Cardiology: Hypertension Flashcards
What is the NICE diagnosis of of hypertension [1]
BP above 140/90 in a clinical setting confirmed with ambulatory or home readings above 135/85
Describe the aetiological factors that cause HTN? [2]
Essential hypertension: 90%
- Unknown cause
Secondary hypertension:
R enal disease
O besity
P regnancy induced / pre-eclampsia
E ndocrine
D rugs
Which renal disease are significantly contribute to causing HTN? [6]
- Diabetes nephropathy
- Glomerulonephritis
- Chronic pyelonephritis
- Renal cell carcinoma
- Adult polycystic kidney disease
- Renal artery stenosis
Which endocrine disorders significantly contribute to causing HTN? [6]
- Primary hyperaldosteronism (Conns)
- Phaechromocytoma
- Cushings
- Liddles syndrome
- Congenital adrenal hyperplasia (11 beta-hydroxylase deficiency)
- Acromegaly
Which drugs cause hypertension? [8]
- Alcohol
- Cocaine
- Combined oral contraceptive pill
- Erythropoietin
- NSAIDs
- Corticosteroids
- Venlafaxine (an antidepressant medication of the serotonin-norepinephrine reuptake inhibitor class)
- Oestrogens used in HRT
What investigation should you perform if you consider renal artery stenosis is causing HTN? [1]
Duplex ultrasound
MR or CT angiogram
Describe the cardiac complications of hypertension [1]
How would you detect this on a examination? [1]
May develop LV hypertrophy; causing sustained and forceful apex beat
What symptoms might patients present with when suffering from hypertension?
Often asymptomatic / symptoms only present when > 200/120mmHg
- Headaches
- Visual disturbance
- Seizures
Describe how you would make a diagnosis of HTN? [1]
BP above 140/90 in a clinical setting confirmed with ambulatory or home readings above 135/85 frr 24 hrs
NICE rec. both arms and if the difference is more than 15mmHg use higher BP
What are the different stages of HTN? [3] (include both clinic and home readings)
Stage 1:
- Clinic: >140/90
- Home / Ambulatory: Above 135/85
Stage 2:
- Clinic: >160/100
- Home / Ambulatory: Above 150/90
Stage 3:
- Clinic: >180/120
NICE recommends all patients who are newly diagnosed with hypertension to have which checks to investigate for end organ damage? [4]
Urine albumin:creatinine ratio for proteinuria and dipstick for microscopic haematuria to assess for kidney damage
Bloods for HbA1c, renal function and lipids
Fundus examination for hypertensive retinopathy
ECG for cardiac abnormalities, including left ventricular hypertrophy
What score would you also calculate on a new diagnosis of HTN? [1]
QRISK
A patient is newly diagnosed with HTN.
A QRISK is performed and their risk of cardiac events is calculated at 14%.
What treatment should you give? [1]
Offer atorvastatin 20mg daily (at night)
Which drugs are used in the general management of HTN? [5]
(non-specific to patient populations)
A – ACE inhibitor (e.g., ramipril)
B – Beta blocker (e.g., bisoprolol)
C – Calcium channel blocker (e.g., amlodipine)
D – Thiazide-like diuretic (e.g., indapamide)
ARB – Angiotensin II receptor blocker (e.g., candesartan)
Describe the specific management plans for treating HTN for patients who are under 55 / DMT2 / Black or Afro-Caribbean [4]
Under 55 / NO DMT2 / Black or Afro-Caribbean:
STEP 1:
- CCB
STEP 2:
- CCB and ACE inhibitor
OR
- CCB and Thiazide-like diuretic
STEP 3:
ACE inhibitor and CCB and Thiazide-like diuretic
STEP 4:
- If K ≤4.5 add low dose spironolactone
- If K ≥4.5 add alpha blocker or beta blocker
- If not controlled with 4 drugs: specialist review
Describe the specific management plans for treating HTN for patients who are over 55 / DMT2 [4]
Under 55 / NO DMT2 / Black or Afro-Caribbean:
STEP 1:
- ACEin / ARB
STEP 2:
- CCB and ACEin / ARB
OR
- ACEin / ARB and Thiazide-like diuretic
STEP 3:
ACE inhibitor and CCB and Thiazide-like diuretic
STEP 4:
- If K ≤4.5 add low dose spironolactone
- If K ≥4.5 add alpha blocker or beta blocker
- If not controlled with 4 drugs: specialist review
When should you prioritise an ARB over an ACE inhibitor?
If cough present in ACEin
What is step 4 of the hypertensive treatment plan? [4]
STEP 4:
- If K ≤4.5 add low dose spironolactone
- If K ≥4.5 add alpha blocker or beta blocker
- If not controlled with 4 drugs: specialist review
What are the specific treatment BP targets for patients over 80 and under 80? [2
Under 80:
- SBP < 140
- DBP < 90
Over 80:
- SBP < 150
- DBP < 90
Spironolactone has the risk of causing which AE? [1]
What is its MoA? [1]
Hyperkalaemia
Inhibits aldosterone
What is meant by the term malignant / accelerated hypertension? [1]
What is the management plan for someone with ^? [1]
blood pressure above 180/120, with retinal haemorrhages or papilloedema.
The NICE guidelines recommend a same-day referral
What are the IV options for managing an hypertensive emergency [4]
Z2F:
- Sodium nitroprusside
- Labetalol
- Glyceryl trinitrate
- Nicardipine
Lecture:
- BB (bisoprolol)
- Alpha blocker (doxazocin)
- Alpha 2 agonist (moxonidine)
- Hydralazine vasodilator
Which drug would be given in a hypertensive emergency caused by pheochromocytoma? [1]
Phentolamine (alpha-adrenergic antagonist)
Why do you need to check renal function before giving ACEin / ARB for HTN? [1]
Can cause renal impairment, especially if a patient is suffering from renal artery stenosis
State two AEs of ACE inhibitors [2]
Cough
Angiooedema
Which patient populations should ACE inhibitors be avoided in? [3]
Pregnant women - teratogenic
AKI
Renal artery stenosis
Describe the MoA of ACE inhibitors
Inhibits the action of angiotensin-converting enzyme
Reduces conversion of ATI to ATII
ATII causes vasoconstriction and stimulates aldosterone (which causes Na absorption)
Blocking ATII production also reduces afterload (peripheral vascular resistance) which reduces BP.
Particularly causes efferent arteriole to dilate (and therefore reduces intraglomerular pressure and CKD)
Give a very basic overview of ARB MoA [1]
Blocks the action of ATII on ATI receptor
State some important side effects of amlodipine and nifedipine [4]
Vasodilation and compensatory tachycardia:
- Ankle swelling
- Flushing
- Headaches
- Palpitations
Name a common AE of verapamil [1]
& more serious but rarer AEs [3]
Constipation
But can lead to bradycardia, heart block and cardiac failure
Diltiazem and verapamil are contra-indicated with which drug class? [1] (why?)
Beta blockers
Both drug classes are negatively inotropic and chronotropic (and together can cause heart failure)
Diltiazem and verapamil are contra-indicated with which medical conditions? [2]
(why?)
- Impaired LV function (can worsen HF)
- AV nodal conduction delay (may provoke heart block)
Explain why amlodipine and nifedipine are contra-indicated with which medical conditions? [2]
Unstable angina: vasodilation causes increase in contractility and tachycardia, which increase myocardial oxygen demand
Severe aortic stenosis: can cause myocardial collapse
CCBs all cause which side effect? [1]
Gum hypertrophy!
Which anti-hypertensive drugs should be prescribed in pregnany? [3]
Labetalol (acts on alpha and beta)
Nifedipine
*Methyl dopa**
