Hypertension

Exam

• Irreg HR

• Waist circum / BMI

• Fundoscopy: Retinal haemorrhages, cotton wool spots, AV nipping, papilloedema

• Goitre: Hyperthyroidism as a secondary HTN cause

• HF signs: Displaced apex, elevated JVP, bibasal crackles, ± peripheral oedema

• Renal bruits: Suggest renovascular HTN

• Radiofemoral delay: Seen in coarctation of the aorta

• Palp for enlarged kidneys: Suggests ADPKD

Investigations

• FBC, UECs, FBG (no LFTs)

• Urinalysis (blood), urine ACR

• Fasting lipids

• ECG

• ABPM

• Consider echo and carotid US (if smoker, diabetic, old)

Ambulatory BP

• Borderline HTN: Confirms or excludes sustained BP elevation, particularly in white coat or masked HTN

Blood Pressure Targets

• General population: <140/90 mmHg

• Diabetes: <130/80 mmHg

• CKD: <130/80 mmHg

• Elderly (≥75 years): <150/90 mmHg, individualised based on frailty and sx

Monitoring and Follow-Up

• Initial diagnosis: Review within 4 weeks

• Stable HTN: Review every 3–6 months

• Monitor:

  • Home BP readings if available

  • Electrolytes and renal function (6–12 monthly with ACEi/ARBs)

  • Adherence and SEs of medications

  • Annual fundoscopy and CV risk reassessment

Management of Hypertensive Emergencies

• BP >180/120 mmHg with acute end-organ damage: Immediate intervention required

• Common presentations:

  • Encephalopathy: Confusion, headache, seizures

  • Papilloedema ± retinal haemorrhages

  • Acute pulmonary oedema

  • AKI

• Immediate management:

  • Admit to hospital

  • IV antihypertensives (e.g., labetalol, GTN, sodium nitroprusside)

  • Gradual BP reduction over 24–48 hours (to avoid ischaemia)

Notes:

• 24-hr ABPM: Diagnostic threshold = SBP ≥130/80 mmHg​

• Electrolyte imbalances:

  • Hyperaldosteronism causes fatigue, weakness, and cramps

  • Diabetes insipidus-related hypokalaemia can cause polydipsia and polyuria

Stepwise Progression

• Start with first-line agents (ACE-I, ARB, CCB, thiazides) based on patient-specific factors

• Combination therapy is often required to achieve BP targets, starting with a low dose and titrating upwards​

Monitoring

• Baseline UEC and repeat testing 1–2 weeks after starting ACE-I or ARB to monitor renal function and potassium​

• Accept a 25% drop in eGFR or 30% rise in creatinine, provided it stabilises within 1–2 months​

Pharmacological Management

1st Line Agents

ACE-I / ARB

• Indications: Preferred in patients with HFrEF, CKD (including diabetic nephropathy), or younger patients​

• Examples:

  • Perindopril: 5mg daily (max 10mg)

  • Telmisartan: 40mg daily (max 80mg)

• Key SEs: Hyperkalaemia, angioedema, and renal impairment

  • Avoid in bilateral renal artery stenosis

CCB

• Use: Effective for older patients and in those with stable angina​

• Example: Amlodipine 5mg daily (max 10mg)

• Key SEs: Peripheral oedema (dose-dependent)

Thiazides

• Indication: Particularly effective in patients >65 years and those with isolated systolic hypertension​

• Example: Hydrochlorothiazide or indapamide 1.25–2.5mg daily

• Caution: Worsens gout and increases diabetes risk​

• Monitoring: Repeat UEC at 4 weeks for hypokalaemia or hyponatraemia​

2nd Line Agents

Beta Blockers 

• Indications: HFrEF, post-MI, or stable angina​

• Example: Metoprolol XR 25mg daily (max 100mg BD)

• Caution: Avoid in asthma and bradycardia​

Non-Dihydropyridine CCBs

• Use: Stable angina when BBs are contraindicated​

• Example: Diltiazem XR 180mg daily (max 360mg)

• Key SEs: Avoid in HFrEF due to negative inotropic and chronotropic effects​

Other Agents

• Potassium-Sparing Diuretics: Used adjunctively in resistant HTN; monitor for hyperkalaemia

• Alpha Blockers: Considered in resistant HTN or those with concurrent benign prostatic hyperplasia (BPH)

Notes:

• Resistant HTN: If BP remains uncontrolled on maximum tolerated doses of 2–3 agents, consider secondary HTN investigations​

• Combination Therapy: ACE-I or ARB + CCB is recommended as initial dual therapy in most patients​

• CKD Guidelines: A 25% drop in eGFR within 2 months is acceptable but warrants close monitoring if decline continues​

Severe HTN with No Symptoms

Diagnosis:

• BP >180/110, asymptomatic

• Can be managed in GP unless high-risk features: coagulopathy/anticoags, severe HF (e.g., APO), kidney impairment, recent surgery needing tight BP control, aortic dissection, pregnancy

Treatment:

• Observe with repeated BP measurements to confirm persistence

• Start/continue regular antihypertensive (e.g., ramipril 5mg daily)

• Follow up within days to monitor response

Hypertensive Urgency

Diagnosis:

• BP >180/110 with symptoms and mild end-organ dysfunction

• Symptoms: mild headache, epistaxis, agitation, dizziness, blurry vision, proteinuria

Treatment:

• Start or adjust BP meds (e.g., ACEi, CCB) if not already initiated

• ED referral only if symptoms worsen; otherwise monitor in GP

• Advise low salt diet and avoid acute stressors

Hypertensive Emergency

Diagnosis:

• BP >200–220/140 with severe symptoms and end-organ damage

• Symptoms: APO, chest pain (MI), confusion (HTN encephalopathy), seizures, intracranial haemorrhage

Investigations:

• ECG, UEC, LFT, urinalysis

Treatment:

• Immediate ED referral for ICU care

• IV hydralazine 1mg/min or labetalol GTN infusion (reduce BP <25% over 2 hrs)

Special considerations:

• Aortic dissection/pregnancy: Use BB

• Adrenergic crisis (meth OD): Avoid BB

• APO: Use GTN

Additional notes:

• Reassess long-term BP control once acute phase resolves

• Ensure lifestyle advice includes sodium reduction (<6g/day), weight management, and increased physical activity

Causes of Resistant HTN

Measurement-related:  (only if question  asks for “causes of high BP reading” not “causes of patient’s HTN”)

• Measurement error from incorrect cuff size

• Anxiety during measurement (White coat HTN—common in up to 20% of patients)

• Poor technique, e.g., patient talking or unsupported arm during measurement

Patient-related:

• Non-adherence to medications (common and under-reported)

• High dietary salt intake or hidden sources (e.g., processed foods)

• Sedentary lifestyle and low physical activity

• Recent weight gain

• Excessive alcohol consumption (>2 standard drinks/day in men, >1 in women)

• Illicit substance use (e.g., cocaine, amphetamines)

• Effects of other medications:

  • NSAIDs

  • Corticosteroids (e.g., prednisone)

  • Decongestants (e.g., pseudoephedrine)

  • Oral contraceptives

  • Calcineurin inhibitors (e.g., cyclosporine, tacrolimus)

• Secondary hypertension causes:

  • Renal failure (e.g., CKD, renovascular disease)

  • Primary aldosteronism

  • Obstructive sleep apnoea (OSA)

  • Phaeochromocytoma

Additional Notes:

Evaluate adherence and lifestyle factors before considering further investigations or adding medications. 24-hour ambulatory BP monitoring (ABPM) may help differentiate between true resistant HTN and white coat HTN.

Secondary Causes of Hypertension

Most Common Causes

• OSA

• Kidney pathology

Simplified classification:

1. Parenchyma

   • Primary kidney diseases: PCKD, nephritis (e.g., IgA nephropathy), and CKD

2. Vessels

   • Renal artery stenosis (via atherosclerosis or fibromuscular dysplasia):

     • Investigate with renal artery duplex ultrasound or CT angiogram

3. Hormones

   • Primary aldosteronism:

     • Most common cause is bilateral adrenal hyperplasia (60%)

     • Investigations:

       • Plasma renin/aldosterone ratio (requires specialist interpretation, especially if on antihypertensives)

       • CT adrenal scan (with contrast)

   • Adrenal-secreting adenoma (Conn’s syndrome): Accounts for 40% of primary aldosteronism

Less Common Causes

• Cushings

• Hypothyroid

• Hyperparathyroid

• Coarctation of aorta

• Pheochromocytoma

  • Presents with episodic headaches, palpitations, and flushing

  • Investigations:

    • 24-hour urinary catecholamines or metanephrines (screening)

    • Plasma free metanephrines for confirmation

Notes:

• Always assess for these conditions in patients with resistant hypertension, especially if aged <40 or with sudden-onset or severe hypertension.

• Secondary hypertension accounts for ~10% of cases, so ensure thorough workup in refractory cases.

• eTG recommends specific testing based on clinical presentation to avoid unnecessary investigations.