CVD- HYPERTENSION Flashcards
What is hypertension and why is it bad
High blood pressure which can increase the risk factor of CVD
What are the 2 stages of Hyper tension?
Stage 1
Stage 2
What is BP target clinic?
140/90 mmhg
What is BP clinic target for 80+ years patient?
150/90 mm hg
What is first line HTN treatment for T1 diabetes?
ACEi or ARB
What is first line treatment for hypertension for patient UNDER 55 and not african?
ACEi (ARB if not tolerated)
What is 1st line tx for hypertension if patient OVER 55 years and black?
CCB (thiazide-like diuretic if not tolerated e.g. indapamide )
What is 1st line tx for hypertension and type 2 DM?
ARB or ACEi
What is 1st line tx for hypertension with T2 DM?
ACEi or ARB
What is step 3 if all meds not working for HTN?
ACT- test
What to give if K+ is LESS than 4.5?
Low dose spironolactone
What to give if K+ is more than 4.5?
High dose alpha blocker or BB.
What is 1ST line HTN treatment in pregnancy?
oral Labetalol
What is one negative about labetalol?
hepatotoxic
What is HTN BP target in pregnancy?
135/85mmhg
What is an alternative to labetalol in HTN?
Nifedipine MR
What is last case med given in HTN pregnant women if nifedipine MR not working?
Methyldopa - unlicensed- stop 2 days AFTER birth
What is BP monitoring target for under 80 year?
less than 140/90 mm hg
What is BP target in patient with kidney disease?
<140/90mm hg
What is BP target in patient with T1 DM and kidney disease with ACR>70?
<130/80mmhg
What is ACR?
Albumin creatinine ratio in urine
What is BP target for T1 diabetes ?
<140/90 mm hg
What is BP target for T1 diabetic and ACR <70?
<140/90 mm hg
What is BP target in T1 diabetic who is over 80?
<150/90mm hg regardless of ACR
What is T2 diabetic BP target?
T2 DM= same as normal adult target
What is MOA of ACEI and ARB?
Blocks Angiotensin converting enzyme.
Prevents conversion of Angiotensin 1 to angiotensin 2.
Angiotensin 2 receptor blocker (ARB)- alternative
How does prevention of angiotensin 2 lower BP?
vasodilation, aldosterone modulated.
Decreases blood plasma volume = lowers BP
What is Dose regimen for ACEi + ARBs?
OD dose
What specific ACEi is used BD?
Captopril
List 9 ACEi?
Captopril
Enalapril
Fosinopril
Imidapril
Lisinopril
Perindopril
Quinapril
Ramipril
Trandolapril
What ACEi is meant to be taken 30-60 mins before food?
Perindopril
List 8 ARBs?
Azilsartan
Candesartan
Eprosartan
Irbesartan
Losartan
Olmesartan
Telmisartan
Valsartan
What 2 drug classes are used 1st line for HTN + HF?
ACEi and ARB
What are 3 common side effects of ACEi/ARB?
Persistent dry cough
HypERkalaemia
1st dose hypOtension
What is a counselling point to say if patient experiences 1st dose hypotension?
Take first dose night time
What drug causes dry cough?
ACEi so try ARB.
Who is at risk of hyperkalaemia caused by ACEI/ARB?
Patients with renal impairment and diabetes.
What is a caution for high dose diuretics?
caution in HF - >80mg furosemide or similar= specialist
What is a main organ related SE of ARB/ACEI?
Nephrotoxicity
What to monitor when on ACEI/ARB?
renal function - electrolytes e.g. K+
What is a caution for ARB/ACEi as it is nephrotoxic?
Patients with atherosclerosis + peripheral vascular disease
What to do with ARB/ACEi on sick days/AKI?
Temporarily stop - it
What 3 drug classes should be temporarily stopped on sick days due to AKI?
NSAIDS- cause vasoconstriction
ACEI/ARB - Vasodilation
Diuretic - Reduces plasma volume
What are some side effects of captopril?
Cough
Angioedema
Postural hypotension
Taste disturbance
Oral thrush
Potassium - high , hyperkalaemia
Renal impairment
Indigestion
Low BP- 1st dose
Can ACEi be used in pregnancy?
NO- teratogenic
What can happen if patient given ACEI and other anti-hypertensive drugs?
Increased Hypotension
What anti-hypertensives can interact with ACEI?
Alpha-blocker e.g doxazosin
BB
CCB
What drug classes interact with ACEi to cause low BP?
Anti-hypertensives
Dopaminergic drugs
Antipsychotics/ phosphodiesterase type-5 inhibitors, TCAs
What drug class can interact with ACEi and increase AKI?
NDAIDS
interaction between ACEi and spironolactone?
HypERkalaemia
What can interact with ACEi to cause increased renal impairment/ high k+ and hypotension?
other ACEi/ARB and aliskiren (renin inhibitors).
What is a MOA of CCB?
affects ca+ influx in vascular smooth muscle + heart.
Reduces BP, HR + contraction force
What are CCBs split into?
- Dihydropyridine
- Rate limiting
List 7 Dihdropyridine CCBs?
Amlodipine
Felodipine
Lacidipine
Lercanadipine
Nicardipine
Nifedipine
Nimodipine
List 2 Rate limiting CCBs?
Diltiazem
Verapamil
What is Verapamil used for?
Arrhythmia
What 2 CCBs are taken OD?
Amlodipine
Felodipine
What is Nimodipine used for specifically?
Aneurysmal subarachnoid haemorrhage
When is diltiazem dose the same for MR as?
When it is above 60mg
The standard formulations containing 60 mg diltiazem hydrochloride are licensed as generics + there is no requirement for brand name dispensing
What dihydropyridine CCB has same brand for MR?
Nifedipine
What is CCB indication?
Hypertension - 1st line
Can treat angina + arrhythmias
What condition should CCBs be avoided in?
Heart failure - can increase symptoms + depress cardiac function.
What are the 6 key SE of CCBs?
Ankle swelling, flushing, headache,
Tachycardia/ palpitations
Angioedema, gingival hyperplasia
What SE does verapamil cause?
Constipation
What mouth related SE is linked to CCB?
Gingival hyperplasia
What CCB can be used in HF?
Amlodipine - fewer SE
What are the SE of CCB - DEATHFOG?
Dizziness
Erectile dysfunction
Ankle swelling/ angioedema
Tachycardia
Head ache
Flushing
Oedema
Gingival hyperplasia
What can increased CCB levels do?
toxicity
What 2 drug classes interact with CCB to increase toxicity?
Macrolides
Azole anti-fungals
What food/drink avoided when on CCB?
Grapefruit juice
What are macrolides and azole antifungals?
Enzyme inhibitors
What warning label is usually on BB?
Do NOT STOP taking this medicine unless your doctor tells you to stop
What 4 drugs decrease CCB levels?
Carbamazepine
phenytoin
Rifampicin
St John’s wort
What drug class interacts with CCB to cause hypotension?
Diuretics - volume depletion
What other 2 drug classes can increase risk of hypotension when using CCB?
Anti-hypertensive + dopaminergic drugs
Give some examples of dopaminergic drugs?
Levodopa
Nitrates
phosphodiesterase type-5 inhibitor e.g. sildenafil
SGLT2 inhibitor -e.g. canagliflozin
TCA anti-depressants
What 2 drugs increase bradycardia when with CCB?
- Verampamil
- Diltiazem
What does verapamil and beta blocker together do?
Bradycardia
Severe hypotension
Heart failure in ischaemic heart disease
What is a dihydropyridine CCB?
type of (CCB), which refer to a group of medications that block calcium channels located in the muscle cells of heart.
What other drug used in arrhythmia can interact with CCB to cause Bradycardia?
Amiodarone
What is MOA of Beta blocker?
Blocks B- adrenoceptor in peripheral vasculature + heart.
Lowers BP, HR, force of contraction, SA node automaticity + AV node conductivity.
List 15 beta blockers?
Acebutolol
Atenolol*
Bisoprolol*
Carvedilol
Celiprolol
Esmolol
Labetalol
Metoprolol
Nadalol
Nebivolol
Oxprenolol
Pindolol
Propranolol *
Sotalol
TIMOLOL
What BB is taken IV only?
Esmolol
What Beta blocker is used for pregnancy?
Labetalol
What is a SE of labetalol?
Hepatoxicity
What beta blocker is good for elderly patient with stable mild-moderate HF?
Nebivolol
What 3 conditions can propranolol be used for?
Anxiety
Migraine prophylaxis
Thyrotoxicosis - aka hyperthyroidism.
What is sotalol?
Class 3 anti-arrhythmic
What is ONE dangerous SE of sotatlol?
Can cause torsade de pointes
What is the 1st line indication of BB?
HF + angina
- HTN, arrhythmia + MI
What 4 BB are given OD? TIP - ABC-N
Atenolol
Bisoprolol
Celiprolol
Nadolol
What 4 BB can reduce bradycardia and cold extremity? PACO
Pindolol
Acebutolol
Celiprolol
Oxprenolol
What 4 BB are water soluble? - CANS
Celiprolol
Atenolol
Nadolol
Sotalol
What should be done to water-soluble BB in RI patients?
reduce dose - as excreted by kidneys usually
What 4 BB are cardio-selective + reduce bronchospasm? BAN-Me
Bisoprolol
Atenolol
Nebivolol
Metoprolol
What can non- soluble BB cause?
Sleep disturbances
What are the 7 main SE of BB? -BADFISH
Bradycardia + bronchospasm
Atrioventricular block
Disturbs glucose metabolism
Fainting + dizziness
Impotence
Sleep disturbances
HypOtension, HF + cold HF
What 5 conditions are BB contra-indicated in?
Marked bradycardia
Asthma
2nd or 3rd heart block
HypOtension
Uncontrolled HF.
What 2 cautions for BB?
Diabetes - can cause hypoglycaemia in patients with and without DM.
Masks hypoglycaemia
What drug class increases hypOtension when combined with BB?
Diuretics- causes volume depletion
What effect can BB and rate-limiting CCB or digoxin/amiodarone cause?
Cardio depression
What 4 BB have a peripheral vasodilating effect?
Labetalol
Celiprolol
Carvedilol
Nebivolol
Give 2 vasodilator names?
Hydralazine
Minoxidil
When is Minoxidil used?
Treatment of severe HTN resistant to other drugs.
What is given with minoxidil for severe HTN + why?
Vasodilatation is accompanied by increased cardiac output and tachycardia and children develop fluid retention.
What does Minoxidil cause?
Hypertrichosis (excess hair growth)
Drug unsuitable for females.
What is Hydralazine used for?
given adjunct to other antihypertensives for the treatment of resistant HTN but is rarely used.
What happens when hydralazine is used alone?
when used alone it causes tachycardia and fluid retention.
What are 3 centrally acting anti-hypertensives?
- Methyldopa
- Clonidine
- Moxonidine
What is a SE of prolonged use of centrally acting anti-hypertensives?
fluid retention
What is Methyldopa also useful for?
HTN in pregnancy
What is the disadvantage of using clonidine as anti-hypertensive?
Sudden withdrawal may cause a hypertensive crisis
What other indications is clonidine used for?
pain management, sedation, + opioid withdrawal, ADHD, and Tourette syndrome.
What is pulmonary HTN?
Condition affects the blood vessels in lungs.
Develops when the BP in your lungs is higher than normal.
What is phaechromocytoma?
Type of neuroendocrine tumor that grows from cells called chromaffin cells.
What is a hypertensive crisis?
sudden, severe increase in blood pressure.
BP reading is 180/120 (mm Hg) or greater.
What is shock?
Threatening medical emergency due to profound hypOtension.
What 2 alpha blockers are used in hypertension?
Doxazosin + pazosin
Why 2 alpha blockers are used in hypertension?
lowers BP + rarely causes tachycardia.
Why are Adrenergic neurone blocking drugs not used in HTN anymore?
do NOT control supine blood pressure + may cause postural hypotension
How do we monitor midodrine?
Hepatic + renal function BEFORE treatment and at regular intervals during treatment.
Regular monitoring of supine + standing blood pressure due to the risk of HTN in the supine position.
What is indication of midodrine?
Severe orthostatic hypotension
What is 1st line treatment for shock?
Inotrope + vasoconstrictor sympathomimetics
What are 5 causes of shock?
Sepsis
Neurogenic
Cardiogenic
Hypovolemic- bleed
Anaphylactic
What is MOA of vasoconstrictor sympathomimetic?
Acts on alpha- receptors on peripheral vasculature.
Causes vasoconstriction + Increases BP
What is use of vasoconstrictor sympathomimetic?
for acute hypotension - if other methods fail
Give 5 examples of vasoconstrictor sympathomimetic?
Ephedrine
Midodrine
Noradrenaline
Phenylephrine
What is long acting vasoconstrictor sympathomimetic?
phenylephrine
What vasocontrictor sympathomimetic has a dual action of Increasing BP + HR?
Ephedrine
What is 1 SE of vasoconstrictor sympathomimetics?
reduced organ perfusion (fluid circulation).
What is stage 1 hypertension?
Clinic BP ranging from 140/90 -159/99 mmHg,
AND
ambulatory daytime average/ home BP average ranging from 135/85 -149/94 mmHg.
What is stage 2 hypertension
Clinic BP of 160/100 mmHg - less than 180/120 mmHg,
AND
an ambulatory daytime average/ home BP average of 150/95 mmHg or higher.
What 5 criteria points should patients under 80 have in order to start stage 1 HTN tx? (1 or more)
target-organ damage (for example left ventricular hypertrophy,
chronic kidney disease or hypertensive retinopathy),
established cardiovascular disease,
renal disease, diabetes,
or a 10 year cardiovascular risk ≥10%.
For patients aged under 40 years with stage 1 hypertension what to do?
specialist advice for evaluation of secondary causes of hypertension
what is Severe hypertension?
clinic systolic BP of 180 mmHg or higher, or a clinic diastolic BP of 120 mmHg or higher.
When would patients need for same day referral done for HTN? (3)
phaeochromocytoma (e.g labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis).
Clinic BP of 180/120 mmHg or higher with signs of retinal haemorrhage or papilloedema (accelerated hypertension),
OR
Life-threatening symptoms for example new onset confusion, chest pain, signs of heart failure, or acute kidney injury.
What is home BP target in under 80s?
<135/85 mm hg
What is home BP target in patients over 80?
<145/85 mmhg
What is clinic BP target for those with stroke before?
<130/80 mm hg
home = <125 mmhg
What is BP target for patients with severe bilateral carotid artery stenosis?
140-150mm hg
If ACEi not tolerated due to cough, what to give?
ARB
In HTN, if CCB not tolerated due to oedema, what to give?
TLD e.g. indapamide
What is preferred - thiazide like or conventional diuretics?
Thiazide.
What 2 thiazides can be used for patients with HTN, stable + controlled BP?
Bendro + hydrochlorothiazide
What to give patients with isolated systolic HTN?
same treatment
What is isolated systolic HTN?
BP >160 or more
What to give 1st line in HTN if patient black despite age?
CCB always
What are 7 symptoms of pre-eclampsia?
Severe headache
vision issues
severe pain below ribs
swelling hands, feet
Proteinuria
BP >140/90
vomiting
What should be done if HTN in pregnancy after 20 weeks?
Secondary care referral - seen within 24 hrs
What should be done if severe HTN in pregnancy after 20 weeks?
same day assessment
Pregnant women at high risk of developing pre-eclampsia if they have:?
CKD
DM
Autoimmune disease
HTN before
Chronic HTN
What are females at high risk of pre-eclampsia recommended to take from week 12 of pregnancy until baby born?
Aspirin
Can mothers breastfeed with antihypertensives?
Yes - low levels present
risk vs benefit
What HTN drug for females who breastfeed as 1st line HTN during post-natal period?
Enalapril
What HTN drug for black females who breastfeed as 1st line HTN during post-natal period?
Nifedipine or amlodipine
When should females be reviewed for HTN post birth?
2 weeks after birth
In under 80s when to start HTN tx with stage 1 who have 1 or more of the 4 following:
target organ damage
established cardiovascular disease
renal disease
diabetes
an estimated 10‑year risk of cardiovascular disease of 10% or more.
What is recommended in african patients with DM?
ARB
Most common SE of CCB?
Oedema
Most common SE of verapamil?
constipation
When to offer BP treatment ?
For stage 2 hypertension (clinic blood pressure of 160/100 mmHg or more but less than 180/120 mmHg and subsequent ambulatory daytime average or home blood pressure average of 150/95 mmHg or higher):
Offer antihypertensive drug treatment + lifestyle advice to adults with persistent stage 2 hypertension, regardless of age.
When to offer BP treatment in stage 1?
under 60 years with stage 1 HTN + an estimated 10-year CVD risk below 10%. Bear in mind that 10-year cardiovascular risk may underestimate the lifetime probability of developing CVD.
> 80 years with a clinic blood pressure more than 150/90 mmHg.
When to discuss BP treatment in Stage 1?
People under 80 years with persistent stage 1 HTN who have one or more of the following: target organ damage, established cardiovascular disease (CVD), renal disease, diabetes, an estimated 10-year risk of CVD of 10% or more.
