Hypertension Flashcards
What are the stages of hypertension
One: 140/90
- Lifestyle advice
- Antihypertensive drugs
Two: 160/100
- Antihypertensive for all
Three: >180/110
- Treat promptly
When would you offer medication in stage one hypertension?
80+ and BP 150/90
Under 80 w/:
- Target organ damage (CKD, retinopathy)
- 10 year CVD risk >10% (consider if under 60)
- Diabetic, kidney disease
What is given as first line in hypertension?
<55 / T2DM
ACE inhibitor (ARB if not tolerated - dry cough)
55+ / Black
CCB (Thiazide related diuretic if not tolerated (oedema) / HF)
What is given for black african w/ type 2 diabetes
ARB
What is given for a newly diagnosed patient with hypertension who has a medical history of type 2 diabetes + HF and is already on an ACEi?
Thiazide related diuretic
What is second line in hypertension?
(before adding, increase dose of monotherapy) +
<55 / T2DM
ADD CCB OR TRD
55+ / Black
ADD ACEi (or ARB) OR TRD
What is third line in hypertension?
Offer ALL medication (ACEi/ARB and CCB and thiazide like diuretic)
What is fourth line in hypertension?
Confirm resistent hypertension:
K+ <4.5: low dose
spironolactone
K+ > 4.5: high dose alpha blocker OR beta blocker
What is the treatment in pregnant women?
Target: <135/85
- First line: Labetalol (hepatotoxic, STOP if jaundice occurs)
- Alt: nifedipine MR
- If both unsuitable: methyldopa (stop 2 days after birth)
What is the BP targets in <80?
<140/90
What is the BP targets in >80?
<150/90
What is the BP targets in kidney disease?
<140/90
ACR >70: 130/80
What are the BP targets in type 1 diabetes?
<140/90
- ACR >70: <130/80
- 80: <150/90
What is the MOA of ACEi?
Block ACE enzymes that convert angiotensin I to angiotensin II
Angiotensin II raise BP by constricting blood vessels + stimulates release of aldosterone, increasing plasma volume
How is perindopril taken?
30-60 min before food
What are the indications of ACEi and ARB?
- First line: HPT + HF
- LT management after heart attack
- CVD prevention
- Diabetic nephropathy
- CKD
What are the side effects of ACEi/ARBs?
CAPTOPRIL
- Cough dry (ACEi)
- Angioedema (swollen lips + tongue esp in Black)
- Postural hypotension
- Taste disturbance
- Oral ulcer (ACEi)
- Potassium INC
- Renal impairment (RED blood flow to kidneys, lowers GFR by vasodilating the efferent arterial of the glomerulus)
- Indigestion (ACEi)
- Lower BP (1st dose)
Can you use ACi/ARB in pregnancy?
No - teratogenic
What are the interactions of ACEi/ARBs?
Hypotension:
- Diuretics - volume depletion (urinate more, RED blood plasma volume, blood pressure is regulated by plasma volume)
- Anti-hypertensive
- Dopaminergic drug: levo-dopa, dopamine-receptor antagonist
Hyperkalaemia:
- Spironolactone
- Potassium supplements
- Potassium sparing diuretics
- NSAIDs - also INC AKI
What is the MOA of CCB?
- Interferes w/ Ca2+ influx in vascular smooth muscle and heart
- DEC BP, HR + force of contraction, SA note automaticity + AV node conductivity
What are examples of dyhydropyradine CCB
ACT ON BLOOD VESSELS
- Amlodipine (OD)
- Felodipine (OD)
- Nifedipine (SAME brand for MR when dose >60mg)
- Nimodipine (indication: aneurysmal subrachnoid haemorrhage)
Give examples of rate limiting CCB
DEPRESS THE HEART BY RED HR + FORCE OF CONTRACTION
- Diltiazem (SAME brand for MR when dose >60mg)
- Verapamil (arrhythmias)
What are the indications of CCB?
- First line: Hypertension
- Angina
- Arrhythmias
- HF - amlodipine (MUST avoid other CCB due to RED cardiac output)
What are the side effects of CCB?
- Oedema, flushing, headache - associated w vasodilation
- Tachycardia + palpitations
- Angioedema, gingival hyperplasia (enlargement of gums)
- Constipation (verapamil)
What are the interactions of CCB?
Enzyme inhibitors (clarith + eryth, azole antifungal, grapefruit) → INC CCB levels
Enzyme inducers→ DEC CCB levels
Hypotension:
- Diuretics
- Anti-hypertensive:
- Dopaminergic drug: levo-dopa, dopamine-receptor antagonist
Verapamil/diltiazem + beta-blocker → bradycardia, severe hypotension + HF in IHD
Verapamil/diltizem + digoxin → bradycardia
What is the MOA of beta blockers?
-Blocks B-adrenoreceptors in peripheral vasculature + heart
-DEC BP, HR + force of contraction, SA note automaticity + AV node conductivity
-Part of fight/flight SNS, activated by noradrenaline + adrenaline
What is the indication of nebivolol?
stable mild-mod HF in 70+
What are the indications for propranolol?
migraine prophylaxis, anxiety, thyrotoxicosis
What is the side effect of sotalol?
Torsade de pointes
What are the indications for beta blockers?
- First line: HF + angina
- Hypertension
- Arrhythmias
- LT management after heart attack
PACO
DEC bradycardia
DEC cold extremity
Pindolol Acebutolol Celiprolol Oxprenolol
Water CANS
Water soluble (red dose in renal impairment)
DEC sleep disturbance
Celiprolol Atenolol Nadolol Sotalol
BAN Me
Cardio-selective
DEC bronchospasm (best for asthma)
Bisoprolol Atenolol Nebivolol Metoprolol
ABC-N
Once daily (long duration)
Atenolol Bisoprolol Celiprolol Nadolol
What are the side effects of betablockers?
BAD FISH
- Bradycardia + bronchospasm
- Atrioventricular block
- Disturbs glucose metabolism
- Fainting + dizziness
- Impotence
- Sleep disturbances
- Hypotension, HF, hands + feet cold
What are the CI of betablockers?
- Marked bradycardia
- Asthma
- 2nd/3rd heart block
- Hypotension
- Uncontrolled HF
When would you be cautious to use betablockers?
Diabetics - masks hypo
What are the interactions of betablockers?
- Verapamil/diltiazem + beta-blocker → bradycardia, severe hypotension + HF in IHD
- Amiodarone, digoxin, rate limiting CCB → cardiodepression
What is the treatment for hypotension + shock?
Intrope (Adrenaline + dopamine) → INC heart contracts, pumping more blood + improving cardiac output
Vasoconstrictors
Avoid in cardiogenic shock bc BP will probably already be high + can worsen problem
What are the causes of shock?
- Cardiogenic - heart attack
- Septic
- Neurogenic - brain/spinal cord injury
- Anaphylactic
- Hypovolemic - haemorrhage
What is the MOA of vasoconstrictor sympathomimetics?
Act on a-adrenergic receptor on peripheral blood vessels, causes vasoconstriction + raises BP
What is the indication of vasoconstrictor sympathomimetics?
Acute hypotension if other measures fail
What are examples of vasoconstrictor sympathomimetics?
- Ephedrine (INC HR, dual action)
- Midodrine
- Noradrenaline
- Phenylephrine (LA: prolonged INC BP)
What is the side effect of vasoconstrictor sympathomimetics?
RED organ perfusion - INC blood pressure which can reduce blood flow to vital organs like kidneys, leading to organ failure
