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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
Q

What is the purpose of using 24-hour blood pressure monitors?

A

24-hour blood pressure monitors help avoid cases of ‘white coat’ hypertension, where blood pressure rises in clinical settings.

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26
Q

Why are 24-hour blood pressure monitor readings preferred?

A

Studies have shown that readings from 24-hour blood pressure monitors correlate better with clinical outcomes.

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27
Q

What should be assessed in a patient with newly diagnosed hypertension?

A

It is important to ensure they do not have any end-organ damage.

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28
Q

What is fundoscopy used for in hypertension assessment?

A

Fundoscopy is used to check for hypertensive retinopathy.

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29
Q

What does a urine dipstick check for in hypertension patients?

A

A urine dipstick checks for renal disease, either as a cause or consequence of hypertension.

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30
Q

What does an ECG check for in hypertension assessment?

A

An ECG checks for left ventricular hypertrophy or ischaemic heart disease.

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31
Q

What is the correct cuff size for measuring blood pressure in children?

A

The correct cuff size is approximately 2/3 the length of the upper arm.

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32
Q

Which Korotkoff sound is used to measure diastolic blood pressure in children?

A

The 4th Korotkoff sound is used until adolescence, when the 5th Korotkoff sound can be used.

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33
Q

What should blood pressure results in children be compared with?

A

Results should be compared with a graph of normal values for age.

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34
Q

What is the most common cause of secondary hypertension in younger children?

A

Renal parenchymal disease accounts for up to 80% of cases.

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35
Q

What are some causes of hypertension in children?

A

Causes include renal parenchymal disease, renal vascular disease, coarctation of the aorta, phaeochromocytoma, congenital adrenal hyperplasia, and essential or primary hypertension.

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36
Q

How does the prevalence of essential or primary hypertension change with age in children?

A

Essential or primary hypertension becomes more common as children become older.

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37
Q

What is hypertension?

A

Hypertension is a chronically raised blood pressure and an important risk factor for cardiovascular disease.

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38
Q

What is considered a ‘normal’ blood pressure?

A

Most healthy people have a blood pressure between 90/60 mmHg and 140/90 mmHg.

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39
Q

How does NICE define hypertension?

A

Hypertension is defined as a clinic reading persistently above >= 140/90 mmHg, or a 24-hour blood pressure average reading >= 135/85 mmHg.

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40
Q

What are the two categories of hypertension?

A

The two categories are primary (essential) hypertension and secondary hypertension.

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41
Q

What causes primary hypertension?

A

Primary hypertension is caused by complex physiological changes as we age, with no single disease responsible.

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42
Q

What are some causes of secondary hypertension?

A

Secondary hypertension can be caused by renal disease, endocrine disorders, and other factors such as medications and pregnancy.

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43
Q

What symptoms may occur with very high hypertension?

A

Symptoms may include headaches, visual disturbances, and seizures.

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44
Q

How is hypertension typically diagnosed?

A

Hypertension is diagnosed by checking blood pressure, often using 24-hour blood pressure monitors to avoid ‘white coat’ hypertension.

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45
Q

What tests are recommended after diagnosing hypertension?

A

Recommended tests include urea and electrolytes, HbA1c, lipids, ECG, and urine dipstick.

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46
Q

What are the main aspects of managing hypertension?

A

Management includes drug therapy, modification of risk factors, and monitoring for complications.

47
Q

What are common drug classes used to treat hypertension?

A

Common drug classes include ACE inhibitors, calcium channel blockers, thiazide diuretics, and angiotensin II receptor blockers (A2RB).

48
Q

What is the mechanism of action of ACE inhibitors?

A

ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II.

49
Q

What are common side effects of ACE inhibitors?

A

Common side effects include cough, angioedema, and hyperkalaemia.

50
Q

What is the first-line treatment for younger patients with hypertension?

A

ACE inhibitors are the first-line treatment for younger patients (< 55 years old).

51
Q

What is the mechanism of action of calcium channel blockers?

A

Calcium channel blockers block voltage-gated calcium channels, relaxing vascular smooth muscle.

52
Q

What are common side effects of calcium channel blockers?

A

Common side effects include flushing, ankle swelling, and headache.

53
Q

What is the first-line treatment for older patients with hypertension?

A

Calcium channel blockers are the first-line treatment for older patients (>= 55 years old).

54
Q

What is the mechanism of action of thiazide diuretics?

A

Thiazide diuretics inhibit sodium absorption at the beginning of the distal convoluted tubule.

55
Q

What are common side effects of thiazide diuretics?

A

Common side effects include hyponatraemia, hypokalaemia, and dehydration.

56
Q

What is the purpose of angiotensin II receptor blockers (A2RB)?

A

A2RBs block the effects of angiotensin II at the AT1 receptor, used when patients cannot tolerate ACE inhibitors.

57
Q

What is the common ending for drug names of ACE inhibitors?

A

Drug names for ACE inhibitors typically end in ‘-pril’.

58
Q

What is the common ending for drug names of angiotensin II receptor blockers (A2RB)?

A

Drug names for A2RBs typically end in ‘-sartan’.

59
Q

What did NICE publish in 2019 regarding hypertension?

A

NICE published updated guidelines for the management of hypertension, building on significant guidelines from 2011.

60
Q

What key recommendations were made in the 2011 hypertension guidelines?

A

The guidelines recommended classifying hypertension into stages and using ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM).

61
Q

What is ‘white coat hypertension’?

A

‘White coat hypertension’ refers to a subgroup of patients whose blood pressure increases by 20 mmHg in clinical settings, potentially leading to misdiagnosis.

62
Q

Why are ABPM and HBPM important?

A

ABPM and HBPM provide a more accurate assessment of a patient’s overall blood pressure, helping to prevent overdiagnosis of hypertension.

63
Q

What are the criteria for Stage 1 hypertension?

A

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
Q

What are the criteria for Stage 2 hypertension?

A

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
Q

What defines severe hypertension?

A

Severe hypertension is defined as a clinic systolic BP >= 180 mmHg or clinic diastolic BP >= 120 mmHg.

66
Q

What does NICE recommend when diagnosing hypertension?

A

NICE recommends measuring blood pressure in both arms and repeating measurements if the difference is more than 20 mmHg.

67
Q

What should be done if the blood pressure reading is >= 180/120 mmHg?

A

Admit for specialist assessment if there are signs of retinal hemorrhage, life-threatening symptoms, or if a phaeochromocytoma is suspected.

68
Q

What is the protocol for ambulatory blood pressure monitoring (ABPM)?

A

ABPM requires at least 2 measurements per hour during waking hours, using the average value of at least 14 measurements.

69
Q

What is the protocol for home blood pressure monitoring (HBPM)?

A

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
Q

What is the treatment recommendation for ABPM/HBPM >= 135/85 mmHg?

A

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
Q

What did NICE recommend for adults under 60 with stage 1 hypertension and a 10-year risk below 10%?

A

NICE suggested considering antihypertensive drug treatment in addition to lifestyle advice.

72
Q

What is the treatment recommendation for ABPM/HBPM >= 150/95 mmHg?

A

Offer drug treatment regardless of age.

73
Q

What did NICE publish in 2019 regarding hypertension management?

A

NICE published updated guidelines that included lowering the treatment threshold for stage 1 hypertension in patients under 80 years from 20% to 10%.

74
Q

What can be used instead of ACE-inhibitors according to NICE guidelines?

A

Angiotensin receptor blockers can be used instead of ACE-inhibitors where indicated.

75
Q

What is the treatment recommendation if a patient is already taking an ACE-inhibitor or angiotensin receptor blocker?

A

A calcium channel blocker OR a thiazide-like diuretic can be used.

76
Q

What are the criteria for Stage 1 hypertension?

A

Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg.

77
Q

What are the criteria for Stage 2 hypertension?

A

Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg.

78
Q

What defines Severe hypertension?

A

Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 120 mmHg.

79
Q

What lifestyle advice is recommended for managing hypertension?

A

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
Q

What is the recommendation for treating Stage 1 hypertension in patients under 80 years?

A

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
Q

What should be considered for adults under 60 with Stage 1 hypertension and a 10-year risk below 10%?

A

Consider antihypertensive drug treatment in addition to lifestyle advice.

82
Q

What is the treatment recommendation for Stage 2 hypertension?

A

Offer drug treatment regardless of age.

83
Q

What is the first step in treating patients under 55 years or with type 2 diabetes?

A

Start with an ACE inhibitor or an angiotensin receptor blocker.

84
Q

What should be used for patients aged 55 years or of black African or African-Caribbean origin?

A

Calcium channel blocker.

85
Q

What is the second step in hypertension treatment?

A

If already taking an ACE-i or ARB, add a calcium channel blocker or a thiazide-like diuretic.

86
Q

What is the third step in hypertension treatment?

A

Add a third drug to the regimen.

87
Q

What defines Step 4 treatment for resistant hypertension?

A

Consider adding a 4th drug or seeking specialist advice.

88
Q

What are the blood pressure targets for patients under 80 years?

A

Clinic BP: 140/90 mmHg; ABPM/HBPM: 135/85 mmHg.

89
Q

What are the blood pressure targets for patients over 80 years?

A

Clinic BP: 150/90 mmHg; ABPM/HBPM: 145/85 mmHg.

90
Q

What percentage of hypertension patients have primary hyperaldosteronism?

A

Between 5-10% of patients diagnosed with hypertension have primary hyperaldosteronism, including Conn’s syndrome.

This makes it the single most common cause of secondary hypertension.

91
Q

What renal diseases can cause secondary hypertension?

A

Conditions that may increase blood pressure include glomerulonephritis, pyelonephritis, adult polycystic kidney disease, and renal artery stenosis.

92
Q

What endocrine disorders can result in increased blood pressure?

A

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
Q

What drugs can cause secondary hypertension?

A

Drug causes of secondary hypertension include steroids, monoamine oxidase inhibitors, the combined oral contraceptive pill, NSAIDs, and leflunomide.

94
Q

What are other causes of secondary hypertension?

A

Other causes include pregnancy and coarctation of the aorta.

95
Q

What is the most common cause of primary hyperaldosteronism?

A

Bilateral idiopathic adrenal hyperplasia is the most common cause, accounting for around 60-70% of cases.

96
Q

What was the previously thought common cause of primary hyperaldosteronism?

A

Adrenal adenoma, termed Conn’s syndrome, was previously thought to be the most common cause.

97
Q

What are the causes of primary hyperaldosteronism?

A
  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
Q

What are the features of primary hyperaldosteronism?

A
  1. Hypertension
  2. Hypokalaemia (e.g. muscle weakness)
  3. Metabolic alkalosis
99
Q

What is a classical feature of primary hyperaldosteronism in exams?

A

Hypokalaemia is a classical feature, but studies suggest it is only seen in 10-40% of patients.

100
Q

What should be screened for primary hyperaldosteronism?

A

Patients with hypertension and hypokalemia or treatment-resistant hypertension should be screened.

101
Q

What is the first-line investigation for suspected primary hyperaldosteronism?

A

A plasma aldosterone/renin ratio is recommended as the first-line investigation.

102
Q

What results indicate primary hyperaldosteronism in the plasma aldosterone/renin ratio test?

A

High aldosterone levels alongside low renin levels indicate primary hyperaldosteronism.

103
Q

What investigations follow the plasma aldosterone/renin ratio?

A

A high-resolution CT abdomen and adrenal vein sampling are used to differentiate between unilateral and bilateral sources.

104
Q

What is the management for adrenal adenoma?

A

Surgery (laparoscopic adrenalectomy) is the management for adrenal adenoma.

105
Q

What is the management for bilateral adrenocortical hyperplasia?

A

An aldosterone antagonist, e.g. spironolactone, is used for bilateral adrenocortical hyperplasia.

106
Q

What is the mechanism of action of thiazide diuretics?

A

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
Q

What is a consequence of thiazide diuretics on potassium levels?

A

Potassium is lost as a result of more sodium reaching the collecting ducts.

108
Q

What is the role of thiazide diuretics in heart failure treatment?

A

Thiazide diuretics have a role in the treatment of mild heart failure although loop diuretics are better for reducing overload.

109
Q

What was the main use of bendroflumethiazide?

A

The main use of bendroflumethiazide was in the management of hypertension.

110
Q

What do recent NICE guidelines recommend regarding thiazide diuretics?

A

Recent NICE guidelines now recommend other thiazide-like diuretics such as indapamide and chlortalidone.

111
Q

What are common adverse effects of thiazide diuretics?

A

Common adverse effects include dehydration, postural hypotension, hypokalaemia, hyponatraemia, hypercalcaemia, gout, impaired glucose tolerance, and impotence.

112
Q

What causes hypokalaemia in thiazide diuretics?

A

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
Q

What is a potential benefit of thiazide diuretics related to calcium?

A

Thiazide diuretics can lead to hypocalciuria, which may be useful in reducing the incidence of renal stones.

114
Q

What are rare adverse effects of thiazide diuretics?

A

Rare adverse effects include thrombocytopaenia, agranulocytosis, photosensitivity rash, and pancreatitis.

Year 6 Cardiology (36 decks)

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