Hypertension

Question 1

BP > 140/90 in clinic. What do?

Answer 1

ABPM to confirm

Question 2

Useful Ix in HTN?

Answer 2

Urinalysis
U&Es
eGFR
Fundoscopy
ECG

Question 3

Endocrine causes of HTN

Answer 3

Conn’s syndrome (adrenal adenoma secreting aldosterone (unilateral))
Bilateral adrenal hyperplasia (aldosterone up)
Cushing’s syndrome (cortisol excess)
Phaechromocytoma (adrenaline tumour)

Question 4

Renal causes of HTN

Answer 4

Renal artery stenosis
Renal parenchymal disease

Differentiate with clinical exam, doppler etc

Question 5

General drug approach - step 1/3 (under 55 white)

Answer 5

ACEi or ARB

Question 6

General drug approach - step 1/3 (over 55 or black)

Answer 6

CCB- Amlodipine

Question 7

General drug approach - step 2/3

Answer 7

ACEi (or ARB) + CCB

Question 8

General drug approach step 3/3

Answer 8

ACEi (or ARB) + CCB + Thiazide-like-diuretic

Question 9

Angiotensin-converting enzyme inhibitors

ACEi’s

Answer 9

Enalapril, ramipril, lisinopril, perindopril

HTN, chronic heart failure (improve symptoms and prognosis), ischaemic heart disease, CKD with proteinuria

Angiotensin II - usually a vasocontrictor and stimulates aldosterone secretion.

So blocking this = lower BP, and dilates efferent glomerular arteriole reducing intrglomerular pressure - helping slow CKD.
- Less aldosterone - more Na/H20 excretion, less venous return - happy heart in HF

ACE usually breaks down bradykinin - so ACEi = more bradykinin which can cause a dry cough
-angioedema (swelling of face etc) can happen - 5x more likely in black people

Contraindications - renal failure, renal artery stenosis - but sometimes can use for CKD if you’re a baller.
Hypotension sometimes happens on first dose

Question 10

Angiotensin receptor blockers

ARB’s

Answer 10

Candesartan, losartan, irbesartan

HTN, chronic heart failure (improve symptoms and prognosis), ischaemic heart disease, CKD with proteinuria

Same method as ACEi - but don’t interfere with ACE so no dry cough from bradykinin nor angioedema

Question 11

Calcium channel blockers 1/3

Answer 11

Amlodipine, nifedipine, diltiazem, verapamil

HTN, stable angina (symptoms), [diltiazem, verapamil rate control in supraventricular tachycardia, AF, atrial flutter]

Stop Ca entry into vascular/cardiac cells = vasodilation arterial smooth muscle and reduce cardiac contractility . Suppress cardiac conduction - esp. at AV node - slow ventricular rate

> reduces cardiac O2 demand = better angina

Ankle swelling, palpitations etc.

Question 12

Calcium channel blockers 2/3

Dihydropyridines

Answer 12

Amlodipine, nifedipine

Relatively selective for vasculature

Question 13

Calcium channel blockers 3/3

Non-dihydropyridines

Answer 13

Verapamil, diltiazem

Relatively selective for the heart

Diltiazem affects the heart and vessels

Avoid is patients with AV node blocks

Question 14

Thiazide diuretics

Answer 14

Bendroflumethiazide (thiazide), indapamide and chlortalidone (thiazide-like)

Hypertension

Inhibit Na/Cl cotransporter in DCT - prevents reabsorption of Na/H2O

Hyponatraemia can occur - can lead to hypokalaemia as Na/K cotransporters try to compensate (arrhythmias)
Can cause impotence
Reduce uric acid excretion (gout)