CVD - Hypertension

Question 1

(5) What does hypertension predispose to?

Answer 1

• coronary heart disease
• stroke
• cardiac hypertrophy
• heart failure
• kidney failure

Question 2

Compare prevalence of primary & secondary hypertension

Answer 2

Primary hypertension:
•In 95% of hypertension, no specific cause is identified.

Secondary
•In 5% of hypertension a specific cause is identified.

Question 3

(4) Causes of secondary hypertension

Answer 3

•renal disease
•renal artery stenosis
•adrenal tumors secreting
–aldosterone
–cortisol
–catecholamines
•sleep apnea

Question 4

Causes of primary hypertension

• (3) genetic
• (3) environmental

Answer 4

•polygenic
–sympathetic hyperactivity
–renin activation
–susceptibility to salt

•multi-environmental
–obesity
–excess salt (especially in elderly)
–alcohol

Question 5

How do you diagnose hypertension?

Answer 5

• BP > 140/90 mmHg
• after 5 minutes seated rest
• 2 readings 2 minutes apart

Question 6

(5) routine tests in hypertensive patients

Answer 6

•FBE
–associated anemia of CKD
•LFTs
–associated fatty liver or drug reaction
•urine albumin/creatinine ratio
–evidence of renal damage
•MSU
–clues as to causes of renal disease
•ECG and echocardiogram
–to detect coronary disease and cardiac hypertrophy

Question 7

When do you treat hypertension?

Answer 7

• SBP > 180 mmHg
• DBP > 110 mmHg
• SBP > 160 mmHg & DBP 140 mmHg or DBP > 90 mmHg WITH associated conditions (diabetes, existing CV or renal disease) OR high CV risk

Question 8

High CV risk

• risk of CV event over 5 years
• by (5) standard risk factors
• by (4) end organ damage

Answer 8

> 15%

Standard RF:
•Age
•Systolic pressure
•Total:HDL cholesterol ratio
•Smoking
•Diabetes

End organ damage as a RF: 
•Microalbuminuria or low eGFR
–renal damage
•LV Hypertrophy
–cardiac damage
•High pulse wave velocity
–stiff large arteries
•Increased intima-media thickness
–reflects atherosclerosis

Question 9

(5) Non-pharm treatment of hypertension

Answer 9

• Lose weight
• Improve fitness
• Avoid excess salt
• Moderate alcohol
• Stop smoking

Question 10

Which is more important in pharmacological blood pressure reduction: how or how much?

Answer 10

How much

Question 11

(4) drug treatments of hypertension (antihypertensives)

Answer 11

ABCD

ACE inhibitors, ARBs
Beta-blockers
Ca antagonists
Diuretics

NOTE:
•Most patients require more than 1 drug
•Wait 2-3 weeks before adding drugs
•Combination drugs are simpler

Question 12

Describe the antihypertensives drug treatment algorithm

• step 1
• step 2
• step 3
• step 4

Answer 12

Step 1:
- Monotherapy; A, C or D

Step 2:
- Dual therapy: A+C or A+D

Step 3:
- Triple therapy: A+C+D

Step 4: “resistant hypertension”
•consider adding spironolactone, beta-blocker, centrally-acting agent, alpha-blocker or vasodilator
•question compliance
•check for use of NSAIDs, cold remedies, antidepressants, etc
•consider secondary causes

Question 13

What are the general considerations for the use of ABCD antihypertensives?

Answer 13

ACEI/ARBs:

• Useful in coronary disease and heart failure
• Renoprotective in diabetes
• Contra-indicated in pregnancy

Beta blockers:
- Useful in coronary disease and heart failure

Ca2+ blockers:
- Avoid verapamil & diltiazam in heart failure

Diuretics:
- Thiazide-like drugs have less metabolic side-effects

Question 14

What is the most important cause of “resistant hypertension”?

Answer 14

Poor compliance

Question 15

Why are beta blockers not favoured as step 1 antihypertensive?

Answer 15

Due to SE of increased weight and insulin resistance