Cardiovascular System

Hypertension (high blood pressure)

Essential
Isolated systolic
Iatrogenic
Secondary
Malignant/accelerated
Major risk factor for :

ischaemic and haemorrhagic stroke

myocardial infarction
heart failure
chronic kidney disease
cognitive decline
premature death

- Each 2mmHg rise in systolic blood pressure associated with a 7% increased risk
of mortality from ischaemic heart disease and a 10% increased risk of mortality
from stroke.
 Systolic pressure: the higher measurement when the
heart beats, pushing blood through the arteries

Diastolic pressure: the lower measurement when the

heart rests between beats
Essential hypertension
Primary / idiopathic hypertension
No known cause
About 95% of the cases
Multifactorial aetiology:
* Genetic factors
* Environmental factors (obesity; alcohol intake;
sodium intake)
Isolated systolic hypertension
diastolic (the bottom number of a blood pressure
measurement) less than 90 millimeters of mercury
(mm Hg) and a systolic number (the top number of a
blood pressure measurement) greater than 140 mm
Hg
Associated with two- to three- fold increase in cardiac
mortality
Found particularly in elderly hypertensives, since SBP
(systolic blood pressure) is known to rise with advancing
age, whereas DBP usually levels off and then tends to
decrease in the elderly
Iatrogenic hypertension
Iatrogenic - Due to the activity of a physician or therapy
White coat syndrome: phenomenon in which patients exhibit a blood
pressure level above the normal range, in a clinical setting, though
they don't exhibit it in other settings

Drug-induced hypertension: variety of drugs and chemical substances

have been shown to elevate blood pressure
- steroids
- oral contraceptives containing oestrogens
- immunosuppressive agents
- sympathomimetic agents
Secondary hypertension
Blood pressure elevation is the result of a specific and potentially treatable cause
(consequence of specific disease or abnormality leading to sodium retention and/or
peripheral vasoconstriction)

Found in about 5% of the cases

Renal disease:
- Polycystic kidney disease
- Renal vascular disease
- Diabetic nephropathy

Endocrine disease:
- Cushings syndrome
- Thyroid disease
- Acromegaly
- Phaeochromocytoma
Malignant hypertension
Occurs when blood pressure rises rapidly
Severe hypertension (diastolic BP >120mmHg)
Fibrinoid necrosis microvascular damage with necrosis in
walls of small arteries and arterioles
Causes rapidly progressive end organ damage (renal
failure; heart failure)
Retinopathy - Changes in retina (cotton wool spots, hard
exudates, papilloedema, haemorrhages)
High risk of cerebral oedema and haemorrhage with
resultant hypertensive encephalopathy
Diagnosis
If the clinic blood pressure is 140/90 mmHg or higher,
offer ABPM (ambulatory blood pressure monitor) to
confirm the diagnosis of hypertension
If a person is unable to tolerate ABPM, HBPM (home
blood pressure monitor) is a suitable alternative
Cardiovascular risk assessment
QRISK2 is the recommended formal risk assessment tool
to assess CVD risk
online assessment tool for estimating the 10-year risk of
having a cardiovascular event, in people who do not
already have heart disease
Adults aged 85 years and over and those with existing
CVD, type 1 diabetes, chronic kidney disease or familial
hypercholesterolaemia should be considered to be at an
increased risk of CVD events without using QRISK2
NICE guideline
References:
http://ndt.oxfordjournals.org/content/16/6/1095.full
https://www.nice.org.uk/guidance/cg127
https://cks.nice.org.uk/hypertension-not-diabetic
Kumar and Clarks Clinical medicine
Davidsons Principles and Practice of Medicine
HYPOTENSION
Orthostatic/Postural hypotension
Hypovolemic shock
Cardiogenic shock