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Hypertension

Medicine > Cardiovascular

Essential (Primary) Hypertension

Background Knowledge 🧠

Definition

  • High blood pressure with no identifiable cause, accounting for about 90-95% of hypertension cases. It is a major risk factor for cardiovascular diseases as well as chronic kidney disease.

Epidemiology

  • High prevalence of hypertension globally, with estimates of up to 1 billion adults being affected by the disease.
  • Prevalence of the disease rises with age.

Pathophysiology

  • Complex interplay between genetic and environmental factorsleading to increased systemic vascular resistance and/or increased cardiac output.

Aetiology/Risk Factors

  • Genetic predisposition
  • Lifestyle factors: High salt intake, obesity, physical inactivity, excessive alcohol or caffeine consumption.
  • Age
  • Family history
  • Ethnicity (higher in African-Caribbean populations)

Clinical Features 🌡️

Symptoms

  • Often asymptomatic
  • Headache, especially in the morning
  • Blurry vision
  • Shortness of breath

Investigations 🧪

Tests

  • Clinic blood pressure: if BP is between 140/90 mmHg and 180/120 mmHg, NICE recommend an ambulatory blood pressure monitoring (ABPM) for further investigation.
    • Clinic BP of 140/90 mmHg or higher as well as an average ABPM reading of 135/85 mmHg or higher is diagnostic of Hypertension.
  • Bloods: FBC, Urea & electrolytes, Hba1C, cholesterol.
  • Urine dipstick: assess for signs of kidney damage.

Management 🥼

Management

  • Lifestyle modifications: Salt reduction, weight loss, exercise, reducing alcohol intake.
  • Medications: ACE inhibitors, calcium channel blockers, beta-blockers, diuretics, angiotensin II receptor blockers (ARBs).

  • Regular monitoring and follow-up.

Complications

  • Coronary artery disease
  • Chronic kidney disease
  • Myocardial infarction
  • Heart failure
  • Hypertensive retinopathy
  • Vascular dementia

Key Points

  • Essential hypertension can be defined as high BP with no identifiable cause. 
  • It is the biggest risk factor for developing cardiovascular disease such as stroke and myocardial infarction.
  • 24 hour ABPM is used to confirm a diagnosis of hypertension following a high clinic BP measurement (>140/90mmHg).
  • Management includes a combination of lifestyle modifications and antihypertensive drug treatment.

Secondary Hypertension

Background knowledge 🧠

Definition

  • High blood pressure resulting from an identifiable underlying secondary cause.

Epidemiology

  • Secondary hypertension is far less common than primary hypertension, accounting for about 5-10% of hypertension cases.

Aetiology/Causes

  • Renal: Chronic kidney disease, renal artery stenosis, glomerulonephritis.
  • Endocrine: Cushing’s syndrome, hyperaldosteronism, pheochromocytoma, hyperthyroidism, acromegaly.
  • Vascular: Coarctation of the aorta.
  • Medications: Oral contraceptives, NSAIDs, steroids, sympathomimetics.
  • Obstructive sleep apnoea.

Clinical Features 🌡️

Clinical Features

  • Resistant to standard antihypertensive treatments.
  • Signs or symptoms related to the underlying cause (e.g., leg pain in coarctation).
  • Severe hypertension in younger patients (<30 years) or sudden onset in older patients.

Investigations 🧪

Investigations

  • Blood tests: Renal function, potassium, thyroid function tests.
  • Renal ultrasound
  • Specialist tests: Plasma aldosterone to renin ratio, urinary catecholamines.

Management 🥼

Management

  • Treat the underlying cause.
  • Medications: May differ based on the secondary cause.
  • Regular monitoring and follow-up.

Prognosis

  • Secondary hypertension is a potentially life-threatening condition and therefore, early diagnosis of the primary underlying cause and appropriate management is essential.

Complications

  • Coronary artery disease
  • Peripheral vascular disease
  • Stroke
  • Chronic kidney disease

Key Points

  • Secondary hypertension should be suspected in cases of an early age of onset, are severe, or resistant to standard antihypertensive medications. 
  • Causes can be broken down into: renal, endocrine, vascular or pharmacological.
    • The most common cause of secondary hypertension is primary hyperaldosteronism. 
  • Special tests including urinary catecholamines and Plasma aldosterone to renin ratio assessments can help identify underling cause.

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Cardiovascular