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Therapuetics > Hypertension > Flashcards

Hypertension Flashcards

1
Q

Hypertension Cause

A

Largely unknown but multifactorial.

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2
Q

Hypertension definition

A

A BP associated with significant cardiovascular risk

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3
Q

Secondary hypertension causes (8)

A

Less common (<10%) is secondary hypertension, it is due to another disease:

  • Renal disease
  • Reno vascular disease
  • Cushing’s syndrome
  • Conn’s syndrome
  • Hyperthyroidism
  • Phaeochromocytoma
  • Pregnancy
  • Drugs - e.g. NSAIDS, corticosteroids, venlafaxine, ciclosporin, sympathomimetics
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4
Q

Hypertension Treatment Goals - General

A

A reduction in BP (and when this involves drug treatment, this should be with as few side effects as possible).

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5
Q

Hypertension Treatment Goals - NICE

A

SBP < 140 mmHg

DBP < 90 mmHg (<80 in diabetes)

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6
Q

Hypertension Treatment Goals - Specific (5)

A
  • Reduction in cardiovascular damage
  • Preservation of renal function
  • Limitation/ reversal of left ventricular hypertrophy
  • Prevention of IHD
  • Reduction in mortality due to stroke/ MIs.
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7
Q

RAAS

A
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8
Q

Mechanism of ACEIs

A

Inhibit Angiotensin Converting Enzyme and therefore halt production of Angiotensin 2

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9
Q

Example ACEIs

A

e.g. captopril, enalapril, lisinopril, perindopril, ramipril

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10
Q

ACEI/ Reduction in A2 - Consequences (5)

A
  • Reduction in arterial and venous vasoconstriction
  • Reduced aldosterone production leads to reduced salt & water retention
  • Also potentiate bradykinin (usually broken down by ACE) - COUGH
  • May increase potassium - interaction with salt (KCl) substitute
  • Angioedema - rapid swelling (edema) of the dermis, subcutaneous tissue, mucosa and submucosal tissues.
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11
Q

ACEIs - Renal consequences

A

Should be AVOIDED in RENOVASCULAR DISEASE:
RAAS & Renin-dependent hypertension, ACEIs lead to underperfusion and severe hypotension.

May lead to worsening of renal function - if this occurs discontinue! Monitor creatinine before & during use.

Conversley ACEIs effective in PREVENTION OF NEPHROPATHY in DM - may be agents of choice in diabetes pts.

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12
Q

AT1R Antagonists - Action & Examples

A

e.g. Candesartan, losartan, valsartan

BLOCK action of A2 at AT1 receptor
AT1 receptor antagonist

Similar consequences as ACEIs but do not give rise to a cough.

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13
Q

Calcium Channel Blockers - Examples

A

e.g. diltiazem, verapamil, dihydropyridines (amlodipine, felodipine, nifedipine)

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14
Q

Calcium Channel Blockers - Action

A

Vasodilators

Inhibit Voltage gated Calcium channels on vascular smooth muscle, leading to vasoldilation, and a reduction in BP.

VERAPAMIL - exerts most of its effects on the heart
compared with
DIHYDROPYRIDINE effects -
which are greater on arteriole smooth muscle.

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15
Q

ALPHA BLOCKERS - Examples

A

e.g. doxazosin, prazosin

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16
Q

ALPHA BLOCKERS - Action

A

Competitive receptor antagonists of alpha-1 adrenoceptors.

Last choice antihypertensives:
widepread side effects therefore poorly tolerated.

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17
Q

Diuretics: Thiazide-like Examples

A

e.g. chlortalidone and indapamide

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18
Q

Thiazides: Example, use & action (3).

A

e.g. bendroflumethiazide
THIRD line antihypertensives.

  • Inhibit NA+/Cl- in distal convoluted tubule
  • Reduction in circulating volume
  • Also causes vasodilation
19
Q

Thiazides: Caution & Side Effects

A

Ineffective in moderate renal impairment (except metolazone).
Measure renal function (creatinine) before and during use.

SIDE EFFECTS:
Hypokalaemia
Postural hypotension
Impaired glucose control
Do NOT use in Gout

20
Q

Beta Blockers Action

A

e.g. Antenolol (most common) & propanolol.

Unclear mechanism

Reduction sympathetic drive to heart, reducing cardiac output.
Reduction in sympathetically evoked renin release.

21
Q

Beta Blockers: Contraindication

A

May block bronchial beta-2 receptors and are

contrindicated in ASTHMA
caution in COPD.

True even for beta-1 selective agents
(they are only selective not SPECIFIC).

22
Q

ACEIs - Adverse Effects (3)

A

Cough (10%) may be intolerable
Severe first dose hypertension
Renal damage?

23
Q

Calcium Channel Blockers - Adverse Effects (3)

A

Peripheral Oedema
Postural hypotension
Constipation (some)

24
Q

Alpha Blockers - Adverse Effects (2)

A

Widespread (poorly tolerated)
Postural hypotension

NB. (Also prescribed in prostate gland enlargement, relax muscles around bladder and prostate allowing urine to pass).

25
Q

Thiazides - Adverse Effects (6)

A

Urination
Diabetogenic
Alter lipid profile
Hypokalaemia
Impotence?
Postural Hypotension

26
Q

Beta Blockers - Adverse Effects (2)

A

Bronchospasm
Reduce hypoglycaemic awareness

27
Q

Treating Hypertension - Lifestyle changes (7)

(play a central and primary role)

A

Reduce overall CARDIOVASCULAR RISK:

  • Reduce alcohol consumption (alcohol increases BP in signifancant proportion of pts)
  • Weight loss
  • Increase exercise
  • Smoking Cessation
  • DIET: Reduce excess caffeine
  • DIET: Reduce salt and fat intake
  • DIET: Increase fruit and oily fish
28
Q

Treating Hypertension - How to confirm Hypertension

After lifestyle changes

A

Should be confirmed by further measurements:

Ambulatory - 14 measurements ish
Home devices
Both arms

29
Q

Hypertension Stages

A

Stage 1 > 140/90
Stage 2 > 160/100
Stage 3 > 180/110

30
Q

Who to treat with antihypertensives?

A

Stage 1 pts WITH one/more of:
end organ damage
diabetes
CV disease
high CV risk (>20% over 10yrs - see back BNF).

All stage 2 pts

31
Q

Which antihypertensives?

A

Choice governed by concurrent diseases and guidelines

32
Q

ACEIs - Compelling Indications and Contraindications

A

+ Heart failure
+ Left ventricular hypertrophy
+ Diabetic nephropathy
- Renovascular disease

33
Q

Calcium Channel Blockers - Compelling Indications and Contraindications

A

+ Afro-Caribbean ethnicity
+ DNPs in isolated systolic HT
+ Diltiazem/ Verapamil in angina (but NOT CHF)

34
Q

Alpha Blockers - Compelling Indications and Contraindications

A

+ Resistance to other drugs
+ Prostatic hypertrophy

35
Q

Thiazides - Compelling Indications and Contraindications

A

+ Elderly
- Gout

?Diabetes? - Unclear

36
Q

Beta Blockers - Compelling Indications and Contraindications

A

+ MI
+ IHD
+ CHF
- Asthma/ COPD
- Heart block

37
Q

ACD Rules: Meaning

A 
A = ACEI
C = Calcium channel antagonist
D = Diuretic

(AT1RAs may substitute for ACIEs)

38
Q

ACD Rules:

Young (<55)

non-black

high renin

A
  1. A
  2. A + C
  3. A + C + D
  4. Resistance
    • Add alpha blocker
    • or Spironolactone (Aldosterone Receptor Antagonist)
    • or Other diuretic
    • or Beta blocker
39
Q

ACD Rules:

Older (>55)
Black
Low renin

A
  1. C
  2. A + C
  3. A + C + D
  4. Resistance
    • Add alpha blocker
    • or Spironolactone (Aldosterone Receptor Antagonist)
    • or Other diuretic
    • or Beta blocker
40
Q

The Role of Beta Blockers (4)

A

Patients with angina or past MI

Child bearing

Increased sympathetic drive

Intolerance to ACEIs / ATRA

41
Q

Why are beta-blockers inferior?

Evidence base

A

Lancet 366
Comparison:
Atenolol (+bendroflumethiazide as required)
Amlodipine (+ perindopril as required)

–> Equal BP Control
AMLODIPINE reduced CV eventsmore
and induced less diabetes.

Therefore amlodipine based therapy superior in patients at moderate CV disease risk. Hence NICE/NHS guidelines.

42
Q

ALLHAT Trial

Anithypertensive drugs

A

JAMA 288.

Thiazide type diuretics are superior in preventing 1 or more major forms of CVD.
They should be preferred for first-step antihypertensive therapy.

Essentially viewed as first-line even for diabetics.

43
Q

Statin Use - Heart Protection Study 2002

A

Simvastatin reduced CV events in high risk (e.g. hypertensive) pts even with ‘normal’ cholesterols.

Statins should be considered for al high risk patients
irrespective of cholesterol level.

Therapuetics (15 decks)

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