Hypertension Flashcards
What are the complications of hypertension for the brain?
Haemorrhage, stroke and cognitive decline
What are the complications of hypertension for the heart?
LVH, coronary heart disease, congestive heart failure and MI
What are the complications of hypertension for the kidneys?
Renal failure, dialysis, transplantation and proteinuria
What is the complication of hypertension for the vascular system?
Peripheral vascular disease
What is the complication of hypertension for the eyes?
Retinopathy
What is the definition of hypertension?
The blood pressure at which the benefits of treatment outweigh the risks in terms of morbidity and mortality
What is the definition of stage 1 hypertension?
Clinic blood pressure 140/90 mmHg or higher
ABPM average 135/85 mmHg or higher
What is the definition of stage 2 hypertension
Clinic blood pressure 160/100 mmHg or higher
ABPM average 150/95 mmHg or higher
What is the definition of severe hypertension?
Clinic systolic blood pressure is 180mmHg or higher or diastolic blood pressure is 110mmHg or higher
What are the possible causes of secondary hypertension?
Chronic renal disease, renal artery stenosis, endocrine disease (Cushing’s and Conn’s syndrome, phaeochromocytoma and GRA)
What health factors increase the risk of developing hypertension?
Smoking, diabetes, renal disease, male, hyperlipidaemia, previous MI/stroke and LVH
What are the likely causes of hypertension?
Increased reactivity of the resistance vessels and a sodium homeostatic effect
What factors can cause hypertension?
Age, genetics and FH, environment, weight, alcohol intake and race
In genetics, which relations have the closest correlation for hypertension?
Siblings
What effect does lowering sodium intake have on blood pressure?
It lowers blood pressure in those who are hypertensive but has little effect on those whose blood pressure is already normal
What effect does alcohol have on blood pressure?
Small amounts tend to decrease BP
Large amounts tend to increase BP
What effect does weight have on blood pressure?
Obese patients have a higher BP
Losing weight can reduce BP
What is the correlation between birth weight and blood pressure?
The lower the birth weight the higher the likelihood of developing hypertension and heart disease
What is the correlation between race and blood pressure?
Caucasians have a lower BP than black populations living in the same environment
What drugs can cause secondary hypertension?
NSAIDs, oral contraceptive and corticosteroids
What health conditions can cause hypertension?
Pregnancy, sleep apnoea, endocrine disorders and coarctation of the aorta
What investigations are used to diagnose hypertension?
Ambulatory blood pressure monitoring (ABPM) or Home blood pressure monitoring (HBPM)
What investigations would be used to assess for end organ damage?
ECG, echocardiogram, proteinuria, renal ultrasound and renal function tests
Which treatable causes should be screened for?
Renal artery stenosis/FMD, Cushing’s disease, Conn’s syndrome and sleep apnoea
What is the approach to treating hypertension?
A stepped approach which uses low doses of several drugs
What are the BHS Guidelines for treating hypertension?
A - ACE Inhibitor/ARB (Young)
C - Calcium Channel Blocker (Elderly)
D - Thiazide Type Diuretic (Elderly)
What are the criteria for treating someone with stage 1 hypertension?
An ABPM greater than 135/85 mmHg with one of the following:
Target organ damage, established CVS disease, renal disease, diabetes or a 10yr CVS risk equivalent to 20% or greater
What is the criteria for treating someone with stage 2 hypertension?
If there ABPM is greater than 150/95 mmHg then start an anti-hypertensive drug regardless of age
What other measure should be taken for those under 40yrs with stage 1 or greater hypertension?
Referral to a specialist for evaluation of secondary causes and a more detailed evaluation of potential target organ damage
What is the blood pressure target for those aged 80yrs or over?
A blood pressure of less than 145/85 mmHg
What is the step 1 treatment for hypertension?
Calcium Channel Blocker to those aged over 55yrs and to those of African/Caribbean family origin of any age
If a CCB is not suitable or there is evidence/high risk of heart failure then offer a thiazide like diuretic
If a patient is under 55yrs offer an ACE Inhibitor/ARB (not to Afro-Caribbean or woman of child bearing age)
What is step 2 treatment for hypertension?
Add in a thiazide type diuretic (e.g. clortalidone or indapamide) or an ACE inhibitor/ARB
What is the step 3 treatment for hypertension?
CCB, ACE Inhibitor and Diuretic combined
What is step 4 treatment for hypertension?
Consider further diuretic therapy with low-dose spironolactone if the blood potassium is lower than 4.5mmol/l or lower and the GFR is normal.
consider higher dose thiazide like diuretic treatment if the blood potassium level is higher than 4.5mmol/l
What type of anti-hypertensive drug is Ramipril?
ACE Inhibitor
What are the contraindications for Ramipril?
Renal artery stenosis, renal failure and hyperkalaemia
What are the adverse drug reactions for Ramipril?
Cough, first dose hypotension, taste disturbance, renal impairment and angioneurotic oedema
What drugs will have interactions with Ramipril?
NSAIDs - precipitate acute renal failure
Potassium supplements and potassium sparing diuretics cause hyperkalaemia
What are the ARBs that are commonly used to treat hypertension?
Losartan, valsartan, candersartan and irbesartan
How do angiotensin 2 antagonists (ARB) work?
They competitively block the actions of angiotensin 2 at the angiotensin AT1 receptor
What is the advantage of using ARBs over ACE inhibitors?
They don’t produce a cough
What are the calcium channel blockers used as vasodilators?
Amlodipine/Felodipine
What are the calcium channel blockers used to limit heart rate?
Verapamil/Diltiazem
How do calcium channel blockers work?
They block the L type calcium channels, relaxing large and small arteries and reducing the peripheral resistance and reducing cardiac output
In which groups of people are calcium channel blockers the anti-hypertensive of choice?
Those aged over 55yrs and women of child bearing age
What are the contraindications of calcium channel blockers
Acute MI, heart failure and bradycardia (rate limiting CCBs)
What are the adverse reactions of CCBs?
Flushing, headache, ankle oedema, indigestion and reflux oesophagitis
What additional adverse reactions do rate limiting CCBs cause?
Bradycardia and constipation
What are the common thiazide type diuretics used to treat hypertension?
Indapamide/Clortalidone
In which group of people are thiazide type diuretics used as first line treatment/
Afro-Caribbean’s with mild-moderate hypertension
What are the benefits of thiazide type diuretics?
They can be used in combination with any other hypertensive agents and have a proven benefit in stroke and MI reduction
How do thiazide type diuretics work?
They effect the urinary excretion of sodium
How long does the full effect of thiazide type diuretics take to come into effect?
It make take weeks to fully come into effect
What are the adverse drug reactions of thiazide type diuretics?
They are uncommon but include gout and impotence
What are the less commonly used agents?
Alpha-adrenoceptor antagonists (doxazosin), centrally acting agents (methyldopa and moxonidine) and vasodilators (hydralazine and minoxidil)
How do alpha-adrenoceptor antagonists work?
They selectively block post synaptic adrenoceptors and oppose vascular smooth muscle contraction in arteries
What are the adverse drug reactions of alpha-adrenoceptor antagonists?
First does hypotension. dizziness, dry mouth and headaches
When is methyldopa used as a hypertensive?
Its main use is during pregnancy
How does methyldopa work
It is converted to alpha-methylnoradrealine which acts on the CNS alpha adrenoceptors which decrease central sympathetic outflow
What are the adverse drug reactions for methyldopa?
Sedation, drowsiness, dry mouth, nasal congestion and orthostatic hypotension
What is moxonidine?
a centrally acting imidazoline agonist
What is preeclampsia
When the patient is pregnant and their blood pressure rises severely from about 20 weeks (BP>140/90 mmHg) and they have proteinuria
What antihypertensives are not suitable for use during pregnancy?
ACE Inhibitors and ARBs are not suitable for use during pregnancy
What additional treatment is needed to treat preeclampsia?
IV hydralazine, esmolol and labetalol
