HTN Flashcards

1
Q

Aged U55

A
  1. ACEI/ ARB
  2. CCB
  3. Thiazide like diuretic
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2
Q

Over 55

A
  1. CCB
  2. Thiazide like diuretic
  3. ACEI/ARB
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3
Q

ACEI

MOA

A
  • ACEI block the action of ACE, to prevent the conversion of Angiotensin I => Angiotensin II
  • Ang II is a vasoconstrictor and stimulates aldosterone secretion
  • Blocking its action reduces peripheral vascular resistance (afterload), which lowers blood pressure
  • It particularly dilates the efferent glomerular arteriole, which reduces pressure and slows the progression of CKD
  • Reducing aldosterone levels promotes Na and water secretion
    • Reduces proload, good in HF
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4
Q

ACEI

Important adverse effects

A
  • Hypotension
  • Persistent dry cough- Increased levels of bradykinin (inactivated by ACE)
  • Hyperkalaemia
  • Worsen renal failure
  • Angioedema
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5
Q

ACEI

warnings

A
  • Renal artery stenosis
  • Acute kidney injury
  • Pregnant and breastfeeding
  • SOME forms of CKD
  • Profound hypotension on first dose (particularly when on diuretics), start low and titrate up
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6
Q

ACEI

Important interactions

A
  • Pottasium elevating drugs
    • K supplements
    • K sparring diuretics
    • NSAID
  • Ibuprofen- Kidney damage
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7
Q

ACEI

Monitoring

A
  • Monitor efficacy- symptoms of breathlessness (HF)
  • Check electrolyte and renal function before treatment and 1-2 weeks into treatment
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8
Q

Angiotensin receptor blockers (ARB) MOA

Losartan, candesartan, irbesartan

A
  • Similar to ACEI but instead of inhibiting Ang I=> Ang II
  • Blocks Ang II => AT1 receptor
  • Rest is the same
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9
Q

ARB

Important adverse effects + Warning

A
  • Hypotension (First dose)
  • Hyperkalaemia
  • Renal failure
  • Renal artery stenosis
  • AKI
  • Pregnant + Breastfeeding
  • CKD
  • NB- interactions are the same as ACEI + Monitoring
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10
Q

CCB MOA

Amlodipine

A
  • CCB decrease Ca entry into the vascular and cardiac cells, reducing the intracellular calcium concentration
  • This causes relaxation and vasodilation in arterial smooth muscle, lowing arterial pressure
  • In heart, CCB reduces myocardial contractility
  • Suppress cardiac conduction across the AV node, slowing ventricular rate
  • Amlodipine (Dihydropyridines) are relatively selective for the vasculature
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11
Q

CCB (Amlodipine)

Important adverse effects + Warnings

A
  • ANKLE SWELLING, Flushing, Headache, Palpitations
    • Caused by vasodilation and compensatory tachycardia
  • Unstable angina- vasodilation causes reflex increase in contractility and tachycardia, increase O2 demand
  • Severe aortic stenosis- provoke collapse
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12
Q

Amlodipine

Monitoring

A
  • Treatment efficacy can be judged by regular BP monitoring for HTN, enquiry about chest pain for angina and by pulse rate from exam or ECG
  • 24 hour tape can be performed to review arrhthmias
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13
Q

Thiazide like diuretics

Indapamide

MOA

A
  • Thiazides inhibit the Na+/Cl- co-transporter in the distal convoluted tubule of the nephron
  • This prevents reabsorption of sodium and its osmotically associated water
  • The resulting diuresis causes an initial fall in the extracellular fluid volume
  • Over time, compensatory changes (e.g. activation of RAS) tend to reverse this, at least in part
  • The long term anti-hypertensive if vasodilation (not understood)
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14
Q

Thiazide diuertics

Importand side effects + warning

A
  • Preventing sodium ion reabsorption from nephron= Hyponatraemia
  • Increases K in urine = may cause hypokalaemia + Cardiac arrhythmias
  • Impotence in men
  • Hypokalaemia
  • Hyponatraemia
  • Gout
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15
Q

Thiazide diuretics

Interactions + Monitoring

A
  • NSAIDs- reduce their effectiveness (not low dose aspirin_
  • Loop diuretics= hypokalaemia
  • Serum electrolytes before you start and 2-4 weeks after initiation of therapy
  • NB- TLD cause hypokalaemia, ACEI cause hyperkalaemia- reduce side effects- also synergistic BP-lowering effect
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16
Q

Methyldopa

Indications + MOA

A
  • Hypertension
  • Methyldopa is metabolised to alpha-methylnoradrenaline, which lowers arterial pressure by stimulation of central inhibitory alpha-adrenergic receptors
  • False neurotransmission
  • Reduction in plasma renin activity
  • Methyldopa has been shown to cause a net reduction in the tissue concentration of serotonin, DA, Adrenaline, NA
17
Q

Methyldopa

Adverse effects

A
  • Sedations- usually transient during inital therapy- not to operate heavy machinery
  • Headache, asthenia + weakness are all transient
    *
18
Q

Methyldopa

Warnings

A
  • Contraindicated in
    • acute porphyrias (liver disorders in which substances called porphyrins build up in the body, negatively affecting the skin or nervous system)
    • Depression
    • Paraganglioma
    • Phaeochromocytoma (Adrenal gland tumour = to much adrenaline)
  • Cautioned in
    • Hepatic impairment
    • Elderly- STOPP criteria
19
Q

Methyldopa

Interactions

A
  • Li- monitor carefully for Li toxicity
  • Antihypertensives
  • Antagonistic interactions: Sympathomimetics, phenothiazines, TCA and MAOI
  • Fe- decrease in the bioavailability of methyldopa when ingested with Fe
20
Q

Methyldopa

Monitoring

A
  • BP
  • FBC- Before treatment and at intervals during first 6-12 weeks or if unexplained fever
  • LFTs- Before treatment and at intervals during first 6-12 weeks or if unexplained fever
21
Q

Minoxidil

Indications

A
  • Severe HTN- in addition to diuretic and BB
  • Androgenetic alopecia
22
Q

Minoxidil

MOA

A
  • Minoxidil lowers systolic and diastolic BP by decreasing vascular resistance by vasodilation
  • The smooth musculature of the resistance vessels must be regarded as the site of action for the relaxant effect of minoxidil
  • The active metabolite of minoxidil activates the ATP-modulated potassium (K-atp) channel causing K efflux, hyperpolarization and smooth muscle relaxation
23
Q

Minoxidil

Adverse effects

A
  • Hair changes
  • Fluid retention- oedema
  • Pericarditis
  • Hypotension
  • With TOP application only 1-2% absorbed (may be increased if skin is inflamed
24
Q

Minoxidil

Warnings

A
  • Contraindicated in
    • Phaeochromocytoma
  • Cautioned in
    • Acute porphyias, after MI, angina
    • Contact with broken, infected, shaved or inflamed skin d
25
Q

Minoxidil

Interactions

A
  • Other anti-HTN
  • Betanidine (sympathetic-blocking agents) may produce excessive BP reduction/ orthostatic hypotension
26
Q

Minoxidil

Monitor

A
  • BP inc L/S BP
  • UO- due to fluid retention
  • U&E- fluid retention