Makindo Medical Notes

Hypertension is defined as a persistent blood pressure >140/90 mmHg. 👉 In >95% of cases the cause is essential (primary) hypertension, where no single reversible factor is found. Secondary hypertension (renal, endocrine, vascular causes) accounts for <5% of cases and should be suspected in younger patients, resistant cases, or when clinical clues are present.

⚠️ Risk Factors for Essential Hypertension

• 🌍 Ethnicity: higher prevalence and severity in Black and Japanese populations
• 🧬 Family history and polygenic inheritance
• 🧂 High dietary salt intake and 🍷 alcohol excess
• ⚖️ Obesity and 🛋 sedentary lifestyle
• 👶 Adverse intrauterine environment (low birth weight, poor growth)
• 🧠 Chronic stress and psychosocial factors

🔎 Clues Suggesting Secondary Hypertension

• 🦵 Radio-femoral delay or murmur → coarctation of the aorta
• 🎧 Abdominal/renal bruit → renal artery stenosis
• 👁 Acromegalic facies or Cushingoid features → endocrine causes
• 😰 Paroxysmal sweating, tremor, palpitations → phaeochromocytoma
• 🫘 Bilateral flank masses → polycystic kidney disease

🚨 Complications of Long-Term Hypertension

• 👁 Hypertensive retinopathy (Grades I–IV)
• ❤️ Left ventricular hypertrophy → forceful/displaced apex beat
• 🌬 Heart failure → pulmonary oedema
• 🧠 Stroke and vascular dementia
• 🧪 Chronic kidney disease with proteinuria
• 💔 Coronary artery disease and myocardial infarction

🩺 Accurate BP Measurement

• ✅ Correct cuff size (too small = overestimation)
• 🚭 Avoid smoking, caffeine, or exercise for 30 min before
• 🪑 Patient seated and rested for ≥5 min
• 🔁 Repeat on two or more occasions
• 📊 Ambulatory BP monitoring (ABPM) recommended by NICE to confirm diagnosis, especially to exclude “white coat” hypertension

📊 Grading of Hypertension

Grade	Systolic	Diastolic	Clinical Significance
✅ Normal	<120	<80	Maintain healthy lifestyle
⚠️ Elevated	120–129	<80	Risk of progression; lifestyle focus
🟡 Stage 1	130–139	80–89	Lifestyle ± meds if target organ damage or high CV risk
🟠 Stage 2	140–159	90–99	Requires meds + lifestyle changes
🔴 Stage 3	>160	>100	Severe; urgent management
🚨 Crisis	>180	>120	Hypertensive emergency → admit

👁 Hypertensive Retinopathy (Keith–Wagener Classification)

Grade	Findings	Significance
1	Arteriolar narrowing, “copper wiring”	Often asymptomatic
2	Arteriovenous (AV) nicking	Predicts systemic vascular damage
3	Retinal haemorrhages, cotton wool spots	High risk of stroke/MI
4 🚨	Papilloedema	Malignant hypertension; medical emergency

🧪 Investigations

• 🩸 Fasting glucose & lipids → metabolic syndrome/cardiovascular risk
• 🧪 U&E, creatinine → renal function
• 🧾 Urinalysis → proteinuria/haematuria
• 📈 ECG → LVH, AF, ischaemia
• 🫀 Echocardiogram if heart failure suspected

💥 Organ Damage from Chronic Hypertension

• 🧠 Stroke (ischaemic or haemorrhagic)
• 🧑‍⚕️ Chronic kidney disease → dialysis risk
• ❤️ Left ventricular hypertrophy → heart failure
• 💔 Coronary artery disease and MI
• ⚡ Atrial fibrillation from LA enlargement
• 👁 Retinal vein occlusion and sudden vision loss

📑 British Hypertension Society (NICE-aligned) ABCD Rule

Step	Age <55 & non-Black	Black or Age ≥55
1	ACEI/ARB	CCB or Thiazide
2	ACEI/ARB + CCB/Thiazide	Same
3	Triple therapy (ACEI/ARB + CCB + Thiazide)	Same
4	Add α-blocker, β-blocker, or spironolactone	Same

🥗 Lifestyle Measures (First-line for All)

• ⚖️ Weight loss if overweight
• 🚭 Stop smoking (reduces overall CV risk)
• 🥦 High fruit/vegetable diet, low salt, low saturated fats
• 🍷 Limit alcohol intake
• 🏃 Regular aerobic exercise
• 🛌 Manage stress and improve sleep

💊 Medications

Class	Drug	Dose	Mechanism	Notes
🧬 ACEI	Ramipril	2.5–10 mg OD	↓ Angiotensin II → vasodilation	Renoprotective; cough/angioedema
🧬 ARB	Losartan	50–100 mg OD	Blocks AT-II receptor	Alternative if ACEI intolerant
💊 CCB	Amlodipine	5–10 mg OD	↓ Ca²⁺ influx → vasodilation	Good for elderly/Black patients; causes oedema
💊 Thiazide	Indapamide	1.5 mg OD	Blocks Na⁺ reabsorption	Useful in elderly; risk hypokalaemia
💊 Beta-blocker	Atenolol	25–100 mg OD	↓ Sympathetic drive	Not first-line; good in IHD/young
💊 Aldosterone Antagonist	Spironolactone	25–50 mg OD	Blocks aldosterone	Resistant HTN; risk hyperkalaemia, gynaecomastia

💡 Clinical Pearls

• 👵 In patients >80, avoid rapid BP lowering – risk of cerebral hypoperfusion.
• 🩺 Always check for secondary causes in resistant, young (<40), or atypical cases.
• 📊 ABPM is more reliable than clinic BP readings and should be used where possible.
• 🧠 Think “end-organ protection”: treat BP not just to lower numbers, but to prevent stroke, MI, CKD, and retinopathy.

🩺 Case 1 — Newly Diagnosed, Young Patient

A 42-year-old man is found to have a BP of 152/94 mmHg on three separate occasions. He has no past medical history, normal bloods, BMI 28, and no evidence of end-organ damage. Management: 🥗 Lifestyle modification first-line — weight loss, salt reduction, alcohol moderation, exercise. In patients <55 years and not Black/Caribbean heritage, an ACE inhibitor (e.g., ramipril) is usually the first drug if pharmacological therapy needed. Avoid: ❌ Starting medication before confirming persistent elevation; avoid ACE inhibitors in women of childbearing potential without discussion.

🩺 Case 2 — Middle-Aged, Symptomatic Patient

A 58-year-old woman presents with headaches and BP readings averaging 168/100 mmHg. She has type 2 diabetes and mild albuminuria. Management: 💊 Immediate pharmacological therapy indicated. ACE inhibitor or ARB preferred due to renal protection in diabetes. Add calcium-channel blocker or thiazide-like diuretic if not controlled. Regular BP monitoring and renal function checks needed. Avoid: ❌ Beta-blockers as first-line in uncomplicated hypertension; avoid NSAIDs where possible as they antagonise BP control and worsen renal function.

🩺 Case 3 — Elderly with Isolated Systolic Hypertension

An 80-year-old man has home BP readings of 168/72 mmHg. He has mild heart failure with preserved EF, no diabetes, and preserved renal function. Management: 📅 Start pharmacological therapy as threshold for treatment is lower in older adults. A calcium-channel blocker (e.g., amlodipine) is first choice in those >55 years. Titrate and add thiazide-like diuretic if not controlled. Avoid: ❌ Aggressive lowering of BP (risk of postural hypotension and falls). Avoid ACE inhibitors/ARBs if significant renal impairment without specialist advice.