Approach to Hypertension

Approach to Hypertension 2018-01-30T16:36:58+00:00

Differential diagnosis

  • Endocrine
    • Adrenal
      • Phaeochromocytoma
      • Conn’s syndrome
    • Cushing’s syndrome
      • Cushing’s disease: ACTH-producing pituitary adenoma
    • Acromegaly
    • Hyperthyroidism
  • Renal
    • Renal artery stenosis
    • Autosomal-dominant polycystic kidney disease
    • Chronic glomerulonephritis
    • Diabetic nephropathy
  • Obstructive sleep apnoea
  • Inflammatory
    • Systemic sclerosis
    • Systemic lupus erythematosus
    • Wegner’s granulomatosis
  • Drug-induced
    • Non-steroidal anti-inflammatory drugs
    • Erythropoietin
    • Cyclosporine / tacrolimus
    • Exogenous steroids
    • Oral contraceptive pill
    • Β-agonists
    • Liquorice
    • Excessive alcohol intake
    • Traditional Chinese medicines
  • Metabolic
    • Obesity
    • Diabetes mellitus
    • Old age
    • Excessive salt intake
  • Neoplastic
    • Intracranial tumours
  • Congenital
    • Coarctation of the aorta
  • Pregnancy

Relevant points in the history

  • Hypertension
    • How long have you had high blood pressure for?
    • Does anyone in the family have high blood pressure?
    • Has the control been getting worse?
    • Do you have any headaches?
    • Have you noticed any blurred vision?
    • Have you ever felt like you are about to faint?
    • Do you have any chest pain?
    • Have you ever noticed any blood in your urine?
  • Endocrine
    • Phaeochromocytoma
      • Do you ever notice your heart beating very quickly?
      • Do you have any unusual episodes of sweating?
      • Do you have any headaches which come on suddenly?
    • Cushing’s syndrome
      • Have you gained any weight?
      • Do you find that you bruise easily if you knock into things?
      • Do you have any difficulty getting up from a sitting position?
      • Do you have any stretch marks?
      • Have you ever fractured a bone from a fall?
    • Acromegaly
      • Has your appearance changed?
      • Do you feel like your shoe size has increased?
    • Hyperthyroidism
      • Are you unusually intolerant of the hot or the cold?
      • Have you noticed a tremor?
      • Have you noticed any double vision?
      • Are your periods unusually heavy?
      • Do you have any diarrhoea?
  • Obstructive sleep apnoea
    • Do you feel very sleepy in the day?
    • Have you ever fallen asleep while driving?
    • Do you snore loudly at night?
  • Renal parenchymal disease
    • Have you ever been tested for kidney disease?
    • Have you ever noticed any bubbles in your urine?
    • Are you passing a normal amount of urine for yourself?
  • Intracranial tumour
    • Have you been troubled by a headache which is worse in the morning?
    • Do you have any weakness?
    • Do you have any tingling on one side of the body?
  • Drug history
    • What medication do you take for your blood pressure?
    • Do you take all your medication as prescribed?
    • Have the doses of any of these changed recently?
    • Do you take any over the counter medicines?
    • Do you take any traditional or over-the-counter medicines?
    • Do you use the oral contraceptive pill?

Examination

  • General
    • Appearance: acromegalic, Cushingoid
    • Graves’ ophthalmopathy
    • Pallor (chronic renal disease)
    • Obesity (OSA, difficult to control hypertension)
  • Cardiovascular
    • Displaced apex beat (malignant hypertension)
    • Ejection systolic murmur (coarctation of the aorta)
      • Radio-femoral delay
    • Carotid bruits
    • Renal artery bruits (renovascular disease)
    • Femoral pulses (may be diminished in coarctation of the aorta)
    • Signs of cardiac failure (hypertensive end-organ damage, hyperthyroidism, acromegaly)
  • Thyroid status
    • Pulse
    • Lid lag
    • Goitre
    • Pre-tibial myxoedema
    • Tremor
  • Cushing’s
    • Abdominal striae
    • Proximal myopathy
    • Cataracts
    • Interscapular fat deposition
  • Acromegaly
    • Prognathism
    • Prominent maxilla
    • Spade-like hands
  • Offer fundoscopy to look for hypertensive retinopathy

Investigations

  • Renal function to look for chronic kidney disease, potassium to look for hypokalaemia (endocrine causes)
  • Morning serum renin : aldosterone ratio (high in Conn’s syndrome)
  • Cushing’s syndrome
    • Overnight dexamethasone suppression test
    • 24 hour urine cortisol collection
  • Phaeochromocytoma
    • 24 hour urine metanephrines
    • Plasma metanephrines
  • Consider Doppler or magnetic resonance angiography of renal arteries to look for RAS
  • Consider CT brain to look for intracranial tumour

Management

  • Multidisciplinary team approach
  • Patient education: weight reduction, reduction in dietary salt intake, increase in physical activity, moderate alcohol intake, compliance to medication
  • Blood pressure targets (Joint National Committee 8, 2014)
    • Age < 60, diabetes or CKD – keep BP < 140/90
    • Age ≥ 60 – keep BP < 150/90
  • Pharmacological management
    • Step 1
      • Age < 55, or patients with CKD – start with ACE inhibitor / angiotensin receptor blocker
      • Age ≥ 55, or Afro-Caribbean of any age – start with calcium channel blocker
    • Step 2: ACE inhibitor + calcium channel blocker
    • Step 3: ACE inhibitor + calcium channel blocker + thiazide-like diuretic
    • Step 4: consider adding β-blocker (may add earlier if the patient has ischaemic heart disease)
  • Secondary hypertension
    • Phaeochromocytoma: α blockade (phenoxybenzamine) → β blockade, then definitive surgery
    • Cushing’s syndrome: stop offending medication, surgical tumour resection
      • Medical management: ketoconazole or etomidate if tumour not amenable to resection
    • Conn’s syndrome: spironolactone/eplerenone, definitive surgery
    • Hyperthyroidism: carbimazole, consider radioactive iodine, thyroidectomy
    • OSA: nocturnal continuous positive airways pressure
    • Renal artery stenosis: consider stenting for refractory patients / recurrent flash pulmonary oedema
      • RCTs: no difference in cardiovascular mortality between angioplasty and medical therapy

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