Hypertension&heart failure

Question 1

ACE inhibitors - names, mechanism, side effects, warnings and contraindications

Answer 1

lisinopril, ramipril
Limits conversion of angiotensin 1 to angiotensin 2 therefore causing vasodilation, decreased aldosterone and decreased ADH. Bradykinin is also a substrate for ACE there for levels are increased also causing vasodilation.

Hypotension, dry cough, hyperkalaemia (low aldosterone), renal failure, angioedema.

Renal artery stenosis, AKD, pregnancy&BF.

Drugs which increase K+, NSAIDS, other antihypertensives.

Question 2

Angiotensin receptor blockers - names, mechanism, side effects, warnings and contraindications

Answer 2

candesartan, losartan
Block AT1 receptors so more effective at inhibiting angiotensin2 mediated vasoconstriction, no effect on bradykinin so less dry cough and angioedema.

Renal artery stenosis, AKD, pregnancy&BF.

Drugs which increase K+, NSAIDs and other antihypertensives

Question 3

What are the 3 classes of CCBs and how do they differ?

Answer 3

dihydropyridines - more selective for vasculature (cerebral vs peripheral)

benzothiazapines - in the middle

phenylalkylamines - more selective for the heart

Question 4

Dihydropyridines - names, mechanism and how they differ, side effects, warnings and contraindications

Answer 4

amlodipine, nimodipine
Amlodipine has a long half life and nimodipine is selective for cerebral vasculature.

Ankle swelling, flushing, headaches, palpitations.

Unstable angina, severe aortic stenosis.

Amlodipine&simvastatin (increases the effect of the statin), and other antihypertensives

Question 5

Phenylalkylamines - names, mechanism, use, side effects, warnings and contraindications

Answer 5

Verapamil
Class IV antiarrhythmic, prolongs the action potential and effective refractory period, less peripheral vasodilation.

Used for arrhythmias, angina, hypertension.

Constipation, bradycardia, heart block, cardiac failure.

Poor LV function, AVN conduction delay.

Beta blockers, other antihypertensive and antiarrhythmics.

Question 6

Benzothiazapines - name

Answer 6

Diltiazem

Question 7

Thiazide and thiazide-like - names, mechanism, side effects, warnings, contraindications

Answer 7

bendroflumethiazide, indapamide
Inhibit N+/Cl- cotransporter in DCT therefore decreasing Na and H2O. Useful in oedema.

Hypokalaemia, hyponatraemia, hyperuricaemia, arrhythmia, increased glucose, increased cholesterol and TAG.

NSAIDS and drugs that decrease K+.

Question 8

What is step 1 and step 2 in prescribing antihypertensives for hypertension with type 2 diabetes, and for someone under 55 and not of black African or African-Caribbean family origin?

Answer 8

step 1 - ACEi/ARB

step 2 - ACEi/ARB + CCB OR thiazide-like

Question 9

What is step 1 and step 2 in prescribing antihypertensives for over 55 or black African or African-caribbean family origin?

Answer 9

step 1 - CCB

step 2 - CCB + ACEi/ARB OR thiazide-like

Question 10

What are steps 3 and 4 in prescribing antihypertensives?

Answer 10

step 3 - ACEi/ARB + CCB + thiazide-like
step 4 - resistant hypertension so add spironolactone if K+ < 4.5
or alpha blocker or beta blocker if K+ > 4.5

Question 11

What is the two pronged approach to ACEi/ARB in hypertensives with type 2 diabetes?

Answer 11

decrease PVR and BP + dilation of efferent glomerular arteriole causing decreased intraglomerular pressure which aids diabetic nephropathy

Question 12

Spironolactone - what is its class, warnings, contraindications?

Answer 12

aldosterone receptor antagonist

hyperkalaemia, Addison’s

drugs which increase K+ including ACEi/ARB

Question 13

Beta blockers - names, mechanism, side effects, warnings, contraindications

Answer 13

labetalol, bisoprolol, metoprolol

Decrease sympathetic tone by blocking noradrenaline and reducing myocardial contraction therefore decreasing cardiac output.

Bronchospasm, heart block, Raynaud’s, lethargy, impotence.

Asthma, haemodynamic instability, hepatic failure.

Nondihydropyridine CCB (verapamil and diltazem - ASYSTOLE!)

Question 14

Alpha blockers - name, mechanism, side effects, contraindications

Answer 14

doxazosin

selective antagonism of a1 receptors reducing peripheral vascular resistance.

Postural hypotension, dizziness, syncope, headache, fatigue.

Contraindications - dyhydropyridine CCB (oedema)

Question 15

In heart failure, what diuretic is prescribed for congestive symptoms?

Answer 15

loop diuretic - furosemide

Question 16

in heart failure with reduced ejection fraction, what are the next steps?

Answer 16

offer ACEi + BB (bisoprolol- allow more time for filling)
add an MRA if symptoms continue (spironolactone)
consider and ARB if intolerant of CE