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A 50-year-old woman with

hypertension

Mrs Colleen Charvis is a 50-year-old factory


worker who attends her GP practice after
an employment medical showed a BP of
165/95 mmHg.
Is this one-off reading sufcient
to diagnose Mrs Charvis with
hypertension?

No. There should be at least 23 readings which are


con- sistently high. Every effort should be made to
measure blood pressure accurately. Ideally, the patient
should be relaxed.
Mrs Charvis comes to see the practice nurse
on two separate occasions, 1 month apart,
to have her BP checked. On the rst occasion
it is 155/90 mmHg, on the second it is
165/95 mmHg.
How would you classify
this blood pressure?

Blood pressure is classied according to Table 15.1. If


systolic BP and diastolic BP fall into different
categories then the higher category should be taken.
Mrs

Charvis

is

reviewed

by

her

GP,

who

decides that she has Grade 2 (moderate)


hypertension and that this is most likely to be
essential (primary) hypertension.
What questions should the GP cover
in this consultation?

Ninety-ve percent of patients who present with


elevated blood pressure have essential hypertension
(EH). In <5%

there is an underlying cause. Risk factors for EH include:


increasing age
BMI >25
sedentary lifestyle (on average less than 30 minutes of
brisk exercise/day)
high alcohol intake (>3 units/day (men), 2 units/day
(women))
salt intake greater than 6.0 g/day (2.g of sodium)
environmental stressors.
Are there any symptoms or signs
which might indicate a secondary
cause for hypertension?

As stated above, the majority of patients with high blood


pressure will have EH. However, in younger patients
(<40 years) or in those with severe hypertension, a
secondary cause should be sought. Secondary causes of
hypertension are listed in Box 15.1 and are mainly
due to renal disease (renovascular or chronic kidney
disease of any cause), endocrine diseases which affect
renal sodium excretion, e.g. Cushings disease, or
pregnancy.
Mrs Charvis works in an electronics factory.
Her job largely involves sitting down. She
does no regular exercise and smokes 20
cigarettes/day. She tells you that she only
drinks on weekends, and then only a gin
and tonic or two on a Saturday night. She
has no past medical history, and rarely
attends the GP surgery. On examination, Mrs
Charvis is a
portly lady with a BMI of 32 kg/m2. She does
not

have

any

tendon

xanthomata

or

xanthelasma visible. Her pulse is 90 bpm and


regular, JVP is not elevated. Her apex beat is
difcult to palpate but her heart sounds are

Nephrology: Clinical Cases Uncovered. By M.


Clatworthy. Published 2010 by Blackwell
Publishing.

audible. There is a soft systolic murmur at the


lower left sternal edge which

118

Part 2: Cases

does not radiate. Chest is slightly hyperinated

including AV nipping and ame

but clear to auscultation. Abdominally, there is a

haemorrhagesTable.1 BHS classication

central distribution of adiposity but no

of hypertension

organomegaly or masses, and no audible bruits.


Systolic BP
(mmHg)

Her fundi have retinal changes consistent with


Grade 3 hypertensive retinopathy (see Box 2),
Normal

<130
<85

High-normal
8589

130139

Grade 1 (mild)
9099

140159

Grade 2 (moderate)
100109

160179

Grade 3 (severe)
>100

>180

Box 1 Secondary causes of hypertension


Renal diseases

CKD of any cause


Renal artery stenosis (due to atheromatous
disease in
90% of cases and bromuscular dysplasia in
10% of cases, usually young women)

Chronic pyelonephritis
Adult polycystic kidney disease (autosomal
dominant, therefore there may be a positive
family history, see case 20)

Acute glomerulonephritis (hypertension is one of


the
presenting features of nephritic syndrome, seen
in IgA

Conns syndrome
Phaeochromocytoma
Acromegaly
Diabetes mellitus

Drugs

Corticosteroids
Erythropoietin
Fludrocortisone
Non-steroidal anti-inammatory drugs
Oral contraceptive
Sympathomimetics (in some cold cures)
Liquorice

nephropathy, postinfectious GN, lupus nephritis)

Autoimmune diseases vasculitis (particularly


polyarteritis nodosa (PAN)), systemic sclerosis
(can present with scleroderma crisis in which
there is accelerated hypertension)

Pregnancy

Pre-eclampsia
Eclampsia
Haemolysis, elevated liver enzymes, low platelets (HELLP)

Endocrine disease

Cushings syndrome

(a)

(b)

Figure 1 (a) Retinal changes in malignant hypertension including papilloedema and ame haemorrhage Grade
4 retinopathy. A normal retina is shown in (b) for comparison.

P AR T 2: CASES

P AR T 2: CASES

Diastolic BP
(mmHg)

The heart
Chronic hypertension provides an increased pressure
against which the left ventricle (LV) must pump. Like
any other muscle consistently exercised, it will
hypertrophy. Left ventricular hypertrophy (LVH) can
be detectable clinically as a hyperdynamic, heaving apex
beat (the term
heaving is usually used to describe a pressure-over-

Box 2 Retinal changes in hypertensive


retinopathy
Grade 1
Silver wiring and AV nipping (vein is squashed/nipped
by thickened artery)
Narrowing of retinal arterioles (normal ratio of
artery : vein is 1/1.1)
Grade 2
Variable calibre of retinal arterioles (areas of constriction
and dilation)
Grade 3
Haemorrhages ame haemorrhages and blot
haemorrhages
Cotton wool exudates
Grade 4
Papilloedema consistent with malignant hypertension
(Figure 1a)

loaded LV and the term thrusting to describe a volumeoverloaded LV). The ECG may show signs of left axis
deviation and LVH (sum of S in V1/2+ R in V5/6
>35 mm) (Box 3) and there may be cardiomegaly on
CXR. As LVH progresses, the cardiac muscle may outstrip its blood supply, leading to ischaemic cardiomyopathy and LV dilation. The apex beat may then become
displaced from its normal position in the fth intercostal
space, midclavicular line. If there is signicant LV dilation, then cardiomegaly becomes readily visible on CXR
(Figure 2).
The kidneys
Hypertension is a major cause of CKD. Typical biopsy
changes include thickening of arterioles and interstitial
brosis in advanced disease (Figure 3).

Box 3 ECG changes associated with chronic


hypertension
Left ventricular hypertrophy sum of S in V1or V2 + R
in V5 or V6 >35 mm

Left axis deviation (LAD) a simple way to determine


this is to look at whether the complexes are
predominantly downwards in II and III. If so, there is
likely to be LAD. To precisely determine axis, look at
leads I, II, III, aVR, aVL, aVF. The axis of the heart lies
at a right angle to the most isoelectric lead
Left heart strain pattern ST depression/T wave
inversion in V5/V6

Figure 2 A chest radiograph demonstrating cardiomegaly. Even

Figure 3 Renal biopsy showing an artery with intimal thickening

though this is an AP lm (and therefore not ideal to assess heart

which signicantly reduces the luminal diameter. Such changes

size), the cardiac shadow is abnormal and occupies signicantly

are typically seen in patients with chronic hypertension.

more than 50% of the total thoracic diameter.

P AR T 2: CASES

Chronic hypertension can also cause end-organ damage


elsewhere including the heart and kidneys.

II

III

aVR

V1

V4

aVL

V2

V5

aVF

V3

V6

P AR T 2: CASES

II

Figure 4 An ECG demonstrating changes of left ventricular hypertrophy (sum of S in V2+R in V5 >35 mm).

What investigations would


you perform?

Routine investigations in hypertension include:


Urine dipstick for blood and protein which may indicate CKD
serum creatinine and electrolytes
blood glucose (assess for impaired glucose tolerance or
diabetes)
serum total cholesterol/HDL ratio
ECG.
Investigations show:
Hb 12.1 g/dL, WBC 6.2 109/L, Platelets
259 109/L U+E: Na 139 mmol/L, K
4.5,mmol/L, Urea 6.3 mmol/L, Creatinine
88 mol/L (eGFR = 63 mL/min/1.73 m2)
Glucose 5.8 mmol/L
Total cholesterol 5.7 mmol/L
Urine dipstick shows protein trace,
negative for blood, leucocytes, nitrite,
and glucose
Comment on Mrs Charvis ECG (Figure 4)
The ECG is in sinus rhythm but shows LVH (sum of S
in V2 + R in V5 >35 mm) and strain (T wave
inversion in V56, aVL).
Could lifestyle changes be effective in
reducing Mrs Charvis blood pressure?

Modifying lifestyle factors such as diet, alcohol intake


and exercise can signicantly lower blood pressure. In the

Dietary
Approaches
to
Stop
Hypertension
(DASH) study, hypertensive patients increased the fruit
and veg- etables in their diets from two to seven
portions per day and reduced the average systolic BP
by 7 mmHg and diastolic BP by 3 mmHg. If this is a
low-fat diet then the reduction achieved may be as
great as 11 mmHg in the systolic BP and 6 mmHg in
the diastolic BP.
Alcohol moderation to less than or equal to 21 units
in men and 14 units in women per week can reduce the
systolic BP by around 34 mmHg.
Weight loss is also associated with a reduction in the
systolic BP. For each 10 kg loss (above a BMI of 25
kg/m2) the expected fall in the systolic BP is 510
mmHg.
The current British Hypertension Society guidelines

recommend that younger patients should do three vigorous aerobic training sessions a week and older patients
should be encouraged to do 2030 minutes of brisk
walking as long as the blood pressure is mild/moderate
and reasonably well controlled. Examples of aerobic
activity include walking, cycling and swimming.
Dietary salt should be restricted to 6 g per day. This
equates to 2.4 g of sodium per day (1 g sodium = 2.5 g
of salt). Although food labels are often unclear, the
average salt intake for the general population is nearer
10 g.
Should Mrs Charvis
hypertension be treated?

Yes. Trials indicate that drug therapy should be offered


to patients with persistently raised blood pressure of
160/100 mmHg or more, or patients with blood pressure

Non-diabetic without CKD <140/85 mmHg


Diabetic without CKD <140/80 mmHg
Diabetic with CKD <125/75 mmHg
Non-diabetic with persistent proteinuria >1 g/24 h
<125/75 mmHg

of greater than 140/90 mmHg with either a raised


cardio- vascular disease risk or target organ damage.
In Mrs
Charvis case, the aim should be to get her BP to
<140/85 mmHg. Current British Hypertension
Society recommended targets are shown in Box 15.4.

Given her additional cardiovascular risk factors,


Mr Charvis is also commenced on aspirin 75
mg and a statin to reduce cholesterol.
What is malignant hypertension?

Malignant hypertension is said to occur when there is


severe diastolic hypertension (>120 mmHg) with Grade
3 or 4 retinopathy. Patients may have associated renal
impairment, proteinuria, encephalopathy or cardiac
failure. The characteristic histological feature on renal
biopsy is arterial brinoid necrosis. It is a medical

CO = SVxHR

Agents which reduce


intravascular volume:

-blockers
Ca2+ channel blockers
ACEI
ARB

Agents which reduce


heart rate:

ACEI
Diuretics

-blockers

Figure 5 The action of anti-hypertensive


agents.

Which anti-hypertensives
might you start Mrs Charvis
on?

Mrs Charvis should be started on an ACEI. She has a


reduced GFR and protein+ on dipstick (CKD stage 3),
therefore an ACEI has additional anti-proteinuric and
renal preservation benets. There are a number of
different classes of anti-hypertensive agents.

Angiotensin-converting enzyme inhibitors


(ACEI)
Angiotensin receptor II blockers
(ARB)
-Blockers
Calcium channel blockers
Diuretics (thiazide, potassium sparing)
-Blockers
Each class acts by reducing either CO (by lowering HR
or SV) or TPR (Figure 5).
The British Hypertension Society has provided
guidelines for the use of anti-hypertensives, which are
summarised in Figure 6. The indications and contraindications of different anti-hypertensive medications
are summarised in Table 2.

Agents which reduce


arterial vasoconstriction:

MAP = COxTPR

< 55 years

Step 1

> 55 years or black

C or D

Step 2

A + C or A + D

Step 3

A+C+D

Step 4

Add -blocker, -blocker

A = ACEI or ARB
C = calcium channel blocker
D = thiazide diuretic
Black = patient of Afro-Caribbean
descent

emergency and
requires
specialist management.

hospitalisation

and

P AR T 2: CASES

Box 4 Recommended targets for blood


pressure treatment

Figure 6 BHS new hypertension treatment


algorithm.

P AR T 2: CASES

Table 2 Indications and contraindications for antihypertensive medications


Class of drug

Indications

Caution/contraindications

ACEI

Patients with early CKD and proteinuria


Patients with LV dysfunction post MI
Diabetes mellitus

Pregnancy
Renovascular disease/renal artery stenosis (RAS)
(young, black males tend to have a poor
response)

ARB

Patients intolerant of ACEI


Diabetes mellitus

Pregnancy
Renovascular disease/RAS

-Blockers

Benign prostatic hypertrophy

-Blockers

Post MI
Angina

Postural hypotension
Urinary incontinence
Asthma /COPD
Peripheral vascular disease
Heart block

Calcium channel blockers

Elderly
Angina

Thiazide diuretics

Elderly
Isolated systolic hypertension

Can exacerbate peripheral oedema

Gout
Can worsen impaired glucose tolerance

C AS E R E V I E W
A 50-year-old lady presents with persistent
moderate hypertension and signs of endorgan damage with early retinopathy and
left ventricular hypertrophy. Secondary
causes of hypertension are considered
unlikely, given that

she has a number of risk factors for EH


including an increased BMI and sendentary
lifestyle. She is managed by giving lifestyle
advice (stop smoking, more exercise, lose
weight) and is started on
an ACEI.

KE Y POI NT S
Hypertension should not be diagnosed on a
one-off reading. There should be at least
two measurements, using an appropriate
sized cuff.

Blood pressure should be monitored every 5


years in all
adults until the age of 80 years. Those who are
known to have a high/normal BP (see Table 1)
should be monitored annually.

Ninety-ve percent of hypertension is essential


or primary,
with no obvious secondary cause. Risk factors
for EH include an increased BMI, older age,
high alcohol intake, high salt (sodium) intake,
sedentary lifestyle and environmental
stressors. Modication of these factors
can signicantly improve BP.

Hypertension is a major risk factor for other


morbidities. Specically:

CVA (7 increase)
coronary artery disease (3 increase)
cardiac failure (4 increase)
peripheral vascular disease (2 increase)
Treatment is advised if BP is persistently
>160/100 mmHg or >140/90 mmHg with
evidence of target organ damage. In diabetics,
treatment should be given if BP
>140/90 mmHg.
Start with an ACEI/ARB or -blocker (for <55
years, non-black) or a calcium channel
blocker or diuretic if
>55 years or Afro-Caribbean.
Consider giving aspirin and statins if there
are other cardiovascular risk factors.

Case 125
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