Antihypertensive pharmacology Flashcards by Heather Lilly

List the features of grade 1 hypertensive retinopathy

Increased tortuosity and reflectiveness of retinal arteries (copper/silver wiring)

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List the features of grade 2 hypertensive retinopathy

Increased tortuosity and reflectiveness of retinal arteries (copper/silver wiring)
PLUS

AV nicking

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List the features of grade 3 hypertensive retinopathy

Increased tortuosity and reflectiveness of retinal arteries (copper/silver wiring)
PLUS
AV nicking
PLUS
hemorrhages and soft (cotton wool) exudates

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List the features of grade 4 hypertensive retinopathy

Increased tortuosity and reflectiveness of retinal arteries (copper/silver wiring)
PLUS
AV nicking
PLUS
hemorrhages and soft (cotton will) exudates
PLUS
papilloedema

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Name the blood tests and investigations that should be performed for hypertensive patients

FBC, U&E’s, TFT’s, fasting lipids, glucose

ECG
CXR
24 hour BP monitor
Echo

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NICE guidelines treatment target BP for people < 80 years old (non-diabetic)

<140/90 mmHG

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NICE guidelines treatment target BP for people > 80 years old (non-diabetic)

<150/90 mmHg

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NICE guidelines treatment target BP for diabetics

<135/85 mmHg

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Name some of the conservative/lifestyle factors for managing HTN

Follow a healthy diet
Exercise regularly
Reduce dietary salt intake
Reduce caffeine consumption
Stop smoking
Reduce alcohol consumption

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Step 1 antihypertensive treatment in someone (non-Afro-Carribbean) < 55 years old and/or diabetic?

A =
Ace Inhibitors (Ramipril, Lisinopril, Enalapril)
ARBs (Candesartan, Losartan)

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Step 1 antihypertensive treatment in a person > 55 years old or of Afro-Caribbean family origin?

C =
CCB (Amlodipine, Diltiazem, Verapamil)

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Step 2 antihypertensive treatment in a person < 55 years old

Ace inhibitor or ARB + CCB or thiazide diuretic

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NICE guidance treatment targets

Diabetes: <135/85 mmHg
Age < 80 years: <140/90 mmHg
Age > 80 years: <150/90 mmHg

NICE guidance treatment targets

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Step 3 antihypertensive treatment for everyone

Ace inhibitor or ARB +
CCB +
Thiazide-like diuretic

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Drug class of Amlodipine?

Dihydropyridine (calcium channel blocker). This type of CCB is relatively selective for vasculature.

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Indications: First or second line treatment of HTN in patients 55 years or older or Afro-Carribean. Reduces risk of stroke, MI, and death from CVD.

Amlodipine

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Mechanism of action: Blocks the L-type voltage-gated calcium channel, decreasing intracellular calcium levels. This causes relaxation and vasodilation in arterial smooth muscle. Decreases force of contraction in cardiac muscle

Calcium channel blockers

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Which of the CCB’s is most negatively inotropic, acting to reduce cardiac contractility and reduce the heart rate (most “cardioselective” of the CCB’s)

Verapamil

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Which anti-hypertensive drug is renowned for causing ankle swelling?

Amlodipine (via preferential dilation of pre-capillary arteriole leading to increased hydrostatic pressure)

Side effects of this class of anti-hypertensives include palpitations (reflex tachycardia), constipation, flushing, HA, and exacerbation of heart failure -D&V-

Calcium channel blockers

Mechanism of action of ace-inhibitors?

Inhibit angiotensin-converting enzyme (ACE), reducing conversion of angiotensin I to angiotensin II. Blocking the action of Angiotensin II reduces peripheral vascular resistance (afterload) which lowers BP.

Important side effects of ace-inihibitors? (3)

Dry cough d/t bradykinin accumulation in lungs
HYPERkalaemia- lower aldosterone level promotes potassium retention
Renal impairment/failure- Especially with renal artery stenosis.

Losartan belongs to which drug class?

ARB’s or angiotensin II receptor antagonist

Mechanism of action of Losartan?

Blocks action of angiotensin II on the AT1 receptor. Has similar physiological effects to Ace-inhibitors.

First and most commonly used ARB in hypertension?

Losartan

First line drug in hyperaldosteronism?

Spironolactone (aldosterone antagonist)

MOA of Spironolactone?

Blocks the upregulation of Na+ channels in the DCT by aldosterone

What are the RENAL secondary causes of HTN?

Glomerulonephritis, diabetic nephropathy, renal artery stenosis, and pyelonephritis

What are some ENDOCRINE secondary causes of HTN?

Cushing's syndrome, Conn's syndrome, steroid therapy, pheochromocytoma

Treatment recommendations: Stage 1: BP >140/90 (Treat if end organ damage or diabetic) Stage 2: BP >160/100 (Treat once confirmed on 24hr BP) Stage 3: SBP > 180 (Treat immediately)

Side effects of calcium channel blockers?

Palpitations (reflex tachycardia) Constipation Flushing Headache Exacerbation of heart failure (D&V)

Side effects of Spironolactone?

Gynaecomastia Hyperkalaemia Impaired renal function

Which of the anti-hypertensive drugs acts to block the Na/Cl symporter in the distal convoluted tubule?

Thiazide diuretics (Bendroflumethiazide)

Which antihypertensive drug activates ATP-sensitive potassium channels in smooth muscle of blood vessels to dilate arterioles?

Indapamide ("Thiazide-like" diuretic)

Side effects of this drug class include: (Kidney) HYPOnatraemia HYPOmagnesaemia HYPOkalaemia Alkalosis HYPERcalcaemia Increase in urate (Gout) Increase in glucose --> diabetes, insulin resistance ?Liver Increase in lipids --> arterial disease

Thiazide diuretics

Which anti-hypertensive drug class is contraindicated in diabetics with recurrent hypoglycaemia?

Beta blockers (eg Bisoprolol) as they can mask sx of hypoglycaemia

MOA: Blocks Alpha-1 receptors, decreasing intra-cellular calcium release in arteriolar smooth muscle

Alpha blockers (eg Doxazosin)

Side effects of Doxazosin?

Palpitations (reflex tachycardia) and psotural hypotension

An assessment tool used to help determine which patients are most at risk of having a stroke or heart attack in the next 10 years

QRISK2 score

A moderate QRISK2 score of 10-20% means that a patient has between a ____-_____% chance of having a stroke or heart attack in the next 10 years

10-20%

Drug class of Bumetanide?

Loop diuretic

This drug class acts primarily on the ascending limb of the loop of Henle, where they inhibit the Na/K/2Cl transporter. This protein is responsible for transporting Na, Cl-, and K+ from the tubular lumen into the epithelial cells

Loop diuretics (eg Furosemide, Bumetanide)

Side effects of loop diuretics?

Dehyrdation Hypotension Electrolyte losses: Na+, Cl-, and K+ (as well as Mg, Ca and H+ ions indirectly)

Which drug is the "potassium sparing" diuretic?

Spironolactone

Side effects of ARB's (Losartan, Candesartan)?

Hypotension (particularly after the first dose) Hyperkalaemia Renal failure

This potent, direct-acting vasodilator breaks down in circulation to release nitric oxide. It can be used in cases of accelerated or malignant HTN

sodium nitroprusside

These drugs can be used IV in hypertensive emergencies (although other agents such as labetalol or sodium nitroprusside, are preferred)

Nitrates Short-acting- Glyceryl trinitrate Long-acting- Isosorbide mononitrate