Blood pressure conditions

Question 1

Hypertension treatment step 1

Answer 1

AB<55: ACE or ARB (B blocker if ACE/ARB not tolerated/CI)
CD 55+* : CCB (if high risk of HF/CCB not tolerated?CI, use TLD)
*includes Africans/Caribbeans

Question 2

Hypertension treatment step 2

Answer 2

AB<55: CCB (if high risk of HF/CCB not tolerated?CI, use TLD)
CD 55+* : ACE or ARB (ARB preferred in African/Caribbean people)

Question 3

Hypertension treatment step 3

Answer 3

All: ACE/ARB + CCB + TLD

Question 4

Hypertension treatment step 4 (resistant HTN)

Answer 4

Add diuretics such as low dose spiro, or high dose TLD (if K+>4.5). If other diuretics ineffective/CI, add B blocker

Question 5

Hypertension stage 1

Answer 5

140/90 - lifestyle advice only. Only treat if under 80 and target organ damage (retinopathy, LVH, CKD), CVD or 10 year risk of CVD >20%, renal disease or diabetes.

Question 6

Hypertension stage 2

Answer 6

160/100 - treat all

Question 7

Hypertension stage 3

Answer 7

> 180/>110 Hypertensive crises
Hypertensive emergency: acute target organ damage- use IV treatment, slowly reduce or reduced perfusion -> blindness, MI, infarcts, AKI.
Hypertensive urgency, no damage, oral, reduce slowly over 24-48h.

Question 8

BP Target: <80

Answer 8

<140/90

<130/80 in artherosclerotic CVD, DM with kidney, eye or cerebrovasc disease

Question 9

BP Target: >80

Answer 9

<150/90

Question 10

BP Target: renal disease

Answer 10

<140/90

<130/80 in CKD, DM, proteinuria (ACE/ARB preferred in proteinuria)

Question 11

BP Target: Diabetes

Answer 11

<140/80

<130/80 if complications (eye, kidney, cerebrovasc)

Question 12

BP Target: pregnancy

Answer 12

<150/100 chronic HTN
<140/90 chronic HTN + target organ damage, given birth
Labetolol (nephrotoxic) 1st choice, widely used in gestational HTN.

Question 13

ACEi ADRs

Answer 13

Persistent dry cough (caused by bradykinin breakdown inhibition, try ARB as alternative), hyperkalemia (high risk in renal imp & DM. anaphylactoid reactions (eg angiodema)

Question 14

ACEi renal effects

Answer 14

Renoprotective in CKD, nephrotoxic in AKI.
Reduces eGFR via efferent arteriole dilation. avoid in renovascular disease (may give if unilateral, NOT in bilateral stenosis)

Question 15

ACEi hepatic effects

Answer 15

can cause cholestatic jaundice, hepatic failure, stop if liver transaminases 3x normal or if jaundice occurs.

Question 16

ACEi ADRs

Answer 16

Renal and hepatic ADRs, mouth ulcers, taste disturbance, hypoglycaemia. Avoid in pregnancy

Question 17

ACEi interactions

Answer 17

^K+ - aliskeren, ARB, K sparing diuretics/aldosterone antagonists.
Nephrotoxicity (NSAIDs)
Hypotension (diuretics)

Question 18

ARB MOA:

Answer 18

block angiotensin II receptor, doesn’t inhibit breakdown of bradykinin (hence no dry cough like ACEi)

Question 19

Alpha blocker MOA:

Answer 19

reduces smooth muscle contraction in blood vessels reducing BP

Question 20

B blocker (ice PACO)

Answer 20

Propranolol, Acebutol, Celiprolol and Oxprenolol

intrinsic sympathomimetic activity - less bradycardia and coldness of extremities

Question 21

B blocker (watering CANS)

Answer 21

Celiprolol, Atenolol, Nadolol, Sotalol

water soluble, don’t cross BBB, less nightmares (reduce dose in renal impairment as renally excreted)

Question 22

B blocker (ABMAN)

Answer 22

Acebutol, Bisoprolol, Metoprolol, Atenolol, Nebivolol

Cardioselective - less bronchospasm - used in well controlled asthma

Question 23

B Blocker (BACoN)

Answer 23

Bisoprolol, Atenolol, Celiprolol, Nadolol

Long acting, OD dosing.

Question 24

B Blocker ADRs

Answer 24

Bradycardia, hypotension, hyper/hypoglycemia (masks symptoms of hypos eg tachycardia)

Question 25

B Blocker CIs

Answer 25

Asthma (including timolol drops), worsening/unstable HF, second/third degree heart block, severe hypotension and bradycardia

Question 26

B blocker interactions

Answer 26

Asystole and hypotension - rate lim CCBs (particularly verapamil inj)
Hyperglycemia- avoid in DM - (TLDs eg bendroflum)

Question 27

CCB MOA

Answer 27

blocks Ca channels, reducing contraction force, conductivity and vascular tone.

Question 28

Dihydropyridines ADRs

Answer 28

Ankle swelling, flushing, headaches

Question 29

Rate lim CCBs info

Answer 29

Verapamil (causes constipation, only CCB licensed in arrhythmias), Diltiazem (brand specific if >60mg)

Question 30

CCB interactions

Answer 30

enzyme inhibitors increase CCB concentrations

Question 31

Hypotension and shock treatment

Answer 31

Vasoconstrictor sympathomimetics eg (Nor)adrenaline

Question 32

Vasoconstrictor sympathomimetics MOA

Answer 32

raise BP transiently by acting on alpha receptors causing vasoconstriction

Question 33

Vasoconstrictor sympathomimetics ADRs

Answer 33

reduced perfusion to vital organs (eg kidneys)