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BNF > CHAPTER 2: CVS: Hypertension > Flashcards

CHAPTER 2: CVS: Hypertension Flashcards

1
Q

What does lowering blood pressure reduce the risk of? (4)

A
  1. Stroke
  2. Coronary heart events
  3. Renal impairment
  4. Heart failure
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2
Q

What lifestyle advice should patients with hypertension be given? (7)

A
  1. Smoking cessation
  2. Weight reduction
  3. Alcohol and coffee intake reduction
  4. Salt reduction
  5. Total and saturated fat reduction
  6. Increasing exercise
  7. Increasing fruit and veg
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3
Q

What should patients presenting with a BP of 140/90mmHg be offered to confirm diagnosis? (2)

A
  1. Ambulatory BP monitoring

2. Home BP monitoring

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4
Q

What is the BP of someone with stage 1 hypertension?

A

140/90mmHg and ambulatory average of 135/85mmHg or higher

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5
Q

Patients UNDER 80 with STAGE 1 hypertension are only treated if they have which other co-morbidities? (5)

A
  1. Target organ damage
  2. Cardiovascular disease
  3. Renal disease
  4. Diabetes
  5. 10 year cardiovascular risk >20%
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6
Q

If a patient under 40 presents with stage 1 hypertension and has no other co-morbidities, what further investigations should be done?

A

Causes of secondary hypertension

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7
Q

How are patients UNDER 80 with STAGE 1 hypertension with no other co-morbidities treated?

A

Lifestyle advice only

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8
Q

All patients with STAGE 2 hypertension should be treated. What is the BP of someone with STAGE 2 hypertension?

A

> 160/100 (ambulatory >150/95)

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9
Q

What should you do if someone has a clinic blood pressure over 180 systolic or over 110 diastolic?

A

TREAT PROMPTLY

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10
Q

What is the target clinic BP of someone with STAGE 1 hypertension?

A

140/90

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11
Q

What is the target home BP of someone with STAGE 1 hypertension?

A

135/85

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12
Q

What is the target clinic BP of someone with STAGE 1 hypertension and cardiovascular disease, diabetes in the presence of kidney, eye or cerebrovascular disease?

A

130/80

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13
Q

When treating hypertension, how long should treatment be tried for to see if it is effective?

A

4 weeks

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14
Q

What is the first line treatment for hypertension in a white person under 55?

A

ACE Inhibitor

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15
Q

First line HPT: What is an option if the ACE inhibitor is not tolerated?

A

Angiotensin Receptor Blocker

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16
Q

First line HPT: What is an option if neither the ACE inhibitor nor the ARB are tolerated?

A

Beta blocker

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17
Q

What is the first line treatment for hypertension in a person over 55 or a black person?

A

Calcium channel blocker

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18
Q

First line HPT >55: What is an option if the calcium channel blocker is not tolerated?

A

Thiazide-like diuretic

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19
Q

What is the second line treatment for hypertension in a white person under 55?

A

ACE inhibitor + Calcium Channel Blocker (or thiazide-like diuretic)

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20
Q

What is the second line treatment for hypertension in a person over 55 or a black person?

A

Calcium Channel Blocker (or thiazide-like diuretic) + ACE inhibitor

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21
Q

Is it advisable to give a Beta-blocker together with a thiazide-like diuretic to treat hypertension in those under 55 or white?

A

NO

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22
Q

What is the third line treatment for hypertension in all patients?

A

ACE Inhibitor + Calcium Channel Blocker + Thiazide-like diuretics

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23
Q

What must you seek if the patient does not respond to third-line antihypertension treatment?

A

Specialist advice

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24
Q

What are the options when third-line antihypertension treatment fails?

A

1) Add low dose spironolactone

2) Increase the dose of the thiazide-like diuretic

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25
Q

If a patient does not tolerate an increased in their thiazide-like diuretic, what 2 other options can be considered?

A
  1. Alpha blocker

2. Beta blocker

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26
Q

Unless contra-indicated, what should all patients with established cardiovascular disease receive?

A

Aspirin

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27
Q

As well as aspirin, which other drug is used in patients with established or to prevent cardiovascular disease?

A

Statin

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28
Q

Is there evidence for the use of aspirin as primary prevention?

A

No

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29
Q

What is the blood pressure target for patients over 80?

A

Clinic: 150/90
Home: 145/85

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30
Q

What is the target blood pressure for patients with diabetes?

A

140/80

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31
Q

What is the target blood pressure for patients with diabetes in the presence of kidney, eye or cererbovascular disease?

A

130/80

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32
Q

Which antihypertensive is recommended in patients with diabetes?

A

ACE inhibitor

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33
Q

When can pregnancy women develop hypertension?

A

In the latter half

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34
Q

What are the 3 treatment options for hypertension in pregnancy?

A
  1. Labetalol
  2. Methyldopa
  3. MR Nifedipine (unlicensed)
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35
Q

What is the target BP of pregnant women with chronic hypertension?

A

<150/100

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36
Q

What is the target BP of pregnant women with chronic hypertension and target organ damage / women with chronic hypertension who have given birth?

A

<140/90

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37
Q

Which medication are pregnancy women at risk of pre-eclampsia recommended to take?

A

Aspirin from week 12 until the baby is born

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38
Q

How long after birth should antihypertensives be stopped in women with gestational hypertension?

A

2 days

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39
Q

If blood pressure is reduced too quickly in a hypertensive crisis, what is there a risk of?

A

Reduced organ perfusion leading to cerebral infarction, blindness, deterioration in renal function, myocardial ischaemia

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40
Q

What is a hypertensive emergency defined as?

A

Severe hypertension with acute damage to target organs

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41
Q

During a hypertensive crisis, prompt IV treatment is needed. What are the options? (7)

A
  1. Sodium nitroprusside
  2. Nicardipine
  3. Labetalol
  4. GTN
  5. Phentolamine
  6. Hydralazine
  7. Esmolol
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42
Q

If BP is >180/110 and no acute organ damage, this is defined as hypertensive urgency. What is the treatment?

A

Oral antihypertensives

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43
Q

For the treatment of resistance hypertension, can the vasodilator hydralazine be used alone?

A

No, must be as an adjunct otherwise causes tachycardia and fluid retention

44
Q

Which drug which can be used as an adjunct in resistant hypertension is not suitable for females?

A

Minoxidil

45
Q

Which class of drug used as options in stage 4 hypertension must be used with caution because they drop blood pressure very quickly?

A

Alpha blockers

46
Q

What are the indications of ACE Inhibitors? (4)

A
  1. Heart Failure
  2. Hypertension
  3. Diabetic nephropathy
  4. Prophylaxis of cardiovascular events
47
Q

Which drug are ACE inhibitors usually combined with in heart failure?

A

Beta blockers

48
Q

Which drugs should be discontinued before starting treatment with ACE inhibitors for heart failure?

A
  1. Potassium supplements

2. Potassium sparing diuretics

49
Q

Providing serum potassium is monitored, which drug can be used with an ACE inhibitor at a low dose for the treatment of heart failure?

A

Spironolactone

50
Q

If a patient with heart failure is already taking a loop diuretic and they are started on an ACE inhibitor, what can be a profound effect?

A

First dose hypotension - may need to initiate under specialist supervision as temporary withdrawal of the diuretic can cause pulmonary oedema

51
Q

What must be monitored before starting treatment with an ACE inhibitor? (2)

A
  1. Renal function

2. Electrolytes

52
Q

What effect do ACE inhibitors have on serum electrolytes?

A

Hyperkalaemia

53
Q

A specialist must be involved in initiating ACE inhibitors in patients with which impairment?

A

Kidney

54
Q

Concomitant treatment with ACE inhibitors and which other drug increases the risk of renal impairment?

A

NSAIDs

55
Q

Concomitant treatment with ACE inhibitors and which other drug increases the risk of hyperkaleamia?

A

Potassium sparing diuretics

56
Q

Is it safe for patients with renal artery stenosis to take ACE inhibitors?

A

No, they should not take them

57
Q

Is it safe for patients with renovascular disease to take ACE inhibitors?

A

No, but they can be used if there is no other option

58
Q

If a patient is taking a loop diuretic at which dose, the ACE inhibitor should be introduced under specialist supervision?

A

Furosemide 80mg or equivalent

59
Q

ACE inhibitors can cause a persistent dry cough, why can’t ARBs also cause it?

A

They do not inhibit the breakdown of bradykinin

60
Q

Which renin inhibitor is an option in hypertension?

A

Aliskerin

61
Q

Why is a combination of 2 drugs affecting the RAAS not advised? (3)

A
  1. Hypotension
  2. Hyperkalaemia
  3. Renal impairment
62
Q

In which organs do bete-blockers block the beta-adrenoceptors? (5)

A
  1. Heart
  2. Peripheral vasculature
  3. Liver
  4. Lungs
  5. Pancreas
63
Q

Give an example of a really water soluble beta blocker

A

Atenolol

64
Q

Which beta blocker is less likely to cause the side effect of nightmares? Why?

A

Atenolol. It is less likely to cross the BBB due to low lipid-solubility

65
Q

How are water soluble beta-blockers excreted?

A

By the kidneys, Dose adjustment in renal failure sometimes necessary

66
Q

Give 2 examples of beta blockers with an intrinsically long duration of action, allowing for once daily dosage

A
  1. Atenolol

2. Bisoprolol

67
Q

Why are beta blockers contra-indicated in patients with second or third degree heart block?

A

They slow heart rate and depress the myocardium

68
Q

As well as in patients with heart block, who else are beta-blockers contraindicated in?

A

Worsening unstable heart failure

69
Q

Why should beta-blockers be avoided in patients with a history asthma?

A

Can precipitate bronchospasm

70
Q

Where necessary, can patients with controlled asthma or COPD receive beta blockers?

A

Yes

71
Q

Give 4 examples of caridoselective beta blockers with less of an effect on airway resistance

A
  1. Atenolol
  2. Bisoprolol
  3. Nebivolol
  4. Metoprolol
72
Q

Give 3 side effects of beta-blockers

A
  1. Coldness of the extremities
  2. Sleep disturbance including nightmares
  3. Fatigue
73
Q

Affecting carbohydrate metabolism, what can beta-blockers cause in patients with or without diabetes?

A

Hypoglycaemia or hyperglycaemia

74
Q

In diabetics, what can beta blockers mask?

A

Symptoms of hypoglycaemia such as tachycardia and tremor

75
Q

Why are beta blockers effective in angina?

A

Reduce cardiac work and improve exercise tolerance

76
Q

Is it advised to stop taking beta blockers suddenly in angina?

A

No, gradual dose reduction

77
Q

If a beta blocker is used with which drug, can heart failure be precipitated in established ischaemic heart disease?

A

Verapamil

78
Q

Which drug can beta blockers be used with in AF, especially in patients with thyrotoxicosis?

A

Digoxin

79
Q

Which beta blocker is licensed for mild to moderate heart failure in patients over 70?

A

Nebivolol

80
Q

Before which operation are beta blockers used?

A

Thyroidectomy

81
Q

What are some other uses of beta blockers?

A
  1. Migraine prophylaxis
  2. Anxiety
  3. Glaucoma
82
Q

What are the symptoms of overdose with beta blockers? (3)

A
  1. Lightheadedness
  2. Syncope
  3. Dizziness`
83
Q

Which 2 calcium channel blockers must be avoided in heart failure?

A
  1. Verapamil

2. Diltiazem

84
Q

What is verapamil used to treat? (3)

A
  1. Angina
  2. Hypertension
  3. Arrythmias
85
Q

Verapamil is a highly negatively inotropic calcium channel blocker. What does it reduce?

A
  1. Cardiac output

2. Heart rate

86
Q

Can Verapamil be used with beta blockers?

A

No

87
Q

What is a common side effect of Verapamil?

A

Constipation

88
Q

Does nifedipine have much influence on the myocardium?

A

No, more on the vessels - smooth muscle relaxation and dilation of coronary vessels

89
Q

Can nifedipine precipitate heart failure?

A

No

90
Q

Which other calcium channel blockers resemble nifedipine in the way they act? Peripherally, used to treat angina and hypertension

A
  1. Amlodipine
  2. Felodipine
  3. Nicardipine
91
Q

Give 3 side effects of calcium channel blockers. All become less obtrusive after a few days

A
  1. Flushing
  2. Headache
  3. Ankle swelling
92
Q

Which calcium channel blocker must be used with caution with beta blockers?

A

Diltiazem

93
Q

Give 8 signs of calcium channel blocker overdose

A
  1. Nausea
  2. Vomiting
  3. Dizziness
  4. Agitation
  5. Confusion
  6. Coma
  7. Metabolic acidosis
  8. Hyperglycaemia
94
Q

Do standard release preparations of diltiazem need to be prescribed by brand?

A

NO

95
Q

Do modified release preparations of diltiazem need to be prescribed by brand?

A

YES

96
Q

What effect can diuretics have on electrolytes?

A

Hypokaleamia

97
Q

Which type of diuretics have a greater impact on potassium loss?

A

Thiazide

98
Q

If a patient is taking diuretics and there is a concern over potassium loss, what else can be prescribed? This is seldom necessary in the routine treatment of hypertension

A
  1. Potassium sparing diuretics

2. Potassium supplements

99
Q

In hepatic failure, what can hypokalaemia precipitate?

A

Encephalopathy

100
Q

In which group of people should lower initial doses of diuretics be used?

A

Elderly `

101
Q

Diuretics should not be routinely prescribed for simple oedema. Which measure can be taken instead? (3)

A
  1. Raising legs
  2. Increased movement
  3. Stockings
102
Q

Which 3 conditions can thiazides exacerbate?

A
  1. Gout
  2. Diabetes
  3. Systemic lupus
103
Q

What should be monitored with use of thiazide diuretics?

A

Electrolytes

104
Q

What should be monitored both at baseline and during treatment with ARBs? (2)

A
  1. Renal function

2. Electrolytes

105
Q

What should be monitored both at baseline and during treatment with ACE inhibitors? (2)

A
  1. Renal function

2. Electrolytes

106
Q

When treating hypertension, when should the first dose of an ACE inhibitor be given?

A

At bedtime

BNF (28 decks)

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