hypertension

Question 1

stages of hypertension?

Answer 1

stage 1:
140/90 - 159/99 mmhg (clinic)
OR
135/85 - 149/94 (ambulatory)
- don’t need treatment

if < 80 with kidney disease, diabetes, CVD or 10% risk of CVD in 10 years - lifestyle advice + discuss starting treatment

if < 60 with <10% risk of CVD in 10 years - offer lifestyle advice + drug treatment

stage 2 - high risk hypertension
160/100 - 180/120 mmhg (clinic)
OR
>150/95 (ambulatory)
- TREAT ALL PATIENTS

stage 3
>180/120 mmhg - medical emergency
- hypertensive crisis

Question 2

hypertension treatment

Answer 2

if pt < 55 or T2DM:
1 - ACEi/ARB
2 - ACEi/ARB + CCB or TLD
3 - ACEi/ARB + CCB + TLD
4 - if k < 4.5 - low dose spironolactone

if k > 4.5 - alpha/beta blocker

pt > 55 or afro-carribean:
1 - CCB
2 - CCB + ACEi/ARB or TLD
3 - CCB + ACEi/ARB + TLD
4 - if k < 4.5 - low dose spironolactone

if k > 4.5 - alpha/beta blocker

afro-carribean with T2DM - arb preferred

Question 3

ACE-i/arb imp points

Answer 3

ramipril enalapril lisinopril perindopril

SEs:
C - cough (use ARB)
H - hyperkalaemia
H - hepatic failure
A - angioedema
R - renal impairment
D - dizziness & headaches

ARBs (candersartan, irbesartan, losartan, valsartan)
- similar SEs except cough and angioedema

interactions:
increase risk of renal failure
- ARBs, NSAIDs, K+ sparing diuretics

increased hyperkalaemia
- heparins, ARBs, K+ sparing diuretics, NSAIDs, beta blockers

increase risk of volume depletion
- diuretics

increases plasma lithium levels

Question 4

beta blockers imp points

Answer 4

diff classes:
cardio selective - less likely to cause bronchospasm
B - bisoprolol
A - atenolol
t
M - metoprolol
A - acebutalol
N - nebivolol

water soluble - less likely to cross bbb - cause nightmares etc.
C - celiprolol
A - atenolol
N - nadolol
S - sotalol

intrinsic sympathomimetic - less likely to cause cold extremities
P - pindolol
A - acebutalol
C - celiprolol
O - oxprenolol

most common BB - bisoprolol, atenolol, carvedilol, labetalol, propranolol, sotalol, timalol
- LABETALOL USED IN PREGNANCY

SEs:
- bradycardia - can lead to HF
- blunts effects of hypoglycaemia
- can cause hyperglycaemia
- bronchospasm - c/i in asthma

interactions:
- digoxin - heart block
- other anti-hypertensives

Question 5

CCB imp points

Answer 5

dihydropyridine - amlodipine felodipine lacidipine lercanidipine nifedipine

rate limiting - diltiazem verapamil

SE’s:
- dizziness
- gingival hyperplasia - most common in nefidipine
- vasodilatory - flushing, ankle swelling, headaches (more in dihydropyridines)
- complete AV block (more in rate limiting)

Question 6

hypertension - pregnancy

Answer 6

if pt at high risk of developing pre-eclampsia e.g. kidney disease, autoimmune, diabetes, hypertension
- give aspirin from week 12 of pregnancy until birth

if pt has BP > 140/90 mmhg:
1st line - labetalol
2nd line - nifedipine or methyldopa
- aim for 135/85

Question 7

what are the hypertension targets?

Answer 7

aged < 80 = 140/90 (clinic)
aged < 80 = 135/85 (ambulatory)
aged > 80 = 150/90 (clinic)
aged > 80 = 145/85 (ambulatory)
pregnancy = 135/85 (clinic)

• Patients with CKD (ACR 70 +) = 130/80 mmHg
• Patients with CKD (ACR < 70 ) = 140/90 mmHg
• Patients with CKD + T1DM (ACR 70 +) = 130/80 mmHg
• Patients with CKD + T1DM (ACR < 70 ) = 140/90 mmHg
• Patients with CKD + T1DM (Age 80 +) = 150/90 mmHg