Cardiovascular drugs 2

Question 1

Hypertension clinical diagnosis

Answer 1

> 140/90

Two consecutive seated measurements, at least 1 minute apart

Blood pressure is recorded twice a day for at least 4 days

Question 2

Secondary causes

Answer 2

Renal disease:

• renovascular disease
• renal parenchymal disease

Endocrine disease

• Conn’s
• Cushing’s
• phaeo

Drugs

• COC pill
• steroids
• NSAIDs
• cocaine

Vascular

Others

Question 3

Contributory factors for hypertensions

Answer 3

Increased BMI

> 14 units alcohol

Salt intake

Lack of exercise

Stress

Question 4

Hypertension risk factors

Answer 4

Male

Age

Family history and ethnicity

Smoker

Cholesterol

Diabetes

Question 5

Hypertension symptoms

Answer 5

Headache

Blurred vision

Dizziness

Shortness of breath

Palpitations

Epitaxis

Question 6

Hypertension investigations

Answer 6

Urinalysis- proteinuria

ECG- LVH, AF

Blood tests- U&E, LFT, lipids, glucose/HbA1C

Question 7

Non- drug treatment of hypertension

Answer 7

Weight reduction

DASH eating plan

Dietary sodium restriction

Physical activity

Alcohol moderation

Question 8

Stage 1 hypertension

Answer 8

CMP >140/90mmHg, ABPM/HBPM >135/85

and

• target organ damage
• established CV risk
• renal disease
• diabetes
• 10 year CV risk >20%

Question 9

Stage 2 hypertension

Answer 9

CBP >160/100, ABPM/HBPM >150/95

Question 10

Severe hypertension

Answer 10

CBP >180/110

Question 11

Step 1 treatment

Answer 11

Aged under 55: ACEi or ARB

Aged over 55 or African/ Caribbean: CCB

Question 12

Step 2 treatment

Answer 12

ACEi and CCB

Question 13

Step 3 treatment

Answer 13

ACEi/ARB and CCB and thiazide like diuretic

Question 14

Step 4 treatment

Answer 14

Resistant hypertension

ACEi/ARB and CCB and thiazide like diuretic and further diuretic and alpha/beta blocker

Consider seeking expert advice

Question 15

ACEi/ARBs

Answer 15

Check creatinine and potassium

• before starting therapy
• after 1-2 weeks
• after subsequent dose increases

If creatinine rises >30% or GFR falls ?25% of K >6

• stop drug
• repeat tests
• consider other causes

Question 16

ACEi/ARBs in pregnancy

Answer 16

Contraindicated in pregnancy

Contraindicated in breast feeding

Alternatives- labetalol, methyldopa, nifedipine/ amlodipine

Question 17

Targets for low proteinuria

Answer 17

ACR<70 or PCR <100

Target blood pressure <140/90

Question 18

Targets for high proteinuria

Answer 18

ACR>70 or PCR>100

Target blood pressure <130/80

Question 19

Causes of treatment failure

Answer 19

Psuedo resistant hypertension (non-adherance, white coat effect)

Secondary hypertension

Resistant hypertension

Question 20

Hypertensive emergency

Answer 20

Severe hypertension with acute damage to the target organs

BP>180/110

Lower BP in minutes to hours

Question 21

Hypertensive urgency

Answer 21

Severe hypertension without acute damage to the target organs

Lower BP in 1-2 days

Question 22

Hypertensive crises- pathophysiology

Answer 22

Dysfunction of the renin-angiotensin- aldosterone system

Acute baroreflex failure

Autodysregulation

Question 23

Hypertensive crises- clinical features

Answer 23

Asymptomatic

Headache

Epitaxis

Presyncope

Palpitations

Chest pain

Dyspnoea

Neurological deficit

Question 24

Hypertensive crises- acute target organ damage

Answer 24

Eyes (papilloedema)

Brain (encephalopathy, stroke)

Heart (pulmonary oedema, MI)

Kidneys (AKI)

Aortic dissection

Question 25

Hypertensive crises- secondary causes

Answer 25

Intracranial haemorrhage/ SOL Phaeochromocytoma Drugs Pre-eclampsia/ eclampsia Renal artery stenosis Carotid baroreceptor dysfunction

Question 26

Hypertensive emergency treatment

Answer 26

IV therapy- labetalol, GTN, sodium nitroprusside, esmolol Reduce BP/MAP (20-255 in the 1-2 hours) Target of 160/100 in 6 hours

Question 27

Hypertensive urgency treatment

Answer 27

Oral treatment GP review in 48 hours

Question 28

Statins for primary prevention of CVD

Answer 28

40-85 year olds should have CVD risk estimated Lifestule modification Offer atorvastatin for a 10% or greater 10 year risk of developing CVD Offer statins in diabetes, CKD, familial hypercholesterolaemia For people 85 or older consider atorvastatin

Question 29

Statins for secondary prevention of CVD

Answer 29

Start statin treatment in people with CVD Do not delay statin treatment to manage modifiable risk factors

Question 30

Blood tests before statins

Answer 30

Lipid measurement Liver function tests- 3 x upper limit of normal Renal function HbA1C Thyroid stimulating hormone Creatine kinase- 5 x upper limit of normal

Question 31

Follow up after statins

Answer 31

Lipid measurement (3 months after)- 40% reduction in non-HDL cholesterol LFT (3 months after) Creatine kinase- if symptoms Annual medication review

Question 32

Statins not tolerated?

Answer 32

Stop, reduce dose or switch statin Specialist input Ezetimibe Not fibrates

Question 33

Ezetimibe

Answer 33

Option for treating primary hypercholesterolaemia in adults in whom initial statin therapy is contraindicated or not tolerated Co-adminstered with statin might be appropriate

Question 34

Framingham heart study- risk

Answer 34

AGE Gender LDL cholesterol HDL cholesterol BP Diabetes Smoking Obesity

Question 35

CV risk calculators

Answer 35

QRISK2- 10 year CV risk JBS3- lifetime CV risk QRISK3- 10 year CV risk