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4TH YEAR - CPTP > Hypertension/HF > Flashcards

Hypertension/HF Flashcards

1
Q

What are the symptoms of acute heart failure?

A

Sudden onset breathlessness, crackles, fatigue, oedema, cough/wheeze, pink phlegm

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2
Q

What are the causes of acute heart failure?

A
  • Infection
  • Allergic reaction
  • PE
  • Bypass surgery
  • MI
  • Arrhythmias
  • Acute on chronic
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3
Q

How is acute heart failure treated?

A

1st - LMNOP - furosemide, morphine, nitrates, high flow oxygen, position
(NICE do not recommend nitrates but they are being increasingly used)

DONT GIVE B BLOCKERS

2nd - NIV, mechanical ventilation, inotropes, surgery for vascular disease

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4
Q

What do you give to patients with acute heart failure after they have stabilised?

A
  • Beta blocker and ACEi
  • Salt/fluid restriction
  • DVT prophylaxis - tinzaparin
  • Increase furosemide, add thiazide, monitor U&E
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5
Q

How is heart failure diagnosed?

A

Pro-BNP and cardiac abnormalities on ECHO

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6
Q

What are the symptoms of chronic heart failure?

A

Shortness of breath, wheeze, fatigue, oedema

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7
Q

What causes chronic heart failure?

A
  • Cardiomyopathy
  • Cor pulmonale
  • Hypertension
  • Diabetes
  • Valvular disease
  • Coronary artery disease
  • Inherited conditions
  • Pericarditis
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8
Q

How is chronic heart failure treated?

A

1st - ACEi/ARB and B blocker and diuretics
2nd - Spironolactone, hydralazine + nitrate
3rd - Digoxin

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9
Q

Which drugs give prognostic benefit?

A

ACEi/ARB and beta blockers, particularly to those with HF due to LVSD

Spironolactone - need to monitor U&E

Hydralazine/nitrates for those intolerant to ACEi/ARB

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10
Q

Which patients should be given digoxin for chronic heart failure?

A

Treatment resistant or AF (elderly, sedentary)

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11
Q

Which drugs give symptomatic benefit?

A

Loop diuretics - furosemide

Digoxin

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12
Q

What are the aims of treatment in patients with heart failure?

A 
Symptom relief
•	reduce SOB, fluid retention
•	diuretics, ACEI
•	digoxin if still symptomatic on optimal dose ACEI/diuretics
Survival benefit
•	ACEI
•	Beta Blocker
•	Spironolactone (post MI)
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13
Q

What comorbidities do you need to be aware of when treating HF?

A

BP – high or low
• If hypotensive – cant use GTN as nitrates make you hypotensive

Asthma – avoid β blockers

Renal - Toxicity of ACEi and ARB

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14
Q

Do you use beta blockers in acute HF?

A

NO!!! - If used in acute heart failure you could patient into cardiogenic shock and kill them. Need to wait until HF has stabilized.

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15
Q

What drugs do we use in acute HF?

A

Inotropes - e.g dobutamine (acute/cardiogenic shock)
Opiates - Diamorphine
Nitrates - e.g GTN
Loop diuretics - furosemide

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16
Q

What drugs do we use in chronic HF?

A 
Loop diruetics - furosemide
K sparing diuretics - spironolactone
ACEis - lisinopril, ramipril
ARBs - losartan
Beta blockers - atenolol
Cardiac glycosides - digoxin
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17
Q

What is the use of furosemide in HF?

A

Acutely used IV in combo with oxygen therapy, used to shift fluid (put in a catheter)

Chronic – figure out what dose ~40mg

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18
Q

What is the use of diarmorphine in HF?

A

Acute phase breathlessness

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19
Q

What is the use of GTN in HF?

A

Offload the preload of the heart (careful of hypotension)

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20
Q

What is the use of inotropes in HF?

A

Help to continue kidney perfusion, but can cause arrhtymias

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21
Q

What is the use of K+ sparing diuretics in HF?

A

Spironolactone - often used in combo with loop diuretics to fine tune treatment in chronic.
Can cause hyperkalaemia.

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22
Q

What is the use of ACEis in HF?

A

Chronic - Start with a low dose and titrate up, checking kidney function as you go. Common side effect is the dry cough.

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23
Q

What is the use of ARBs in HF?

A

Chronic - Start with a low dose and titrate up, checking kidney function as you go. Alternate if ACE cause bad side effects.

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24
Q

What is the use of loop diuretics in HF?

A

Symptomatic benefit - loss of oedema and work on the heart

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25
Q

What is the use of digoxin in HF?

A

Use in treatment resistant or AF, very narrow therapeutic range → can cause digoxin toxicity.

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26
Q

What is the ACD rule when managing hypertension?

A
  1. Acei/ARB or CCB
  2. Add thiazide like Diuretic
  3. Add further Diuretic of a/b blocker
27
Q

Which ACEis are used in HTN?

A

Lisinopril, ramipril, enalapril

28
Q

What are the indications for using ACEis in HTN?

A

First line for <55, non-afrocarribbean

29
Q

What are the contraindications to using ACEis in HTN?

A
  • Pregnancy
  • Peripheral vascular disease
  • Renal disease
  • Hyperkalemia
30
Q

What are the side effects of ACEis?

A

Dry cough, hypotension, fatigue, headache, renotoxic (must monitor U&E)

31
Q

How do ACEis work?

A

Stop the action of ACE and therefore prevent conversion of angiotensin 1 to angiotensin 2, thus inhibiting the RAAS

32
Q

Which CCBs are used in HTN?

A

Nifedipine, amlodipine, verapamil

33
Q

What are the indications for using CCBs in HTN?

A

First line for >55 or black afrocaribbean (as they have a more salt sensitive HTN)

34
Q

What are the contraindications for using CCBs in HTN?

A

Right sided heart failure

35
Q

What are the side effects of CCBs?

A

Dizziness, constipation, facial redness (no metabolic effects)

36
Q

How do CCBs work?

A

Stop calcium influx into vascular smooth muscle therefore stopping vasoconstriction

37
Q

Which ARBs are used in HTN?

A

Losartan

38
Q

What are the indications for using ARBs in HTN?

A

Cant tolerate ACEis

39
Q

What are the side effects of ARBs?

A

Headache, dizziness, myalgia

40
Q

How do ARBs work?

A

Stop angiotensin binding to receptor, thus inhibiting the RAAS system

41
Q

Which b blockers are used in HTN?

A

Atenolol (sometimes combined with an alpha blocker such as doxazosin)

42
Q

What are the indications for b blockers in HTN?

A

Use of unable to tolerate other drugs or women of child bearing age

43
Q

What are the contraindications for b blockers in HTN?

A
  • Asthma
  • COPD
  • Heart block
44
Q

What are the side effects of beta blockers?

A

Dizziness, SOB

45
Q

How do b blockers work?

A

Antagnose B1 receptors in the heart to reduce HR

46
Q

Which a blockers are used in HTN?

A

Doxazosin (use in combo with b blocker)

47
Q

What are the indications and contraindications for a blockers?

A

I - prostatism

CI - urinary incontinence

48
Q

Which diuretics are used in HTN?

A

Thiazide like - sulphonamide, indapamide
Potassium-sparing - spironolactone
Thiazides - bendroflumathiazide

49
Q

What are the indications for diuretics in HTN?

A

Varied, usually when people haven’t responded well to ACEis/ARB/CCB

50
Q

What are the contraindications for diuretics in HTN?

A

Gout, renal failure

51
Q

How do diuretics work?

A

Thiazide-like - net loss of Na and H20
Spironolactone - act on DCT and collecting duct
Thiazides - net loss of Na and H20

52
Q

What are the side effects of diuretics?

A

Hyperglycaemia, hyperlipidemia

53
Q

Which drugs are best used in pregnancy ?

A

Methyldopa
Nifedipine
Labetolol

54
Q

Which drugs can’t you use in pregnancy?

A

Beta blockers (excpet labetolol)
• Unsafe in pregnancy before 28weeks gestation (growth retardation)
Thiazides
• Unsafe in pregnancy (oligohydramnios)
ACE Inhibitors
• Unsafe throughout pregnancy (congenital malformations (1st trimester exposure) and ACEI fetopathy (2nd trimester exposure).

A2 Antagonists also contraindicated.

55
Q

What is stage 1 hypertension?

A

Clinic BP >140/90 AND ABPM>135/85

56
Q

What is stage 2 hypertension?

A

Clinic BP>160/100 AND ABPM>150/95

57
Q

What is stage 3 hypertension?

A

Clinic BP>180 systolic or 110 diastolic

58
Q

When do you start initiating treatment in a pt with hypertension?

A 
Offer to stage 1 if they also have:
- target organ damage
- renal disease
- established cardiovascular disease
- diabetes
- 10yr cardiovascular risk >20% using the QRISK score
Offer to all in stage 2 or above
59
Q

What is white coat hypertension?

A

A discrepancy of over 20/10 mmhg between clinic and home readings

60
Q

Aside from medication, what should be offered to all people with HTN?

A

Urine dip - proteinuria, albumin:creatinine ratio, haematuria
Bloods - glucose, electrolytes, creatinine, eGFR, cholesterol
Fundi exam - hypertensive retinopathy
ECG - cardiovascular, K
Lifestyle advice - smoking, diet, exercise

61
Q

What is the target BP if under 80yo with HTN?

A

140/90

62
Q

What is the target BP if over 80yo with HTN?

A

150/100

63
Q

What are the causes of secondary HTN?

A
  • Renal disease, renal artery stenosis (fibromuscular hyperplasia in this age group), pre-eclampsia,
  • Conn’s syndrome (primary hyperaldosteronism causes sodium retention and low potassium),
  • Cushing’s syndrome, Coarctation, Phaeochromocytoma, Acromegaly
64
Q

What are the complications of HTN?

A

• MI
• Left ventricular hypertension → very tall QRS
• Stroke → Cerebral infarction, brain haemorrhage, Lacunar syndromes, Multi-infarct disease
• Hypertensive nephrosclerosis → monitor protein urea. Also monitor urine for Albumin-creatinine ratio (ACR). ACR<2 is normal. Haematuria if a bad sign, especially in men, of kidney damage.
• Eyes → Earliest HTN sign is silver wiring – silver look to the arteries. Severe = papilloedema.
• Dissecting aortic aneurysm → severe tearing pain… measure BP in both arms, it will be significantly lower in the left arm than the right arm.
• Peripheral Vascular disease → especially in combination with smoking and diabetes
• Accelerated (malignant) Hypertension – Medical emergency (SBP >200)
o Headache, Visual impairment, Renal impairment, Cardiac failure, Neurological signs, Microangiopathic haemolytic anaemia, Fundal changes

4TH YEAR - CPTP (19 decks)

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