Cardiology: Hypertension

Question 1

What is the NICE diagnosis of of hypertension [1]

Answer 1

BP above 140/90 in a clinical setting confirmed with ambulatory or home readings above 135/85

Question 2

Describe the aetiological factors that cause HTN? [2]

Answer 2

Essential hypertension: 90%
- Unknown cause

Secondary hypertension:
R enal disease
O besity
P regnancy induced / pre-eclampsia
E ndocrine
D rugs

Question 3

Which renal disease are significantly contribute to causing HTN? [6]

Answer 3

• Diabetes nephropathy
• Glomerulonephritis
• Chronic pyelonephritis
• Renal cell carcinoma
• Adult polycystic kidney disease
• Renal artery stenosis

Question 4

Which endocrine disorders significantly contribute to causing HTN? [6]

Answer 4

• Primary hyperaldosteronism (Conns)
• Phaechromocytoma
• Cushings
• Liddles syndrome
• Congenital adrenal hyperplasia (11 beta-hydroxylase deficiency)
• Acromegaly

Question 5

Which drugs cause hypertension? [8]

Answer 5

• Alcohol
• Cocaine
• Combined oral contraceptive pill
• Erythropoietin
• NSAIDs
• Corticosteroids
• Venlafaxine (an antidepressant medication of the serotonin-norepinephrine reuptake inhibitor class)
• Oestrogens used in HRT

Question 6

What investigation should you perform if you consider renal artery stenosis is causing HTN? [1]

Answer 6

Duplex ultrasound
MR or CT angiogram

Question 7

Describe the cardiac complications of hypertension [1]
How would you detect this on a examination? [1]

Answer 7

May develop LV hypertrophy; causing sustained and forceful apex beat

Question 8

What symptoms might patients present with when suffering from hypertension?

Answer 8

Often asymptomatic / symptoms only present when > 200/120mmHg
- Headaches
- Visual disturbance
- Seizures

Question 9

Describe how you would make a diagnosis of HTN? [1]

Answer 9

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

Question 10

What are the different stages of HTN? [3] (include both clinic and home readings)

Answer 10

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

Question 11

NICE recommends all patients who are newly diagnosed with hypertension to have which checks to investigate for end organ damage? [4]

Answer 11

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

Question 12

What score would you also calculate on a new diagnosis of HTN? [1]

Answer 12

QRISK

Question 13

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]

Answer 13

Offer atorvastatin 20mg daily (at night)

Question 14

Which drugs are used in the general management of HTN? [5]

(non-specific to patient populations)

Answer 14

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)

Question 15

Describe the specific management plans for treating HTN for patients who are under 55 / DMT2 / Black or Afro-Caribbean [4]

Answer 15

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

Question 16

Describe the specific management plans for treating HTN for patients who are over 55 / DMT2 [4]

Answer 16

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

Question 17

When should you prioritise an ARB over an ACE inhibitor?

Answer 17

If cough present in ACEin

Question 18

What is step 4 of the hypertensive treatment plan? [4]

Answer 18

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

Question 19

What are the specific treatment BP targets for patients over 80 and under 80? [2

Answer 19

Under 80:
- SBP < 140
- DBP < 90

Over 80:
- SBP < 150
- DBP < 90

Question 20

Spironolactone has the risk of causing which AE? [1]
What is its MoA? [1]

Answer 20

Hyperkalaemia
Inhibits aldosterone

Question 21

What is meant by the term malignant / accelerated hypertension? [1]
What is the management plan for someone with ^? [1]

Answer 21

blood pressure above 180/120, with retinal haemorrhages or papilloedema.

The NICE guidelines recommend a same-day referral

Question 22

What are the IV options for managing an hypertensive emergency [4]

Answer 22

Z2F:
- Sodium nitroprusside
- Labetalol
- Glyceryl trinitrate
- Nicardipine

Lecture:
- BB (bisoprolol)
- Alpha blocker (doxazocin)
- Alpha 2 agonist (moxonidine)
- Hydralazine vasodilator

Question 23

Which drug would be given in a hypertensive emergency caused by pheochromocytoma? [1]

Answer 23

Phentolamine (alpha-adrenergic antagonist)

Question 24

Why do you need to check renal function before giving ACEin / ARB for HTN? [1]

Answer 24

Can cause renal impairment, especially if a patient is suffering from renal artery stenosis

Question 25

State two AEs of ACE inhibitors [2]

Answer 25

Cough
Angiooedema

Question 26

Which patient populations should ACE inhibitors be avoided in? [3]

Answer 26

Pregnant women - teratogenic
AKI
Renal artery stenosis

Question 27

Describe the MoA of ACE inhibitors

Answer 27

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)

Question 28

Give a very basic overview of ARB MoA [1]

Answer 28

Blocks the action of ATII on ATI receptor

Question 29

State some important side effects of amlodipine and nifedipine [4]

Answer 29

Vasodilation and compensatory tachycardia:
- Ankle swelling
- Flushing
- Headaches
- Palpitations

Question 30

Name a common AE of verapamil [1]
& more serious but rarer AEs [3]

Answer 30

Constipation
But can lead to bradycardia, heart block and cardiac failure

Question 31

Diltiazem and verapamil are contra-indicated with which drug class? [1] (why?)

Answer 31

Beta blockers
Both drug classes are negatively inotropic and chronotropic (and together can cause heart failure)

Question 32

Diltiazem and verapamil are contra-indicated with which medical conditions? [2]

(why?)

Answer 32

• Impaired LV function (can worsen HF)
• AV nodal conduction delay (may provoke heart block)

Question 33

Explain why amlodipine and nifedipine are contra-indicated with which medical conditions? [2]

Answer 33

Unstable angina: vasodilation causes increase in contractility and tachycardia, which increase myocardial oxygen demand

Severe aortic stenosis: can cause myocardial collapse

Question 34

CCBs all cause which side effect? [1]

Answer 34

Gum hypertrophy!

Question 35

Which anti-hypertensive drugs should be prescribed in pregnany? [3]

Answer 35

Labetalol (acts on alpha and beta)
Nifedipine
*Methyl dopa**