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Module 308 > Hypertension > Flashcards

Hypertension Flashcards

1
Q

Hypertension prevalence by WHO region

A

Finish slide

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2
Q

High BP affects more than 1 in … adults in England

A

1 in 4

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3
Q

High BP is the … biggest risk factor for premature death and disability in england after …

A

3rd - after smoking and poor diet

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4
Q

people from the most deprived areas in England are … more likely than the least-deprived to have high BP

A

30% more likely

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5
Q

The proportion of adults with untreated high BP has …

A

decreased

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6
Q

England’s performance in terms of diagnosing and treating high BP

A

still far from optimal compared to other countries advancement

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7
Q 
For every 10mmHg reduction in BP...
...% reduction of CHD
...% reduction of stroke
...% reduction of heart failure
...% reduction of all-cause mortality
A

17% reduction of CHD
27% reduction of stroke
28% reduction of heart failure
13% reduction of all-cause mortality

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8
Q

BP equation

A

BP = CO X SVR

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9
Q

CO = …

A

HR X SV

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10
Q

clinical hypertension

Arterial BP >

A

clinical hypertension

Arterial BP > 140/90 mmHg

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11
Q

artefacts which make elevate blood pressure

A 
small cuff
talking
distended bladder
smoking
legs crossed
pain
unsupported back/arm/leg
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12
Q

next step if a clinic reading above 140/90

A

do ambulatory blood pressure monitoring or home blood pressure monitoring

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13
Q

confirming diagnosis of hypertension

A

need a raised clinic blood pressure and an ABPM average of 135/85 or higher

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14
Q

true hypertension

A

hypertensive both in the clinic and on ABPM

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15
Q

What is white coat hypertension?

A

patients exhibit elevated blood pressure in the doctor’s office but not with ABPM at home

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16
Q

masked hypertension

A

normotensive in clinic but hypertensive at home

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17
Q

symptoms of hypertension

A

Asymptomatic, headache, dizziness/ faint, SOB, impaired concentration, epistaxis

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18
Q

examinations for hypertension (3)

A

cardiovascular
abdomen
fundoscopy

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19
Q

non drug tx for hypertension (lifestyle changes) - 5

A 
weight reducton
DASH eating plan
dietary sodium restriction 
physical activity
alcohol moderation
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20
Q

hypertension treatment ladder if under 55 and not black afrocaribbean

A

ACEi/ARB
add CCB or thiazide-like diuretic
add CCB/thiazide-like diuretic
confirm resistance then treat that

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21
Q

treating resistant hypertension options

A

if potassium under 4.5 then spironolactone, if above 4.5 then alpha/beta blocker

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22
Q

treatment ladder for hypertension if over 55 or afrocaribbean

A

then ACEi/ARB or thiazide
then ACEi/ARB or thiazide (whichever not added 2nd)
then confirm resistance and treat that

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23
Q

Pseudo-resistant HTN

A

could be due to non-adherence, white coat effect, drug intolerance

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24
Q

white coat effect (on hypertension)

A

patients who are confirmed hypertensives have a discrepancy of >20/10mmHg in clinic vs at home

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25
Q

types of hypertensive crisis

A

Hypertensive emergency

Hypertensive urgency

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26
Q

target BP in people over 80

A

target BP in people over 80

150/100

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27
Q

why is target BP higher in over 80s?

A

higher risk of postural hypertension, falls etc

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28
Q

hypertensive emergency

A

Blood pressure >180/120 mm Hg AND target organ damage

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29
Q

hypertensive urgency

A

Severe HTN (>180/110) without signs of end organ damage

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30
Q

hypertensive emergency vs urgency?

A

Blood pressure >180/120 mm Hg AND target organ damage = emergency

Severe HTN (>180/110) without signs of end organ damage = urgency

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31
Q

treating hypertensive emergency

A

IV labetalol, GTN, sodium nitroprusside

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32
Q

treating hypertensive urgency

A

aim to lower BP after a review within 7 days

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33
Q

Sodium nitroprusside - what is this?

A

sold under the brand name Nitropress among others, is a medication used to lower blood pressure.[1] This may be done if the blood pressure is very high and resulting in symptoms, in certain types of heart failure, and during surgery to decrease bleeding.[1] It is used by continuous injection into a vein.

Onset is nearly immediate and effects last for up to ten minutes.[1] It has been known to cause reflex tachycardia. It is often used as the vasodilator of choice in acute, emergency situations.

34
Q

Treating hypertensive urgency

A

aim to lower BP after a review within 7 days

35
Q

Treating Hypercholesterolemia (4 options)

A

statins
ezetimibe
ezetimibe with bempedoic acid
PCSK9 inhibitors

36
Q

are statins different to each other?

A

yes, vary in intensity, if one is not tolerated switching can be beneficial

37
Q

who is ezetimibe indicated for?

A

treating primary hypercholesterolaemia in adults who can’t tolerate statins/contraindicated

38
Q

issue with ezetimibe

A

some GI side effects, which may cause non-adherence

39
Q

Ezetimibe may cause what side effects which may lead to Non-adherence?

A

GI side effects

40
Q

Bempedoic acid

A

ATP citrate lyase inhibitor which decreases cholesterol synthesis

41
Q

QRISK3

What is this?

A

cardiovascular risk calculator, if over 10% start a statin

42
Q

HTN treatment overview

A
43
Q

… cause a reduction in circulating angiotensin II & aldosterone.

A

ACE inhibitors cause a reduction in circulating angiotensin II & aldosterone.

44
Q

Examples of ACEi

A

Examples: Ramipril, Lisinopril.

45
Q

Angiotensin-converting enzyme (ACE) inhibitors are a commonly used class of antihypertensives. They are also frequently utilised in heart failure and …

A

Angiotensin-converting enzyme (ACE) inhibitors are a commonly used class of antihypertensives. They are also frequently utilised in heart failure and chronic kidney disease.

46
Q

Mechanism of action

ACE inhibitors act by blocking the effect of ACE, causing a reduction in circulating angiotensin II. Reduction of angiotensin II has numerous effects:

A

Reduced aldosterone secretion - involved in volume regulation via sodium and potassium excretion.
Reduced ADH secretion - anti-diuretic hormone (ADH) acts on the kidneys to increase water reabsorption (independent of sodium).
Reduced arterial vasoconstriction
Reduced sympathetic activity

47
Q

What is a common side effect of ACEi?

A

A dry cough is a common side effect of ACE inhibitors. This is due to an increase in bradykinin within the lungs (ACE breaks down bradykinin).

Caution is also advised during intercurrent illnesses when using an ACE inhibitor. Their mechanism disrupts the kidneys autoregulation mechanisms and may prevent maintenance of adequate renal perfusion - resulting in an acute kidney injury (AKI). It is often advisable to stop ACE inhibitors during severe illness.

48
Q

Adverse effects of ACEi?

A 
Dry cough
Headache
Postural hypotension
Rashes
Angio-oedema
Strongly teratogenic
49
Q

Calcium channel blockers (CCBs) are also a commonly used class of antihypertensives.

There are two main types of CCBs:

A

Dihydropyridine: predominantly anti-hypertensive effects.

Non-dihydropyridine: predominantly anti-arrhythmic effects.

50
Q

Dihydropyridine CCBs block the action of …-type calcium channels, which are found in vascular and cardiac tissue.

A

Dihydropyridine CCBs block the action of L-type calcium channels, which are found in vascular and cardiac tissue.

51
Q

Examples of Dihydropyridine CCBS?

A

Examples: Amlodipine, Nifedipine.

52
Q

Mechanism of action - CCBs

A

CCBs block the action of voltage-gated L-type calcium channels, which are found in vascular and cardiac tissue. Within vascular smooth muscle, L-type channels permit the entry of calcium ions leading to contraction and subsequent vasoconstriction. Dihydropyridine CCBs inhibit this influx of calcium ions and induce vasodilatation, which reduces the peripheral vascular resistance.

53
Q

6 adverse effects of CCBs?

A 
Headache
Flushing
Dizziness
Peripheral oedema
Reduced cardiac contractility
Constipation
54
Q

Thiazide diuretics

- mechanism in HTN

A

The mechanism of the antihypertensive effects of thiazide diuretics are poorly understood.

55
Q

List 2 thiazide diuretics

A

Examples: Bendroflumethiazide, Indapamide.

56
Q

Mechanism of action of thiazide diuretic

A

Thiazide diuretics act on the distal convoluted tubule (DCT) of the nephron where it inhibits the Na+/Cl- co-transporter. This prevents sodium and chloride entering the tubule cells and, therefore, water cannot follow.

This mechanism has an initial hypotensive effect, however, this is mostly abolished by the renin-angiotensin system (RAS). The long-term antihypertensive effects may be due to vasodilation of peripheral vasculature through a mechanism that is poorly understood.

57
Q

List 8 adverse effects of thiazide diuretics

A 
Gout
Impotence
Hyperuricaemia (precipitating gout)
Hypercalcaemia
Hypokalaemia
Hyponatraemia
Hyperlipidaemia
Urinary frequency
58
Q

Alpha-1 blockers

A

Alpha-1 blockers act to blockade alpha-1 adrenoreceptors.

59
Q

Name an alpha-1 blocker

A

Doxazosin

60
Q

Alpha-1 adrenoreceptors are found in most sympathetic tissues including vascular smooth muscle and have excitatory effects. Stimulation results in vasoconstriction.

A

Consequently, blockade of alpha-adrenoreceptors causes:

Reduced arteriolar tone - lowering peripheral vascular resistance.
Venous dilation - reducing venous return and cardiac output

61
Q

6 adverse effects of alpha-1 adrenoreceptors?

A 
Postural hypotension
Headaches
Dizziness
Nausea
Rhinitis
Urinary frequency
62
Q

Beta-blockers act to reduce … activity

A

Beta-blockers act to reduce sympathetic activity

63
Q

Beta-blockers

Beta-blockers act to reduce sympathetic activity

A

Different agents may have variably selective action on beta-1 receptors (predominantly found in the heart) and beta-2 receptors (predominantly found in the lungs).

64
Q

Beta-blockers cause a reduction in blood pressure through a number of mechanisms:

A

Reduced cardiac output - through negative inotropic and negative chronotropic effects.
Reduced renin release - blockage of the sympathetic triggered release.
Vasodilation - due to blockade of beta-2 receptors in vascular smooth muscle (though the effect is thought to be minimal).

65
Q

Adverse effects of beta blockers?

A 
Postural hypotension
Cold peripheries
Headache
Dizziness
Insomnia, sleep disturbance
Bradycardia
AV nodal block (heart block)
Bronchoconstriction (nonselective beta-blockers, a particular consideration in asthma and COPD)
Hypoglycaemia (nonselective beta-blockers)
Erectile dysfunction
66
Q

Which of the following scenarios is correct regarding first-line antihypertensive therapy?

A 57 year old caucasian male started on ramipril 2.5mg OD
B 45 year old afro-caribbean female started on amlodipine 5mg OD
C 28 year old pregnant mother started on ramipril 2.5mg OD
D 43 year old caucasian female started on indapamide 2.5mg OD
E 55 year old afro-caribbean male started on doxazosin 1mg OD

A

B

67
Q

Which of the following statements best describes the mechanism of ACE-inhibitors?

A Inhibit the the release of angiotensin-converting enzyme
B Inhibit the conversion of angiotensinogen into angiotensin I
C Directly inhibit the release of renin
D Inhibit the conversion of angiotensin I into angiotensin II
E Directly antagonise the angiotensin II receptor

A

D Inhibit the conversion of angiotensin I into angiotensin II (correct answer)

68
Q

ACE-inhibitors work through the inhibition of the angiotensin-converting enzyme, which subsequently prevents the conversion of … into …

A

ACE-inhibitors work through the inhibition of the angiotensin-converting enzyme, which subsequently prevents the conversion of angiotensin I into angiotensin II.

69
Q

Which statement best describes the cause of a dry cough with ACE-inhibitor use?

A Angiotensin converting enzyme blockade causes decreased degradation of bradykinin
B Inhibition of angiotensin converting enzyme leads to increased levels of angiotensin I
C Inhibition of angiotensin converting enzyme causes massive histamine release
D Angiotensin converting enzyme blockade increases levels of kininogen
E Inhibition of angiotensin converting enzyme leads to increased synthesis of bradykinin

A

Angiotensin converting enzyme blockade causes decreased degradation of bradykinin (correct answer)

70
Q

Inhibition of ACE leads to decreased degradation of …, which has a number of physiological effects including vasodilatation.

A

Inhibition of ACE leads to decreased degradation of bradykinin, which has a number of physiological effects including vasodilatation.

71
Q

Reduced degradation is thought to lead to bronchoconstriction, which can cause a dry cough. Development of the dry cough warrants conversion from an ACE-inhibitor to…

A

Reduced degradation is thought to lead to bronchoconstriction, which can cause a dry cough. Development of the dry cough warrants conversion from an ACE-inhibitor to a newer angiotensin receptor blocker (ARB), as these are often better tolerated.

72
Q

Which of the following is not a contraindication to beta-blocker therapy?

A	Asthma
B	Phaeochromocytoma
C	First-degree AV block
D	Marked bradycardia
E	Severe peripheral arterial disease
A

ALL of the above answers are considered contraindications to beta-blocker therapy, except the presence of first-degree AV block.
In first-degree AV block, beta-blocker therapy should be used with caution. There are caveats to the contraindication of beta-blockers in patients with asthma or phaeochromocytoma.

Asthma - “Beta-blockers, including those considered to be cardioselective, should usually be avoided in patients with a history of asthma or bronchospasm. However, when there is no alternative, a cardioselective beta-blocker can be given to these patients with caution and under specialist supervision” (British National Formulary, 2015)

Pheochromocytoma - “Beta-blockers can be used to control the pulse rate in patients with phaeochromocytoma. However, they should never be used alone as beta-blockade without concurrent alpha-blockade may lead to a hypertensive crisis. Thus, phenoxybenzamine should always be used alongside beta-blockers” (British National Formulary, 2015)

73
Q

Which of the following is not a recognised side-effect of thiazide diuretics?

A	Hyperkalaemia
B	Pancreatitis
C	Hypomagnesaemia
D	Hyperglycaemia
E	Hyperuricaemia
A

Hyperkalaemia (correct answer)

Thiazide diuretics are now second/third-line anti-hypertensive agents used in the treatment of hypertension.

Previously, older agents like bendroflumethiazide were commonly used to treat hypertension and were accompanied by numerous side-effects.
These can be grouped into different categories to aid memorisation.

Electrolytes - hyponatraemia, hypokalaemia, hypomagnesaemia
Gastrointestinal - mild disturbances
Metabolic - hyperglycaemia, hyperuricaemia (gout)
Severe - pancreatitis, agranulocytosis, cholestasis

74
Q

reviously, older agents like bendroflumethiazide were commonly used to treat hypertension and were accompanied by numerous side-effects.
These can be grouped into different categories to aid memorisation.

A

Previously, older agents like bendroflumethiazide were commonly used to treat hypertension and were accompanied by numerous side-effects.
These can be grouped into different categories to aid memorisation.

Electrolytes - hyponatraemia, hypokalaemia, hypomagnesaemia
Gastrointestinal - mild disturbances
Metabolic - hyperglycaemia, hyperuricaemia (gout)
Severe - pancreatitis, agranulocytosis, cholestasis

75
Q

Which two medications used in the treatment of cardiovascular disease should be avoided?

A	Ramipril and indapamide
B	Atenolol and furosemide
C	Bendroflumethiazide and lisinopril
D	Enalapril and amlodipine
E	Atenolol and verapamil
A

Atenolol and verapamil

Concomitant use of beta-blockers and Verapamil / Diltiazem should be avoided due to the risk of profound hypotension and asystole.

76
Q

Concomitant use of beta-blockers and … should be avoided due to the risk of profound hypotension and asystole.

A

Concomitant use of beta-blockers and Verapamil / Diltiazem should be avoided due to the risk of profound hypotension and asystole.

77
Q

Which of the following is not a typical side-effect of ACE-inhibitors?

A	Angio-oedema
B	Hyperkalaemia
C	Ankle swelling
D	Postural hypotension
E	Dry cough
A

All of the above are recognised side-effects of ACE-inhibitors, with the exception of ankle swelling.
Ankle swelling is a classical side-effect of calcium-channel blocker therapy. ACE-inhibitors should be introduced carefully in patients with known renal disease because they can impair renal function. Therefore, renal function should be checked before and during ACE-inhibitor use. Side-effects such as hyperkalaemia are more common in renal impairment.

78
Q

Ankle swelling is a classical side-effect of …blocker therapy.

A

Ankle swelling is a classical side-effect of calcium-channel blocker therapy.

79
Q

ACE-inhibitors should be introduced carefully in patients with known renal disease because they can impair renal function. Therefore, renal function should be checked before and during ACE-inhibitor use. Side-effects such as … are more common in renal impairment.

A

ACE-inhibitors should be introduced carefully in patients with known renal disease because they can impair renal function. Therefore, renal function should be checked before and during ACE-inhibitor use. Side-effects such as hyperkalaemia are more common in renal impairment.

80
Q

Which of the following is not a side-effect associated with beta-blockers?

A	Cold extremities
B	Impotence
C	Bronchospasm
D	Heart failure
E	Rhinitis
A

All of the above are recognised side-effects of beta-blockers, except rhinitis.
Beta-blockers are used for a variety of cardiovascular pathologies. While beta-blockers may lead to heart failure and bradycardia due to their negative inotropic and chronotropic effects, a select number have been shown to improve mortality in cardiac failure and post-myocardial infarction. However, treatment with beta-blockers should be initiated by those experienced in the management of heart failure.

81
Q

Which of the following is the predominant site of action of thiazide diuretics?

A	Glomerulus
B	Proximal convoluted tubule
C	Loop of Henle
D	Distal convoluted tubule
E	Collecting duct
A

Thiazide diuretics are used in the treatment of hypertension after the failure of first-line therapies (e.g. ACE-inhibitors and calcium channels blockers).

Thiazide diuretics predominantly work on the distal convoluted tubule through inhibition of the Na+/Cl- co-transporter.

82
Q

Which of the following beta-blockers is the least cardioselective?

A	Propranolol
B	Nebivolol
C	Metoprolol
D	Bisoprolol
E	Atenolol
A

Older beta-blockers (e.g. propranolol) have non-selective binding to beta-receptors meaning they are less cardioselective and have a wider range of side-effects.
Beta-adrenergic receptors can be found throughout the body. The type and relative quantity of beta-adrenergic receptors alter depending on the tissue. Within the lungs, beta-2 receptors predominate over beta-1. Within the heart, beta-1 receptors predominate over beta-2.

Module 308 (17 decks)

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