Hypertension Flashcards
What are the Framingham Criteria
What are the main causes of death in hypertensive patients
Stroke 45%
Heart Failure 35%
Kidney Failure 3%
others 17%
What factors increase the risk of dying in hypertensive patients
male
young
family hx
increasing diastolic pressure
What is malignant hypertension
Diastolic >120mmHg and exudative vasculopathy retinal and kidney circulations.
What is refractory Hypertension
BP >140/90mmHg despite max dosage of two drugs for >3-4months
What is Essential Hypertension
presence of sustained hypertension in the absence of underlying, potentially correctable kidney, adrenal or other factors.
What is grade 1 hypertension (mild)
140-159/90-99
What is Grade 2 Hypertension (moderate)
160-179/100-109
What is grade 3 hypertension (severe)
> 180/>110
How do you stratify CV risk
based on BP level, absolute CV risk factors, assoc clinical conditions, target organ damage
How common is Essential HTN verse Secondary HTN
Essential HTN is the cause in 90-95% of all HTN patients
Secondary HTN is implicated in 5-10% of cases.
What are the causes of secondary Hypertension
Kidney, ENdocrine, misc (Coarctation of the aorta, Immune disorder (e.g. polyarteritis nodosa), Drugs (NSAIDs, corticosteroids) Pregnancy
What Endocrine causes of HTN are there
Primary Aldosternoism (conn Sydx Cushing Syndrome Phaeochromocytoma oral contraceptives other endocrine factors
what kidney causes of HTN are there
glomerulnephritis reflux nephropathy kidney artery stenosis diabetes other renovascular dx
What clinical features would you look for as a cause of secondary hHTN
- abdominal systolic bruits (Kidney artery stenosis)
- proteinuria, haematuria, casts (glomerulonephritis)
- Bilateral kidney massess +/- Haematuria (polycystic dx)
- Hx of claudication and delayed femoral pulse (coarctation of aorta)
- progressive nocturia, weakness (Primary aldosteronism)
- paroxysmal hypertension with headache, pallor, sweating, palpitations (phaeochromocytoma)
How would you investigate for renal artery stenosis?
Arterial artery Doppler USS
What symptoms would indicate possible end organ damage from HTN
headache dyspnoea cehst pain claudication ankle oedema haematuria
What pro-hypertensive medications are there?
Oral & depot contraceptives HRT steroids NSAIDs/COX 2 inhibitors nasal decongestants and other cold remedies appetite suppressants amphetamines MAOI ergotamine (migraine Rx) cyclosporin (immune supressor - organ transplant) tacrolimus (immunosupressant) carbenoxolone & liqourice buproprion (anti smoking pill) sibutramine (diet pill - no longer available)
What routine tests would you perform in a pt with elevated BP
BSL Lipid studies (complete) Serum creatinine/eGFR serum uric acid serum potassium and sodium Hb and Haematocrit U/A (& urinary sediment) ECG
What tests would be recommended in HTN
Echo Carotid/femoral US postprandial BSL CRP Microalbuminuria Quantatative Proteinuira (if U.A Positive) Fundoscopy
what are the benefits of BP control
reduces CV and total mortality
reduces stroke
reduces coronary events
this is true of all types of BP
what are some non-pharmacological life-style mx options
- weight loss
- Alcohol - reduction of excessive alcohol intake - increases the BP and makes Rx harder - can reduce BP by 5-10mmHg
- Reduce Na intake - (<100mmol/day)
- increased exercise - walking ok, avoid weights and other forms of isomeric exercises as they incr BP
- stress reduction - either avoid or reduce with meditation/relacxtion
- diet - avoid liquorice, lacto-vegan diet or high calcium, low fat, low caffeine may be beneficial
- smoking - may negate any Rx benefits
- Mx sleep apnoea
What would you start a new HTN pt on?
ACEI or ARB
or Ca Chanel blocker (CCB)
or low dose thiazide diuretic (if >65yrs)
If pt fails initial drug what second line agent would you use
ACEI or ARB + CCB
or
ACEI or ARB + thiazide
If target not reached with 2 drugs what would you then give
ACEI/ARB & CCB & Thiazide
What combinations of antihypertensives should you not use.
ACEI/ARB & K+ sparing diuretic - causes hyperkaleamia
or
More than one drug from same family - eg. B-Blockers and Verapamil - causes heart block/failure
What combination of antihypertensives are not very effective
diuretic and CCB
B-Blockers and ACEI
What diuretics are a good first line choice
Thiazides
when would you not use a thiazide and why?
In pt with kidney impairment - less effective
T2DM
Hyperuricameia
what diuretic would you use in a patient with cardiac or kidney failure
loop diuretic
what Thiazde diuretics are there?
Indapamide
hydrochlorothiazide
chlorathalidone
What B-Blockers are there
Atenolol
Metoprolol
pindolol
propranolol
what Calcium chanel blockers are there
amlodipine diltiazem felodipine lercandipine nifedipine Verapamil
What ACE inhibitors are there
ramipril
captopril
enalapril
lisinopril
What ARBs are there?
irbesartan
losartan
when would you use a central acting agent and what options are there?
Pergnancy and asthma,
Methyldopa
Clonidine
What alpha-blockers are there
Prazosin
Terasozin
Labetalol (alpha and beta blocer)
what hypertensive agent my precipitate gout
thiazide diuretic
why should you not have NSAIDs if Hypertensie
NSAIDS reduces the effects of diuretics
why would you choose indapamide over the other thiazides
Less effect on serum lipids
what could taking Verapamil and B-Blocker result in
Heart block by uncovering a conduction abnormality
what effect does stopping a B-blocker in someone with likely IHD do
can cause Angina at rest
How do Calcium Chanel blockers work?
vadodilation
Can CCb be used with a B-Blocker?
Only some - Verapamil and diltiazem slow the heart so should not be used with B-Blockers
When is it not safe to use verapmil
in 2nd and 3rd heart block
what effect does NSAID have on B-Blockers?
reduces its hypotensive effect
If one b-blocker has failed to reduce HTN sufficiently would changing to another be useful?
No. If one has failed, another is unlikely to have a different effect.
what are the downsides to using the calcium channel blockers - nifedipine and felodipine?
They have more vasodilation than other druge therefore more side effects
are calcium channel blockers of the dihydropiridine compounds (nifedipine and felodipine) safe to use with B-blockers?
Yes
How does ACE-I work?
ACE converts Angiotensin I into Angiotensin II (which acts a vasoconstrictor and stimulates aldosterone secretion), and breaks down Bradykinin (a vasodilator)
how common is the ACE-I induced cough?
15% of patients
does the ACE-I cough decrease with time or dose
Sometimes
When else would you consider using an ACE-I outside of HTN?
In diabetics with microalbuminuria, Even if normotensive.
Can you use ARBS with Thiazide diuretics?
Yes
why would you choose an ARB over an ACE-I
Generally ACE-I are better but if pt has discontinued due to cough then ARB is a good alternative as they have similar kidney protecting profiles
What do you need to warn pts about, when starting Prazosin?
That for their first dose they may have an acute syncopal episode after 90 minutes. Therefore should take it at night before bed
in which patients would you consider Prazosin as a first line Rx?
in those patients unsuitable for diuretics or B-Blocker therapy
eg. diabetics, asthma or hyperlipidaemia
Can you use Prazosin with B-Blockers?
Yes - they actually increase the effect of B-Blockers and if possible should be used together.
what vascular smooth muscle relaxants are there?
Calcium channel blockers
hydralazine
minoxidil
diazoxide
When would you use vascular smooth m.m relaxants?
In refractory HTN or HTN emergencies.
What affect does aldosterone have on the body?
vasoconstirction an dvascular remodellin
How would you treat a pt with mild HTN
avoid medication as much as possible due to likely risks outweighing benefits
non-pharmacological Rx
If not successful in 6 months then Rx with medication
What drugs are preferred in management of isolated systolic HTN
ACE-I, Ca - channel blocker, and/or diuretics
when treating hypertension in the elderly what is the first line treatment option
indapamide or low dose thiazide diuretic review in 2-4 weeks and if hypokaleamia develops add a K-sparing diuretic feather than K supplements
what type of drug is frusemide
a loop diuretic
what antihypertensive agents are assoc with erectile dysfunction
B-Blocker, thiazide diuretics, methyldopa, resrpine,
what antihypertensive agents would you use in a pt with Erectile dysfunction
ACE-I, and calcium channel blockers
