Evidence based medicine for treatment of hypertension Flashcards
what is an NHS health check
- a health check for adults in England aged 40-74
2. designed to spot early signs of stroke, kidney disease, heart disease, type 2 diabetes, or dementia
what information is gathered during an NHS health check
- family history, smoking, drinking, physical activity
- weight and height
- age, gender and ethnicity
- blood pressure and pulse taken
- blood test to check cholesterol and blood sugar level
what symptoms may occur in high blood pressure
- headaches, dizziness, recurrent epistaxis, palpitations, sweating, weight and hair loss
- or may be asymptomatic
what is ambulatory blood pressure monitoring
- takes blood pressure every 30 minutes
- need at least 14 daytime readings for diagnosis
- mean daytime blood pressure
what is home blood pressure monitoring
- alternative to ABPM
- at least 4 days and ideally 7 days
- 2 readings morning and 2 readings evening at least 1 minute apart
- discard day 1 readings and then average blood pressure from all other days
what are the top tips for taking blood pressure
- patient needs to be relaxed
- take the pulse for 1 minute
- arm should be supported at heart level
- the correct cuff should be used
- no talking
- back supported, feet lat on floor
- take 2 readings
- use the same arm for blood pressure monitoring
what are the consequences of high blood pressure
could lead to:
- organ damage
- stroke
- heart failure
- vision loss
- heart attack
- kidney disease
describe the investigation for target organ damage and to establish CV risk
- urinalysis for blood and protein
- renal function- blood test
- electrolytes- blood test
- HbA1c- blood test
- lipid profile- blood test
- TFT and LFT
- ECG
- eyes- optician
what is the QRISK3 risk calculator
- calibrated for UK population
- calculates risk of having a heart attack or stroke over next 10 years
- based on data from GPs
- annually updated to remain accurate - this is for a primary prevention patient
what is primary prevention of hypertension
90-95%
- no identifiable cause
what is secondary prevention of hypertension
5-10%
- cause identified
- often rapid progression with very high blood pressure
give examples of ace inhibitors and when they would be used
- enalipril, ramipril
- first line in younger caucasian patients
- diabetics
- primary and secondary prevention of CVD
- heart failure
what cautions should be taken with use of ace inhibitors
- avoid k+ sparing diuretics and NSAIDs
- care with diuretic therapy
- caution with aortic stenosis
- contraindications include bilateral renal artery stenosis
- don’t use in pregnancy
give examples of ARBs and when they are used
- candesartan, losartan
- an alternative to ace inhibitor
- for black patients of African or Caribbean origin
- lower risk of angio oedema
give examples of dihydropyridine calcium channel blockers and when they are used
- amlodipine, nifedipine
- vasodilation of coronary and peripheral arteries and relax vascular smooth muscle
- also used in treatment of stable angina
what are the side effects of dihydropyridine calcium channel blockers
flushing, headaches, ankle swelling (peripheral oedema)
where are CCBs metabolised
all metabolised by liver
what are the 2 classes of calcium channel blockers
dihydropyridine and non dihydropyridine
give examples of non dihydropyridine calcium channel blockers and what they are used for
- phenylalkalamines (verapamil)
- benzothiazepines (diltiazem)
- also used to treat angina and arrhythmias
what is a common side effect of non dihydropyridine calcium channel blockers
constipation
describe how non dihydropyridine calcium channel blockers work
interfere with myocardial conduction
- slow the heart rate ( don’t use verapamil and beta blocker)
- contractility may be reduced, therefore not used in heart failure
give an example of a thiazide diuretic
indapamide
what should be monitored with use of thiazide diuretics
- renal function
- electrolytes
- lipid profile
- gout
give an example of a loop diuretic
furosemide or bumetanide
what should be monitored with use of loop diuretics
check renal function and electrolytes within one month of starting
give an example of a K+ sparing diuretic
spironolactone, amiloride
give an example of an alpha blocker and describe how they work
- doxazosin, tamsulosin
- vasodilator of vascular smooth muscle
- care with initial dose
- no effect on heart rate
- may cause drowsiness/dizziness
- used for BPH (older men)
describe the main properties of beta blockers
- intrinsic sympathomimetic activity (ISA)- partial agonist, stimulate and block adrenergic receptors
- cause less bradycardia/cold extremities
- acebutolol, oxprenolol - water soluble- cause less sleep disturbances
- renal excreted, reduce dose in renal impairment
- atenolol - cardioselective (not specific)- cause less bronchospasms
- atenolol, bisoprolol, metoprolol - prolong QT interval- sotalol
give examples of vasodilators and when they are used
- hydralazine: monitor LFTs
- minoxidil: causes hypertrichosis
- potent/rapid reduction in blood pressure
- used for severe/resistant hypertension
- can cause fluid retention/tachycardia, therefore caution if used alone
- other agents often co prescribed
give examples of centrally acting pharmacological therapy and when they would be used
- methyldopa- used in pregnancy
- monitor FBC for blood dyscrasias
-LFTs - clonidine- caution with driving
- not recommended as sudden withdrawal may cause hypertensive crisis - moxonidine- avoid in liver disease
- reduce dose in renal impairment
all cause CNS effects- dry mouth, drowsiness
give examples of renin inhibitors in pharmacological therapy
- aliskiren- licensed for hypertension only
- rarely used
- expensive
what factors are involved when choosing a treatment option
- age- increased risk of side effects
- renal impairment - ethnicity- afro-caribbean patients respond less well to ACE/ARBs
- co morbidities- diabetes, renal disease, previous CV event
- current drug therapy- choose OD prep if possible
- onset and severity
- pregnancy
what special considerations must be taken into account when choosing a treatment option
- elderly- limited evidence >80
- treat if persistent
- consider any co morbidities
- targets higher if >80
- consider postural hypotension and frailty
- CCB first line therapy - isolated systolic hypertension- treat same as patients with raised SBP and DPB
- diabetes- treatment prevents macro and microvascular complications
- ACE inhibitor drug of choice - renal disease- target 130/80 or lower if proteinuria >1g in 24 hours
- ACE inhibitor if proteinuria present - pregnancy- labeiolol or methyldopa
describe the adjunct therapy that can be used
- aspirin 75mg daily- not for primary prevention
- only prescribed if established CVD disease - statins- primary prevention
- CV risk assessment using validated tool
- secondary prevention: known CV disease
- CKD, type 1 diabetes
