Case Study 2- Hypertension Flashcards
What is the normal range for blood pressure?
120mmHg/80mmHg
What conditions is hypertension a risk factor for?
Cardiovascular disease:
- Stroke
- MI
- Heart failure
- CKD
- Cognitive decline
- Premature death
What are the aims of treatment for hypertension?
Reduce the risk of cardiovascular morbidity and mortality by lowering blood pressure
What is the difference between ABMP ( Ambulatory Blood Pressure Monitoring) and HBMP (Home Blood Pressure Monitoring) ?
ABMP:
- When blood pressure is measured as you move around, living your normal daily life.
- It is measured for up to 24 hours
HBMP:
- When blood pressure readings are taken at specific times during the day and night whilst the patient is seated and resting
- Ideally taken between 4-7 days (ideally 7)
How would you diagnose hypertension?
- Taking BP reading within the consultation
- If blood pressure reading is confirmed to be between 140/90mmHg and 180/120 mmHg after multiple readings then offer a ABMP or HBMP to confirm diagnosis
More information available on the nice guidelines
Hypertension is usually non symptomatic however some patients can experience symptoms. What symptoms would you expect a patient with hypertension to have?
- Blurred vision
- Nosebleeds
- Shortness of breath
- Chest pain
- Dizziness
- Headaches
What lifestyle advice can you offer patients with hypertension?
- Eat Less salt (sodium intake) and more fruits and veg
- Reducing excess consumption of coffee and other caffeine rich products
- Reducing alcohol intake (14 units per week MAX)
- Exercising regularly
- Losing weight
- Smoking cessation
The asked you to recommend an appropriate antihypertensive medicine for Ben.
Ben has newly been diagnosed with hypertension by the doctor.
He is a Caucasian male age 45 with type 2 diabetes. What antihypertensive would you recommend? Give the dose.
ACEi such as Ramipril
Initially between 1.25-2.5mg Ramipril once daily.
Dose should be taken at night to reduce the effects of hypotension
Increase if necessary up to 10mg once daily, dose to be increased at intervals of 2-4 weeks
OR
ATRA (angiotensin II receptor antagonists)/ARBs e.g, candesartan
Initially 8mg once daily of candesartan, dose to be increased at intervals of 4 weeks; usual dose 8mg once daily
6 months later ben comes to the GP for a review.
The GP notices that his blood pressure is still not controlled even after increasing the dose of Ramipril to the maximum.
The GP asks for some advice. What medication would you add on to an ACEi?
ADD CCI or Diuretic
What is the final combination of hypertensive medications that you can offer to a patient before referring them to a specialist?
ACEi + CCI + Diuretic
What is the first line treatment for a black patient who has been newly diagnosed with hypertension
CCI
What is the mechanism of action of an ramapril
- Ramipril is an angiotensin converting enzyme inhibitor
- It inhibits the enzyme ACE which is involved in the RAAS system (renin angiotensin aldosterone system)
- This stops the conversion of angiotensin I angiotensin II
Causing:
1. vasodilation in the veins and small blood vessels
- Reduction of aldosterone production that leads to reduction of salt and water retention
What is the key side effect of Ramipril and why is this caused?
Dry cough
- ACE is used to breakdown bradykinin
- If ACE is inhibited bradykinin will not be broken down increasing its levels
- Bradykinin stimulates a cough
What would you do if patient is experiencing a dry cough whilst on Ramipril?
Prescribe a ATRA (angiotensin II Receptor antagonist)
What is the mechanism of action of canderstartan?
- Candesartan is an angiotensin II receptor antagonist
- Therefore it blocks the action of angiotensin II at the AT1 receptor
- This will cause vasodilation at the veins and small blood vessels
- Reduced production of angiotensin which leads to less salt and water retention
HOWEVER, does not cause a cough like ACEi
