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Hypertension - Coggle Diagram
Hypertension
Secondary Hypertension
Renal
- chronic pyelonephritis
- diabetic nephropathy - indicated by microalbuminuria or proteinuria
- Glomelulonephritis - often indicated by microscopic haematuria
- Polycystic kidney disease - suggested by abdominal or flank mass, micro haematuria or family history
- Obstructive uripathy - may have an abdominal or flank mass
- Renal cell carcinoma - classically haematuria, loin pain and a loin mass but asymptomatic renal cell CA can be identified incidentally on USS or CT
Vascular disorders
- Coarctation of the aorta - usually upper-limb HTN, can be significant difference in BP between arms. Other signs can include absent or weak femoral pulses, radio-femoral delay, palpable collateral blood vessels in the back muscles, and a suprasternal murmur radiating through to the back
- Renal artery stenosis - suspect if peripheral vascular disease and an abdominal bruit, or if HTN resistant to treatment
Endocrine Disorders
- Primary hyperaldosteronism - most common curable cause of HTN. Present with hypokalaemia, alkalosis and hypernatremia (Na >140mmol/l) or larger than expected drop in potassium using low-dose thiazide-type diuretic. Symptoms non-specific, rarely it presents with tetany, muscle weakness, nocturia or polyuria. Calcium-channel blocker can mask features . Identification of possible adrenal adenoma on CT or MRI with tertiary referral
-Phaeochromocytoma - present with intermittently high or labile BP, or postural hypotension, headaches, sweating attacks, palpitations or unexplained fever and abdominal pains. May be asymptomatic. Rarest but important cause of hypertension to diagnose as malignant transformation or catastrophic haemorrhage can be fatal
- Cushing's syndrome - suspect when clinical features present, rarely presents with hypertension alone
- Acromegaly - suspect if clinical features (enlargement of hands and feet, facial changes, sweating)
- Hypothyroidism - HTN may result from altered levels of renin, angiotensin and aldosterone, associated with increased diastolic BP. Clinical features include fatigue, weight gain, dry skin and hair loss, constipation and muscle weakness
- Hyperthyroidism - increased systolic BP may result. Clinical features include tremor, anxiety, sweating, weight loss, diarrhoea and heat intolerance
Drugs
- alcohol misuse - most common individual cause of secondary hypertension
Ciclosporin
- Cocaine and other substances of abuse
- Combined oral contraceptive
- Corticosteroids
- Erythropoietin
- Leflunomide
- Liquorice - present in some herbal medicines
- NSAIDs
- Sympathomimetics - may be found in OTC cough/cold remidies (ephedrine and phenylpropanolamine)
- Venlafaxine
Other
- Connective tissue disorders - (scleroderma, systemic lupus erythematosus, polyarteritis nodosa)
- Retroperitoneal fibrosis
Obstructive sleep apnoea
Investigation
Refer for same-day specialist investigation if:
- Signs of retinal haemorrhage and/or papilloedema
- Life-threatening symptoms such as new onset confusion, chest pain, signs of HF or AKI
- if target organ damage identified consider starting antihypertensive drug treatment immediately, without waiting for results of ABPM or HBPM
Assess for Target organ damage (TOD)
- test for haematuria
- Urine albumin:creatinine ratio/ urine dip for proteinuria
- HbA1C
- Electrolytes, creatinine and eGFR
- Examine fundi
- Arrange for 12 lead ECG (assess cardiac function and detect LV hypertrophy
- Lipid profile
Assign score for CVD
-
Classification
- optimal S <120 and D <80
- Normal S 120-129 and/or D 80-84
- High Normal S 130-139 and/or D 85-89
- Grade 1 HTN S 140-159 and/or D 90-99
- Grade 2 HTN S 160-179 and/or D 100-109
- Grade 3 HTN S >180 and/or D >110
- Isolated Systolic HTN S >140 and D <90
Complications
- Heart failure
- Coronary artery disease
- Stroke
- CKD
Peripheral arterial disease
- Vascular dementia
Management
Refer for same day assessment if clinical BP >180/120 with:
- Signs of retinal haemorrhage and/or papilloedema
- Life-threatening symptoms such as new onset confusion, chest pain, signs of HF or AKI
- Suspected phaeochromocytoma, e.g. labile BP or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis
Lifestyle measures - for all people with HTN or high normal
- Diet and exercise - Explain healthy diet and regular exercise can reduce BP. If overweight/obese offer weight loss advice
- Caffeine - discourage excessive consumption
- Dietary sodium - encourage to keep dietary sodium low by reducing or substituting (contraindicated in those with renal impairment including people on ACEi) sodium salt
-Smoking - offer advice and cessation support
- Alcohol - encourage reduced intake
High normal BP
- Lifestyle advice
- Consider drug treatment in very high risk patients with CVD especially coronary artery disease
-
Grade 1 HTN
- Lifestyle advice
- Immediate drug treatment in high or very high risk patients with CVD, CKD, or TOD
- Drug treatment in low-moderate risk patients without CVD, CKD or TOD after 3-6 months of lifestyle intervention if BP not controlled
-
Grade 2 HTN
- Lifestyle advice
- Immediate drug treatment in all patients
- aim for BP control within 3 months
-
Grade 3 HTN
- Lifestyle advice
- Immediate drug therapy in all patients
- aim for BP control within 3 months
Treatment
Step 1
- For people < 55yo not of a black African or Caribbean family origin offer a ACEi
- f ACEi not tolerated, e.g. due to cough, offer an ARB
- Do not combine ACEi with ARB
- For those >55 yo or BA/AC family origin offer a calcium channel blocker
-If not tolerated, e.g. oedema, offer thiazide-like diuretic such as indapamide, in preference to conventional thiazide diuretic (if adjusting existing treatment consider switch)
Step 2
Discuss with person if taking mediation as prescribed, support adherence to treatment
If HTN not controlled on step 1 with ACEi or ARB offer add:
- a CCB or
-a thiazide-like diuretic (Indapamide)
If HTN not controlled on step 1 with CCB offer add: - an ACEi or ARB (consider ARB in preference in BA/AC origin)
- a thiazide-like diuretic
Step 3 Review mediation and ensure being taken in optimally titrated doses, discuss adherence to treatment
If HTN not controlled with step 2 offer combination of:
- an ACEi or ARB and
- a CCB and
- a thiazide-like diuretic
Step 4
If HTN not controlled in people taking optimal doses of ACEi or ARB plus CCB and Thiazide-like diuretic regard them as having resistant hypertension
Before considering further treatment:
- confirm BP with ABPM or HBPM
-assess for postural hypotension
- discuss adherence to treatment
- in confirmed resistant hypotension seek specialist advice or add a fourth antihypertensive drug (low dose spironolactone if K <4.5mmol/l or alpha or beta-blocker if K >4.5mmol/l
BP targets on treatment
- aged < 80yo <140/90
- Aged > 80yo (use clinical judgement in frailty or comorbidity) <150/90
- Use standing BP readings if postural drop >20mmHg or symptoms of postural hypotension
Primary Hypertension
- about 90% of people with HTN
- no identifiable cause
Risk factors
- Age - BP tends to increase with advancing age
- Sex - up to age 65 women tend to have lower BP than men
- Ethnicity - people of black African or Africa-Caribbean origin more at risk of HTN
- Genetic factors
- Social deprivation
- Lifestyle - smoking, excessive alcohol, excess dietary salt, obesity and lack of physical activity
- Anxiety and emotional stress