Hypertension CPC

10.11.06

Case 1
• Male aged 42, software salesman.
• Non-smoker and light drinker.
• Colleagues said he was prone to unpredictable fits of rage, described as "like apoplexy."
• Apparently fit and well.
• Suddenly died while driving his car.

• Autopsy conducted at request of coroner.
• Enlarged heart 450g (LVH).
• No obvious thrombus/infarct.

Phaeochromocytoma
• Tumour of adrenal medulla.
• Produces NA.
• Paroxysmal release.
• 10% bilateral/malignant.
• Large, pleomorphic cells with vascular architecture. Dense core granules on electron micrograph.

Case 2
• Female aged 48 presents with asymptomatic systemic hypertension of 150/110, discovered at insurance medical.
• Company director.
• FH: father died age 49 of stroke, vague history of large kidneys.

Investigations
• U + E:
-Creatinine 410.
-Urea 16.
-Potassium 4.8.
• Hb 11.1.
• Creatinine clearance 35 ml/min.
• USS: bilateral large kidneys.
• IVU: poor excretion and large kidneys.

Polycystic kidney, another renal cause of hypertension
• Autosomal dominant.
• 1:500 births.
• 10% chronic renal failure needing treatment.
• Middle-aged onset of symptoms.
• Associated with cysts of other organs (liver 40%) and berry aneurysms.

Case 3
• Male aged 59, PE teacher, generally well, goes to gym and does weights.
• Presents with severe abdominal pain of sudden onset ("tearing").
• Shocked: BP 100/55 on admission.
• Not anaemic, U + E normal.

• Abdominal wall become discoloured, purplish-brown.
• Angiogram shows leaking aortic aneurysm.
• Stabilised, then…
• Taken to theatre urgently.
• Open repair of aneurysm.
• Makes full recovery.

Aortic aneurysm
• Predisposing factors:
-Hereditary.
-Atheroma.
-Syphilis.
• Sites.
• Treatment:
-Open.
-Endovascular.
• Normal diameter ~ 1.5-2.5cm.
• Risky >5cm.
• Likely to rupture in 12 months >6cm.
• Screening programme for people at risk (+FH).
• Endovascular repair somewhat better results than open (current BMJ data).

BP
• Measurement errors.
• 24-hour recording shows wide variation.
• Spikes possible in moments.

Case 4
• Female, aged 55, florist.
• Presents with severe headaches, not relieved by aspirin.
• Noticed swollen ankles lately.
• BP 190/140.
• U + E: sodium 148, potassium 5.1, creatinine 380, urea 16.8.
• Renal biopsy shows:
-Necrotising arteriolitis.
-Hyperplastic arteriolitis (onion-skinning).
-Necrotising glomerulonephritis.
• Fails to respond to aggressive antihypertensive therapy.
• Develops stroke - becomes comatose.
• CT brain shows subarachnoid haemorrhage.
• Some recovery occurs, but left with severe deficit.