Hypertension

Question 1

What is secondary hypertension due to?

Answer 1

Renal disease
Renovascular disease
Conn's syndrome
Cushing's syndrome 
Hyperthyroidism 
Phaeochromocytoma (tumour of adrenal gland releasing adrenaline)
Pregnancy
Drugs (NSAIDs, corticosteroids, venlafaxine, ciclosporin, sympathomimetics)

Question 2

What are the NICE treatment targets?

Answer 2

SBP <140mmHg

DBP <90mmHg (<80mmHg in diabetes)

Question 3

What are specific goals in treating hypertension?

Answer 3

Reduction in cardiovascular damage
Preservation of renal function
Limitation or reversal of left ventricular hypertrophy
Prevention of IHD
Reduction in mortality due to stroke and MIs

Question 4

What are common ACEIs?

Answer 4

Captopril
Enalapril
Lisinopril
Perindopril
Ramipril

Question 5

What do ACEIs do?

Answer 5

Reductions in angiotensin II
reductions in arterial and venous vasoconstriction
Reduced aldosterone production leading to reductions in salt and water retention
Potentiate bradykinin (cough)
Prevention of nephropathy in DM

Question 6

What are the side effects of ACEIs?

Answer 6

May increase potassium- interaction with salt (KCL) substitute
Angioedema
Worsening renal function

Question 7

When should ACEIs be avoided?

Answer 7

Renovascular disease

Renin-dependent hypertension, ACEIs lead to renal undwrperfusion and severe hypotension

Question 8

What are AT1 receptor antagonists (ATRAs/ARBs)?

Answer 8

Candesartan, losartan, valsartan
Block the action of AII at the AT1 receptor
These agents have similar consequences as ACEIs but don’t give rise to a cough

Question 9

What are common calcium channel blockers?

Answer 9

Dilitiazem
Verapamil
Dihydropyridines (amlodipine, felodipine, nifedipine)

Question 10

What do calcium channel blockers do?

Answer 10

Vasodilators

Inhibit voltage operated calcium channels on vascular smooth muscle, leading to vasodilation and a reduction in BP

Question 11

How does verapamil differ from the dihydropyridines?

Answer 11

Verapamil exerts most of its effects on the heart compared with dihyropyridine which has a greater effect on arteriole smooth muscle

Question 12

What are alpha-blockers?

Answer 12

Doxazosin, prazosin
These are competitive receptor antagonists of a1 adrenoceptors
Last choice antihypertensives
Wide spread side effects makes them poorly tolerated

Question 13

What are adverse effects of calcium channel blockers?

Answer 13

Peripheral oedema
Postural hypotension
Constipation

Question 14

What are the adverse effects of thiazides?

Answer 14

Urination 
Diabetogenic
Alter lipid profile 
Hypokalaemia
Impotence
Postural hypotension

Question 15

What are the adverse effects of beta blockers?

Answer 15

Bronchospasm

Reduce hypoglycaemic awareness

Question 16

What are the adverse effects of alpha-blockers?

Answer 16

Widespread

Postural hypotension

Question 17

What lifestyle changes should occur to try and treat hypertension?

Answer 17

Alcohol consumption should be reduced
Weight reduction 
Reduce excess caffeine
Reducing fat and salt intake 
Increasing fruit and oily fish in the diet
Increasing exercise
Smoking cessation

Question 18

How should hypertension be confirmed by further measurements?

Answer 18

Ambulatory- 14 measurements
Home devices
Both arms

Question 19

What are the stages of hypertension?

Answer 19

Stage 1: >140/>90
Stage 2: >160/>100
Stage 3: >180/>110

Question 20

Who should be treated with antihypertensive drugs?

Answer 20

Stage 1 with 1 or more of: end organ damage, diabetes, CV disease< high CV risk
All patients with stage 2

Question 21

What are the rules for use of antihypertensives in certain conditions?

Answer 21

Choose B-blockers in IHD
Avoid B-blockers in asthma
Choose ACEI in diabetic neuropathy 
Choose ACEI in CHF
Avoid ACEI in renovascular disease
Avoid thiazides in gout

Question 22

When should you use ACEis (or AT1 receptor antagonists)?

Answer 22

Heart failure
Left ventricular hypertrophy
Diabetic neuropathy

Question 23

When should you use calcium channel blockers?

Answer 23

Afro-caribbean ethnicity
DHPs in isolated systolic HT
Dilitiazem/verapamil in angina but not CHF

Question 24

When should you use thiazides?

Answer 24

Elderly

Question 25

When should you use beta-blockers?

Answer 25

MI
IHD
CHF

Question 26

When should you use alpha blockers?

Answer 26

Resistance to other drugs

Prostatic hypertrophy

Question 27

What is the flow chart for prescribing antihypertensives?

Answer 27

Young (<55) and non-black, high renin- A
Older (>55) black, low renin- A
Step 2- A+C
Step 3- A+C+D
Step 4 (resistance): add alpha blocker, spironolactone, other diuretic, other beta-blocker

Question 28

What has the ALLHAT trial shown>

Answer 28

Thiazides are viewed as first line drugs, even for patients with diabetes

Question 29

When should statins be considered?

Answer 29

For all patients with high risk for CV disease, irrespective of cholesterol level

Question 30

How is Conn’s syndrome diagnosed via a blood test?

Answer 30

Evidence of Na retention or K loss

Question 31

How is Addison’s disease diagnosed via a blood test?

Answer 31

Evidence of Na loss or K retention

Associated with hypotension

Question 32

Why is an ECG sometimes required?

Answer 32

Identify left ventricular hypertrophy

Question 33

What are common side effects of calcium channel blockers?

Answer 33

Headache

Ankle swelling due to arteriolar vasodilatation

Question 34

What are most effective at lowering triglycerides?

Answer 34

Fibrates

Question 35

What is simvastatin?

Answer 35

Used in hypercholesterolaemia
HMG CoA reductase inhibitor
Should be taken at night, when cholesterol synthesis is greatest

Question 36

What are the side effects of simvastatin>

Answer 36

Headaches
Nausea
GI upset
Muscle myopathy (rare)