Professional Documents
Culture Documents
hypertension
Charvis
is
reviewed
by
her
GP,
who
have
any
tendon
xanthomata
or
118
Part 2: Cases
of hypertension
<130
<85
High-normal
8589
130139
Grade 1 (mild)
9099
140159
Grade 2 (moderate)
100109
160179
Grade 3 (severe)
>100
>180
Chronic pyelonephritis
Adult polycystic kidney disease (autosomal
dominant, therefore there may be a positive
family history, see case 20)
Conns syndrome
Phaeochromocytoma
Acromegaly
Diabetes mellitus
Drugs
Corticosteroids
Erythropoietin
Fludrocortisone
Non-steroidal anti-inammatory drugs
Oral contraceptive
Sympathomimetics (in some cold cures)
Liquorice
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-
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).
P AR T 2: CASES
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).
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?
CO = SVxHR
-blockers
Ca2+ channel blockers
ACEI
ARB
ACEI
Diuretics
-blockers
Which anti-hypertensives
might you start Mrs Charvis
on?
MAP = COxTPR
< 55 years
Step 1
C or D
Step 2
A + C or A + D
Step 3
A+C+D
Step 4
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
P AR T 2: CASES
Indications
Caution/contraindications
ACEI
Pregnancy
Renovascular disease/renal artery stenosis (RAS)
(young, black males tend to have a poor
response)
ARB
Pregnancy
Renovascular disease/RAS
-Blockers
-Blockers
Post MI
Angina
Postural hypotension
Urinary incontinence
Asthma /COPD
Peripheral vascular disease
Heart block
Elderly
Angina
Thiazide diuretics
Elderly
Isolated systolic hypertension
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
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.
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
125