnosis