Hypertension and cardiovascular drugs Flashcards
What are the main risk factors for hypertension?
- Age
- Race (African >> caucasian)
- Family history
- Obesity
- Inactivity
- Active smoking
- High-sodium diet
- Low-potassium diet
- Alcohol
- Stress
What are the different types of hypertension?
- Primary hypertension
- Secondary hypertension
What are underlying causes of secondary hypertension?
- Obstructive sleep apnea
- Kidney disease
- Renal artery stenosis
- Polycystic kidney disease
- Endocrine dysfunction
- Primary hyperaldosteronism
- Phaeochromocytoma
- Cushing’s disease
- Thyroid problems
- Congenital heart disease
- Illegal drugs, such as cocaine and amphetamines
What are complications of hypertension?
MI
Stroke
Aneurysm
Heart failure
Nephropathy
Metabolic syndrome
How is hypertension diagnosed?
- Clinical reading > 140/90
- Offer ABMP or HBPM
If BP >135/80: stage I hypertension, if no comorbidities: no treatment
If BP >150/95: stage II hypertension –> treat
What is a hypertensive crisis?
A blood pressure measurement higher than 180/120 mm Hg is an emergency situation that requires urgent medical care
What are pieces of lifestyle advice given to people with hypertension?
- Cut salt intake
- Lose weight
- Limit alcohol intake
- Exercise regularly
- Cut down on caffeine
- Stop smoking
What are common side effects of calcium channel blockers?
Ankle oedema, flushing, headache
What are common side effects of ACE-I?
Dry cough, oedema, hyperkalaemia
What are common side effects of thiazide diuretics?
Hyponatraemia, hypokalaemia
What is malignant hypertension?
High blood pressure with symptoms and signs indicative of acute impairment of one or more organ system – typically with a systolic BP of > 180 mmHg
What are the symptoms of malignant hypertension?
- Chest pain
- Headache
- Dyspnoea
- Anxiety
- Palpitations
What are causes of malignant hypertension?
- Discontinuation of medication
- Drug use
- Head trauma
- Eclampsia
How would you treat malignant hypertension?
IV sodium nitroprusside injection 0.5-1.5 micrograms/kg/minute
How would you manage hypertension in those over 55 or of African/Caribbean origin?
- CCB
- ACE-I or ARB or thiazide-like diuretic
- ACE-I or ARB WITH CCB and thiazide-like diuretic
How would you manage hypertension in those under 55 or with T2DM?
- ACE-I or ARB
- CCB or thiazide-like diuretic
- ACE-I or ARB WITH CCB and thiazide-like diuretic
Name 11 types of cardiovascular drugs
- ACE-I
- ARB
- Anticoagulant medicines
- Antiplatelets
- Beta-blockers
- Statins
- CCB
- Digoxin
- Nitrates
- Diuretics
What is digoxin used for?
Treat arrhythmias
Name 3 ACE inhibitors
Ramipril, captopril, benazepril
Name 3 ARBs
Losartan, azilsartan, olmesartan
Name 3 antiplatetes
Aspirin, ticagrelor, clopidogrel
Name a beta-blocker
bisoprolol
Name 3 CCBs
amlodipine, verapamil, diltiazem
What sort of drug is amlodipine?
CCB
What sort of drug is verapamil?
CCB
What sort of drug is diltiazem?
CCB
What sort of drug is ticagrelor?
Antiplatelet
What sort of drug is clopidogrel?
Antiplatelet
What sort of drug is Ramipril?
ACE-I
What sort of drug is Losartan?
ARB
What sort of drug is benazepril?
ACE-I
What are the most common siide effects for CCBs?
What are the most common side effects of ACE-I?
Dry, irritating cough
Who benefits most from ACE-Is?
Those under 55
Who do ACE-Is not work well for?
What are the most common side effects of ARBs?
ARBs are generally well-tolerated but, as with any drug, they can cause unwanted effects, including dizziness, headache and fatigue
What are the most common side effects of antiplatelets?
Antiplatelets can irritate the lining of the stomach, so there is a risk of gastrointestinal side effects such as indigestion and stomach aches
Prone to nosebleeds and bruising
What are the most common side effects of beta-blockers?
Yhey may cause cold hands and feet, particularly in older people, and may also be associated with unusually vivid dreams. Some patients experience fatigue, perhaps related to excessive slowing of the heart rate
What are the most common side effects of digoxin?
Side effects include nausea, vomiting, diarrhoea, tiredness, insomnia, visual disturbances, palpitations and fainting
What are NOACs and when are they used?
Noval Oral AntiCoagulants
They can be used in the prevention of stroke for people with non-valvular AF, which is when AF is not associated with a problem in a heart valve. They can also be used in the management of venous thromboembolism, which is when a blood clot forms in a vein
Name four NOACs
rivaroxaban
dabigatran
apixaban
edoxaban
What is the mechanism of action for NOACs?
NOACs act by two different mechanisms:
- direct thrombin inhibitor
- direct factor Xa inhibitor.
The former category inhibits coagulation by directly binding to thrombin and prevents the formation of fibrin by restricting thrombin from breaking fibrinogen. The latter group inhibits factor Xa which is trypsin-like serine protease that plays a critical role in the blood coagulation cascade.
It has a principal position in linking the intrinsic and extrinsic pathways to the final common coagulation pathway.
These agents bind directly to factor Xa and prevent them from cleaving prothrombin to thrombin
What is the mechanism of action for Warfarin?
Warfarin antagonises vitamin K (needed for the synthesis of clotting factors) and takes 2-3 days to exert its full effect.
What is the main indication for warfarin use?
Prevention of stroke in AF
When taking warfarin:
- What needs to be measured?
- How often?
- What is the target value?
- International normalised ratio (INR): the time it takes for blood to clot
- If your INR is stable, you might only need to go for an INR test every eight weeks; if it’s unstable or you’ve just started on warfarin, you may have to go weekly
- 2.5
What are contra-indications for warfarin?
Known hypersensitivity to warfarin or to any of the excipients.
Haemorrhagic stroke.
Clinically significant bleeding.
Within 72 hours of major surgery with risk of severe bleeding.
Within 48 hours postpartum.
Pregnancy (first and third trimesters, can cause congenital malformations and fetal death).
Drugs where interactions may lead to a significantly increased risk of bleeding - eg, antiplatelet drugs, non-steroidal anti-inflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors (SSRIs), venlafaxine or duloxetine
Name three factors that can:
- Increase Warfarin’s effect
- Decrease Warfarin’s effect
Increase:
- Loss of weight.
- Acute illness.
- Cessation of smoking.
Reduction of warfarin effect can occur in:
- Weight gain.
- Diarrhoea.
- Vomiting.
A 75 year old man is found collapsed at home and is brought to the Emergency Department. He has right sided weakness and reduced consciousness. He has a history of type 2 diabetes mellitus, atrial fibrillation and hypertension. He is taking warfarin.
Investigations:
INR is 4.6 (<1.4).
CT scan of the head shows a large intracranial haemorrhage.
He is given intravenous vitamin K.
Which is the most appropriate next additional treatment?
A) Cryoprecipitate
B) Fresh frozen plasma
C) Fibrinogen concentrate
D) No additional treatment needed
E) Prothrombin complex concentrate
E – prothrombin complex concentrate. Give beriplex (PCC) after vit K if patient on warfarin and catastrophic bleeding.
A 42 year old man has 1 week of chest pain and shortness of breath. His pulse rate is 125 bpm, BP 77/42 mmHg and oxygen saturation 85% breathing air.
Investigations: Chest X-ray: no abnormality CT pulmonary angiogram: massive pulmonary embolus.
Which is the most appropriate immediate treatment?
A) Intravenous alteplase
B) Intravenous heparin (unfractionated)
C) Oral dabigatran etexilate
D) Oral warfarin sodium Exclude
E) Subcutaneous low molecular weight heparin
A - Intravenous alteplase – treatment of massive (haemodynamically unstable) PE give systemic thrombolytic therapy. if they are normotensive then give heparin.
