Hypertension Written Notes DR - Numan

1) A 70-year-old male presented with severe headache and resp distress, O/E p-84, BP-240/140mmhg.
with creps in
both lungs. How will you manage such case? (Ja-15)
Ans:
2) A 65-year lady presented with severe breathlessness. She is a known case of CKD on MHD. O/E P-60 bpm, BP-
240/130 mmHg, chest – bilateral creps. How will you investigate and treat such case? (Ju-15)
Ans:
3) What is hypertensive emergency and urgency. Difference between hypertensive emergency and urgency. (Ja-16,
17)
Ans:
4) How will you manage a case of hypertensive emergency? (Ju-19)
Ans:
5) What is hypertensive crisis? (Ju-20, Ja-21)
Ans:
6) Write down the investigation to exclude secondary HTN. (Ja-16)
7) What is pseudo HTN? (Ju-17)

Ans:
8) A young boy of 16-year age presented with HTN. BP 180/110mmhg. How will you evaluate and treat him? (Ja-
16)
Ans:
9) How will you evaluate and manage a 32-year-old male presented with malignant HTN? (Ja-18)
10) A 32 weeks’ pregnant lady referred to cardiology dept. with headache and disorientation, her BP 220/110. How
will you proceed to manage that pt? (Ja-18)
Ans:
11) Write down the management of Renovascular HTN. (Ju-18)
Ans:
12) A 42-year-old man has come to ED with central chest pain, headache and blurring of vision. How will you
proceed to manage the pt? (Ju-18)
Ans:
13) What is masked HTN. How will you manage HTN in pregnancy? (Ja-19, Ju-18, 21)
Ans:
14) What is resistant HTN. What are the common cause of resistant HTN? What is pseudo resistance? (Ja-19, Ju-15)
Ans:
15) Discuss the role of ambulatory BP monitoring in management of white coat HTN and masked HTN. (Ju-
16, 17, 20, Ja-20, 21)
Ans:
16) A 20-year-old male presented with accelerated HTN. Abd USG revealed small left kidney. How will you
approach and manage the case? (Ja-20)
Ans:
17) What is subclinical target organ damage in patient with hypertension? Mention the clinical, laboratory &
imaging clues for Renovascular hypertension. (Ja-22)
Ans:
18) What is resistant hypertension? How will you evaluate a case of resistant hypertension? (Jan-23)
Ans:
19) What are the hypertensive emergencies? Give outline of management of patients with Hypertension with
dissection of Aorta. (Ju-23)
Ans:
20) A 25 year Female presented with orthopnea and shortness of breath in her third trimester pregnancy. She has
history of Acute Rheumatic Fever in her early childhood. How will you evaluate and manage her? (NICVD Block-
230
Ans:
21) What is postural hypotension and postural Hypertension? What are the causes of postural hypotension? How
will you diagnose it? (NICVD Block-23)
Definition of hypertension
According to the previous 2018 European and current international guidelines [32–34], hypertension is
defined based on repeated office SBP values more than equal 140 mmHg and/or DBP
90 mmHg
Confirming the diagnosis of hypertension
Because of the variability of BP, an elevation of office BP (SBP 140 mmHg or DBP 90 mmHg) should be
confirmed by at least two to three visits, unless the BP values recorded during the first visit are markedly
elevated (grade 3 hypertension) or
CV risk is high, including the presence of HMOD.
:
15) Discuss the role of ambulatory BP monitoring in management of white coat HTN and masked HTN. (Ju-
16, 17, 20, Ja-20, 21)
ABPM has the same advantages over OBPM than those reported for HBPM,
1. Greater reproducibility of 24 h mean BP values,
2. Closer association with HMOD
3. Prediction of HMOD
4. Better prediction of outcomes and mortality
5. Ability to identify WCH and MH
6. Possibility to discriminate between apparent and true-resistant hypertension
7. To quantify BP characteristics such as 24 h BP variability and the morning BP surge, which have
been found to have an adverse prognostic value, independently of 24 h mean BP.

8. Quantification of the dipping status, i.e. the magnitude of nocturnal BP change, which is clinically
relevant because night BP reduction and absolute night BP values have been found to predict
events better than daytime BP, with a markedly elevated risk in patients with no night-time BP
reduction or nocturnal hypertension
9. May facilitate the identification of daily life hypotensive episodes and the persistency of BP
control by treatment during the periods between drug intakes.
Limitations
1. Not suitable for frequent use
2. Expensive
3. Not widely available in primary care settings
4. May cause discomfort to some patients, especially during sleep
5. No outcome-based RCTs have been conducted to explore the effect of ABPM-guided versus
OBPM-guided treatment and
6. No BP thresholds and goals for treatment have been directly established

TRUE-RESISTANT HYPERTENSION
In the 2018 Guidelines, hypertension was defined as
✓ Resistant to treatment
✓ when appropriate lifestyle measures and
✓ Treatment with optimal or best tolerated doses of three or more drugs (a Thiazide/Thiazide-like
diuretic, an RAS-blocker and a CCB)
✓ fail to lower office BP to <140/90 mmHg
Pseudoresistant hypertension
Evidence of adherence to therapy and exclusion of secondary causes of hypertension are required
to define resistant hypertension, otherwise resistant hypertension is only apparent and termed as
Pseudoresistant hypertension.
Effective treatment of resistant hypertension should combine
❖ lifestyle changes
i. Reduction of sodium reducing sodium intake (<2 g/day) or NaCl intake (<5 g/day)and alcohol
intake,
ii. Implementation of regular physical activity and
iii. weight loss in overweight or obese patients
iv. discontinuation of interfering substances,
❖ Rationalization of current treatment
❖ the sequential addition of antihypertensive drugs to the existing triple therapy
❖ Drugs should be used at the maximal tolerated doses
❖ SPCs should be preferred when available to reduce pill burden and improve adherence to
treatment
❖ Increasing the intensity of diuretic therapy
❖ switching to a possibly more potent and longer acting Thiazide-like diuretic (indapamide or
chlorthalidone) If eGFR is is more than 30 ml/min
❖ Careful monitoring of kidney function, serum electrolyte levels and fluid status
❖ After optimizing the ongoing therapy, a stepwise addition of other antihypertensive drugs should be
considered if BP is still not at goal
❖ In patients with resistant hypertension, the fourth line treatment should include the MRA
spironolactone, based on the evidence of its efficacy in the PATHWAY-2 trial
RDN can be considered as an additional treatment option in patients with resistant

hypertension if eGFR is >40 ml/min/1.73m 2
Hypertension emergencies
➢ Are conditions in which severe hypertension (grade 3) is associated with acute symptomatic HMOD.
➢ can be life-threatening and
➢ require immediate intervention to lower BP, usually with intravenous (i.v.) therapy
Typical clinical presentations of a hypertension emergency are:

1. Severe hypertension associated with conditions that need intensified BP management:
• acute stroke (hemorrhagic or ischemic/thromboembolic),
• aortic aneurysm or dissection,
• acute HF,
• acute coronary syndrome and
• kidney failure.
These emergency conditions are compatible also with a relatively modest BP increase, which is
sufficient to precipitate organ failure.
2. Hypertension caused by phaeochromocytoma or exogenous sympathomimetics substances
(e.g. substance abuse).
Ingestion of sympathomimetic drugs such as meta-amphetamine or cocaine may precipitate acute
and severe BP increases that may result in hypertension emergencies when there is evidence of
acute HMOD.
3.Severe forms of HDP, including preeclampsia/eclampsia with a HELLP syndrome
Malignant hypertension with or without thrombotic microangiopathy or acute kidney failure is

a hypertensive emergency
characterized by small artery fibrinoid necrosis in the kidney, retina and brain. There might be
also funduscopic changes (flame hemorrhages and papilloedema), microangiopathy,
disseminated intravascular coagulation, encephalopathy
‘Hypertension urgency’ has been used to describe severe hypertension in patients in

whom there is no evidence of acute HMOD
suspected hypertension emergency, the diagnostic work-up

hypertensive urgencies
Patients with hypertensive urgencies

do not usually require hospitalization. However, they require BP reduction,
which can be obtained by oral administration of antihypertensive drugs,
aimed at lowering BP gradually over 24–48 h.
Oral treatment may include reinstitution or intensification of previous
treatment or starting new treatment. DHP-CCBs are
suggested as first choice in an untreated patient as they have few or no
contraindications and do not interfere with the
diagnostic work-up for secondary hypertension.

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1) A 70-year-old male presented with severe headache and resp distress, O/E p-84, BP-240/140mmhg.

7) What is pseudo HTN? (Ju-17)

Confirming the diagnosis of hypertension

1. Greater reproducibility of 24 h mean BP values,

2. Closer association with HMOD

4. Better prediction of outcomes and mortality

5. Ability to identify WCH and MH

6. Possibility to discriminate between apparent and true-resistant hypertension

been found to have an adverse prognostic value, independently of 24 h mean BP.

reduction or nocturnal hypertension

control by treatment during the periods between drug intakes.

1. Not suitable for frequent use

3. Not widely available in primary care settings

4. May cause discomfort to some patients, especially during sleep

OBPM-guided treatment and

6. No BP thresholds and goals for treatment have been directly established

RDN can be considered as an additional treatment option in patients with resistant

Typical clinical presentations of a hypertension emergency are:

Malignant hypertension with or without thrombotic microangiopathy or acute kidney failure is

‘Hypertension urgency’ has been used to describe severe hypertension in patients in

suspected hypertension emergency, the diagnostic work-up

Patients with hypertensive urgencies

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