hypertension Flashcards
what is the clinic measurement of high blood pressure
a clinic blood pressure of 140/90mmhg or more
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systolic = 140 or more
(diastolic = 90 or more)
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what are the 3 stages of hypertension and their clinic blood measurements
stage 1 = from 140/90mmhg (clinic bp). (home/ambulatory bp 135/85mmhg)
stage 2= from 160/100 mmhg . (150/95 for home/ambulatory bp)
stage 3 (severe)= a systolic of 180mmhg + or a diastolic of 120mmhg+
note all of these are clinic blood pressures not home blood pressure monitoring
what is accelerated (or malignant) hypertension
when your blood pressure suddenly raises to more than 180mmhg and you have signs of retinal haemorrhage or papilloedema (swelling of the optic nerve)
when should you refer patients with hypertension for a same day specialist appointment
- if they have severe hypertension (systolic = 180mmhg+ or diastolic= 120mmhg+) with or without symptoms such as: retinal haemorrhage, accelerated hypertension, chest pain, confusion, acute kidney injury or signs of heart failure
- signs of phaeochromocytoma (tumour on the adrenal glands) such as postural hypotension, headache, palpitations, abdominal pain, pale skin (pallor)
what is the target blood pressure patients UNDER 80 years old
clinic blood pressure = 140/90mmhg
home blood pressure monitor (HBPM) = 135/85 mmhg
what is the target blood pressure for patients OVER 80 years old
clinic blood pressure = 150/90 mmhg
home blood pressure monitor (HBPM)= 145/85 mmhg
when should you consider starting a patient on anti-hypertensive drug treatment
- under 80 with stage 1 hypertension and target organ damage or with a 10 year cardiovascular risk of > 10%
- all patients with stage 2 hypertension regardless of age
- severe hypertension (same day specialist referral). Start IV antihypertensives immediately
- if under 40 with stage 1 hypertension, seek specialist advice for secondary causes of hypertension
what should you do if a patient is under 40 with stage 1 hypertension
get specialist advice for secondary causes of hypertension
which patients do you need to assess their cardiovascular risk
need to assess cardiovascular risk of all patients with confirmed hypertension using clinic blood pressure measurements
what monitoring should occur when you assess a patients cardiovascular risk
- glycated haemoglobin
- electrolytes
- creatinine
- estimated glomular filtration rate (EGFR)
- total and HDL cholesterol
- tests for the presence of proteinuria, haematuria, and hypertensive retinopathy undertaken
- 12-lead ECG performed
what must be controlled before aspirin is given
blood pressure
why is aspirin not recommended for PRIMARY prevention of cardiovascular disease
because there is limited benefit of its use in primary cardiovascular disease but there is still an increased risk of bleeding
what can be used in primary prevention of cardiovascular disease
a lipid-lowering drug (statin)
*note statins used in both primary + secondary CVD prevention)
what patients should start a low dose of atorvastatin for primary prevention of cardiovascular disease
- those with 10% or greater 10-year risk of developing CVD (using the QRISK2 calculator)
- patients with chronic kidney disease
- type 1 diabetes and 40+ years old
- have had type 1 diabetes for more than 10 years
- type 1 diabetes with nephropathy or other CVD risks
what is the target for non-HDL cholesterol when taking statins
a 40% or more reduction in non-HDL cholesterol
if this is not achieved, check adherence and lifestyle
when would ezetimibe be used in primary prevention of cardiovascular disease
if a patient had a high CVD risk but statins were contraindicated and in patients with familial hypercholesterolaemia
what should be discussed at the annual review of a patient taking statins
name some monitoring tests
- non-fasting, non-HDL cholesterol concentration
- CVD risk factors
- medication adherence
- lifestyle modifications
montoring tests:
- liver function (statins can cause liver damage)
- creatine kinase (test myalgia + rhabdomyolysis)
what should be checked 3 months after starting a high intensity statin
- total cholesterol, HDL-cholesterol, and non-HDL-cholesterol concentration
- liver function test
aiming for a 40%+ reduction in non-HDL cholesterol
name the 3 high intensity statins and their doses
- atorvastatin (20mg or over dose)
- rosuvastatin (10mg or over dose)
- simvastatin (80mg dose)
what antiplatelets are used in secondary prevention of cardiovascular disease
- low dose aspirin (75mg daily)
- clopidogrel in patients who are intolerant to aspirin or aspirin is contra-indicated
why is high dose simvastatin generally avoided unless a patient has been stable on it for at least one year
there is a high risk of myopathy (muscle weakness)
what is the first line treatment for patients with:
- type 2 diabetes + hypertension
- type 1 diabetes + hypertension
- <55 years old + hypertension and NOT black african / caribbean
- name examples of drugs
first line treatment =
ACE inhibitor e.g ramipril, lisinopril, enalapril
or
ARB e.g candersartan, losartan, irbersartan, valsartan
name 3 examples of ace inhibitors
they end in “ril”
rampiril, lisinopril, enalapril
name 3 examples ARB (angiotensin receptor blockers)
end in “sartan”
candesartan, losartan, irbersartan, valsartan,
why would you switch a patient from an ACE inhibitor to ARB
if they can a persistent dry cough on the ACE inhibitor (common side effect) so couldn’t tolerate the ACE inhibitor.
what is the first line treatment for hypertension in patients:
- more than 55 years old
- black african / Caribbean (any age)
- name examples of drugs
calcium channel blockers (CCB) e.g amlodipine, felodipine, nifedipine
if intolerant offer thiazide-like diuretic
name 3 examples of calcium channel blockers (CCB)
dihydropyridines: amlodipine, felodipine, nifedipine
non-dihydropyridines: diltiazem, verapamil
what is the 2nd line + 3rd line treatment for hypertension
add whichever class of drugs the patient wasn’t already taking. choose from: ACE inhibitor, ARB, CCB, Thiazide-like diuretics
2nd line: two treatments (note avoid ACE inhibitors in black african/caribbean, give ARB instead)
3rd line: three treatments
4th line (known as resistant hypertension): consider adding spironolactone or a beta/alpha blocker
at each step, optimise to max dose before adding
name 3 examples of thiazide-like diuretics used for hypertension
end in “ide”
indapamide, bendroflumethiazide, chlortalidone
what is hypertension in the first 20 weeks of pregnancy known as
chronic hypertension
what is hypertension AFTER the first 20 weeks of pregnancy known as
gestational hypertension
what is pre-eclampsia
give examples of some symptoms
high blood pressure and protein in urine (proteinuria) that can occur from 20 weeks of pregnancy
symptoms:
- severe headache,
- vision problems
- severe pain below ribs
- vomiting
- sudden swelling of hands, feet or face
what should you do in all pregnant woman with hypertension
refer to specialist
what increases a pregnant women’s risk of pre-eclampsia
high risk:
- chronic kidney disease
- diabetes mellitus
- autoimmune disease
- chronic hypertension
- if they have had hypertension during a previous pregnancy
moderate risk:
- 40+ year olds
- first pregnancy
- BMI above 35 kg/m²
- family history
what drug is given to pregnant women with increased risk of pre-eclampsia
aspirin (75-150mg) from week 12 of pregnancy till birth
note this is given to women with any high risk factors or more than one moderate risk factor
what is the first line anti-hypertensive treatment for women with pre-eclampsia, gestational or chronic hypertension
oral labetalol hydrochloride to achieve a target blood pressure of less than 135/85 mmHg. If labetalol is unsuitable, consider nifedipine. if nidepine + labetalol not suitable, consider methyldopa
note labetalol is a beta blocker
what lifestyle advice can you give to reduce hypertension
- reduce salt intake
- reduce caffeine intake
- reduce alcohol intake if excessive
- smoking cessation
- increase exercise
what are the common side effects of ACE inhibitors
ACE inhibitors= ramipril, lisinopril, perindopril
side effects: dry cough, angioedema, hyperkalemia, sleep disorder
which antihypertensives can cause hyperkalemia (high potassium)
ACE inhibitors, ARB
what are the common side effects of ARB
similar to ACE inhibitors (hypotension, hyperkalemia)
but no dry cough
name 3 medicines that ACE inhibitors and ARB interact with
- Lithium : (they reduce the excretion of lithium so there is an increase lithium concentration. risk of lithium toxicity)
- NSAIDS : increased risk of renal failure
- potassium sparing diuretics : increased risk of hyperkalemia
what are the 2 classes of calcium channel blockers (CCB)
name some examples
dihydropyridines: amlodipine, felodipine, nifedipine
non-dihydropyridines: diltiazem, verapamil
what is the difference between dihydropyridines and non-dihydropyridines calcium channel blockers (CCB)
dihydropyridines are selective for blood vessels. e.g amlodipine, felodipine, nifedipine
non-dihydropyridines are also known as rate-limiting CCBs. They are selective for the heart reduce myocardial contractility and heart rate. e.g diltiazem, verapamil
note both have the same effectiveness for hypertension
name some common side effects of calcium channel blockers
headache, flushing, swelling ankle
name some common side effects of thiazide-like diuretics
- hypo: na+, k+, mg2+
- hypercalcemia (ca2+)
- can exacerbate diabetes + gout
beta blockers are generally not preferred to initially treat hypertension. When may they be used for treatment
- younger people who are intolerant to ACE inhibitors and ARBs
- women of childbearing age/ pregnant. (only use labetalol)
- people with increased sympathetic drive
when do patients with severe hypertension start antihypertensives
patients with 180/120mmg (severe), start antihypertensives immediately
name some examples of the “target organ damage” we would check for once a patient has been diagnosed with hypertension
examples of target organ damage:
- left ventricular hypertrophy
- chronic kidney disease
- hypertensive retinopathy
- renal disease
- established CVD
TRUE OR FALSE:
for antihypertensives, it is recommended to prescribe drugs that are taken once daily
true
what is the target blood pressure in pregnant women taking antihypertensives
135/85 mmhg
name some risk factors for hypertension
age, ethnicity, dietary salt, exercise, alcohol, caffeine, smoking, weight gain
secondary cause: renal disease, endocrine causes (hyper/hypo thyroidism)
why should you ask patients to report muscle pain/weakness if they are taking statins
because statins can cause myopathy and rhabdomyolysis
creatinine kinase and alt tests used to monitor this
When are all ACE inhibitors contraindicated
- history of angioedema (e.g hereditary or idiopathic) before starting treatment with ACE inhibitors
- hypersensitivity to ACE inhibitors (including angioedema)
*idiopathic angiodema= swelling under skin that happens regularly without known cause)
name some common side effects of all ACE inhibitors
- alopecia
- angina pectoris
- angioedema (more common in black patients)
- cough
- dry mouth
- renal impairment
- electrolyte imbalance
- GI side effects
if a pregnant woman was already receiving antihypertensive treatment, what drugs should be stopped
Stop ACE inhibitors, ARBs, thiazide or thiazide-like diuretics due to an increased risk of congenital abnormalities
what monitoring should occur before/ during treatment with ACE inhibitors
Renal function and electrolytes
should be checked before starting ACE inhibitors (or increasing the dose) and monitored during treatment (more frequently if side effects mentioned are present
How does renal impairment affect treatment with ACE inhibitors
renal impairment increases the risk of side effects such as hyperkalemia
name some common side effects of all ARBs (angiotensin 2 receptor blockers)
- abdominal/ back pain
- asthenia (weakness/lethargy)
- hyperkalemia
- postural hypotension
- cough
- nausea + vomiting
what monitoring should occur when a patient is on ARBs (angiotensin 2 receptor blockers)
Monitor plasma-potassium concentration (side effect is hyperkalemia) , especially in the elderly and in patients with renal impairment
what time of the day is the first dose of an ACE inhibitor usually taken
first dose at night
name some common side effects of all CCB (calcium channel blockers)
- abdominal pain
- dizziness
- flushing
- skin reactions
- tachycardia
- peripheral edema
what are the symptoms of calcium-channel blocker (CCB) poisoning
what is the treatment (antidote) for this
- nausea + vomiting
- dizziness
- confusion
- agitation
- coma (in severe poisoning)
- metabolic acidosis
- hyperglycaemia
treatment:
- activated charcoal if within 1st hour or modified release preparation given
- calcium chloride or calcium gluconate is given by injection if patient has significant features of poisoning
- atropine sulfate can be given to correct bradycardia, insulin + glucose for hypotension and heart failure
why should you not suddenly withdraw treatment from calcium channel blockers (CCB)
it is associated with an exacerbation (worsening) of myocardial ischaemia.
*note myocardial ischaemia = blood flow in coronary artery completely / partially blocked due to artherscleortic plaque)
when are all thiazide-like diuretics contraindicated
- Addison’s disease
- hypercalcaemia
- hyponatraemia
- refractory hypokalemia
- symptomatic hyperuricaemia (high uric acid levels)
name the common side effects of all thiazide-like diuretics
- Alkalosis hypochloraemic (excessive loss of chloride)
- electrolyte imbalance (e.g hypokalemia)
- erectile dysfunction
- hyperglycaemia
- hyperuricaemia (high uric acid levels)
