Cardiovascular- hypertension

Question 1

Lowering blood pressure reduces risk of what?

Answer 1

stroke, coronary events, HF and renal impairment

Question 2

What is stage 1 hypertension?

Answer 2

BP>140/90 (home 135>85)

Question 3

Who do we treat with stage 1 hypertension?

Answer 3

patients under 80 with target organ damage, diabetes, 10 year CV risk >20%

Question 4

What is stage 2 hypertension?

Answer 4

BP>160/100 (home 150/95)

Question 5

What is severe hypertension?

Answer 5

Systolic BP>180 or diastolic BP>110. HYPERTENSIVE CRISIS

Question 6

What is the target blood pressure for under 80s?

Answer 6

<140/90

Question 7

What is the target blood pressure in diabetes?

Answer 7

<140/80 (<130/80 with kidney, eye, cerebrovascular damage)

Question 8

How long should you trial each stage of anti-hypertensive treatment?

Answer 8

4 weeks to determine response

Question 9

Step 1 treatment for under 55s

Answer 9

ACE inhibitor. If not tolerated ARB. If both not toelrated consider a beta blocker

Question 10

Step 2 treatment for under 55s

Answer 10

Step 1 + CCB. If not tolerated or HF give thiazide related diuretic i.e. chlortalidone or indapamide.

Question 11

Step 3 treatment

Answer 11

ACE inhibitor (ARB) + CCB + thiazide

Question 12

Step 4 treatment

Answer 12

Add low dose spironolactone (unlicensed) or high dose thiazide if potassium >4.5mmol/L
Monitor RF and electrolytes
If diuretic therapy contraindicated, use beta blocker or alpha blocker

Question 13

Step 1 treatment for over 55 or Afro-Caribbean

Answer 13

CCB. If not tolerated or HF give thiazide related diuretic

Question 14

Step 2 treatment for over 55 or Afro-Caribbean

Answer 14

Step 1 + ACE inhibitor (ARB preferred in Afro-Caribbean patients)

Question 15

What is the target blood pressure for over 80s

Answer 15

150/90

Question 16

What is isolated systolic hypertension and what does it increase the risk of?

Answer 16

Systolic >160 but diastolic <90. Increased CV risk

Question 17

What is the role of ACE inhibitors in diabetes?

Answer 17

Management of diabetic nephropathy.

T2DM can delay progression of microalbuminuria to nephropathy

Question 18

When should you consider ACE inhibitors in renal disease?

Answer 18

patients with proteinuria

Question 19

What is the problem with diuretics in renal impairment?

Answer 19

thiazides may be ineffective. High dose loop diuretics may be required

Question 20

What drugs can be used for hypertension in pregnancy?

Answer 20

methyldopa, labetalol, nifedipine MR (unlicensed)

Question 21

What is the target BP in pregnancy?

Answer 21

<150/100

Question 22

How do ACE inhibitors work?

Answer 22

inhibit conversion of angiotensin 1 to angiotension 2

Question 23

What is the role of ACE inhibitors in HF?

Answer 23

all grades, usually combined with beta blockers.
stop potassium sparing diuretics- risk of hyperkalaemia. Low dose spironolactone beneficial in sever HF. monitor potassium.
If already taking high dose loop diuretics, may get profound first dose hypotension.

Question 24

What are the renal effects of ACE inhibitors?

Answer 24

RF and electrolytes should be monitored before treatment, when doses are increased and during treatment.
Treatment with NSAIDs increases risk to kidneys

Question 25

How do ARBs differ to ACE inhibitors?

Answer 25

They don't inhibit breakdown of bradykinin- less likely to cause cough

Question 26

Name 3 centrally acting antihypertensives

Answer 26

clonidine, methyldopa. moxonidine

Question 27

What happens if you suddenly withdraw clonidine?

Answer 27

rebound hypertension

Question 28

What are the side effects of clonidine and methyldopa?

Answer 28

dry mouth, constipation, bradycardia, drowsiness

Question 29

What patient info do you need to give for clonidine and methyldopa?

Answer 29

may affect skilled tasks and enhance alcohol

Question 30

When is methyldopa contraindicated?

Answer 30

depression

Question 31

What monitoring is needed for methyldopa?

Answer 31

blood counts and LFTs before treatment and during intervals of first 6-12 weeks, or unexplained fever

Question 32

Where do beta blockers work?

Answer 32

heart, peripheral vasculature, bronchi, pancreas, liver

Question 33

What beta blockers have intrinsic sympathomimetic activity and what does this mean?

Answer 33

Oxoprenolol, acebutolol, pindolol, celiprolol- less bradycardia and cold extremities

Question 34

What are the most waters soluble beta blockers and what does this mean?

Answer 34

Celiprolol, atenolol, nadolol, sotalo- less likely to cross BBB, cause less sleep disturbances and nightmares. Excreted by the kidneys

Question 35

Which beta blockers have a longer duration of action and once daily dosing?

Answer 35

atenolol, bisoprolol, celiprolol and nadilol

Question 36

When are beta blockers contraindicated?

Answer 36

2nd/3rd degree heart block

Question 37

Which beta blockers are cardioselective

Answer 37

atenolol, bisoprolol, metoprolol, nebivolol

Question 38

How do beta blockers were in hypertension?

Answer 38

reduce cardiac output, alter baroceptor reflex sensitivity, block peripheral adrenoreceptors

Question 39

How do beta blockers work in angina?

Answer 39

Reduce cardiac work, improve exercise tolerance, relieve symptoms. Risk of precipitating HF is verapamil and beta blocker used together in IHD.

Question 40

What do beta blockers reduce after MI?

Answer 40

Reduce recurrence risk

Question 41

How do beta blockers work in arrhythmias?

Answer 41

Reduce effects of sympathetic system on automaticity and conductivity

Question 42

How do beta blockers work in HF?

Answer 42

Block sympathetic activity. Bisoprolol and carvedilol reduce mortality in any grade stable HF

Question 43

Why should you avoid abrupt withdrawal of beta blockers?

Answer 43

Rebound worsening myocardial ischaemia

Question 44

Name some dihydropyridine CCBs

Answer 44

amlodipine, felodipine

Question 45

When should you avoid verapamil and diltiazem?

Answer 45

HF. May further depress cardiac function causing deterioration

Question 46

What can verapamil be used for?

Answer 46

Angina, HTN, arryhthmias

Question 47

Verapamil is a highly .... ionotrope

Answer 47

negative

Question 48

How does verapamil work?

Answer 48

reduces cardiac output., slows HR

Question 49

How does nifedipine work?

Answer 49

relaxes vascular smooth muscle, dilates coronary and peripheral arteries

Question 50

What is nifedipine used for?

Answer 50

HTN and angina

Question 51

How do CCBs affect calcium ions?

Answer 51

Interfere with inwards displacement of calcium ions through slow channels of active cell membranes.

Question 52

What effect do CCBs have?

Answer 52

Reduce myocardial contractility, depress the formation and propagation of electrical impulses within the heart, diminish coronary or systemic vascular tone

Question 53

Name some peripheral vasodilators

Answer 53

Hydralazine, minoxidil, sildenafil

Question 54

What should you monitor with Hydralazine?

Answer 54

Proteinurea every 6 months and antinuclear factor. | Acetylator status for doses >100mg

Question 55

Name a renin inhibitor

Answer 55

Aliskiren

Question 56

How does renin work?

Answer 56

converts angiotensin to angiotensin 1

Question 57

When are thiazides contraindicated?

Answer 57

Addisons, hypercalcaemia, hyponatraemia, hypokalaemia

Question 58

What condition might thiazides cause?

Answer 58

gout

Question 59

What should you avoid giving thiazides with?

Answer 59

Lithium- sodium depletion increases risk of toxicity

Question 60

What electrolyte disturbances can thiazides cause?

Answer 60

Low potassium, sodium, and high calcium and glucose.