Hypertension

Question 1

Name the four main groups of aetiology of primary/essential hypertension

Answer 1

Major genes, Polygenes, Environment, Individual factors

Question 2

List major genes contributing to hypertension

Answer 2

Angiotensinogen mutation, Diabetes, Hyperlipidemia

Question 3

List polygenetic factors in hypertension

Answer 3

OBESITY, Race - particularly afro-caribbean, Familial history

Question 4

Environmental causes of hypertension

Answer 4

AGE - reduced arteriolar compliance
DIET - high fat, salt, calorie
High alcohol intake
SMOKING - adds 20/10
High caffeine consumption
Oral contraceptive
Low exercise

Question 5

List individual factors contributing to hypertension

Answer 5

Previous MI, Male (2x MI risk), LV hypertrophy (2x MI risk), Stress, Low birthweight

Question 6

What are the two likely mechanisms of primary hypertension

Answer 6

increased arteriolar reactivity and constriction, caused by genetic defects and/or environmental factors, causing increased TPR.

Impaired ability to secrete appropriate amounts of Na at any conc. resulting in retention and increased plasma volume.

Question 7

List the categories of the main causes of 2ndry hypertension

Answer 7

Renal disease
Endocrine causes
OSAD
Drug induced - oral contraceptive, NSAIDs
Pregnancy - preeclampsia 
Vascular  - coarctation of aorta

Question 8

List renal causes of 2ndry hypertension

Answer 8

Chronic pylonephritis
Polycystic kidney disease
Renal artery stenosis
Fibromuscular dysplasia

Question 9

Common endocrine causes of 2ndry hypertension

Answer 9

Conn’s disease - adrenal gland disease causing hyoeraldesteronism
Cushings syndrome - hypercortisolism
Acromegaly
Hypo and Hyperthryroidism

Question 10

Outline stages of hypertension

Answer 10

Stage one: clinic BP 140/90 or ABPM 135/85

Stage 2: Clinic BP 160/100 or ABPM 150/95

Stage 3: Clinic BP systolic >/= 180 or diastolic >/=110

Question 11

Outline the effects of untreated hypertension

Answer 11

Cognitive effects - Increased likelihood of stroke, more rapid cognitive decline

MI, LVF, Coronary heart disease, Congestive heart failure,

Renal damage, causing proteinuria - requiring dialysis, transplant

Peripheral vascular disease - intermittent claudication

Retinopathy

Question 12

Outline investigation and diagnosis of HT

Answer 12

1. Clinic or ABPM
   If patient is 55 or older, or of afro-caribbean descent, begin treatment,
2. If patient is younger than 55, refer to specialist to investigate
   - end organ damage - renal, cognitive, cardiac, vascular
   - secondary causes - Cardio, renal, endocrine, vascular, OSAD

Question 13

Outline treatment of hypertension in >55 and people of afro-caribbean descent

Answer 13

1. CCB. if not tolerated/effective thiazide like diuretic
2. CCB+TLD.
   ACEI or ARB if TLD not tolerated/already in use
3. CCB+TLD+ACEI/ARB
4. Consider further diuretic therapy
   - if K conc.4.5mmol consider higher conc. TLD use

If further diuretic use is contradicted/not tolerable - a/B blocker

5. If hypertension still uncontrolled trial less commonly used agent: Central acting, alpha adrenoreceptor

Question 14

Outline treatment of hypertension in patients >55

Answer 14

1. ACEI or ARB
2. above + CCB or TLD
3. ACEI/ARB+CCB+TLD
4. Consider further diuretic therapy
   - if K conc.4.5mmol consider higher conc. TLD use

If further diuretic use is contradicted/not tolerable - a/B blocker

5. If hypertension still uncontrolled trial less commonly used agent: Central acting, alpha adrenoreceptor

Question 15

name 2 commonly used ACEI and their action

Answer 15

Ramipril and Perondipril

Inhibit conversion of Angiotensin I to II by ACE.

Angiotensin II acts on AT1 receptors and is a potent stimulator of vasoconstriction, vascular and LV hypertrophy, vascular and myocardial fibrosis.

Question 16

Contraindications of Ramipril and Perondipril use

Answer 16

Renal failure/artery stenosis

hyperkalemia

Question 17

Possible ADRs of Ramipril and Perondipril

Answer 17

COUGH
Renal impairment/damage
first dose hypotension

Question 18

Drug-drug interactions of Ramipril and Perondipril

Answer 18

NSAIDs - renal damage/failure

TLD - hyperkalemia

Question 19

List the 4 commonly used Angiotensin II antagonsists, outline action

Answer 19

SARTANs - Losartan, Valsartan, Irbesartan, Candesartan.

Binding A1 angiotensin receptors, prevents vasoconstriction, LVH, vascular and myocardial hypertrophy and fibrosis.

Question 20

Types of CCB’s and examples

Answer 20

Vascular specific - Nifedipine, Amlodipine. Reduce contractility/TPR

Cardiac specific - Verapamil, Diltiazem. Reduce rate and contractility, therefore CO

Both act on L type calcium channels

Question 21

what is the advantage of ARB use over ACEI

Answer 21

no cough, better compliance

Question 22

List advantages, contraindications and ADRs of CCB’s

Answer 22

Advantages- high compliance, low side effects

Contra’s - MI, Heart failure, bradycardia (rate limiting CCBs)

ADR – Headache, Ankle oedema, Indigestion and reflux oesophagitis, constipation.

Question 23

What are Chlortalidone and Indapamide

Answer 23

Thiazide like Diuretics

Question 24

Describe mech of TLD’s

Answer 24

Block reabsorption of Na, increase diuresis

Question 25

List less commonly used agents i.e. step 5

Answer 25

Central acting - Methyldopa: Acts on CNS alpha receptors, reduces sympathetic outflow

Alpha-adrenoreceptor antagonist - Doxasosin. Prevents vasoconstriction

Question 26

name the types of HT in pregnancy

Answer 26

pre-existing, gestational, pre-eclampsia

Question 27

Outline treatment of HT in pregnancy

Answer 27

DO NOT USE ACEI/ARB - both teratogenic
TLD -

1. CCB - Slow release Nifedipine.
2. Thiazide like diuretic
3. B-blocker or central acting agent - possibly further diuresis.

If Preeclampsia: As above plus IV Beta blocker and Vasodilator Hydralizine