Hypertension

Question 1

What is the MOA of spironolactone?

Answer 1

Potassium-sparing diuretic. Aldosterone antagonist —> sodium/water excretion and potassium reabsorption. Increases the risk of hyperkalaemia.

Question 2

Other than potassium-sparing diuretics, which other drug increases the risk of hyperkalaemia?

Answer 2

ACEi

Question 3

Thiazide diuretics increase the risk of…

Answer 3

Hypokalaemia

Question 4

Why is it important to monitor U&Es regularly when using ACEi and all diuretics?

Answer 4

They can cause electrolyte disturbances.

Question 5

Define malignant (accelerated hypertension)

Answer 5

A BP >180/120 with signs of papilloedema and/or retinal haemorrhage. Also signs of end organ damage e.g. AKI

Question 6

Why does chronic renal disease cause hypertension?

Answer 6

Increased sodium and water retention, increased renin release and raised BP in attempt to restore GFR.

Question 7

What is essential (primary) hypertension?

Answer 7

Hypertension with no identifiable cause. 95% of cases.

Question 8

What are the causes of secondary hypertension?

Answer 8

Renal disease. Consider renal artery stenosis if BP is very high/treatment resistant.
Obesity.
Pregnancy/pre-eclampsia.
Endocrine e.g. hyperaldosteronism, phaeochromocytoma.

Question 9

What is the most common cause of secondary hypertension?

Answer 9

Renal disease

Question 10

What are the complications of hypertension?

Answer 10

IHD, stroke, CKD/hypertensive nephropathy, hypertensive retinopathy, HF, AAA.

Question 11

Why should patients with clinic BP >140/90 have ambulatory BP or home BP to confirm diagnosis?

Answer 11

Due to white coat syndrome giving higher readings.

Question 12

What are the 3 stages of hypertension?

Answer 12

Stage 1: clinic >=140/90, ABPM/HBPM >=135/85.
Stage 2: clinic >=160/100, ABPM/MBPM >=150/95.
Stage 3 >=180 systolic or >=120 diastolic.

Question 13

All patients with a new diagnosis of hypertension should have which investigations done to assess for end organ damage?

Answer 13

Urine ACR for proteinuria and dipstick for haematuria.
Bloods: HbA1c, U&Es, lipid profile.
Fundus examination.
ECG.

Question 14

List the anti-hypertensive medications

Answer 14

ACEi (ramipril).
Beta blockers (bisoprolol).
Calcium channel blockers (amlodipine).
Diuretics, thiazide-like (indapamide).
Angiotensin receptor blockers (candesartan).

Question 15

When should ARBs be used instead of ACEi?

Answer 15

If they’re not tolerated (e.g. dry cough) or patient is of black/Caribbean descent.

Question 16

Can ARBs and ACEi be used in combination?

Answer 16

No!!

Question 17

Describe the management principles for hypertension

Answer 17

Lifestyle advice: healthy diet, stop smoking, reduce alcohol/caffeine/salt intake, regular exercise, weight loss.
Consider anti-platelets or statins.
Antihypertensive medications.

Question 18

What is the indication for antihypertensives?

Answer 18

Aged <80 years with stage 1 hypertension and either: end organ damage, CVD, renal disease, diabetes or QRISK >=10%.
Stage 2/3 hypertension at any age.

Question 19

What is the first line medication for a patient <55 years with hypertension?

Answer 19

ACEi

Question 20

What is the first line medication for patients >= 55 or of black/Caribbean descent with hypertension?

Answer 20

Calcium channel blocker.

Question 21

Describe the step-wise management of hypertension

Answer 21

Step 1: <55 use A. >=55 or black use C.
Step 2: A+C
Step 3: A+C+D
Step 4: A+C+D+additional. K+ <=4.5 mmol/L use spironolactone. K+ >4.5 mmol/L use alpha blocker or beta blocker.

Question 22

What are the treatment targets for hypertension?

Answer 22

<80 years —> <140/90
>=80 years —> <150/90

Question 23

What is the maximum dose of amlodipine?

Answer 23

10mg daily

Question 24

What is the first line medication for a diabetic with hypertension?

Answer 24

ACEi/ARB

Question 25

What is the blood pressure target for a diabetic with hypertension?

Answer 25

< 140/90 mmHg (T2D)
< 135/85 mmHg (T1D)