Hypertension

Question 1

A patient comes into the practice with a BP of 147/94. What should you do next?

Answer 1

Repeat the BP a 2nd and 3rd time and record the lowest measurement

Question 2

After 3 measurements a patient’s BP is at best 145/90. What do you do?

Answer 2

Arrange either home BPs or Ambulatory BP measuring

Question 3

A 68 year old diabetic has an average BP of 140/85 after ambulatory BP monitoring. What should you do?

Answer 3

Prescribe a CCB

Question 4

A 44 year old lady has an average ABPM BP of 155/95. How should you manage this according to NICE?

Answer 4

ACEI plus CCB

Question 5

What lifestyle advice would you give someone with hypertension?

Answer 5

reduce salt intake; avoid alcohol excess; excerise moderately 3-4 times/week; reduce saturated fat intake and increase fruit and veg; lose weight if centrally overweight

Question 6

For what reason would you not prescribe both an ACEi and ARB together for HTN?

Answer 6

Risk of hyperkalaemia

Question 7

If an Afrocaribbean 57 year old man with a BP of 150/95 attended your surgery how would you treat him?

Answer 7

with a CCB (all afrocaribbean HTN patients! as well as all >55)

Question 8

How would you manage a 50 year old lady with a BP persistently around 150/95 and above?

Answer 8

Treat her with ACEi (or ARB if contraindicated) and refer for investigation for secondary causes and target organ damage

Question 9

If a 68 year old man in persistently getting BPs of around 160/99 despite treatment with Amlodipine what would you do?

Answer 9

Add an ACEi (or ARB of ACEi contraindicated/not tol.) to the CCB.

Question 10

If BP is not controlled adequately with both an ACEi and a CCB what would you add?

Answer 10

A thiazide diuretic

Question 11

How to thiazide diuretics act?

Answer 11

They act at the beginning of the distal convoluted tubule and inhibit the reabsorption of sodium

Question 12

Before step 3 of HTN management as advised by NICE when would you use thiazide diuretics?

Answer 12

If a patient is intolerant of CCBs, has oedema or is at risk of heart failure

Question 13

Define resistant HTN.

Answer 13

BP or >140/90 despite use of 3 antihypertensives (given at optimal tolerated doses)

Question 14

When resistant HTN occurs what should you do?

Answer 14

Add a 4th antihypertensive and / or Refer to specialist

Question 15

What 4th drug might you add to a resistant HTN patient?

Answer 15

one of: - low dose spironalactone

• increase dose of thiazide diuretic
• alpha-blocker - beta-blocker

Question 16

What metabolic effects can thiazide diuretics have?

Answer 16

reduced sodium and potassium (hyponatraemia/kalaemia)

deranged lipids, hyperglycaemia, hyperuraemia

Question 17

In what conditions are ACEi contraindicated?

Answer 17

• Severe AS / MS or LV outflow obstruction
• Bilateral renal artery stenosis
• Pregnancy
• Hx of idiopathic or familial angioedema

Question 18

Which is the only ACEi indicated in children?

Answer 18

Captopril

Question 19

Explain very briefly what happens with Calcium ions when smooth muscle contracts and relaxes

Answer 19

Contraction = Ca++ influx
Relaxation = Ca++ efflux (&inhibition of influx)
Action of CCBs is to block calcium influx

Question 20

What overall effect do dihydropyridine CCBs have?

Answer 20

1) Vascular Smooth Muscle relaxation - dilate coronary and peripheral arteries

Question 21

What additional effect do Verapamil and Diltiazem have besides VSM relaxation? (non-dihydropyridine CCBs)

Answer 21

Slow heart rate (used in arrhythmias) by targeting conducting cells in heart - due to negatively inotropic nature

Question 22

What drug group should Verapamil never be prescribed with?

Answer 22

Beta-Blockers as both act to slow HR

Question 23

Name three indications for diltiazem

Answer 23

• HTN - IHD (esp. asthmatics / COPD)

- arrhythmia management

Question 24

What are the main side effects of diltiazem and verapamil

Answer 24

flushing; constipation; headaches; ankle swelling

Question 25

In what 2 circumstances would you use labetelol for BP control?

Answer 25

Pregnancy and IV infusion for rapid correction of HTN e.g. in aortic dissection