HPN Flashcards
Deaths in hypertensive patients have been shown to be due to 1 2 3 4
stroke 45%, heart failure 35%,
kidney failure 3% and others 17%.
Factors increasing chances of dying in hypertensive patients are: 1 2 3 4
male patient, young patient, family
history, increasing diastolic pressur
For adults aged 18 years
and older hypertension is:
- diastolic pressure >90 mmHg and/or
* systolic pressure >140 mmHg
•__________ is that of
≥ 140 mmHg in the presence of a diastolic
pressure <90 mmHg
Isolated systolic hypertension
__________ is the presence of
sustained hypertension in the absence of
underlying, potentially correctable kidney,
adrenal or other factors
Essential hypertension
____________is that with a diastolic
pressure >120 mmHg and exudative vasculopathy
in the retinal and kidney circulations
Malignant hypertension
_________ is a BP >140/90 mmHg
despite maximum dosage of tw o drugs for 3–4
months
Refractory hypertension
90% of HPN are ________
essential
What kind of HPN?
It is also more likely in patients
whose BP is responding poorly to drug therapy,
patients with well-controlled hypertension whose BP
begins to increase, and patients with accelerated or
malignant hypertension
Secondary hypertension
PE for secondary HPN
Abdominal systolic bruit
Kidney artery stenosis
PE for secondary HPN
Proteinuria, haematuria, casts
Glomerulonephritis
PE for secondary HPN
Bilateral kidney masses with or without haematuria
Polycystic disease
PE for secondary HPN
History of claudication and delayed femoral pulse
Coarctation of the aorta
PE for secondary HPN
Progressive nocturia, weakness
Primary aldosteronism (check serum potassium)
PE for secondary HPN
Paroxysmal hypertension with headache, pallor,
sweating, palpitations
Phaeochromocytoma
Renal Artery Stenosis
_______ kidney artery stenosis accounts for
the majority of cases, while ______
remains an important cause
Atherosclerotic
fibromuscular dysplasia
How record HPN?
On each occasion when the BP is taken, two or more
readings should be averaged. Wait at least 30 seconds
before repeating the procedure.
When to repeat BP readings?
If the first two readings differ by more than 6 mmHg systolic or 4 mmHg diastolic, more readings should be taken
Whom to measure sitting and standing BP?
Measure sitting and standing BP in elderly
and diabetic patients
If the initial reading is high (DBP >90 mmHg, SBP
>140 mmHg) repeat the measures after______
10 minutes of quiet rest.
The________ influence in the medical
practitioner’s office may cause higher readings so
measurement in other settings such as the home or
the workplace should be managed whenever possible.
‘white coat’
Initial diastolic BP readings of 115 mmHg or more,
particularly for patients with __________
may need immediate drug therapy
target organ damage,
If mild hypertension is found, observation with
repeated measurement over________months should be
followed before beginning therapy
3–6
This is required for the diagnosis and follow-up
of patients with fluctuating levels, borderline
hypertension or refractory hypertension (especially
where the ‘white coat’ effect may be significant
Ambulatory 24-hour monitoring
Guidelines for ambulatory BP measurement: 1 2 3 4 5
- unusual variability of office BP
- marked discrepancy between office and house BP
- resistance to drug treatment
- suspected sleep apnoea
- when two BP readings >140/90
These people have a
type of conditioned response to the clinic or office
setting and their home BP and ambulatory BP
profiles are normal.
‘White coat’ hypertension
T or F
Pts with ‘White coat’ hypertension
They appear to be at low risk of cardiovascular disease but may progress to sustained
hypertension
T
If the average diastolic BP at the initial visit is
90–100 mmHg, and there is no evidence of end organ
damage, _____ is indicated
non-pharmacological therapy is indicated for a
3-month period
Hovell has estimated that for every
1 kg of weight lost, BP dropped________
by 2.5 mmHg
systolic and 1.5 mmHg diastolic
Drinking more than _______of alcohol a day
raises BP and makes treatment of established
hypertension more difficult.
20 g
Reduction or withdrawal of regular alcohol intake
reduces BP by ______
5–10 mmHg
Reduction of sodium intake to less than ______
sodium per day is advised
100 mmol
_____ and_______ exercise helps to
reduce BP
Regular aerobic or isotonic
There is evidence that _______ and _______ supplementation can reduce BP
lacto–vegetarian diets and
magnesium
HPN Tx
A period of _______weeks is needed for the effect to
become fully apparent
4–6
Relatively ineffective combinations of anit HPN
- Diuretic and calcium-channel blocker
* β -blockers and ACE inhibitors
Undesirable combinations • More than one drug from a particular pharmacological group: — \_\_\_\_\_\_\_\_\_\_\_(heart block, heart failure) — \_\_\_\_\_\_\_\_\_\_ (hyperkalaemia)
β -blockers and verapamil
potassium-sparing diuretics and ACE
inhibitors or ARB
_________ are good first-line therapy for
hypertension
Thiazides
___________ are less potent as antihypertensive
agents but are indicated where there is
concomitant cardiac or kidney failure and in
resistant hypertension
Loop diuretics
________ are less effective where there is kidney
impairment
Thiazides
_______ may antagonise the antihypertensive
and natriuretic effectiveness of diuretics
NSAIDs
A diet high in potassium and magnesium should
accompany _______ therapy (e.g. lentils, nuts,
high fibre
diuretic
_______ has different properties to the thiazide
and loop diuretics and has less effect on serum lipids
Indapamide
NSAIDs may interfere with the hypotensive
effect of ________
β -blockers.
___________plus a β -blocker may unmask
conduction abnormalities causing heart block
Verapamil
• These drugs reduce BP by vasodilatation.
• The properties of individual drugs vary,
especially their effects on cardiac function
CCB
The ________ compounds (nifedipine and
felodipine) tend to produce more vasodilatation
and thus related side effects
dihydropyridine
Unlike verapamil or diltiazem (which slow the
heart), ___________ drugs can be used safely
with a β -blocker
dihydropyridine
_________ is contraindicated in second and third
degree heart block
Verapamil
______ and _______ should be used with
caution in patients with heart failure
Verapamil and diltiazem
Angiotensin-converting enzyme is responsible for
1
2
3
1. converting angiotensin I to angiotensin II (a potent vasoconstrictor and 2. stimulator of aldosterone secretion) and 3. for the breakdown of bradykinin (a vasodilator).
Cough, which occurs in about _______of patients, may disappear with time or a reduction in dose but it often persists and requires a change in drug in some patients.
15%
_______ a potentially life-threatening condition,
may occur in 0.1–0.2% of subjects.
Angioedema,
These agents competitively block the binding of
angiotensin II to type I angiotensin receptors and
block the effects of angiotensin more selectively
than the ACE inhibitors
Angiotensin II receptor
antagonists (sartans
They
are useful alternatives for hypertensive patients who
discontinue an ACE inhibitor because of cough and
may be used in combination with thiazide diuretics.
Angiotensin II receptor
antagonists (sartans
A specific problem of this alpha blocker is the ‘firstdose
phenomenon’; this involves acute syncope about
90 minutes after the first dose, hence treatment
is best initiated at bedtime
Prazosin
Prazosin potentiates_______ and works best if used with them
β -blockers
Other than calcium-channel blockers these include
hydralazine, minoxidil and diazoxide, which are
not used for first-line therapy but for refractory
hypertensive states and hypertensive emergencies
Vascular smooth muscle relaxants
example of such a central acting agent is______
which apparently stimulates the imidazoline
receptors in the brain to inhibit sympathetic outflow
in the body
moxonidine,
Typical
presentations of hypertensive emergencies (which
are rare) include
hypertensive encephalopathy, acute
stroke, heart failure, dissecting aortic aneurysm and
eclampsia.
BP goals in HPN Emergencies
Aim to reduce the
BP by no more than 25% within the first 2 hours then
towards 160/100 mmHg within 2 to 6 hours.
Isolated systolic hypertension is most frequently seen
in __________
elderly people
T or F
Patients with isolated systolic hypertension
should be treated in the same way as those with
classic systolic/diastolic hypertension
________exists where control has not
been achieved despite reasonable treatment for 3–4
months
Refractory hypertension
_____ and_____ are preferable in the young hypertensive, with______ a second agent.
ACE inhibitors or calcium-channel blocking agents
diuretics
Older patients may respond to ______
nonpharmacological
treatment.
Reducing dietary sodium is more beneficial than
with _______
younger patients.
Add only one agent at a time and wait about_______
weeks between dosage adjustments
4
Older patients may respond better to
1
2
3
diuretics,
calcium-channel blockers and ACE inhibitors.
Younger patients may respond better to
1
2
β -blockers
or ACE inhibitors
