Common hypertensive emergency exam questions for medical finals, OSCEs and MRCP PACES

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Question 1.

Define the term hypertensive emergency and explain how this differs from hypertensive urgency

  • Hypertensive emergency: severe hypertension with evidence of acute end organ damage
  • Hypertensive urgency: severe hypertension with no evidence of acute end organ damage

Question 2.

List seven risk factors for essential hypertension

  • Age
  • Family history
  • Salt
  • Alcohol
  • Caffeine
  • Smoking
  • Obesity

Question 3.

Outline the causes of secondary hypertension

  • Renal
    • Renal artery stenosis
    • Glomerulonephritis
    • Chonic pyelonephritis
    • Polycystic kidney disease
  • Endocrine
    • Cushing’s syndrome
    • Conn’s syndrome
    • Acromegaly
    • Hyperthyroidism
    • Phaeochromocytoma
  • Arterial
    • Coarctation of the aorta
  • Drugs
    • Alcohol
    • Cocaine
    • Amphetamines


Question 4. 

List the different types of end organ damage that may occur in hypertensive emergencies

  • Brain: hypertensive encephalopathy, intracerebral haemorrhage
  • Heart: hypertensive cardiomyopathy
  • Kidneys: hypertensive nephropathy
  • Eyes: hypertensive retinopathy
  • Aorta: aortic dissection


Question 5.

Describe the clinical features of hypertensive encephalopathy

  • Headache
  • Visual disturbance
  • Nausea & vomiting
  • Confusion
  • Seizures
  • Drowsiness
  • Coma

Question 6.

What initial investigation is important to exclude intracranial pathology that may cause, complicate or masquerade as hypertensive emergency?

  • CT head

What other investigations would you perform and what abnormalities would you look for?

  • Fundoscopy
    • Silver wiring
    • Cotton wool spots
    • Flame haemorrhages
    • Papilloedema
  • 12 lead ECG
    • Left ventricular hypertrophy (LVH): S wave in V1 or V2 + R wave in V5 or V6 >35 mm
    • Ischaemic changes: ST depression and/or T wave inversion
  •  Urinalysis
    • Proteinuria
    • Haematuria
    • Beta human chorionic gonadotropin (hCG)
  • Urea & electrolytes
    • Acute kidney injury (AKI)
  • Chest radiograph (CXR)
    • Pulmonary oedema
    • Widened mediastinum


Question 7.

Outline your approach to BP reduction in a patient with hypertensive emergency

  • Controlled BP reduction; rapid BP reduction should be avoided because this may compromise blood flow to tissues in which autoregulatory mechanisms are already impared; pharmacological options are:
    • Nitroprusside IV
    • Labetalol IV
    • Nitrates IV
  • Referral to HDU for:
    • Invasive BP monitoring
    • Cardiac monitoring
    • Urine output monitoring
    • Neurological observations


Question 8.

How would you manage a patient with hypertensive urgency who was otherwise fit for discharge?

  • Patients with hypertensive urgency can be discharged once their BP has settled; should this require pharmacological management, a stat dose of amlodipine 5 mg PO is usually adequate

What follow up investigation would you consider for a patient with hypertensive urgency who was not previously known to have hypertension

  • Ambulatory BP monitoring

What lifestyle advice would you give patients about reducing their BP

  • Reduce intake of salt, alcohol and caffeine
  • Health diet
  • Regular exercise
  • Smoking cessation