Hypertension Flashcards

1
Q

What blood pressure reading would need an immediate SAME DAY specialist referal?

A
  • Accelerated Hypertension (BP reading of 180/120mmHg) with signs of
    1. papilloedema,
    2. and/or retinal haemorrhage
    3. or life-threatening symptoms, such as new-onset confusion, chest pain, signs of heart failure, or acute kidney injury.
    4. suspected pheochromocytoma (for example labile or postural hypotension, headache, palpitations, pallor, abdominal pain, or diaphoresis).
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2
Q

What would be the appropriate course of action for someone who had a BP reading of 164/112mmhg after three readings in both arms?

A

Offer AMBPH and consider prescribing ti-hypertnesive medication immediately

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3
Q

What should AMBPH reading be under?

A

Under 135/85mmHG

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4
Q

What is the difference between primary hypertension and secondary hypertension?

A
Primary hypertension (which occurs in about 90% of people) has no identifiable cause.
Secondary hypertension (about 10% of people) has a known underlying cause, such as renal, endocrine, or vascular disorder, or the use of certain drugs.
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5
Q

What should be done for patients under 40 years old with hypertension?

A

Consider specialist investiagtion to see secondary cause of hypertension

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6
Q

If a patient’s first blood pressure reading is equal to or above 140mmHg (systolic) or equal to or above 90mmHg (diastolic), what should be the next course of action?

A

The diagnosis is then confirmed with ABPM or HBPM.

  • While waiting for confirmation of a diagnosis of hypertension, the person should be offered:

Investigations for target organ damage and for secondary causes of hypertension.

-Assessment of cardiovascular risk.

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7
Q

What are the different stages of hypertension?

A

Stage 1 hypertension: CBP = 140/90 or HBPM = 135/85

Stage 2: CBP = 160/100 or HBPM = 150/95

Stage 3: CBP = 180/120

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8
Q

What is accelerated (or malignant) hypertension?

A

A severe increase in blood pressure to 180/120 mmHg or higher (and often over 220/120 mmHg) with signs of retinal haemorrhage and/or papilloedema (swelling of the optic nerve).

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9
Q

What are the target clinic BP reading?

A
  • Under 80 years old: CBP <140/90 or HBPM <135/85

- Over 80 years old: CBP <150/90 or HBPM <145/85

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10
Q

What is the best course of action if a patient’s BP reading is less than 140/90mmHg?

A
  • No medication needed

- Check BP reading every 5 years

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11
Q

What is a normal BP reading?

A

120/80mmHg

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12
Q

What is the initial management for patients who have a BP reading of 140/90mmHg - 180/120mmHg?

A
  • Offer HBPM
  • Offer lifestyle advice
  • Investigate end organ damage
  • Calculate QRISK Score
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13
Q

When do you treat a patient that had a CBP of 140/90 and a HBPM reading of 135/85?

A
  • Offer Lifestyle advice
  • If they are under 80 years old with:
    1. Target organ damge ( e.g. Left Ventricular Hyperthrophy, CKD, Retinopathy)
    2. CVD
    3. Renal Disease
    4. Diabetes
    5. QRISK Score of over 10%
  • If they are under 60 years old with with a QRISK Score under 10%
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14
Q

What lifestyle advice can be given about sodium consumption in patients with hypertension?

A

Dietary sodium — encourage people to keep their dietary sodium intake low, by reducing or substituting sodium salt, as this can reduce blood pressure.

Be aware that salt substitutes containing potassium chloride should not be used by older people, people with diabetes, pregnant women, people with kidney disease, and people taking some antihypertensive drugs (such as angiotensin converting enzyme inhibitors and angiotensin-II receptor blockers). Encourage salt reduction in these groups of people.

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15
Q

What is the next step of managment for stage 2 hypertension (CBP = 160/100mmHg, HBPM 150/95mmHg)

A

Offer antihypertensive drug treatment in addition to lifestyle advice to adults with persistent stage 2 hypertension, regardless of age.

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16
Q

What is first line treatment?

A
  • Under 55 years old and NOT african/carribean = ACEi or A2RBs
  • Over 55 years old or African/Carribean = CCB

Can give Thiazide-Like Diuretic e.g. Indapamide if CCB is contraindicated or not tolerated

17
Q

What to do if Heart failure is present alongside hypertension?

A

Offer a thiazide-like diuretic, such as indapamide.

If starting or changing diuretic treatment for hypertension, offer a thiazide-like diuretic, such as indapamide, in preference to a conventional thiazide diuretic, such as bendroflumethiazide or hydrochlorothiazide.

For people already having treatment with bendroflumethiazide or hydrochlorothiazide who have stable, well-controlled blood pressure, continue with their current treatment.

18
Q

What is second line treatment?

A
  • Before starting next step treatment check adherance and support adherence where possible
  • If hypertension is not controlled with step 1 treatment of an ACE inhibitor or ARB, offer the choice of one of the following drugs in addition to step 1 treatment:
    A CCB or
    A thiazide-like diuretic.
  • If hypertension is not controlled with step 1 treatment of a CCB, offer the choice of one of the following drugs in addition to step 1 treatment:
    1. An ACE inhibitor or ARB (consider an ARB in preference to an ACE inhibitor in people of black African or African–Caribbean family origin) or
    2. A thiazide-like diuretic.
19
Q

What is third line treatment?

A

Before considering next step treatment for hypertension:

  1. Review the person’s medications to ensure they are being taken at the optimal tolerated doses.
  2. Discuss adherence to treatment

If hypertension is not controlled with step 2 treatment, offer a combination of:

  • An ACE inhibitor or ARB (consider an ARB in preference to an ACE inhibitor in people of black African or African–Caribbean family origin), and
  • A CCB, and
  • A thiazide-like diureti
20
Q

What is fourth line treatment?

A

For people with confirmed resistant hypertension, seek specialist advice or add a fourth antihypertensive drug.

  • For people with a blood potassium level of 4.5 mmol/l or less, consider further diuretic therapy with low-dose spironolactone. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia. Monitor blood sodium and potassium, and renal function within 1 month of starting further diuretic therapy, and repeat as needed thereafter.
  • For people with blood potassium level of more than 4.5 mmol/l, consider an alpha-blocker or beta-blocker.
21
Q

Which angiotensin-converting enzyme inhibitor is recommended?

A
  • For people with heart failure and hypertension, enalapril, lisinopril, ramipril, and trandolapril may be preferred.
  • For people who have diabetes and hypertension, enalapril, lisinopril, PERINDOPRIL, ramipril, or trandolapril may be preferred.
  • For people who have had a previous myocardial infarction (without heart failure), lisinopril, perindopril, or ramipril may be preferred.
22
Q

When is ACEi contraindicated?

A
  • People with history of angioedema associated with previous exposure to an ACE inhibitor.
  • People with hereditary or recurrent angioedema.
  • People with diabetes mellitus, or with an estimated glomerular filtration rate (eGFR) less than 60 mL/minute/1.73 m2, who are also taking ALISKIREN.
  • Pregnant women and those planning a pregnancy — due to risks to the fetus. Treatment with an ACE inhibitor should ideally be stopped as soon as pregnancy is detected and, if appropriate, alternative treatment should be started.
23
Q

When do you use ACEi in caution

A
  • Of black African or Caribbean origin, or with primary aldosteronism — may respond less well to ACE inhibitors.
  • With renal impairment — hyperkalaemia and other adverse effects are more common, and the dose may need to be reduced.
  • Taking diuretics.
  • With peripheral vascular disease or generalised atherosclerosis — due to risk of clinically silent renovascular disease.
  • With hypertrophic cardiomyopathy.
  • With severe or symptomatic aortic stenosis — due to risk of hypotension.
  • With collagen vascular disease — possible increased risk of agranulocytosis — blood counts recommended.
24
Q

What are the ADR of ACEi?

A
  • Renal impairment — monitor renal function 1–2 weeks after starting and after each increase in dose, and regularly throughout treatment.
  • Hyperkalaemia — monitor serum electrolytes 1–2 weeks after starting an ACE inhibitor, after each increase in dose, and regularly throughout treatment.
  • Cough
  • Angioedema ( A2RBs can also trigger angioedema?)
  • Dizziness and headaces (most commonly in people who are hypovolaemic or hyponatraemic)
  • Hepato-biliary disorders — stop treatment if marked elevation of hepatic enzymes or jaundice occur. This is a very rare adverse effect
25
Q

What are the drug interactions with ACEi?

A
  • Angiotensin-II receptor blockers and aliskerin — concomitant use of two drugs affecting the renin-angiotensin system increases the risk of hyperkalaemia, hypotension, and renal impairment.
  • Diuretics — ACE inhibitors can cause a very rapid fall in blood pressure in a person who is volume-depleted.
    Start at very low doses.
    If the dose of diuretic is greater than 80 mg furosemide or equivalent, the ACE inhibitor should be initiated under close supervision and in some cases the diuretic dose may need to be reduced, or the diuretic discontinued at least 24 hours beforehand.
    If high-dose diuretic therapy cannot be stopped, close observation is recommended for at least 2 hours following the first dose of ACE inhibitor, or until the blood pressure has stabilised.
  • Allopurinol — possible increased risk of leucopenia and hypersensitivity reactions, especially in people with renal impairment.
  • Bee/wasp venom extracts — risk of severe anaphylaxis.
  • NSAIDs - increased risk of renal impairment, and hypotensive effect antagonised with concomitant use
  • Antacids — possible decreased absorption of ACE inhibitors
  • Amiloride, eplerenone, heparins, ciclosporin, potassium canrenoate, potassium salts, triamterene, trimethoprim — increased risk of hyperkalaemia.
  • Insulin, metformin, and sulfonylureas — enhanced hypoglycaemic effect.
  • Digoxin — concomitant use with captopril can increase plasma concentrations of digoxin
  • Everolimus — increased risk of angioedema.
  • Corticosteroids, oestrogens — hypotensive effect antagonised with concomitant use.
  • Alpha-blockers, antipsychotics, anxiolytics, beta-blockers, calcium channel blockers, clonidine, co-beneldopa, co-careldopa, diazoxide, hydralazine, hypnotics, levodopa, MAOIs, methyldopa, minoxidil, moxisylyte, moxonidine, nitrates, sodium nitroprusside, tizanidine — enhanced hypotensive effect.
  • Lithium — concomitant use can increase plasma levels of lithium. Regular monitoring of serum lithium concentrations is advised
  • Sacubitril — manufacturer advises to avoid concomitant use of lisinopril with sacubitril/valsartan therapy. Lisinopril must not be initiated earlier than 36 hours after the last dose of sacubitril/valsartan.
26
Q

What are the contraindications of Thiazide like diuretic?

A
  • Refractory hypokalaemia.
  • Hyponatraemia.
  • Hypercalcaemia.
  • Addison’s disease.
  • Asymptomatic hyperuricaemia.
  • Severe liver disease.
  • eGFR of less than 30 mL/minute/1.73 m2 — due to lack of efficacy.
  • Pregnant women — due to risk of neonatal thrombocytopenia, bone marrow suppression, jaundice, electrolyte disturbance, hypoglycaemia, and reduced placental perfusion.
27
Q

What are the cautions for Thiazide like diuretic?

A
  • Diabetes, gout, and systemic lupus erythematosus — due to risk of exacerbation of these conditions.
  • Hyperaldosteronism
  • Malnourishment.
  • Nephrotic syndrome.
  • Severe cardiovascular disease, or who are being treated with cardiac glycosides — due to the danger posed by hypokalaemia in these people.
  • Mild to moderate hepatic
    impairment.
28
Q

What are the ADRs for Thiazide-like diuretic?

A
  • Postural hypotension.
  • Hyperglycaemia.
  • Hypokalaemia.
  • hyponatraemia
  • hypomagnesaemia,
  • hypercalcaemia
  • Cardiac arrhythmias.
  • Dizziness and headache.
  • Erectile dysfunction.
  • Acute respiratory toxicity — very rare severe cases of acute respiratory toxicity, including acute respiratory distress syndrome (ARDS), have been reported after taking hydrochlorothiazide.
    Pulmonary oedema typically develops within minutes to hours after hydrochlorothiazide intake. At the onset, symptoms include dyspnoea, fever, pulmonary deterioration and hypotension. If ARDS is suspected stop hydrochlorothiazide treatment.
29
Q

What are the drug interactions of Thiazide like diuretics?

A
  • ACEi and ARBs - rapid hypotension in a person who is volume-depleted.
  • Alpha-blockers — enhanced hypotensive effect and increased risk of first-dose hypotension.
  • Amisulpride, atomoxetine, pimozide — increased risk of ventricular arrhythmias.
  • Aminophylline, reboxetine — increased risk of hypokalaemia.

NSAIDs — increased risk of nephrotoxicity and antagonism of diuretic effect with concomitant use.

  • Amiodarone, disopyramide, flecainide — hypokalaemia caused by thiazide diuretics increases the risk of cardiac toxicity of these drugs.
  • Rifampicin, lymecycline — concurrent use not advised by manufacturers
  • Aminoglycosides — increased risk of ototoxicity.
  • Tricyclic antidepressants — increased risk of postural hypotension.
  • Aldesleukin, alprostadil, anxiolytics, baclofen, beta-blockers, calcium channel blockers, clonidine, co-beneldopa, co-careldopa, hydralazine, hypnotics, levodopa, MAOIs, methyldopa, minoxidil, moxonidine, nitrates, phenothiazines, sodium nitroprusside, tizanidine — enhanced hypotensive effect.
30
Q

What are the treatment options for CCB?

A
  • For hypertension alone, amlodipine may be preferred on the basis of cost.
  • Hypertension and angina, amlodipine, felodipine, and modified-release nifedipine may be preferred.
  • Hypertension and Type 2 diabetes, amlodipine, felodipine, and once-daily modified-release nifedipine may be preferred.
31
Q

What are the contraindications and cautions of CCBs?

A
  • Heart failure:
    All CCBs can precipitate heart failure in predisposed people.
    Verapamil and diltiazem should NOT be used in people with heart failure.
    Although dihydropyridines rarely aggravate heart failure (any negative inotropic effect is offset by a reduction in left ventricular work), they should not be initiated in people with uncontrolled heart failure. Amlodipine may be used cautiously in stable heart failure.
  • Cardiac outflow obstruction: vasodilatation may result in reduced cardiac output.
  • Second degree atrioventricular block — verapamil and diltiazem may induce complete atrioventricular block.
  • Hepatic impairment
    The half-life of diltiazem and verapamil is prolonged in people with impaired liver function. Low doses should be used.
  • Modified-release nifedipine should be avoided in people with hepatic impairment because the duration of effect is considerably prolonged.
  • Renal impairment — although diltiazem and verapamil are extensively metabolized in the liver, the manufacturers recommend a dose reduction in people with renal impairment.
32
Q

What are the adverse effects of CCBs?

A
  • Abdominal pain and nausea may result from use of amlodipine and felodipine.
  • Atrioventricular block may be caused by use of diltiazem and verapamil.
  • Bradycardia may result from taking diltiazem or verapamil.
  • Constipation may result from use of nifedipine, verapamil, diltiazem
  • Dizziness and somnolence may be caused by amlodipine, especially at the beginning of treatment.
  • Erythema, pruritis, and urticaria may result from use of diltiazem and verapamil.
  • Palpitations may result from use of calcium channel blockers.
  • Vertigo and tinnitus may result from use of verapamil.
  • Vomiting and diarrhoea may result from use of diltiazem and verapamil.
33
Q

What are the drug interactions of CCBs?

A
  • Amiodarone — increased risk of bradycardia, AV block and myocardial depression when given with diltiazem or verapamil.
  • Aminophylline and theophylline — plasma concentrations increased by concurrent use of calcium channel blockers.
  • tricyclic antidepressants, mirtazapine, and trazodone should be prescribed with caution in people taking calcium-channel blockers, as there is an increased risk of postural hypotension.
  • Atazanavir — plasma concentration of diltiazem increased with concurrent use (reduce dose of diltiazem).
  • Carbamazepine — concurrent use with diltiazem or verapamil may lead to enhanced effects of carbamazepine.
  • Colchicine — diltiazem and verapamil possibly increase risk of colchicine toxicity—suspend or reduce dose of colchicine (avoid concomitant use in hepatic or renal impairment).
  • Beta-blockers — verapamil contraindicated (risk of reduced cardiac output and heart failure); diltiazem with caution (diltiazem has a smaller negative inotropic effect than verapamil
  • hypotensive effect enhanced with all calcium channel blockers.
  • Dabigatran and lenalidomide — verapamil possibly increases plasma concentrations of these drugs.
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