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Hypertension Flashcards

1
Q

What are the 1st line anti-hypertensive agents?

A

ACEis, ARBs, CCBs and thiazides for most patients with no compelling indication for a specific antihypertensive drug class.

*beta-blocker is not appropriate for 1st line

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2
Q

How to determine the number of anti-hypertensive agents to start implementing drug therapy?

A

Stage 1 hypertension: 1 medication as initial therapy

Stage 2 hypertension: 2 medications as initial therapy

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3
Q

What are the differences between hypertensive urgency and hypertensive emergency?

A

hypertensive urgency/ hypertensive emergency:

symptoms: No or minimal/ Yes
acute target organ damage/ complication: No/ Yes
BP reduction rate: hours to days/ minutes to hours
evaluation for secondary hypertension: Yes/ Yes

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4
Q

What is hypertensive emergencies?

A
  1. A severe elevation of BP associated with new or progressive end organ damage/ complication such as acute heart failure, dissecting aneurysm, acute coronary syndromes, hypertensive encephalopathy, subarachnoid hemorrhage and acute renal failure.
  2. All these patients should be admitted.
  3. The BP needs to be reduced rapidly.
  4. It is suggested that the BP be reduced by 25% depending on clinical scenario over 3 to 12 hours but not lower than 160/90 mmHg.
  5. Best achieved with parenteral drug.
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5
Q

What is hypertensive urgency?

A
  1. A severe increase in BP which is not associated with acute end organ damage/ complication,
  2. and these include patients with grade III or IV retinal changes (also known as accelerated and malignant hypertension respectively),
  3. These patients may need admission.
  4. BP measurement should be repeated after 30 minutes of bed rest.
  5. Initial treatment should aim for about 25% reduction in BP over 24 hours but not lower than 160/90 mmHg. (Level III).
  6. Oral drugs proven to be effective (captopril 12.5 mg, nifedipine 10 mg, labetalol 200 mg).
  7. Combination therapy is often necessary.
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6
Q

What is the aim of management of severe hypertension?

A

to reduce BP in a controlled, predictable, and safe manner, to avoid provoking or aggravating acute coronary syndrome, cerebral or renal ischemia

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7
Q

What are the common causes of severe hypertension?

A
  1. parenchymal renal disease- CKD
  2. endocrine- pheochromocytoma
  3. drugs- NSAIDS/ COX-2 inhibitors
  4. pregnancy related- preeclampsia
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8
Q

What are the 3 categories of severe hypertension?

A
  1. asymptomatic severe hypertension
  2. hypertensive urgencies
  3. hypertensive emergencies
  • 2 and 3 are also referred to as hypertensive crises
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9
Q

What are the common precipitating factors?

A
  1. lack of family care physician
  2. no regular health checks
  3. age- elderly
  4. subtherapeutic management
  5. non-adherence to medication
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10
Q

Examples of patient presentations of severe HPT.

A
  1. incidental finding in an asymptomatic non-previously diagnosed patient
  2. non-specific symptoms like headache, dizziness, lethargy
  3. symptoms and signs of acute target organ damage.
  4. acute heart failure
  5. acute coronary syndromes
  6. acute renal failure
  7. dissecting aneurysm
  8. hypertensive encephalopathy
  9. stroke
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11
Q

What is severe hypertension?

A

Severe hypertension is defined as persistent elevated SBP > 180 mmHg and/or DBP > 110 mmHg

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12
Q

List 3 monitoring parameters for HPT pts.

A
  1. Have the patient return in 4 weeks to assess efficacy
  2. May have patient follow-up sooner if BP particularly worrisome
  3. If there is an inadequate response from the first agent (and adherence verified) and no compelling indication exists, initiate therapy with a drug from a different class
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13
Q

Give 3 considerations within specific patient populations.

A
  1. Patients with ischemic heart disease
    - Potent vasodilators may cause reflex tachycardia, thereby increasing myocardial oxygen demand (eg. hydralazine, minoxidil, DHP CCB)
    - Can attenuate this by also using an atrioventricular nodal depressant (eg. DHP CCB or beta blocker)
  2. elderly patients
    - Caution with antihypertensive agents and orthostatic hypotension
    - Initiate with low dose and titrate slowly
  3. pregnant women
    - Methyldopa and hydralazine are recommended if a new therapy is initiated
    - Most anti-hypertensives (except for ACEis and ARBs) can be safely continued in pregnancy.
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14
Q

Give example of considerations with specific antihypertensive agents.

A
  1. BETA-BLOCKER
    -Caution with asthma, severe chronic obstructive pulmonary disease
    (especially higher doses) because of pulmonary β-receptor blockade
    -Increased risk of developing diabetes, use caution in patients at high risk of diabetes mellitus
    - May mask some signs of hypoglycemia in patients with diabetes mellitus
    - May cause depression
  2. THIAZIDES
    - May worsen gout by increasing serum uric acid
    - Increased risk of developing diabetes, use caution in patients at high risk of diabetes mellitus
    - May assist in the management of osteoporosis by preventing urine calcium loss
  3. ANGIOTENSIN-CONVERTING ENZYME INHIBITORS (ACEi) and ARBs
    - Contraindicated in pregnancy
    - Contraindicated with bilateral renal artery stenosis
    - Monitor K closely, especially if renal insufficiency exists or another K-sparing drug is in use.
    - The presence of diabetic nephropathy should influence the choice of ACE inhibitor versus ARB.
  4. ALISKIREN
    - A direct renin antagonist
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15
Q

Explain drug treatment strategy for HPT and AF.

A
  1. initial therapy- (dual combination) (ACEi/ ARB + beta blocker or non-DHP CCB or beta blocker + CCB)
  2. step 2- (triple combination) (ACEi/ ARB + beta blocker + DHP CCB/ diuretic or beta blocker + DHP CCB + diuretic)
    * non DHP CCB: verapamil or diltiazem)
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16
Q

Explain drug treatment strategy for HPT and Heart Failure with Reduced Ejection Fraction (HFrEF).

A
  1. initital therapy- (ACEi/ ARB + diuretic (loop diuretic) + beta blocker)
  2. step 2- (ACEi/ ARB + diuretic (loop diuretic) + beta blocker + MRA)
17
Q

Explain drug treatment strategy for HPT and CKD.

A
  1. initial therapy- (single pill) (dual combination) (ACEi/ ARB + CCB/ACEi) or (ARB + diuretic or loop diuretic)
  2. step 2- (single pill) (triple combination) (ACEi/ ARB + CCB + diuretic or loop diuretic)
  3. step 3- (2 pills) (triple combination + spironolactone or other drug) (resistant HPT, add spironolactone (25-50 mg od) or other diuretic, alpha/beta blocker)
  • consider beta blocker at any step of treatment when there is specific indication
  • a reduction in eGFR and rise in serum creatinine is expected who received BP lowering therapy especially with an ACEi or ARB
18
Q

Explain drug treatment strategy for HPT and CAD.

A
  1. initial therapy- (single pill) (dual combination) (ACE/ ARB + beta blocker/ CCB) or (CCB + diuretic/ beta blocker) or (beta blocker + diuretic)
  2. step 2- (single pill) (triple combination) (triple combination of above) *consider initiate therapy when SBP more than or equal 130 mmHg in very high risk pt with established CVD
  3. step 3- (2 pills) (triple combination + spironolactone or other drug) (resistant HPT, add spironolactone or other diuretic/ alpha blocker/ beta blocker)
19
Q

Explain drug treatment strategy for uncomplicated hypertension.

A
  1. initial therapy- (single pill) (dual combination) (ACEi/ ARB + CCB or diuretic) [ consider monotherapy in low risk grade 1 HPT or in very old or frailer pt.
  2. step 2- (single pill) (triple combination) (ACEi/ ARB + CCB + diuretic)
  3. step 3- (2 pills) (triple combination + spironolactone or other drug) (resistant HPT, add spironolactone or other diuretic, alpha-blocker or beta-blocker)
    * consider beta-blocker at any step when there is specific indication, intolerance or contraindication to ACEi/ARB, women of child bearing potential, pts with evidence of increased sympathetic drive.
20
Q

list 6 non-pharmacological management of HPT.

A
  1. regular physical exercise
  2. weight reduction
  3. sodium intake
  4. avoidance of alcohol intake
  5. cessation of smoking
  6. healthy eating
21
Q

what are the 3 assessment of HPT?

A
  1. complete history- duration of high BP, symptoms of 2ry causes of HPT, TOD, concomitant disease DM, HF, family hx of HPT, other CV risk, drug, lifestyle, dietary
  2. phycical examination- general physical xm (ht, wt, waist sirsumference), more than 2 blood measurement taken, fundoscopy, cardiac xm, CXR, neurological xm
  3. initial investigation- FBC, urinalysis, lipid profile, renal profile, FBS
22
Q

What are the 2 classification of HPT?

A
  1. isolated office (“white-coat) hypertension: BP high in clinic but normal at other times
  2. isolated systolic hypertension: SBP > 140 mmHg and DBP < 90 mmHg
23
Q

hypertension-related complications?

A
  1. BRAIN- stroke, transient ischemic attack, dementia
  2. EYES- retinopathy
  3. HEART- left ventricular hypertrophy (LVH), angina, prior MI, prior coronary revascularization, HF
  4. KIDNEY- CKD
  5. PERIPHERAL VASCULATURE- peripheral arterial disease (PAD)
24
Q

signs and symptoms?

A

previous BP values in the elevated or the hypertension category
usually none related to elevated BP

25
What are example of risk factors of hypertension?
1. age- men (more or equal 55 years), women (more or equal 65 years) 2. diabetes (type 1 or 2) 3. dyslipidemia 4. albuminemia 5. family history of premature CV disease 6. overweight- BMI (25-29.9 kg/m2) or obesity, BMI ( more or equal to 30 kg/m2) 7. physical inactivity 8. tobacco use
26
What can influence and regulate BP? Give 5.
1. adrenergic nervous system- control alpha and beta receptors 2. the RAAS- regulated systemic and renal blood flow 3. renal function and renal blood flow- influences fluid and electrolyte balance 4. several hormonal factors- vasopressin, insulin 5. vascular endothelium- regulates release of nitric oxide, bradykinin, endothelin
27
Definition of hypertension
persistent elevation of SBP of 140 mmHg or greater and/or DBP of 90 mmHg or greater

PHC550 (3 decks)

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