Hypertension

Question 1

What is hypertension?

Answer 1

Blood pressure at which the benefits of treatment outweigh the risks of morbidity and mortality
Abnormally high blood pressure usually 140/90 mmhg
Usual systolic BP- 120mmhg

Question 2

Primary causes of hypertension?

Answer 2

Genetic:

• Increased TPR- due to increase reactivity of resistance vessels- related to genetic defect in lining of smooth muscle
• Sodium homeostatic effect-inability of sodium to excrete appropriate amounts of sodium so fluid is retained

ENVIRONMENTAL:

• Age: fewer elastic fibres in resistance vessels leads to decrease in compliance in arteries
• Genetics: increased probability with siblings
• Stress
• Sodium intake and diet- reducing intake of salt in hypertensive individuals does reduce BP- does not have much effect in normal individuals
• Alcohol- in moderation good for BP
• Weight- 30% of hypertension is related to obesity
• Birth weight- low BW associated with hypertension
• Race- higher in black people

Question 3

Secondary causes of hypertension?

Answer 3

• Renal disease:
• Pregnancy: pre-eclampsia
• Endocrine disease
• Drug induced : NSAID, oral contraceptive, corticosteroids
• Vascular : co-archtation of the aorta
• Sleep Apnoea

Question 4

Investigations for hypertension

Answer 4

-MEASURE BP
-ASSESS RISK:
previous family history
risk factors
-ASSESS END-ORGAN DAMAGE:
ECG
ECHO
renal failure test
proteinuria test
-SCREEN FOR POSSIBLE UNDERLYING CAUSES
Renal artery stenosis
Cushing’s disease
Sleep apnoea
Conn’s disease

Question 5

Risk factors

Answer 5

previous MI
diabetes mellitus 
smoking 
family history
hypercholesteremia 
male

Question 6

stage 1 hypertension values

Answer 6

140/90 mmhg

ABPM: 135/ 85mmhg

Question 7

stage 2 hypertension values

Answer 7

160/100 mmhg

ABPM: 155/95

Question 8

severe hypertension values

Answer 8

180/100 mmhg or higher

Question 9

Treatment in under 55s/not pregnant/not afro Caribbean?

Answer 9

1-ACE inhibitor: angiotensin converting enzyme inhibitor OR ARB: angiotensin 2 antagonist- completely blocks angiotensin 2
2- Add Thiazide:
-urinary excretion of sodium
OR Calcium channel blockers:
-block L channels
-causes arterioles to dilate so TPR reduced
3- add ACEI/CCB and thiazide together
4-if resistant:
-low potassium levels - add low dose extra diuretics
-higher than 4.5 mol/l -higher dose diuretics

Question 10

contraindications of ACE and ADRs

Answer 10

-renal artery stenosis
-renal failure
-hyperkalemia (high potassium levels)
ADRS:
-cough
-taste disturbance
-hypotension
-renal impairment

Question 11

Contraindications for CCBs and adverse drug reactions

Answer 11

Contraindications:

• MI
• bradycardia

Adverse drug reactions:

• flushing
• headaches
• ankle oedema
• indigestion

Question 12

ADRs for thiazide

Answer 12

• Gout

- Impotence

Question 13

How to treat accelerated hypertension

Answer 13

BP: 180/110 or higher

• reduce MAP by 25% in first hours
• bring down to 160/100 in next 2-6 hours
• do not bring down too suddenly- do not give sublingual; treatment/intermuscular
• once goal BP has been achieved then oral treatment cam be begun and Iv can be titrated down

Question 14

what can hypertension lead to?

Answer 14

End-organ damage:

• kidneys
• heart
• blood vessels

Question 15

Treatment for people who are over 55/afro Caribbean?

Answer 15

1- CCB/ Thiazide type diuretic

2- add CCB, thiazide appropriately

Question 16

What drug- drug interactions with ACEI?

Answer 16

• NSAID= acute renal failure
• K+ supplements= hyperkalemia
• K+ sparing diuretics = hyperkalemia

Question 17

Methyldopa

-ADRs

Answer 17

first choice in pregnant ladies 
centrally acting agent 
converted to methylnoradrenaline 
works on alpha adrenoreceptors 
decreases sympathetic flow
ADR:
dizziness
dry mouth 
hypotension

Question 18

DOXAZOSIN

Answer 18

alpha1 adrenoreceptor antagonist 
prevents contraction in smooth muscle of arterioles
ADRs:
dry mouth 
dizziness 
hypotension

Question 19

Moxonidine

Answer 19

vasodilator

Question 20

Name of:

• main ACEI
• main thiazide type diuretic
• different types of CCB

Answer 20

ACEI: Ramipril 
Thiazide: Indapamide
CCB:
vasodilator
Rate limiting: Verapamil

Question 21

End-organ damage in untreated hypertension?

Answer 21

Adds 40% risk of developing stroke
Peripheral vascular disease
Cardiac disease
Renal failure-proteinuria

Question 22

Treatment in pregnancy?

Answer 22

Pre- pregnancy:
-CCB
-beta blocker
-methyldopa 
During pregnancy:
-add thiazide type diuretic