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6. Cardiovascular System > 7. Hypertension > Flashcards

7. Hypertension Flashcards

1
Q

What is the WHO clasification of hypertension?

A

140/90mmHg.

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2
Q

Write an equation for BP.

A

BP = CO X TPR.

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3
Q

What is the definition of hypertension?

A

> 140/90mmHg based on 2+ readings on separate occasions

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4
Q

What is the clinical diagnosis of hypertension?

A

BP ≥ 140/90mmHg.

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5
Q

On average, by how much does having high blood pressure shorten life?

A

7 years. Although this depends on onset and severity.

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6
Q

Give 3 risk factors for hypertension

A

Age, FHx, male gender, African or Caribbean origin, high salt intake, sedentary lifestyle, overweight/obese, smoking, excess alcohol intake.

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7
Q

Give 5 causes of hypertension.

A
  1. Kidney disease.
  2. Genetics and family history.
  3. Lifestyle factors e.g. high salt diet, excess alcohol, obesity, stress, caffeine.
  4. Recreational drug use e.g. cocaine.
  5. Drugs such as OCP and NSAIDS.
  6. Hyperaldosteronism.
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8
Q

List 3 causes of secondary hypertension

A

Renal disease - diabetic nephropathy, chronic glomerulonephritis, PKD, chronic tubulointerstitial nephritis.

Endocrine disease - Conn’s, phaeochromocytoma, Cushing’s, acromegaly.

Coarctation of the aorta (a birth defect in which a part of the aorta is narrower than usual).

Pregnancy.

Steroids.

The Pill.

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9
Q

Name 3 endocrine diseases that can cause secondary hypertension.

A
  1. Conn’s syndrome - hyperaldosteronism.
  2. Cushing’s syndrome - prolonged cortisol exposure -> raised BP.
  3. Phaeochromocytoma - adrenal gland tumour, excess NAd and Ad release -> high BP.
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10
Q

Name 5 conditions that hypertension is a major risk factor of.

A
  1. MI (IHD).
  2. Stroke.
  3. Heart failure.
  4. Chronic renal disease.
  5. Dementia.
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11
Q

What investigations might you do in someone with hypertension?

A
  1. Take blood pressure again on at least 1 other occasion.
  2. 24h ambulatory BP monitoring (ABPM) to confirm a diagnosis.
    = exclude white coat effect
  3. ECG and blood tests may be done to identify secondary causes of hypertension.
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12
Q

Why might you examine the eyes of someone with hypertension?

A

Very high BP can cause immediate damage to small vessels, this can be seen in the eyes where there are small exposed blood vessle.s

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13
Q

What are the criteria for treating hypertension?

A

ALL with sustained >160/100mmHg.

Those with sustained >140/90 that are at high risk of coronary events, have diabetes or end-organ damage

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14
Q

What is the threshold BP for giving treatment to the following:

a) high risk individuals.
b) low risk individuals.

A

a) High risk - 140/90mmHg.
b) Low risk - 160/100mmHg.

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15
Q

What are the NICE treatment targets for the following:
a) People aged <80?
b) People aged >80?

A

a) Below 140/90mmHg in those aged less than 80.
b) Below 150/90mmHg in those aged above 80.

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16
Q

If you gave someone 1 blood pressure tablet, by how much would you expect their blood pressure to decrease?

A

1 tablet = 10mmHg reduction in BP.

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17
Q

Name 2 systems that are targeted pharmacologically in the treatment of hypertension.

A
  1. RAAS.
  2. Sympathetic nervous system (NAd)
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18
Q

Outline RAAS.

A

Angiotensinogen

↓ Enzyme: Renin

Angiotensin I

↓ Enzyme: ACE

Angiotensin II

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19
Q

Give 4 functions of angiotensin II.

A
  1. Potent vasoconstrictor.
  2. Activates sympathetic nervous system; increased NAd.
  3. Activates aldosterone = Na+ retention.
  4. Vascular growth, hyperplasia and hypertrophy.
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20
Q

Give 3 ways in which the sympathetic nervous system (NAd) lead to increased BP.

A
  1. Noradrenaline is a vasoconstrictor = increased TPR.
  2. NAd has positive chronotropic and inotropic effects.
  3. It can cause increased renin release.
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21
Q

The 2 main types of treatment for hypertension?

A
  1. Lifestyle modification (non-pharmacological): reduce salt intake, lose weight, reduce alcohol.
  2. Drug therapy (pharmacological): ABCD.
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22
Q

Give 3 examples of non-pharmacological measures you would encourage a patient with hypertension to take.

A

Weight reduction.
Mediterranean diet - oily fish, low saturated fat, low salt.
Limit alcohol consumption.
Exercise.
Smoking cessation.
Increase fruit and vegetable intake.

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23
Q

Pharmacological interventions for hypertension

A

A - ACEi e.g. rampiril or ARB e.g. candesartan.
B - Beta blockers e.g. bisoprolol.
C - Ca2+ channel blocker e.g. amlodipine, diltiazem or verapamil.
D - Diuretics e.g. bendroflumethiazide or furosemide.

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24
Q

Will anti-hypertensives make someone feel better?

A

Anti-hypertensives won’t necessarily make someone feel better as there are few symptoms associated with high BP although headache symptoms may improve.

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25
Q

Name 3 ACE inhibitors.

A
  1. Ramapril.
  2. Enalapril.
  3. Perindopril.
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26
Q

In what diseases are ACE inhibitors clinically indicated?

A
  1. Hypertension.
  2. Heart failure.
  3. Diabetic nephropathy.
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27
Q

Give 4 potential side effects of ACE inhibitors.

A
  1. Hypotension.
  2. Hyperkalaemia.
  3. Acute renal failure.
  4. Teratogenic.
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28
Q

Why do ACE inhibitors lead to increased kinin production?

A

ACE -> non-specific enzyme

Also converts bradykinin to inactive peptides

Therefore: ACE inhibitors lead to a build up of kinin

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29
Q

ACE inhibitors: give 3 potential side effects that are due to increased kinin production.

A
  1. Dry chronic cough.
  2. Rash.
  3. Anaphylactoid reaction.
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30
Q

Give 5 potential side effects of rampiril.

A

Side effects of ACE inhibitors:

  1. Hypotension.
  2. Acute renal failure.
  3. Hyperkalaemia.
  4. Teratogenic.
  5. Cough, rash, anaphylactoid due to increased kinin production.
31
Q

What are ARBs?

A

Angiotensin II receptor blockers.

32
Q

At which receptor do ARB’s work?

A

AT-1 receptor.

33
Q

Name 3 ARBs.

A
  1. Candesartan.
  2. Valsartan.
  3. Losartan.
34
Q

On what receptor does valsartan act?

A

AT-1, prevents Ang 2 binding.

35
Q

Give 4 side effects of valsartan.

A

Side effects of valsartan:

  1. Hypotension.
  2. Renal dysfunction.
  3. Hyperkalaemia.
  4. Rash.
  5. Contraindicated in pregnancy.
36
Q

In what diseases are ARBs clinically indicated?

A
  1. Hypertension.
  2. Heart failure.
  3. Diabetic nephropathy.
37
Q

Give 4 potential side effects of ARBs.

A

ARBs have similar side effects to ACEi:

  1. Hypotension.
  2. Hyperkalaemia.
  3. Renal dysfunction.
  4. Rash.

Contraindicated in pregnancy.

38
Q

How do calcium channel blockers work to reduce hypertension?

A

Decrease calcium entry into vascular smooth muscle cells - vasodilation of arterial smooth muscle, lowering arterial pressure.

39
Q

On what channels do calcium channel blockers work?

A

L type Ca2+ channels.

40
Q

What are the 3 categories of CCBs?

A
  1. Dihydropyridines
  2. Phenylalkylamines
  3. Benzothiazepines
41
Q

Name 4 Calcium channel blockers.

A
  1. Amlodipine.
  2. Felodipine.
  3. Diltiazem.
  4. Verapamil.
42
Q

Name 2 dihydropyridines and briefly explain how they work.

A

Dihydropyridines are a class of calcium channel blockers. Amlodipine and felodipine are examples of dihydropyridines. They are arterial vasodilators.

43
Q

Name a calcium channel blocker that acts primarily on the heart.

A

Verapamil - it is negatively chronotropic and inotropic.

44
Q

Name a calcium channel blocker that acts on the heart and on blood vessels.

A

Diltiazem - acts on the heart and the vasculature.

45
Q

In what diseases are calcium channel blockers clinically indicated?

A
  1. Hypertension.
  2. IHD.
  3. Arrhythmia.
46
Q

Give 3 side effects of CCBs.

A

Bradycardia, headaches, flushing

47
Q

Give 3 potential side effects that are due to the vasodilatory ability of calcium channel blockers.

A
  1. Flushing.
  2. Headache.
  3. Oedema.
48
Q

Give a potential side effect that is due to the negatively inotropic ability of calcium channel blockers.

A

Worsening caridac failure.

49
Q

Give 2 potential side effects that are due to the negatively chronotropic ability of calcium channel blockers.

A
  1. Bradycardia.
  2. Atrioventricular block.
50
Q

Give 3 side effects of amlodipine.

A

Side effects of dihydropyridines (CCB):

  1. Flushing.
  2. Headache.
  3. Oedema.
  4. Palpitations.
51
Q

Give 4 potential side effects of verapamil.

A
  1. Worsening cardiac failure (-ve inotrope).
  2. Bradycardia (-ve chronotrope).
  3. Atrioventricular block (-ve chronotrope).
  4. Constipation!
52
Q

Name 3 beta blockers.

A
  1. Bisoprolol (beta 1 selective).
  2. Atenolol.
  3. Propanolol (beta 1/2 non selective).
53
Q

In what diseases are beta blockers clinically indicated?

A
  1. IHD.
  2. Heart failure.
  3. Arrhythmia.
  4. Hypertension.
54
Q

Give 5 potential side effects of beta blockers.

A
  1. Fatigue.
  2. Headache.
  3. Nightmares.
  4. Bradycardia.
  5. Hypotension.
  6. Cold peripheries.
  7. Erectile dysfunction.
  8. Bronchospasm.
55
Q

Give 5 side effects of bisoprolol.

A

Side effects of beta blockers:

  1. Hypotension.
  2. Fatigue.
  3. Headaches.
  4. Nightmares.
  5. Bradycardia.
  6. Hypotension.
  7. Erectile dysfunction.
  8. Cold peripheries.
56
Q

Diuretics: where in the kidney do thiazides work?

A

The distal tubule.

57
Q

Name a thiazide.

A

Indapamide (NICE-recommended hypertension guideline)

Bendroflumethiazide

58
Q

Give 5 side effects of bendroflumethiazide.

A

Side effects of diuretics:

  1. Hypovolemia.
  2. Hypotension.
  3. Reduced K, Na, Mg, Ca.
  4. Hyperuricaemia -> gout.
  5. Erectile dysfunction.
59
Q

Name 2 loop diuretics.

A
  1. Furosemide.
  2. Bumetanide.
60
Q

Name a potassium sparing diuretic.

A

Spironolactone.

61
Q

Why are potassium sparing diuretics especially effective?

A

They have anti-aldosterone effects too.

62
Q

In what diseases are diuretics clinically indicated?

A
  1. Heart failure.
  2. Hypertension.
63
Q

Give 5 potential side effects of diuretics.

A
  1. Hypovolemia.
  2. Hypotension.
  3. Reduced serum Na+/K+/Mg+/Ca2+.
  4. Increased uric acid -> gout.
  5. Erectile dysfunction.
  6. Impaired glucose tolerance.
64
Q

You see a 45 y/o patient who has recently been diagnosed with hypertension. What is the first line treatment?

A

ACE inhibitors e.g. ramapril or ARB e.g. candesartan.

65
Q

You see a 65 y/o patient who has recently been diagnosed with hypertension. What is the first line treatment?

A

Calcium channel blockers (as this patient is over 55) e.g. amlodipine.

66
Q

You see a 45 y/o patient who has recently started taking ACE inhibitors for their hypertension. Unfortunately their hypertension still isn’t controlled. What would you do next for this patient?

A

You would combine ACE inhibitors or ARB with calcium channel blockers.

67
Q

You see a 45 y/o patient who has been taking ACE inhibitors and calcium channel blockers for their hypertension. Following several tests you notice that their blood pressure is still high. What would you do next for this patient?

A

You would combine the ACEi/ARB and calcium channel blockers with a thiazide diuretic e.g. bendroflumethiazide.

68
Q

A patient with hypertension has come to see you about their medication. You see in their notes that ACE inhibitors are contraindicated. What might you prescribe them instead?

A

An ARB e.g. candesartan.

69
Q

You see a patient who is taking ramipril. They say that since starting the medication they have had a dry and persistent cough. What might have caused this?

A

ACE inhibitors lead to a build up of kinin. One of the side effects of this is a dry and chronic cough.

70
Q

A patient comes to see you who has recently started taking calcium channel blockers for their hypertension. They complain of constipation. What calcium channel blocker might they be taking?

A

Verapamil.

71
Q

What drug would you prescribe for a 45yo caucasian patient with hypertension with no other medical history?

A

ACE inhibitor - ramipril
If CI (cough) - ARB - losartan

72
Q

What drug would you prescribe a 67yo Afro-Caribbean man with hypertension?

A

Calcium channel blocker - amlodipine

73
Q

If first line treatment is failing to control a patient’s hypertension, what drug regime would you prescribe them? And if this fails?

A

ACE inhibitor + CCB or ACE inhibitor + thiazide.
All 3 if a combination of 2 fails to control.

6. Cardiovascular System (24 decks)

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