Hypertension

Question 1

What are the complications of HT?

Answer 1

HT itself doesn’t do any damage, it is the complications it causes:

• Haemorrhage, stroke, cognitive decline, retinopathy, PVD, LVH, CHD, CHF, MI, renal failure etc –> many complications.

Question 2

Define HT.

Answer 2

That BP above which the benefits of treatment outweigh the risks in term of morbidity and mortality.

Question 3

What is the difference between normotensive and hypertensive BP?

Answer 3

Normotensive BP is below 140 mmHg systolic. Hypertensive BP is above 140 mmHg systolic –> 140/90 is hypertension.

Question 4

Define stage 1 HT.

Answer 4

Clinic BP of 140/90, ABPM of 135/85.

Question 5

Define stage 2 HT.

Answer 5

Clinic BP 160/100, ABPM 150/95.

Question 6

Define severe HT.

Answer 6

Clinic systolic BP 180 or over, and diastolic 110 or over –> 180/110.

Question 7

What are the causes of secondary HT?

Answer 7

• Chronic renal disease: renal artery stenosis, polycystic kidneys
• Endocrine disease: Cushings, Conns etc
• Pregnancy: pre-eclampsia
• Drug-induced: NSAID’s, OCP, corticosteroids
• Vascular: coarctation of aorta
• Sleep apnoae

Question 8

What are the factors that contribute to HT?

Answer 8

Smoking (adds 10-20 mmHg), DM, renal disease, male, hyperlipidaemia, previous MI/stroke or LVH.

Question 9

How is BP controlled?

Answer 9

CO, SV, HR and peripheral vascular resistance (TPR).

Question 10

How does the sympathetic system control BP?

Answer 10

Vasoconstruction, reflex tachycardia and increased CO. Sympathetic system increases BP.

Question 11

What is the renin-angiotensin-aldosterone system stimulated by?

Answer 11

Fall in BP, fall in circulating BV or Na+ depletion. Renin released from juxtaglomerular apparatus.

Question 12

What is the function of the RAAS?

Answer 12

Renin converts angiotensin to angiotensin 1. Angiotensin 1 is then converted to angiotensin 2 by ACE.

Question 13

What are the functions of angiotensin 2?

Answer 13

Vasoconstriction, anti-natruiretic and stimulates aldosterone release from adrenal glands. Aldosterone is anti-diuretic and anti-natruiretic.

Question 14

What are key targets for HT treatment?

Answer 14

RAAS and sympathetic system.

Question 15

What are the 2 main causes of HT?

Answer 15

Increased reactivity of resistance vessels and resultant increase in TPR by hereditary causes; or due to kidneys being unable to excrete Na –> Na and fluid are retained, and BP increases.

Question 16

What other factors contribute to HT?

Answer 16

Age

Genetics and FH: closest correlation between siblings

Environment: mental and physical stress

Na intake/diet: BP

Race: African-American popultions are genetically selected to be Na retainers and so have higher BP than Caucasian populations

Weight: obese patients have > BP, 30% of all HT cases are attributable to obesity alone

Birth weight: low birth weight is associated with development of HT in later life

Question 17

What would you do before starting treatment for HT?

Answer 17

Assess risk: previous stroke/MI, smoking, DM etc

Assess end organ damage: ECG, echocardiogram, renal function

Screen for treatable causes: renal artery stenosis, Cushings, Conns, sleep apnoea

Question 18

What does using a ‘stepped approach’ mean?

Answer 18

Adding medications to current therapy until a target BP is achieved - not continuously changing medication.

Question 19

How should young and elderly people with HT be treated?

Answer 19

Young: high renin and ACE inhibitor

Elderly: low renin, Ca channel blocker and Thiazide-type diuretic

Question 20

When should stage 1 HT patients be given treatment?

Answer 20

Patients

Question 21

When should stage 2 HT patients be given treatment?

Answer 21

ABPM > 150/95 at any age.

Question 22

What is the BP target for > 80 year olds?

Question 23

Describe the 4 steps of anti-hypertensive drug treatment.

Answer 23

1) Offer with Ca blocker (over 55 or Afro-Caribbean), evidence of heart failure add a thiazide-like diuretic, under 55 do not give ACEI
2) Add thiazide-type diuretic
3) Add CBB, ACEI and diuretic together
4) Consider further diuretic therapy if K+ is 4.5 mmol/L. Over 55? CCB. Under 55? ACEI.

Question 24

Should ACEI be given during pregnancy?

Answer 24

No, they can cause malformations and stillbirths if given in the first trimester.

Question 25

Name 2 ACEI’s.

Answer 25

Ramipril and perindopril.

Contraindications: renel artery stenosis, renal failure, hyperkalaemia.

ADR’s: cough, first-dose HT, taste disturbance, renal impairment, angioneurotic oedema.

Drug-drug interactions: NSAID’s, K+ supplements.

Question 26

What is the advantage of ARB’s over ACEI?

Answer 26

No cough.

Question 27

Describe the actions of CCB’s.

Answer 27

Block L-type Ca channels. Anti-hypertensive of choice in women of child-bearing age and over 55’s.

Question 28

Describe the actions of thiazide-like diuretics.

Answer 28

Block reabsorption of Na+ and enhance urinary Na+ loss.

Question 29

Which drug is mainly used to treat HT in pregnancy?

Answer 29

Methyldopa

Question 30

Describe treatment regimes for over and under 55’s.

Answer 30

Over 55: start on CCB, add thiazide-like diuretic, add ACEI, add beta-blocker. CTAB

Under 55: ACEI (child-bearing CCB), thiazide-type diuretic, CCB, B-blocker.

Question 31

What is pre-eclampsia?

Answer 31

When BP rises severely from 20 weeks > 140/90 and patient has proteinuria.

Question 32

How are patients wiith hypertensive emergency best treated?

Answer 32

Continuous infusion of a short-acting, titratable anti-HT agent.