Hypertension

Question 1

CVD modifiable risk factors

Answer 1

Physical inactivity, smoking, overweight, psychosocial, hyperlipidaemia, hypertension, diabetes

Question 2

CVD non-modifiable risk

Answer 2

Genetic, gender, ethnicity, family history

Question 3

Angiotensin Converting Enzyme Inhibitor (ACEI) MOA?

Answer 3

1. Inhibit conversion of angiotensin I to angiotensin II.

2. ACEI inhibits breakdown of bradykinin, so it increases bradykinin levels.

Question 4

Effects of ACEI?

> Decreased conversion of AT I to AT II

Answer 4

> Inhibit arteriolar vasoconstriction
Decreased aldesterone production
Inhibit renal proximal tubule of NaCl reabsorption
Decreased ADH (antidiuretic hormone) release

Question 5

Effects of ACE!

> Increased bradykinin levels?

Answer 5

> vascular smooth muscle relaxation

> causes of SEs with ACEI

Question 6

Types of hypertension (HT)

Answer 6

1. Primary hypertension: no identifiable reason

2. Secondary hypertension: secondary to diseases

Question 7

Secondary HT?

Answer 7

> renal disease, Cushing’s syndrome, pheochromocytoma, hyperthyroidism, drug induced (NSAIDs), pregnancy

Question 8

Risks of not treating HT?

Answer 8

1. Target end-organ damage.

2. Contribute to CVD risk factor.

Question 9

End-organ damage of HT?

Answer 9

Eyes: retinopathy, optic neuropathy
Brain: haemorrhogic stroke, encephalopathy
Kidneys: nephropathy
Heart: left ventricular hypertrophy

Question 10

How to measure BP?

Answer 10

> Patient should be seated & relaxed: limited recent exertion, avoid stimulant 2 h prior
Cuff should fit easily around upper arm at heart level: remove bulky sleeve, cuff outlet over brachial artery
Measure both arms initially: use arm with the highest level, calculate average
Confirm at subsequent visit!: to confirm HT (if there is one)

Question 11

Normal BP

Answer 11

S < 120; D < 80

Question 12

High-normal BP

Answer 12

S 120-139; D 80-89

Question 13

Grade 1 HT (mild)

Answer 13

S 140-159; D 90-99

Question 14

Grade 2 HT (moderate)

Answer 14

S 160-179; D 100-109

Question 15

Grade 3 HT (severe)

Answer 15

S > 180; D >110

Question 16

Isolated sytolic HT

Answer 16

S > 140; D < 90

not uncommon in elderly

Question 17

Isolated systolic HT with widened pulse pressure

Answer 17

S > 160; D , 70

Question 18

When to treat?

Answer 18

1. Grade 3 HT
2. Isolated systolic HT with widened pulse pressure
3. Associated condition or target-organ damage

Question 19

Confirmed HT!

> with previous condition

Answer 19

> START DRUG TREATMENT IMMEDIATELY!
Lifestyle modification
Manage associated condition

Question 20

> Confirmed Grades 1-2 HT

> All other adults

Answer 20

Assess 5 year absolute cardiovascular risk

Use CVD risk calculator

Question 21

High risk of CVD (>15%)

Answer 21

> START DRUG TREATMENT IMMEDIATELY
Lifestyle modifications
Manage associated conditions

Question 22

Moderate risk of CVD (10-15%)

Answer 22

> Lifestyle modification

> Monitor BP: Reassess absolute CVD risk in 3-6 mths

Question 23

Low risk of CVD (<10%)

Answer 23

> Lifestyle modification

> Monitor BP: Reassess absolute CVD risk in 6-12 mths

Question 24

Antihypersentive drugs!

Answer 24

> Calcium channel blockers (CCB)
> Thiazide and thiazide like diuretics
> Beta blockers
> ACEI
> Angiotensin !! Receptor antagonist (A2RA)

Question 25

How do you choose the most appropriate drug for HT?

Answer 25

Based on: BENEFIT:RISK
> patient age
> comorbidities
> toxicity!

Question 26

Aim/mainstay of treatment?

Answer 26

> LOWERING BLOOD PRESSURE! to reduce CVD risk and end-organ damage
so MOA not really important, just may have additional benefit for comorbidities management