Hypertension

Acute Management

Diagnosis

1. Severity

   • Hypertension emergency

   • Hypertension urgency

2. Cause

   • (Primary) Essential Hypertension

   • Secondary Hypertension

     1. Acute

     2. Chronic

Essential Hypertension

Background

The vast majority (>90%) of hypertension is primary (essential), therefore hypertension is presumed to be caused by primary hypertension. Secondary causes are considered with poor response to antihypertensives and young age of presentation. 

Chronic Management

NICE 2019

1.  ACEi or CCB

   1. ACEi if < 55yrs or diabetic

   2. CCB if > 55yrs + Afro-Caribbean

2. ACEi + CCB

3. Add thiazide like diuretic

4.  K+ < 4.5: spironolactone, K+> 4.5 doxazocin/ beta blocker

5. Refer to specialist

Comments

• Thiazide like diuretic preferred to thiazide due thiazides effect on glycemic control

Secondary Causes of Hypertension

Treatment Resistant Hypertension

• Definition: BP > 140/90 following 3+ antihypertensives

• Secondary causes of hypertension should be considered in treatment resistant hypertension

Acute

• Stroke

  • Ischaemic: tolerate BP 210/ 120

  • Ischaemic for thrombolysis: < 185/110

  • Hemorrhagic: < 140/90

  • SAH: SBP < 160

• Aortic Dissection: SBP 100-120 (betablockers)

• Drugs

  • Stimulants: coffee, nicotine, MDMA, cocaine

Note sepsis usually caused hypotension > hypertension

Chronic Causes of Secondary Hypertension

• Renal

  • Chronic Kidney Disease

    • Diabetic Nephropathy

    • Glomerulonephritis

    • Polycystic Kidney Disease

    • Obstructive uropathy- BPH, intrabdominal cancer

    • Renal Cell Cancer

    • Liddle Syndrome

    • Reflux Nephropathy

    • Liquorice (pseudohyperaldosteronism)

• Endocrine

  • Hyperaldosteronism

    • Bilateral Adrenal Hyperplasia 

    • Conn's Syndrome: (adrenal tumour)

  • Phaeochromocytoma: adrenal tumour secreting catecholamines

  • Cushing's Syndrome

  • Acromegaly

  • Hypo/hyperthyroidism

• Metabolic

  • Obstructive Sleep Apnea (OSA) 

  • Anxiety Disorders

  • Metabolic Syndrome

  • Exogenous steroids

  • Alcohol

• Vascular: 

  • Coarctation of Aorta

  • Renal Artery Stenosis

Complications of Chronic Hypertension

1. Hypertensive encephalopathy ->  vascular dementia

2. Hypertensive Cardiomyopathy

3. Hypertensive retinopathy

4. Hypertensive nephropathy

Hypertension in Pregnancy

If BP > 140/90

1. Labetalol

2. Methyl dopa

3. Other alternatives: hydralazine, nifedipine

Not safe in pregnancy: ACE inhibitors, ARBs

Page written in 2024.