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BSMS308 > 5. Cardiovascular drugs 2 > Flashcards

5. Cardiovascular drugs 2 Flashcards

1
Q

Hypertension prevalence

A

25% of adults in UK
60% of over 75s
Accounts for 12% of GP visits in England
1% of hypertensive population develop hypertensive crises

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2
Q

For every 10mmHg reduction in blood pressure

A

17% decrease of CHD
27% reduction of stroke
28% reduction of heart failure
13% reduction of all-cause mortality

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3
Q

What is hypertension?

A

Clinic BP 140/90 or higher

need to make absolutely sure, so need to take it again then if there is a big difference take it one more time

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4
Q

Hypertension diagnosis

A

Clinic BP ≥140/90

ABPM/HBPM >135/85

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5
Q

true normotension

A

normotensive by ABPM/HBPM and clinic BP

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6
Q

True hypertension

A

hypertensive by ABPM/HBPM and clinic BP

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7
Q

White coat hypertension

A

Hypertensive based on office BP and normotensive by ABPM/HBPM

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8
Q

masked hypertension

A

normotensive by clinic BP but hypertension by ABPM/HBPM

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9
Q

Hypertension causes

A

90% primary

10% secondary

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10
Q

Secondary causes of hypertension

A
  • Renal disease – renovascular disease, renal parenchymal diseas
  • Endocrine disease – -Conn’s, Cushing’s, Phaeo
  • Drugs – COC Pills, -Steroids, NSAIDS, Cocaine, EPO
  • Vascular
  • Others – OSA, PIH
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11
Q

Contributary factors to hypertension

A

↑BMI; >14 units of alcohol; salt intake; lack of exercise; stress;

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12
Q

Hypertension risk factors

A 
Male
Age
Family history & ethnicity - black African descent
Smoker
Cholesterol
Diabetes
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13
Q

Hypertension symptoms

A 
None - silent killer
headache
blurred vision
dizziness
SOB
palpitations
Epistaxis
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14
Q

Hypertension examination

A 
Cardiovascular system
Abdomen
fundoscopy (examining back of eye)
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15
Q

Hypertension investigations

A

Urinalysis - Proteinuria

ECG – LVH, AF

Blood tests – U&E, LFT, Lipids, Glucose/HbA1C

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16
Q

Effects of hypertension and target organ damage

A

massive increase in CV risk

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17
Q

Hypertension non drug treatment

A

Weight reduction - maintain ideal BMI (20-25) - 5-10mmHg/10kg weight loss

DASH eating plan - fruit & veg, low fat dairy products - 8-14mmHg

Dietary sodium restriction - <6g salt - 2-8mmHg

Physical activity - 4-9mmHg

Alcohol moderation - 14 units or less per week - 2-4 mmHg

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18
Q

Step 1 hypertension drug for: hypertension in people under 55 and not black

A

ACEi (e.g. ramipril) or ARB (losartan)

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19
Q

Step 1 hypertension drug for black people and people over 55

A

CCB e.g. amlodipine

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20
Q

Stage 1 hypertension treatment

A 
Stage 1 (CBP ≥140/90 mmHg; ABPM/HBPM >135/85) 
		\+
	Target organ damage
	Established CV disease
	Renal disease
	Diabetes
	10 year CV risk ≥ 20%
21
Q

Stage 2

A

(CBP≥160/100; ABPM/HBPM >150/95)

use ARB and CCB

22
Q

Severe hypertension

A

(CBP>180/110)

ARB and CCB and thiazide-like diuretic and either further diuretic or alpha/beta-blocker

23
Q

What to check before starting ACE inhibitors/ARB

A

Check serum creatinine and potassium

    Before starting therapy (do not start if K above normal range)
    After 1-2 weeks
    After subsequent dose increases

If creatinine rises >30% or GFR falls >25% or K >6

   Stop drug
   Repeat tests
   Consider other causes

Extra Caution when co-prescribed with Spironolactone!!

24
Q

Effects of ACEi/ARBs in pregnancy and breastfeeding

A

Contraindicated in pregnancy

Contraindicated in breast feeding

Alternatives – labetalol, methyldopa, nifedipine/amlodipine

Check if in doubt!

25
Q

BP threshold

A

when you start treatment

26
Q

BP target

A

what you aim to treat to

27
Q

How to monitor drug treatment

A

use clinic BP measurements to monitor response to treatment and aim for target BP beneath 140/90 for under 80s and 150/90 for over 80s

28
Q

How to monitor drug treatment in pts with white coat effect

A 
White coat effect is when people already have hypertension but get stressed out in clinic and their bp changes
Need to use ABPM or HBPM to monitor
target:
below 135-85 mmHg in under 80s
below 145/85 in over 80s
29
Q

Hypertension proteinuria targets

A

Proteinuria low: ACR<70 or PCR<100 - Target blood pressure <140/90

Proteinuria high: ACR>70 or PCR>100 - Target blood pressure <130/80

30
Q

When should ACE-i or ARBs be used in hypertensive pts with proteinuria?

A

should be included in:
Patients with urinary ACR>30 or PCR>50
Diabetic patients with microalbuminuria

31
Q

Causes of treatment failure

A

Pseudo-resistant Hypertension (Non adherence; white coat effect)

Secondary Hypertension

Resistant Hypertension

32
Q

Step 4 treatment

A

Confirm BPs with ABPM and HBPM
Low dose spirolactone if potassium under 4.5mmol/l
Alpha blocker/beta blocker if potassium over 4.5mmol/l

33
Q

Treatment of hypertension in older patients

A

Check for postural hypotension
Treat to below NICE targets in >80 year old patients ie CBP<150/90 or ABPM/HBPM <145/85
Use clinical judgement

34
Q

Hypertensive emergency

A

Severe “hypertension” (BP≥ 180/120 mmHg) with acute damage to the target organs
Lower BP in minutes to hours!!

35
Q

Hypertensive urgency

A

Severe “hypertension” without acute damage to the target organs
Lower BP after a review within 7 days

36
Q

Clinical features of hypertensive crises

A 
Asymptomatic
Headache
Epistaxis
Presyncope 
Palpitations

Chest pain
Dyspnoea
Neurological deficit

37
Q

Hypertensive crisis - acute target organ damage

A

Eyes (papilloedema)

Brain (encephalopathy, stroke)

Heart (pulmonary oedema, MI)

Kidneys (AKI)

Aortic dissection

38
Q

Treatment for hypertensive emergency

A

Same day specialist review
IV Therapy – Labetalol, GTN, Sodium nitroprusside, Esmolol
Reduce BP/MAP (20–25% in the 1-2 hours)
Target of 160/100 in 6 hours

39
Q

Treatment for hypertensive urgency

A

ABPM/HBPM
GP follow up within 7 days
Oral treatment

40
Q

Statins for primary CVD prevention

A

Under 84 year olds should have CV risk estimated

Lifestyle modification

Offer atorvastatin for a 10% or greater 10‑year risk of developing CVD

For people 85 years or older also consider atorvastatin (no need for CV Risk calculation)

Offer statins in Type 1 diabetes (>40 and long standing) and CKD (no need for CV Risk calculation)

41
Q

Statins for secondary prevention of CVD

A

Start statin treatment in people with CVD

Do not delay statin treatment to manage modifiable risk factors

42
Q

CKD and statins

A

Adults with chronic kidney disease (CKD 3) should be offered atorvastatin

Do not use a risk assessment tool to assess CVD risk in people with an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2 and/or albuminuria

43
Q

Blood tests before statins

A

Lipid measurement
Liver function tests – 3x upper limit of normal
Renal function
HbA1C
Thyroid stimulating hormone
Creatine kinase (CK) - 5x upper limit of normal. No need to do CK unless symptoms

44
Q

Follow up after statins

A

Lipid measurement (3 months after) - 40% reduction in non- HDL Cholesterol

Liver function tests (3 months after)

Creatine kinase (CK) - if symptoms

Annual medication review

45
Q

Ezetimibe

A

Ezetimibe monotherapy is recommended as an option for treating primary (heterozygous‑familial or non‑familial) hypercholesterolaemia in adults in whom initial statin therapy is contraindicated or not tolerated

Ezetimibe co‑administered with statin might be appropriate

46
Q

statins not tolerated

A

Stop, reduce dose or switch statin

Specialist input

Ezetimibe

Not fibrates!!

47
Q

Hypertriglycerridaemia

A

Exclude excess alcohol and poor glycaemic control

Triglyceride >20mmol/l – Refer to specialist

Triglyceride 10–20 mmol/l – repeat as fasting sample within 2 weeks. If still >10 mmol/l then refer to specialist.

Triglyceride 4.5–9.9 mmol/l – check CVD risk and correlate with cholesterol

48
Q

CV risk - Framingham heart study

A 
Age
Gender
LDL cholesterol
HDL cholesterol
Blood pressure
Diabetes
Smoking
Obesity
49
Q

Cardiovascular risk calculators

A

QRISK®2 and 3 – 10 year Cardiovascular risk

JBS3 - Lifetime CV risk

BSMS308 (9 decks)

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