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HYPERTENSION (HYPERTENSIVE EMERGENCIES (CLINICAL FEATURES (SYSTEMIC…

- - - - MYOCARDIAL
        
        chest pain/dyspnoea/myocardial ischaemia or infarction
      - RENAL
        
        oligouria/polyuria
      - RETINAL
        
        visual disturbance
      - HAEMATOLOGICAL
        
        disseminated intravascular coagulopathy (DIC) causing bleeding
      - CEREBRAL
        
        headaches/dizziness/seizures/altered consciousness/stroke
    - - severe hypertension >180/110
      - neurological deficits
      - retinal changes (haemorrhages, papilloedema)
  - - - Blood tests: FBC, U&Es, creatinine, TFTs
      - Urine dipstick + MC: proteinuria and haematuria suggest renal damage
      - ECG: to exclude MI and ischaemia and evaluate for end-organ damage eg LVH
      - CXR: to exclude aortic dissection and complications of MI or HTN itself: both HTN and an MI may cause for eg LV dysfunction and HF
      - fundoscopy to examine for papilloedema or retinal haemorrhages
    - - Plasma aldosterone and renin levels: to exclude hyperaldosteronism
      - 24hr urinary free cortisol excretion measurement (twice) and/or the overnight 1mg dexamethosone suppression test if suspected Cushing's syndrome
      - urine/plasma metanephrine: if suspected phaeochromocytoma (triad of headache, palpitations and HTN)
      - coarctation of the aorta - BP measurement of upper and lower limbs (typically higher in upper and low in lower); echo can establish presence and severity; MRI/CT can localise and grade and assess presence of collaterals
      - CT head: if neurological deficit or symptoms to exclude intracranial haemorrhage
  - - - others: labetalol, nicardipine and fenoldupam
      - IV can be changed to oral once bp is controlled
      - nitroprusside most commonly used
- - - - cardiac contractility and pumping pressure
      - blood vessel tone and systemic resistance
      - intravascular volume regulation, controlled by the kidneys
      - hormones - which control the other 3 mechanisms
  - - - defects in hormonal regulation of bp such as RAAS
      - hormonal regulation anomalies are the target of a host of antihypertensive medications including ACEi and diuretics
      - microvascular and tubulointerstitial kidney drainage due to HTN
  - - - baroreceptor desensitisation
      - reduced levels of vasodilators, inc levels of vasoconstricors by endothelium
      - adrenal dysfunction leading to leaking or poor regulation of catecholamines
      - hyper-responsiveness of blood vessels to catecholamines
      - CNS dysfunction - inc sympathetic tone, abnormal stress responses and abnormal responses to impulses from baro- and vol receptors
      - renal dysfunction: RAAS dysregulation
  - - - Parenchymal damage to the kidney causes: reduced Na and water excretion; increased intravascular volume and cardiac output
      - stenosis of the renal arteries due to atherosclerosis or fibromuscular dysplasia causes: dec renal perfusion, inc renin prod, inc ang II and aldosterone levels, vasoconc, inc Na and water retention
    - - Coarctation of aorta: obstruct BF to kidneys, stimulate RAAS; inc bp flow in area adjacent to aortic narrowing, lead to accelerated atherosclerosis and stiffening of aorta. Baroreceptor response to raised arterial pressure is lost
    - - Conn's syndrome - secrete excess mineralocorticoids (primary aldosteronism) - inc reabsorption of Na at distal convoluted tubule and collecting duct. Inc K+ excretion in the urine
      - Cushing's disease or syndrome - excess glucocorticoids - they stimulate RAAS hormone production
      - Phaeochromocytoma: secrete catecholamine - excess of this causes vasoconstriction and tachycardia (sympathetic activation)
- - - - pts <80 yrs with stage 1 HTN who have target organ damage, CV or renal disease or diabetes
      - pts with stage 2 HTN, regardless of age
    - - accelerated HTN (>180/100 with papilloedema and/or retinal haemorrhage)
      - suspected phaeochromocytoma (headaches, diaphoresis, palpitation)
    - - Over 80yrs old: CBP <150/90
      - diabetics: CBP <130/80
      - under 80yrs old: CBP <140/90mmHg
  - - - Combination: CCB & ACEi or ARB - if intolerant to CCB offfer thiazide like diuretic
    - - Triple combo - ACEi/ARB, CCB and thiazide-like diuretic
    - - <55 = ACEi. ARB if intolerant. never combine both
      - 55/AfroCarrib = CCB. add thiazide-like diuretic if develop SE (periph oedema) or evidence of HF or high risk of failure
    - - consider further diuretic therapy
        
        if K+ <4.5mmol/L = low dose spirinolcatone, with electrolyte monitoring if poor renal function (Risk of hyperkalaemia)
        
        if K+ >4,5 = high dose thiazide like diuretic
      - if diuretic therapy is not tolerated = alpha (such as doxazosin) or B blocker
- - - - RENAL DISEASE - palpable kidneys, audible renal bruit (Suggestive of renovascular disease)
      - ENDOCRINE CAUSES - cushingoid features - facial swellings, weight gain, abdo striae; look and feel for an enlarged thyroid; acromegaly: prognathia, large hands and tongue (macroglossia)
      - OTHER: weak or delayed femoral pulses may indicate coarctation of aorta
      - HTN pts will commonly have signs of hypertensive retinopathy, arteriosclerosis, flame haemorrhages, papilloedema
- - - - renal US
      - ECG - may indicate LV hypertrophy and evidence of IHD
      - urea, creatinine, electrolytes and eGFR to assess renal function
      - ECHO
      - urine dipstick for blood and protein to detect renal pathology
    - - fasting blood glucose - diabetes mellitus
      - fasting serum total and lipid profiling - hypercholesterolaemia
    - - 24HR urinary metanephrines -phaochromocytoma
      - urinary free cortisol. dexamethasone suppression test - Cushing's
      - renin/aldosterone levels - conn's syndrome (a low K+ and high Na will also help support this diagnosis)
- - - - Conn's and Cushing's syndromes
      - glucocorticoid remediable HTN
      - pjaeochromocytoma
      - ACROMEGALY
      - hyperparathyroidism
    - - preg induced HTN
      - aortic coarctation
      - PET
      - obesity
      - excessive dietary salt
      - drugs eg NSAIDs, sympathomimetics, illicit stimulants such as amphetamine, MDMA and cocaine
    - - diabetic nephropathy
      - renovascular disease
      - glomerulonephritis
      - vasculitides
      - chronic pyelonephritis
      - polycystic kidneys