Hypertension Highlights

DEFINITION

• Hypertension is typically diagnosed when the clinic blood pressure is consistently ≥ 140/90 mmHg.

CLASSIFICATION

• Stage 1 hypertension:
  • Clinic BP - 140/90 mmHg to 159/99 mmHg.
  • ABPM/HBPM - 135/85 mmHg to 149/94 mmHg.
• Stage 2 hypertension:
  • Clinic BP - 160/100 mmHg to 179/119 mmHg.
  • ABPM/HBPM ≥ 150/95 mmHg.
• Stage 3 or severe hypertension:
  • Clinic BP ≥ 180/120
• Accelerated (Malignant) hypertension:
  • Clinic BP ≥ 180/120 with retinal haemorrhage and/or papilloedema

AETIOLOGY

• Essential hypertension: the most common form, with no identifiable cause.
• Secondary hypertension: caused by underlying conditions - Renal/Endocrine/Medication.

CLINICAL FEATURES

• Often asymptomatic, but some individuals may experience symptoms such as headaches, dizziness, or visual disturbances.
• Complications of long-standing hypertension may include target organ damage, such as heart disease, stroke, kidney disease, and retinopathy.

INVESTIGATIONS

• Accurate blood pressure measurement using validated devices.
• Confirm diagnosis using ambulatory BP monitoring (ABPM), or home BP monitoring (HBPM) or if not possible through repeated clinic BP measurements.
• ABPM for Hypertension Diagnosis
  • Frequency of Measurements: Ensure at least 2 measurements per hour.
  • Timing: Take measurements during usual waking hours (e.g., 08:00 to 22:00).
  • Confirming Diagnosis: Use the average of at least 14 measurements taken during waking hours.
• HBPM for Hypertension Diagnosis
  • Measurement Protocol: Take 2 consecutive measurements for each recording, at least 1 minute apart.
  • Frequency of Recordings: Record blood pressure twice daily, ideally in the morning and evening.
  • Duration of Monitoring: Continue recording for at least 4 days, ideally for 7 days.
  • Data Utilization: Discard measurements from the first day. Use the average value of all remaining measurements to confirm a diagnosis of hypertension.
• Assess for target organ damage - Urinalysis (urine dip for blood + urine ACR), Bloods (U+E, eGFR, HbA1c, Lipid profile), ECG, and fundoscopy.
• Assess cardiovascular risk using the QRISK calculator.

MANAGEMENT

• Lifestyle modifications:
  • Encourage weight loss, regular physical activity, healthy diet, sodium reduction, moderation of alcohol consumption, and smoking cessation.
• Medications:
  • Consider antihypertensive drug treatment if lifestyle modifications alone are insufficient.
  • Choice of medication depends on various factors, including comorbidities.
• Regular monitoring of blood pressure and adjustment of treatment as needed.
• Provide ongoing support, education, and lifestyle advice to promote long-term management and adherence to treatment.

COMPLICATIONS

• Cardiovascular disease:
  • Increased risk of heart attacks, strokes, heart failure, and peripheral arterial disease.
• Kidney disease:
  • Hypertension can lead to chronic kidney disease and end-stage renal disease.
• Retinopathy:
  • Hypertensive retinopathy can cause vision problems and even blindness.
• Other complications:
  • Hypertension is associated with an increased risk of aortic aneurysm, cognitive decline, and metabolic disorders.