Hypertension Flashcards
What is hypertension
condition where bp is elevated to an extent where clinical benefit is obtained by lowering it
Textbook bp
120/80
Top is systolic and bottom is diastolic
Consequences of hypertension
• Myocardial infarction (MI)
• Cerebral vascular accident (CVA)
(2 biggest)
• Heart failure
• Renal (kidney) disease
• Peripheral vascular disease
• Vascular dementia
Mercury increases
For every 5 mm increase of mercury in diastolic it increases risk of stroke by 35-40%
High risk patients for complications
• Evidence of cardiovascular disease
• Elderly
• Diabetes
• Renal failure
• Lifestyle factors (smoke, diet, stress etc)
How common is hypertension
• UK adult population: 31% men +
26% women
• 65% 65-74yrs
• Ethnicity: Black African + Black
Caribbeans higher incidence
• Still underdiagnosed and
undertreated
• Government target
2 types of hypertension
• 90-95% Primary/Essential
- cause unknown
• 5-10% Secondary
- underlying cause renal (80%) and endocrine disease, pregnancy and drugs
Risk factors of primary
– age
– Gender
– Socio-economic status
– Obesity
– Excess alcohol
– Salt intake
– Ethnicity
– Family history
– Lack of exercise
– Diet (fats)
– Stress
– Smoking
– Other diseases eg DM, renal failure
Drug causes of 2ndary
Rugs that increase BP
• Combined Oral Contraceptives
• NSAIDs e.g. ibuprofen
• Steroids e.g. prednisolone
• Sympathomimetic amines
e.g.pseudoephedrine (cold remedies)
Hypertension clinical presentation
• Asymptomatic
• Headache - unclear if cause or incidental
• Detected at population screening or
presentation of patient with
complication eg. Myocardial infarction,
renal failure etc
Malignant hypertension
• Uncommon
• increase bp (>180/120)
• Confusion, headache, visual loss, coma
• Evidence of small vessel damage:
– Eyes
– Kidneys
– Brain
• Medical emergency
• Rapid control of bp over 12-24 hrs
• Often fatal
• 1 year survival <20%
• Long-term morbidity
• Careful follow-up
Arteries in manual bp measurements
Palpitation of radial artery
Auscultation of brachial artery
Bp can be affected by:
– Fear & anxiety ( including ”white-coat” HT)
– Physical activity
– Caffeine
– Alcohol
– Tobacco
– Temperature
– Full bladder
– Obesity (correct cuff size)
Drug groups to treat hypertension
• Diuretics
• Angiotensin converting enzyme inhibitors
(ACEI’s)
• Angiotensin-II receptor antagonists
(ARBs)
• Calcium channel blockers (CCB)
• Betablockers
• Alpha- blockers
• Centrally acting agents
• Renin inhibitors
Factors which affect which drug to use fast
• (Ability to reduce bp)
• Ability to reduce complications
• Patient characteristics
• Other conditions
• Side-effects
• Adherence
• Cost
What is the 1st factor
Reduce complications
What is the 2nd factor
Patient characteristics
Age - renin drops
ethnicity - people of colour produce less renin
pregnancy - only a few drugs are safe
allergies
When to combine drugs
When target BP isnt reached with monotherapy
75% of people with HT cannot be controlled on one drug alone
How to combine drugs
Combine drugs with different pharmacology/mechanisms of actions or act on different pathways
Avoid combining drugs with same side effects
1st line drugs and their groups
CCB
ACEIs
Diuretics
Aldosterone antagonists
Angiotensin II receptor blockers - ARBs
Beta-blockers
Alpha blockers
Renin inhibitors
Centrally acting agents
CCB
(amodipine, diltiazem) - 1st line for >55years and or black African Caribbean for any age
ACEIs
ACEIs (ramipril, lisinopril) - 1st line for >55yeras and all diabetics
Diuretics
indapamide
Used in combination with other antihypertensives
Can cause low K levels
Not for patients in renal failure
Aldosterone antagonists
Spironolactone
Can cause high K levels
Used for heart failure
Angiotensin II receptor blockers
(ARBs)
Losartan and candesartan
Alternative to ACEIs
Beta blockers
Atenolol and bisoprolol
Used for heart failure
Caution in athsma
Alpha blockers
Doxazosin
Used in renal impairment
Renin inhibitors
Aliskirin
Centrally acting agents
Conidine
