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Pre Reg Pharmacy > Chapter 2 - Blood Pressure Conditions > Flashcards

Chapter 2 - Blood Pressure Conditions Flashcards

1
Q

What is hypertension?

A

Persistently raised arterial blood pressure

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2
Q

How is hypertension diagnosed?

A

Seated with the arm outstretched and support, and in a relaxed environment.

Over 140/90mmHg - take a second reading

Over 140/90mmHg again - offer ABPM or HBPM

Over 180/120mmHg - refer to specialist

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3
Q

What is ABPM and HBPM

A

ABPM - The BP is measured every half an hour for 24 hours and the average is taken

HBPM - The BP is measured twice a day for a minimum of 4 days (ideally 7 days)

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4
Q

How is hypertension classified?

A

Stage 1
Clinic BP 140/90-160/100mmHg
ABPM/HBPM 135/85-150/95

Stage 2
Clinic BP 160/100-180/20mmHg
ABPM/HBPM >150/95

Stage 3
Clinic BP
Systolic >180mmHg, diastolic >120mmHg

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5
Q

What are the blood pressure targets in <80 years and >80 years?

A

<80 - <140/90mmHg

>80 - <150/90mmHg

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6
Q

What are the blood pressure targets in diabetes?

A

Type 1 - <135/85mmHg
Type 2 - <140/90mmHg
Type 2 with renal disease, retinopathy or cerebrovascular disease <130/80

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7
Q

What are the blood pressure targets in renal disease?

A

<140/90mmHg

If there is coexisting diabetes, or if the ACR is >70, <130/80mmHg

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8
Q

What is the blood pressure target in pregnancy?

A

<135/85 mmHg

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9
Q

What are the lifestyle changes you would discuss in people with hypertension?

A 
Lose weight
Increase exercise
Reduce alcohol consumption 
Reduce dietary salt and saturated fat 
Stop smoking
Reduce caffeine intake
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10
Q

How is stage 1 hypertension managed?

A

For all patients give lifestyle advice

Aged >80 - consider treatment is BP is >150/90mmHg

Aged 60-80 - consider treatment if patients have one of:
Target organ damage
Coexisting renal damage, diabetes or CVD
A 10-year CVD risk of over 10%

Aged 40-60 - consider treatment if there is a 10-year CVD risk of over 10%

Aged <40 - refer to specialist

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11
Q

How is stage 2 hypertension managed?

A

Give lifestyle advice

Start drug treatment

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12
Q

How is stage 3 hypertension managed?

A

If there are symptoms of retinal haemorrhage, papilledema, or life threatening symptoms e.g. chest pain, new onset confusion, AKI - same day referral to specialist

If these symptoms aren’t present assess target organ damage
Target organ damage present - start antihypertensives immediately
Target organ damage absent - do ABPM/HBPM

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13
Q

How is hypertension managed in <55 years or in any diabetic patients?

A
  1. ACEi/ARB
  2. ACEi/ARB + CCB/thiazide
  3. ACEi/ARB + CCB + thiazide
  4. Same as above. If potassium <4.5mmol/L spironolactone, if potassium >4.5mmol/L beta blocker or alpha blocker
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14
Q

How is hypertension managed in >55 years or in black African/Caribbean patients?

A
  1. CCB
  2. CCB + ACEi/ARB/thiazide
  3. CCB + ACEi/ARB + thiazide
  4. Same as above. If potassium <4.5mmol/L spironolactone, if potassium >4.5mmol/L beta blocker or alpha blocker
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15
Q

Is an ACEi or an ARB preferred in black African/Caribbean patients?

A

ARB

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16
Q

Why aren’t ACEi/ARBs first line in black African/Caribbean patients?

A

These patients have a greater likelihood of having a lower renin profile

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17
Q

When should you refer hypertension to a specialist?

A

BP uncontrolled despite an optimal dose of 4 drugs

Patients aged <40

Patients with retinal haemorrhage, papilledema, or life threatening symptoms e.g. new onset confusion, chest pain

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18
Q

In patients with heart failure and hypertension, would you offer a CCB or thiazide?

A

Thiazide like diuretic

CCBs can worsen HF, especially rate-limiting CCBs e.g. verapamil

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19
Q

What is gestational hypertension?

A

New-onset hypertension that develops 20 weeks after gestation

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20
Q

What is pre-eclampsia?

A

New-onset hypertension that develops 20 weeks after gestation and is damaged multiple organs e.g. liver and kidneys

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21
Q

Who is more at risk of pre-eclampsia and what should be done to prevent pre-eclampsia is these patients?

A 
Women more at risk:
People with CKD, diabetes, autoimmune disease, chronic hypertension
Aged over 40
BMI over 35
10 year pregnancy interval
Multiple pregnancy 
Family history of pre-eclampsia

Give aspirin 75mg OD from 12 weeks gestation (unlicensed)

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22
Q

What antihypertensives are given in pregnancy?

A

First line labetalol
Second line m/r nifedipine
Third line methyldopa

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23
Q

What is given for hypertension in breastfeeding mothers?

A

Black African/Caribbean patients - nifedipine or amlodipine

Others - enalapril

Monitor the babies BP and be aware of adverse reactions

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24
Q

What is hypertensive urgency and how is this managed?

A

This is severe hypertension without acute target organ damage

Use oral antihypertensives e.g. labetalol to reduce the BP over 24-48 hours

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25
Q

What is hypertensive emergency and how is this managed?

A

This is severe hypertension with acute target organ damage

Treat with IV antihypertensives e.g. hydralazine, labetalol, sodium nitroprusside, to reduce the BP by 20-25% in 2 hours

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26
Q

What are the problems associated with reducing the BP too quickly in hypertensive crisis?

A

Reduced organ perfusion, which can lead to blindness, MI, renal damage, cerebral infarction

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27
Q

What is phaeochromocytoma?

A

A rare and usually non-cancerous tumour of the adrenal gland.

It can result in hypertension, headaches, sweating and panic attack symptoms.

It usually requires surgery

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28
Q

What is pulmonary hypertension and what are the treatment options?

A

High blood pressure in the blood vessels that supply the lungs

Treatment options:
Epoprostenol
Iloprost
Sildenafil, tadafil 
Selexipag
Ambrisentan...
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29
Q

What are the three types of drugs that affect the renin angiotensin system?

Can they be used together?

A

ACE Inhibitors
ARBS
Aliskiren

They are not recommended to be used together, as this increases the risk of hyperkalaemia, hypotension and renal impairment.

The use of aliskiren with an ACEI or ARB is contraindicated in patients with diabetes or an eGFR<60ml/min

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30
Q

How do ACE Inhibitors work?

A

Block the conversion of angiotensin I to angiotensin II

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31
Q

Should more than one drug from the renin-angiotensin system be used at the same time?

A

This is not recommended
There is increased risk of hyperkalaemia, hypotension and renal impairment

Askiren and an ACEi/ARB cannot be used in patients with diabetes or an eGFR <60ml/min

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32
Q

What is the risk of using NSAIDs and ACE Inhibitors?

A

Increased risk of renal damage

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33
Q

What is the risk of using ACE Inhibitors and potassium sparing diuretics?

A

Hyperkalaemia

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34
Q

What is the risk of using an ACE Inhibitor and a diuretic?

A

ACE Inhibitors can cause a very rapid drop in BP in volume depleted patients

Initiate at a low dose and monitor

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35
Q

What are the cautions of ACE Inhibitors?

A

Afro-Caribbean patients - increased risk of angiodema, won’t be as effective due to lower levels of renin

Diabetes - may lower blood glucose levels, but has a renal protective effect

Concomitant use of diuretics

36
Q

What are the main side effects of ACE Inhibitors?

A 
Dry cough 
Angiodema
Electrolyte imbalance (e.g. hyperkalaemia)
Renal impairment 
Hypotension 
Hepatitis (discontinue)
37
Q

What are the monitoring requirements for ACE Inhibitors and ARBs?

A

Monitor renal function, electrolytes and BP before treatment and after each dose change

38
Q

How do you reduce the risk of first dose hypotension when initiating ACE Inhibitors?

A

Take the first dose at night

Initiate at a low dose (1.25mg usually)

39
Q

In renal impairment, what do you do to ACE Inhibitor doses?

A

Usually need to reduce them

40
Q

How often should ramipril doses be increased?

A

Every 2-4 weeks

Remember to monitor the patient

41
Q

Do ARBs produce a dry cough?

Why?

A

Yes, but not as common as an ACE Inhibitor
1-3% ARB, 15% ACEi

This is because they don’t break down bradykinin (unlike ACE Inhibitors)

42
Q

What are the main side effects that are associated with ARBs

A 
Cough
Dizziness
Hyperkalaemia 
Diarrhoea 
Nausea and vomiting 
Renal impairment 
Abnormal hepatic function
43
Q

What dose of ramipril should be used in hypertension?

A

Initially 1.25mg, increased slowly every 2-4 weeks

44
Q

What dose of lostartan should be used in hypertension?

A

18-75 - initially 50mg OD, increase to 100mg OD

76 and over - initially 25mg OD, increase to 100mg OD

45
Q

What is the mechanism of action of askiren?

A

Directly inhibits renin, preventing the conversion of angiotensin to angiotensin I

46
Q

State the two types of CCB, give examples, and explain the main difference between them

A

Dihydropyradine CCBs - amlodipine, nifedipine
These act on the smooth muscle of blood vessels (non-arrythmic)

Rate limiting CCBs - diltiazem, verapamil
These act on the AV node and slow down the heart rate (arrhythmic - don’t use in heart failure)
Note, diltiazem has less of an arrhythmic effect that verapamil

47
Q

What are the main side effects of dihydropyradine CCBs?

A

Flushing, peripheral oedema, headache

48
Q

Should verapamil be used in conjunction with beta blockers?

A

No - increased cardiovascular effects

49
Q

What is the interaction between simvastatin and amlodipine, verapamil or diltiazem?

A

These all increase the exposure to simvastatin

Max dose of simvastatin 20mg

50
Q

Why should the brand name of diltiazem be prescribed?

A

Different preparations containing more than 60mg m/r diltiazem may not have the same clinical effect

51
Q

Should a patient be on a thiazide or thiazide like diuretic if their eGFR is less that 30ml/min?

A

No - if will be ineffective

52
Q

What is the effect of indapamide on the QT interval?

A

It increases it

53
Q

When should indapamide be taken?

A

Morning

Avoid taking after 4pm as after this time it is likely to wake to patient up at night to go to toilet

54
Q

What are the licenced indications of bendroflumethiazide?

A

Hypertension

Oedema

55
Q

What is the main risk associated with hydrochlorithiazide

A

Increased risk of non-melanoma skin cancer (dose dependant)

56
Q

What are ISA beta-blockers and give some examples

A

Intrinsic sympathiomstric activity

Beta blockers that can stimulate as well as block adrenoreceptors

E.g. pindolol, acebutolol, celiprolol, oxprenolol

These are associated with less bradycardia and less coldness of the extremities

57
Q

Give examples of water soluble beta-blockers, and what’s the advantage of these?

A

Sotalol, nadolol, atenolol, celiprolol

These are less likely to cross the BBB and so have a reduced incidence of sleep disturbances and nightmares

Note, water soluble beta-blockers are present in breastmilk in higher amounts than other beta-blockers

These are also renally excreted so the dose will need to be reduced in renal impairment

58
Q

Give examples of cardioselective beta-blockers and when are these given?

A

Atenolol, bisoprolol

Given in asthma and diabetes when there is no other option

59
Q

What is the relationship between beta-blockers and diabetes?

A

Beta-blockers can affect carbohydrate metabolism, causing hypoglycaemia or hyperglycaemia

Beta-blockers can also mask the symptoms of hypoglycaemia

Avoid beta-blockers in patients who experience frequently hypoglycaemia

60
Q

What are some indications of beta-blockers?

A 
Hypertension 
Angina
MI
Arrhythmia 
HF
Thyrotoxicosis 
Anxiety 
Glaucoma (topical)
Migraine
61
Q

What are the contraindications to beta-blockers?

A 
Asthma
Bradycardia (<50 bpm)
Metabolic acidosis 
Uncontrolled HF
2nd or 3rd degree heart block
62
Q

What are some side effects of beta-blockers?

A 
Sleep disorders, nightmares
Bradycardia 
Peripheral coldness
Heart failure
Bronchospasm
63
Q

What is the maximum dose of bisoprolol in hepatic or renal impairment?

64
Q

Who should not take minoxidil?

A

Females - it can cause hypertrichosis

65
Q

What is mandatory with the prescribing of minoxidil?

A

Also prescribing a beta-blocker and a diuretic (usually furosemide)

This is because minoxidil can cause tachycardia and fluid retention

66
Q

What are examples of centrally acting drugs in hypertension?

A

Methyldopa

Clonidine

67
Q

What are the contraindications of thiazide and thiazide like diuretics?

A

Hypercalcaemia, hyperuricaemia

Hypokalaemia, hyponatraemia

68
Q

If a women is managed with methyldopa during pregnancy, when should treatment be discontinued post birth?

A

2 days post birth, then switch to an alternative antihypertensive

69
Q

Are ACE Inhibitors recommend in patients with renal artery stenosis?

70
Q

What should be monitored if a patient is on an ACE Inhibitor and a diuretic?

71
Q

Should beta blockers be stopped abruptly?

A

No - risk of MI

72
Q

What monitoring should be done when on labetalol therapy?

A

Hepatic function - it can cause severe liver injury, even after short term use

73
Q

What is the MRHA advice associated with riociguat?

A

MRHA warning
In patients with pulmonary hypertension and idiopathic intestinal pneumonia’s, taking riociguat is associated with an increased risk of death and serious adverse events

74
Q

When is eplerenone used over spironolactone?

A

CHF after MI

Males experiencing oestrogen like side effects

75
Q

What is sodium nitroprusside indicated in?

A

Hypertensive emergencies

76
Q

Treatment of hypertension in the acute phase of TIA can result in what?

A

Reduced cerebral perfusion

Only lower the blood pressure if there is hypertensive emergency (>180/20mmHg)

77
Q

If a pregnant person is initiated in methyldopa in pregnancy for hypertension, when should she resume her original hypertensive treatment?

A

Within 2 days of birth

If she’s breastfeeding she might have to change to a different antihypertensive

78
Q

When is minoxidil used in hypertension and what are the main issues associated with it?

A

Resistant hypertension

Problems - it can cause tachycardia and fluid overload - prescribe beta blocker and diuretic

79
Q

Are ACEIs recommended in people with renal stenosis?

80
Q

What is the main organ (and related function tests) that should be monitored or labetalol therapy?

A

Liver - can cause damage even with short term treatment

81
Q

What is the main disadvantage of water soluble beta blockers in renal impairment?

A

Water soluble beta-blockers are excreted by the kidneys, so require a dose reduction

82
Q

What group of antihypertensives commonly causes peripheral oedema?

83
Q

Are lower or higher doses of thiazide diuretics preferred in hypertension?

A

Lower - these produce a near maximal reduction in BP

Higher doses have little advantage on BP compared to lower doses and a greater effect on metabolic disturbances

84
Q

What are examples of water soluble beta blockers?

A

CANS

Celiprolol
Atenolol
Nadolol
Sotalol

85
Q

Which beta blockers should be administered once daily?

A

BACoN

Bisoprolol
Atenolol
Celiprolol
Nadalol

Pre Reg Pharmacy (36 decks)

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