4. Blood pressure conditions Flashcards by Osaivbie Joseph

What is a healthy blood pressure

120/80

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Stage 1 hypertension

Stage 1 hypertension: Blood pressure greater than 140/90.
Offer anti-hypertensive if they are
* 80years+ AND have bP of 150/90
* Have organ damage: left ventricular hypertrophy, CKD, retinopathy
* CVD
* if CVD risk is ≥ 10%
* Diabetes mellitus
* Kidney disease

ABPM: 135/85

Do not reduce blood pressure too quickly as this can reduce blood flow to vital organs: heart and brain

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Stage 2 hypertension

Stage 2: 160/100

ABPM: 150/95

Treat all patients

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Stage 3 hypertension

SEVERE:

≥ 180 (Systolic)
≥ 110 (Diastolic)

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NICE guidlines hypertension

ARBs are preferred over ACEinhibitors in black people

ACE/ARBs are preferred in diabetes due to their renal protective properties

If blood pressure remains uncontrolled in stage 1 hypertension, try to increase the dose before adding another drug .

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Hypertension in pregnancy

Target: <135/85

1st line: Labetalol (beta-blocker)

However can cause liver toxicity, STOP if jaundice occurs

ALternatively: Nifedipine MR
ALternative to this: methyldopa (stop 2 days after birth)

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Blood pressure targets

Under 80 years old: <140/90
Over 80: <150/90 (more relaxed target to reduce likelihood of hyPOtension)
Kidney disease: <140/90

If ACR > 70 then <130/80

Type 1 diabetes: <140/90
If ACR >70 then <130/80
If over 80 then <150/90

ACR - urine albumin to creatnine ratio AKA microalbumin

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ACE inhibitor and ARB mechanism of action

Angiotensin II stimulates the release of aldosterone, increasing plasma volume and also constricts blood vessels. ARBS directly block this effect

ACE inhibitors inhibit conversion of angiotensin I to angiotensin II.

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ACE inhibitors and ARB’s

Usually taken once daily except captopril which is taken BD

ACE inhibitors
* Captopril
* Enalapril
* Lisinopril
* Perindopril (30-60min before food)
* Ramipril

ARB’s
* Candesartan
* Losartan
* Valsartan

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ACE inhibitors/ARBS uses

For heart attack
For CVD prevention
For diabetic nephropathy (due to renal protective properties)
For CKD

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ACE inhibitor/ARB’s side effect

Dry cough (due to build up of bradykinin in lungs) - ARBS can be given instead
HypERkalaemia (risk is higher in renal impairement and diabetes)
First-dose hypotension
Can cause dizziness, fainting, especially in the elderly.
Patients must take their first dose at bedtime
Nephrotoxic
Can cause acute kidney injury in short term, characterised by a low GFR.
Renal function must be monitored
They are renal protective in the long term
Kidney sick day rules:
ACEi/ARBs must temporarily be stopped during fever, diarrhoea, vomiting as there is a higher risk of AKI = increased risk of dehydration = therefore increased risk of AKI.
rule also applies to NSAIDS and diuretics

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ACEinhibitors/ARB’s caution

ACEi/ARBs can worsen renal vascular disease, where renal arteries are narrowed, as GFR is reduced.

ACEi/ARBs should also be used in caution in atherosclerosis as this can also narrow renal arteries = low GFR

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ACEinhibitors/ARBs side effect

summed up

CAPTOPRIL

C - cough dry
A -angioedema (common in afro-carribean origin)
P - postural hypotension, hypotension
T - taste disturbance
O - oral ulcers
P - potassium high (hyperkalaemia)
R - renal impairment
I - indigestion
L - Low BP

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ACE inhibitors/ARBs and pregnancy

Teratogenic

Can cause birth defects
Can affect baby’s renal function

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ACE inhibitors/ARBs interactions

Interacts with drugs which are also hypotensive, which further increases hypotension
Alpha-blockers, beta blockers, calcium-channel blockers (anti-hypertensive), levodopa, dopamine-receptor antagonist, MAO-B inhibitor, antipsychotic, nitrate, Phosphodiesterase type 5 inhibitor e.g sildenafil, SGLT2 inhibitor canaglifozin, TCA antidepressant
Interacts with diuretics, they can cause a rapid fall in BP in volume depleted patients.
Intreracts with drugs that also cause hyperkalaemia
Aldosterone antagonist: spiranolactone, alikskiren, ciclosporin, tacrolimus, heparin, potassium-sparing diuretic, potassium supplements, trimethoprim
Interacts with NSAIDs, as there is an increased risk of AKI
NSAIDs may lower GFR as they cause vasoconstriction of afferent arteriole
Interacts with drugs that also affect the renal system as there is an increased risk of renal impairement, hyPERkalaemia and hypotension
ACE inhibitors, ARB’s aliskiren

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Calcium channel blockers mechanism of action

CCB’s interfere with the calcium influx into vascular smooth muscle and the heart

Lowers blood pressure by acting on blood vessels, causing reduced heart rate, blood pressure and force of contraction

Types of calcium channel blockers

Dihydropyridines
Mainly act on blood vessels (coronary arteries and systemic circulation)
so can treat hypertension and angina

amlodipine OD
felodipine OF
Nifedipine (maintain same brand for MR)

Rate-limiting
Mainly depress the heart by reducing the heart rate and force of contraction, reduce cardiac output
* Diltiazem (same brand for MR, when dose is >60mg)
* Verapamil (arrhythmias)

Calcium channel blockers uses

Angina, Arrhythmias, Hypertension (1st line)

Not used in heart failure as CCB reduce cardiac output and there is alre

Calcium channel blockers side effects

Ankle swelling, flushing, headache (associated with vasodilation)
Tachycardia and palpitations (reflux response, as body increases blood pressure to compensate)
Angioedema, gingival hyperplasia
Constipation (with verapamil)

Calcium channel blockers side effect
*summary

D - dizziness
E - erectile dysfunction
A - ankle swelling, angioemdema
T - tachycardia, palpitations
H - headache
F - flushing
O - oedema
G - gingival hyerplasia

Calcium channel blockers interactions

CCB’s are metabolised by cytochrome P450 enzymes

Interacts with drugs which are enzyme inhibitors = higher levels of CCB in body
Clarithromycin, Erythromycin, Azole antigungals: fluconazole
Interacts with drugs which are enzyme inducers = lower levels of CCB in body
Carbamazepine, Pheenytoin, Rifampicin, St John’s Wort
Interacts with drugs which are also hypotensive, which further increases hypotension
ACE inhibitors, ARB’s, beta blockers (anti-hypertensive), levodopa, dopamine-receptor antagonist, MAO-B inhibitor, antipsychotic, nitrate, Phosphodiesterase type 5 inhibitor e.g sildenafil, SGLT2 inhibitor canaglifozin, TCA antidepressant
Interacts with drugs which also cause bradycardia (verapamil and diltiazem cause bradycardia as a side effect)
Amiodarone, beta-blockers (cardiodepression), digoxin (toxicity)

Verapamil AND beta-blockers = SEVERE hypotension and bradycardIa AND heart failure in ischaemic heart disease e.g angina

Beta blockers mechanism of action

Blocks adrenoreceptors in peripheral vessels and heart. This results is lower blood pressure, heart rate and force of contraction.

Beta-blockers list

Atenolol
Nebivolol
Propanolol (for migraine, anxiety, thyrotoxicosis)
Bisoprolol
Labetaolol

Beta blockers counselling

Label: warning. Do not stop taking this medicine unless your doctor tells you to stop.

Beta blockers uses

1st line in heart failure and angina, also treat arrhythmias, hypertension and for long term management following a heart attack

Types of beta -blockers

PACO CANS BANMe ABC-N **PACO**: * Pindolol * Acebutolol * Celiprolol * Oxprenolol **CANS** * Celiprolol * Atenolol * Nadolol * Sotalol **BAN Me** * Bisoprolol * Atenolol * Nebivolol * Metoprolol **ABC-N** * Atenolol * Bisoprolol * Celiprolol * Nadolol

PACO Beta-blockers

PACO - stimulate and block B-adrenoreceptors partial agonists so less likely to cause side effects like bradycardia and cold extremities P- Pindolol A - Acebutolol C - celiprolol O -oxprenolol

CANS beta-blockers

CANS Are water soluble, less likely to cause lipophilic blood brain barrier, therefore less likely to cause sleep disturbances and nightmares as side effects Are excreted in the kidneys, so dose may need to be reduced in renal impairement C - celiprolol A - atenolol N - nadolol S - sotalol

BANme beta-blockers

Are cardioselective and preferably act on the heart. Less likely to act on the bronchi and cause bronchospasms as a side effect * B- bisoprolol * A - atenolol * N - nebivolol * Me -metoprolol Cardioselective beta blockers can be given under supervision in controlled asthma (if no other choice) | Cardioselective beta blockers can be given under supervision in contro

ABC-N beta blocker

Are long-acting and given once daily (different to other beta-blockers which are typically given twice daily) A - atenolol B - bisoprolol C - celiprolol N - nadolol

Beta-blockers side effects *summed up*

B - Bradycardia, bronchospasms A - Atrioventricular block D - Disturb glucose metabolism F - Fainting and dizziness I - Impotence S - Sleep disturbances H - Hypotension, Heart Failure, Hands and feet cold Can also worsen heart failure, as they reduce cardiac output BUT equally they reduce the heart workload = beneficial in heart failure Also affects glucose metabolism, can cause hypo or hyperglycaemia in patients with or without diabetes Can mask signs of hypoglycaemia e.g tachycardia but beta blockers lower heart rate, so tachycardia does not occur

Beta-blockers interactions

* **Interacts with drugs which are also hypotensive, which further increases hypotension** * ACE inhibitors, ARB's, beta blockers (anti-hypertensive), calcium-channel blockers, levodopa, dopamine-receptor antagonist, MAO-B inhibitor, antipsychotic, nitrate, Phosphodiesterase type 5 inhibitor e.g sildenafil, SGLT2 inhibitor canaglifozin, TCA antidepressant * **Interacts with drugs which also cause bradycardia (verapamil and diltiazem cause bradycardia as a side effect)** Amiodarone, beta-blockers (cardiodepression), digoxin (toxicity) Verapamil AND beta-blockers = SEVERE hypotension and bradycardIa AND heart failure in ischaemic heart disease e.g angina

Shock

When the body does not get enough blood flow, causing hypotension. Organs and cells are starved of oxygen = multiple organ failure

Treatment for shock

**Inotrope sympathomimetics:** adrenaline, dopamine Increases heart's force of contraction, so more blood is pumped out to the rest of the body and raises blood pressure **Vasoconstrictor sympathomimetics:** ephedrine, noradrenaline, phenylephrine Constricts blood vessels, increasing blood pressure. Avoid in cardiogenic shock as blood pressure will already be high, and worsen the problem

Causes for shock

Sepsis Major bleeding Haemorrhage -> hypovolemic Anaphylaxis Neurogenic

Vasoconstrictor sympathomimetics mechanism of action

Acts on alpha-adrenergic receptors on peripheral blood vessels, causing vasoconstriction and increases blood pressure

Vasoconstrictor sympathomimetics use

Used to raise blood pressure if other methods have failed

Vasoconstrictor sympathomimetics side effects

* May cause high blood pressure, which can reduce blood pressure to vital organs e.g kidneys, this leading to organ failure

A 38-year old woman with HTN becomes pregnant. She is currently taking Ramipril 2.5mg. She has no other medical conditions. Which of the following is the next appropriate step? a) Stop ramipril and switch to losartan b) Stop ramipril and switch to labetalol c) Continue ramipril at current dose d) Reduce ramipril to 1.25mg e) Pregnancy is contra-indicated in patients with HTN

b) Stop ramipril and switch to labetalol ACEi/ARBs are contraindicated in pregnancy