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Year 6 Cardiology > Essential or secondary hypertension > Flashcards

Essential or secondary hypertension Flashcards

1
Q

What are ACE inhibitors used for?

A

ACE inhibitors are the first-line treatment for hypertension in younger patients and are used to treat heart failure, diabetic nephropathy, and for secondary prevention of ischaemic heart disease.

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2
Q

How do ACE inhibitors work?

A

They inhibit the conversion of angiotensin I to angiotensin II, leading to vasodilation, reduced blood pressure, decreased aldosterone release, and reduced sodium and water retention.

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3
Q

What is the renoprotective mechanism of ACE inhibitors?

A

ACE inhibitors cause dilation of the efferent arterioles, reducing glomerular capillary pressure and mechanical stress on the filtration barriers, which is important in diabetic nephropathy.

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4
Q

What are common side effects of ACE inhibitors?

A

Common side effects include cough, angioedema, hyperkalaemia, and first-dose hypotension.

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5
Q

What causes the cough associated with ACE inhibitors?

A

The cough occurs in around 15% of patients and is thought to be due to increased bradykinin levels.

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6
Q

What are the cautions and contraindications for ACE inhibitors?

A

Avoid in pregnancy and breastfeeding, renal vascular disease, aortic stenosis, and hereditary angioedema. Specialist advice is needed for patients with potassium >= 5.0 mmol/L.

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7
Q

What interactions should be monitored with ACE inhibitors?

A

High-dose diuretic therapy (more than 80 mg of furosemide a day) significantly increases the risk of hypotension.

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8
Q

What monitoring is required for patients on ACE inhibitors?

A

Urea and electrolytes should be checked before treatment and after dose increases. Acceptable changes include a 30% increase in serum creatinine and potassium up to 5.5 mmol/L.

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9
Q

What are examples of common ACE inhibitors?

A

Common ACE inhibitors include ramipril, enalapril, and lisinopril.

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10
Q

What should be considered regarding renal impairment when using ACE inhibitors?

A

Significant renal impairment may occur in patients with undiagnosed bilateral renal artery stenosis.

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11
Q

What are calcium channel blockers primarily used for?

A

Calcium channel blockers are primarily used in the management of cardiovascular disease.

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12
Q

Where are voltage-gated calcium channels present?

A

Voltage-gated calcium channels are present in myocardial cells, cells of the conduction system, and those of the vascular smooth muscle.

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13
Q

Why is it important to differentiate the types of calcium channel blockers?

A

The various types of calcium channel blockers have varying effects on myocardial cells, the conduction system, and vascular smooth muscle.

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14
Q

What are the indications for Verapamil?

A

Angina, hypertension, arrhythmias

Highly negatively inotropic.

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15
Q

What are the side effects of Verapamil?

A

Heart failure, constipation, hypotension, bradycardia, flushing.

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16
Q

What should Verapamil not be given with?

A

Should not be given with beta-blockers as it may cause heart block.

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17
Q

What are the indications for Diltiazem?

A

Angina, hypertension

Less negatively inotropic than verapamil but caution should still be exercised when patients have heart failure or are taking beta-blockers.

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18
Q

What are the side effects of Diltiazem?

A

Hypotension, bradycardia, heart failure, ankle swelling.

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19
Q

What are the indications for dihydropyridines (Nifedipine, Amlodipine, Felodipine)?

A

Hypertension, angina, Raynaud’s.

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20
Q

How do dihydropyridines affect the vascular system?

A

They affect the peripheral vascular smooth muscle more than the myocardium and do not worsen heart failure but may cause ankle swelling.

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21
Q

What is a side effect of shorter acting dihydropyridines?

A

Shorter acting dihydropyridines (e.g. nifedipine) cause peripheral vasodilation which may result in reflex tachycardia.

Flushing, headache, ankle swelling.

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22
Q

What is essential hypertension?

A

Essential hypertension is high blood pressure that typically does not cause symptoms unless it is very high, for example > 200/120 mmHg.

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23
Q

What symptoms may occur with very high hypertension?

A

Patients may experience headaches, visual disturbance, and seizures.

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24
Q

How is hypertension usually detected?

A

Hypertension is usually detected when checking someone’s blood pressure.

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25
What is the purpose of using 24-hour blood pressure monitors?
24-hour blood pressure monitors help avoid cases of 'white coat' hypertension, where blood pressure rises in clinical settings.
26
Why are 24-hour blood pressure monitor readings preferred?
Studies have shown that readings from 24-hour blood pressure monitors correlate better with clinical outcomes.
27
What should be assessed in a patient with newly diagnosed hypertension?
It is important to ensure they do not have any end-organ damage.
28
What is fundoscopy used for in hypertension assessment?
Fundoscopy is used to check for hypertensive retinopathy.
29
What does a urine dipstick check for in hypertension patients?
A urine dipstick checks for renal disease, either as a cause or consequence of hypertension.
30
What does an ECG check for in hypertension assessment?
An ECG checks for left ventricular hypertrophy or ischaemic heart disease.
31
What is the correct cuff size for measuring blood pressure in children?
The correct cuff size is approximately 2/3 the length of the upper arm.
32
Which Korotkoff sound is used to measure diastolic blood pressure in children?
The 4th Korotkoff sound is used until adolescence, when the 5th Korotkoff sound can be used.
33
What should blood pressure results in children be compared with?
Results should be compared with a graph of normal values for age.
34
What is the most common cause of secondary hypertension in younger children?
Renal parenchymal disease accounts for up to 80% of cases.
35
What are some causes of hypertension in children?
Causes include renal parenchymal disease, renal vascular disease, coarctation of the aorta, phaeochromocytoma, congenital adrenal hyperplasia, and essential or primary hypertension.
36
How does the prevalence of essential or primary hypertension change with age in children?
Essential or primary hypertension becomes more common as children become older.
37
What is hypertension?
Hypertension is a chronically raised blood pressure and an important risk factor for cardiovascular disease.
38
What is considered a 'normal' blood pressure?
Most healthy people have a blood pressure between 90/60 mmHg and 140/90 mmHg.
39
How does NICE define hypertension?
Hypertension is defined as a clinic reading persistently above >= 140/90 mmHg, or a 24-hour blood pressure average reading >= 135/85 mmHg.
40
What are the two categories of hypertension?
The two categories are primary (essential) hypertension and secondary hypertension.
41
What causes primary hypertension?
Primary hypertension is caused by complex physiological changes as we age, with no single disease responsible.
42
What are some causes of secondary hypertension?
Secondary hypertension can be caused by renal disease, endocrine disorders, and other factors such as medications and pregnancy.
43
What symptoms may occur with very high hypertension?
Symptoms may include headaches, visual disturbances, and seizures.
44
How is hypertension typically diagnosed?
Hypertension is diagnosed by checking blood pressure, often using 24-hour blood pressure monitors to avoid 'white coat' hypertension.
45
What tests are recommended after diagnosing hypertension?
Recommended tests include urea and electrolytes, HbA1c, lipids, ECG, and urine dipstick.
46
What are the main aspects of managing hypertension?
Management includes drug therapy, modification of risk factors, and monitoring for complications.
47
What are common drug classes used to treat hypertension?
Common drug classes include ACE inhibitors, calcium channel blockers, thiazide diuretics, and angiotensin II receptor blockers (A2RB).
48
What is the mechanism of action of ACE inhibitors?
ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II.
49
What are common side effects of ACE inhibitors?
Common side effects include cough, angioedema, and hyperkalaemia.
50
What is the first-line treatment for younger patients with hypertension?
ACE inhibitors are the first-line treatment for younger patients (< 55 years old).
51
What is the mechanism of action of calcium channel blockers?
Calcium channel blockers block voltage-gated calcium channels, relaxing vascular smooth muscle.
52
What are common side effects of calcium channel blockers?
Common side effects include flushing, ankle swelling, and headache.
53
What is the first-line treatment for older patients with hypertension?
Calcium channel blockers are the first-line treatment for older patients (>= 55 years old).
54
What is the mechanism of action of thiazide diuretics?
Thiazide diuretics inhibit sodium absorption at the beginning of the distal convoluted tubule.
55
What are common side effects of thiazide diuretics?
Common side effects include hyponatraemia, hypokalaemia, and dehydration.
56
What is the purpose of angiotensin II receptor blockers (A2RB)?
A2RBs block the effects of angiotensin II at the AT1 receptor, used when patients cannot tolerate ACE inhibitors.
57
What is the common ending for drug names of ACE inhibitors?
Drug names for ACE inhibitors typically end in '-pril'.
58
What is the common ending for drug names of angiotensin II receptor blockers (A2RB)?
Drug names for A2RBs typically end in '-sartan'.
59
What did NICE publish in 2019 regarding hypertension?
NICE published updated guidelines for the management of hypertension, building on significant guidelines from 2011.
60
What key recommendations were made in the 2011 hypertension guidelines?
The guidelines recommended classifying hypertension into stages and using ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM).
61
What is 'white coat hypertension'?
'White coat hypertension' refers to a subgroup of patients whose blood pressure increases by 20 mmHg in clinical settings, potentially leading to misdiagnosis.
62
Why are ABPM and HBPM important?
ABPM and HBPM provide a more accurate assessment of a patient's overall blood pressure, helping to prevent overdiagnosis of hypertension.
63
What are the criteria for Stage 1 hypertension?
Stage 1 hypertension is defined as a clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg.
64
What are the criteria for Stage 2 hypertension?
Stage 2 hypertension is defined as a clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg.
65
What defines severe hypertension?
Severe hypertension is defined as a clinic systolic BP >= 180 mmHg or clinic diastolic BP >= 120 mmHg.
66
What does NICE recommend when diagnosing hypertension?
NICE recommends measuring blood pressure in both arms and repeating measurements if the difference is more than 20 mmHg.
67
What should be done if the blood pressure reading is >= 180/120 mmHg?
Admit for specialist assessment if there are signs of retinal hemorrhage, life-threatening symptoms, or if a phaeochromocytoma is suspected.
68
What is the protocol for ambulatory blood pressure monitoring (ABPM)?
ABPM requires at least 2 measurements per hour during waking hours, using the average value of at least 14 measurements.
69
What is the protocol for home blood pressure monitoring (HBPM)?
HBPM requires two consecutive measurements taken at least 1 minute apart, recorded twice daily for at least 4 days, discarding the first day's measurements.
70
What is the treatment recommendation for ABPM/HBPM >= 135/85 mmHg?
Treat if under 80 years of age and any of the following apply: target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk of 10% or greater.
71
What did NICE recommend for adults under 60 with stage 1 hypertension and a 10-year risk below 10%?
NICE suggested considering antihypertensive drug treatment in addition to lifestyle advice.
72
What is the treatment recommendation for ABPM/HBPM >= 150/95 mmHg?
Offer drug treatment regardless of age.
73
What did NICE publish in 2019 regarding hypertension management?
NICE published updated guidelines that included lowering the treatment threshold for stage 1 hypertension in patients under 80 years from 20% to 10%.
74
What can be used instead of ACE-inhibitors according to NICE guidelines?
Angiotensin receptor blockers can be used instead of ACE-inhibitors where indicated.
75
What is the treatment recommendation if a patient is already taking an ACE-inhibitor or angiotensin receptor blocker?
A calcium channel blocker OR a thiazide-like diuretic can be used.
76
What are the criteria for Stage 1 hypertension?
Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg.
77
What are the criteria for Stage 2 hypertension?
Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg.
78
What defines Severe hypertension?
Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg.
79
What lifestyle advice is recommended for managing hypertension?
A low salt diet (less than 6g/day), reduced caffeine intake, stop smoking, drink less alcohol, eat a balanced diet, exercise more, and lose weight.
80
What is the recommendation for treating Stage 1 hypertension in patients under 80 years?
Treat if any of the following apply: target organ damage, established cardiovascular disease, renal disease, diabetes, or a 10-year cardiovascular risk of 10% or greater.
81
What should be considered for adults under 60 with Stage 1 hypertension and a 10-year risk below 10%?
Consider antihypertensive drug treatment in addition to lifestyle advice.
82
What is the treatment recommendation for Stage 2 hypertension?
Offer drug treatment regardless of age.
83
What is the first step in treating patients under 55 years or with type 2 diabetes?
Start with an ACE inhibitor or an angiotensin receptor blocker.
84
What should be used for patients aged 55 years or of black African or African-Caribbean origin?
Calcium channel blocker.
85
What is the second step in hypertension treatment?
If already taking an ACE-i or ARB, add a calcium channel blocker or a thiazide-like diuretic.
86
What is the third step in hypertension treatment?
Add a third drug to the regimen.
87
What defines Step 4 treatment for resistant hypertension?
Consider adding a 4th drug or seeking specialist advice.
88
What are the blood pressure targets for patients under 80 years?
Clinic BP: 140/90 mmHg; ABPM/HBPM: 135/85 mmHg.
89
What are the blood pressure targets for patients over 80 years?
Clinic BP: 150/90 mmHg; ABPM/HBPM: 145/85 mmHg.
90
What percentage of hypertension patients have primary hyperaldosteronism?
Between 5-10% of patients diagnosed with hypertension have primary hyperaldosteronism, including Conn's syndrome. ## Footnote This makes it the single most common cause of secondary hypertension.
91
What renal diseases can cause secondary hypertension?
Conditions that may increase blood pressure include glomerulonephritis, pyelonephritis, adult polycystic kidney disease, and renal artery stenosis.
92
What endocrine disorders can result in increased blood pressure?
Endocrine disorders that may cause increased blood pressure include phaeochromocytoma, Cushing's syndrome, Liddle's syndrome, congenital adrenal hyperplasia (11-beta hydroxylase deficiency), and acromegaly.
93
What drugs can cause secondary hypertension?
Drug causes of secondary hypertension include steroids, monoamine oxidase inhibitors, the combined oral contraceptive pill, NSAIDs, and leflunomide.
94
What are other causes of secondary hypertension?
Other causes include pregnancy and coarctation of the aorta.
95
What is the most common cause of primary hyperaldosteronism?
Bilateral idiopathic adrenal hyperplasia is the most common cause, accounting for around 60-70% of cases.
96
What was the previously thought common cause of primary hyperaldosteronism?
Adrenal adenoma, termed Conn's syndrome, was previously thought to be the most common cause.
97
What are the causes of primary hyperaldosteronism?
1. Bilateral idiopathic adrenal hyperplasia: 60-70% of cases 2. Adrenal adenoma: 20-30% of cases 3. Unilateral hyperplasia 4. Familial hyperaldosteronism 5. Adrenal carcinoma
98
What are the features of primary hyperaldosteronism?
1. Hypertension 2. Hypokalaemia (e.g. muscle weakness) 3. Metabolic alkalosis
99
What is a classical feature of primary hyperaldosteronism in exams?
Hypokalaemia is a classical feature, but studies suggest it is only seen in 10-40% of patients.
100
What should be screened for primary hyperaldosteronism?
Patients with hypertension and hypokalemia or treatment-resistant hypertension should be screened.
101
What is the first-line investigation for suspected primary hyperaldosteronism?
A plasma aldosterone/renin ratio is recommended as the first-line investigation.
102
What results indicate primary hyperaldosteronism in the plasma aldosterone/renin ratio test?
High aldosterone levels alongside low renin levels indicate primary hyperaldosteronism.
103
What investigations follow the plasma aldosterone/renin ratio?
A high-resolution CT abdomen and adrenal vein sampling are used to differentiate between unilateral and bilateral sources.
104
What is the management for adrenal adenoma?
Surgery (laparoscopic adrenalectomy) is the management for adrenal adenoma.
105
What is the management for bilateral adrenocortical hyperplasia?
An aldosterone antagonist, e.g. spironolactone, is used for bilateral adrenocortical hyperplasia.
106
What is the mechanism of action of thiazide diuretics?
Thiazide diuretics work by inhibiting sodium reabsorption at the beginning of the distal convoluted tubule (DCT) by blocking the thiazide-sensitive Na+-Clˆ’ symporter.
107
What is a consequence of thiazide diuretics on potassium levels?
Potassium is lost as a result of more sodium reaching the collecting ducts.
108
What is the role of thiazide diuretics in heart failure treatment?
Thiazide diuretics have a role in the treatment of mild heart failure although loop diuretics are better for reducing overload.
109
What was the main use of bendroflumethiazide?
The main use of bendroflumethiazide was in the management of hypertension.
110
What do recent NICE guidelines recommend regarding thiazide diuretics?
Recent NICE guidelines now recommend other thiazide-like diuretics such as indapamide and chlortalidone.
111
What are common adverse effects of thiazide diuretics?
Common adverse effects include dehydration, postural hypotension, hypokalaemia, hyponatraemia, hypercalcaemia, gout, impaired glucose tolerance, and impotence.
112
What causes hypokalaemia in thiazide diuretics?
Hypokalaemia is due to increased delivery of sodium to the distal part of the distal convoluted tubule, leading to increased sodium reabsorption in exchange for potassium and hydrogen ions.
113
What is a potential benefit of thiazide diuretics related to calcium?
Thiazide diuretics can lead to hypocalciuria, which may be useful in reducing the incidence of renal stones.
114
What are rare adverse effects of thiazide diuretics?
Rare adverse effects include thrombocytopaenia, agranulocytosis, photosensitivity rash, and pancreatitis.

Year 6 Cardiology (36 decks)

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