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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
What is hypertensive emergency and how is this managed?
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
26
What are the problems associated with reducing the BP too quickly in hypertensive crisis?
Reduced organ perfusion, which can lead to blindness, MI, renal damage, cerebral infarction
27
What is phaeochromocytoma?
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
28
What is pulmonary hypertension and what are the treatment options?
High blood pressure in the blood vessels that supply the lungs ``` Treatment options: Epoprostenol Iloprost Sildenafil, tadafil Selexipag Ambrisentan... ```
29
What are the three types of drugs that affect the renin angiotensin system? Can they be used together?
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
30
How do ACE Inhibitors work?
Block the conversion of angiotensin I to angiotensin II
31
Should more than one drug from the renin-angiotensin system be used at the same time?
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
32
What is the risk of using NSAIDs and ACE Inhibitors?
Increased risk of renal damage
33
What is the risk of using ACE Inhibitors and potassium sparing diuretics?
Hyperkalaemia
34
What is the risk of using an ACE Inhibitor and a diuretic?
ACE Inhibitors can cause a very rapid drop in BP in volume depleted patients Initiate at a low dose and monitor
35
What are the cautions of ACE Inhibitors?
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
What are the main side effects of ACE Inhibitors?
``` Dry cough Angiodema Electrolyte imbalance (e.g. hyperkalaemia) Renal impairment Hypotension Hepatitis (discontinue) ```
37
What are the monitoring requirements for ACE Inhibitors and ARBs?
Monitor renal function, electrolytes and BP before treatment and after each dose change
38
How do you reduce the risk of first dose hypotension when initiating ACE Inhibitors?
Take the first dose at night | Initiate at a low dose (1.25mg usually)
39
In renal impairment, what do you do to ACE Inhibitor doses?
Usually need to reduce them
40
How often should ramipril doses be increased?
Every 2-4 weeks | Remember to monitor the patient
41
Do ARBs produce a dry cough? Why?
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
What are the main side effects that are associated with ARBs
``` Cough Dizziness Hyperkalaemia Diarrhoea Nausea and vomiting Renal impairment Abnormal hepatic function ```
43
What dose of ramipril should be used in hypertension?
Initially 1.25mg, increased slowly every 2-4 weeks
44
What dose of lostartan should be used in hypertension?
18-75 - initially 50mg OD, increase to 100mg OD 76 and over - initially 25mg OD, increase to 100mg OD
45
What is the mechanism of action of askiren?
Directly inhibits renin, preventing the conversion of angiotensin to angiotensin I
46
State the two types of CCB, give examples, and explain the main difference between them
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
What are the main side effects of dihydropyradine CCBs?
Flushing, peripheral oedema, headache
48
Should verapamil be used in conjunction with beta blockers?
No - increased cardiovascular effects
49
What is the interaction between simvastatin and amlodipine, verapamil or diltiazem?
These all increase the exposure to simvastatin Max dose of simvastatin 20mg
50
Why should the brand name of diltiazem be prescribed?
Different preparations containing more than 60mg m/r diltiazem may not have the same clinical effect
51
Should a patient be on a thiazide or thiazide like diuretic if their eGFR is less that 30ml/min?
No - if will be ineffective
52
What is the effect of indapamide on the QT interval?
It increases it
53
When should indapamide be taken?
Morning Avoid taking after 4pm as after this time it is likely to wake to patient up at night to go to toilet
54
What are the licenced indications of bendroflumethiazide?
Hypertension | Oedema
55
What is the main risk associated with hydrochlorithiazide
Increased risk of non-melanoma skin cancer (dose dependant)
56
What are ISA beta-blockers and give some examples
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
Give examples of water soluble beta-blockers, and what’s the advantage of these?
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
Give examples of cardioselective beta-blockers and when are these given?
Atenolol, bisoprolol Given in asthma and diabetes when there is no other option
59
What is the relationship between beta-blockers and diabetes?
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
What are some indications of beta-blockers?
``` Hypertension Angina MI Arrhythmia HF Thyrotoxicosis Anxiety Glaucoma (topical) Migraine ```
61
What are the contraindications to beta-blockers?
``` Asthma Bradycardia (<50 bpm) Metabolic acidosis Uncontrolled HF 2nd or 3rd degree heart block ```
62
What are some side effects of beta-blockers?
``` Sleep disorders, nightmares Bradycardia Peripheral coldness Heart failure Bronchospasm ```
63
What is the maximum dose of bisoprolol in hepatic or renal impairment?
10mg OD
64
Who should not take minoxidil?
Females - it can cause hypertrichosis
65
What is mandatory with the prescribing of minoxidil?
Also prescribing a beta-blocker and a diuretic (usually furosemide) This is because minoxidil can cause tachycardia and fluid retention
66
What are examples of centrally acting drugs in hypertension?
Methyldopa | Clonidine
67
What are the contraindications of thiazide and thiazide like diuretics?
Hypercalcaemia, hyperuricaemia | Hypokalaemia, hyponatraemia
68
If a women is managed with methyldopa during pregnancy, when should treatment be discontinued post birth?
2 days post birth, then switch to an alternative antihypertensive
69
Are ACE Inhibitors recommend in patients with renal artery stenosis?
No
70
What should be monitored if a patient is on an ACE Inhibitor and a diuretic?
BP
71
Should beta blockers be stopped abruptly?
No - risk of MI
72
What monitoring should be done when on labetalol therapy?
Hepatic function - it can cause severe liver injury, even after short term use
73
What is the MRHA advice associated with riociguat?
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
When is eplerenone used over spironolactone?
CHF after MI | Males experiencing oestrogen like side effects
75
What is sodium nitroprusside indicated in?
Hypertensive emergencies
76
Treatment of hypertension in the acute phase of TIA can result in what?
Reduced cerebral perfusion Only lower the blood pressure if there is hypertensive emergency (>180/20mmHg)
77
If a pregnant person is initiated in methyldopa in pregnancy for hypertension, when should she resume her original hypertensive treatment?
Within 2 days of birth | If she’s breastfeeding she might have to change to a different antihypertensive
78
When is minoxidil used in hypertension and what are the main issues associated with it?
Resistant hypertension Problems - it can cause tachycardia and fluid overload - prescribe beta blocker and diuretic
79
Are ACEIs recommended in people with renal stenosis?
No
80
What is the main organ (and related function tests) that should be monitored or labetalol therapy?
Liver - can cause damage even with short term treatment
81
What is the main disadvantage of water soluble beta blockers in renal impairment?
Water soluble beta-blockers are excreted by the kidneys, so require a dose reduction
82
What group of antihypertensives commonly causes peripheral oedema?
CCBs
83
Are lower or higher doses of thiazide diuretics preferred in hypertension?
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
What are examples of water soluble beta blockers?
CANS Celiprolol Atenolol Nadolol Sotalol
85
Which beta blockers should be administered once daily?
BACoN Bisoprolol Atenolol Celiprolol Nadalol

Pre Reg Pharmacy (36 decks)

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