Hypertension + HF Flashcards
What are mechanisms of physiological control of blood pressure
RAAS:
vasoconstriction
NA + water reabsorption
Aldosterone release
Autonomic nervous system: HR, TPR
What is definition of hypertension
Chronically raised blood pressure:
Clinic BP >140/90
ABPM >135/85
Most important risk factor for CVD (stroke,ihd)
What is white coat hypertension
Raised clinic BP but normal ABPM
Do not treat
What is malignant hypertension
Rapid increase in BP, leading to severe hypertension and vascular damage
>200/130
Treat immediately
What is primary hypertension
Without underlying cause
95%
What is secondary hypertension
Underlying cause
5%
What are secondary causes of Hypertension
Renal: renal artery stenosis, pyelonephritis, glomerulonephritis, PCKD
Endocrine: Conns Syndrome, Cushing’s syndrome, pheochromocytoma, hyperparathyroidism
Drugs: steroids, oral contraceptives, NSAIDs
What are clinical features of hypertension
Asymptomatic
Signs of End organ damage
Malignant: headaches, visual disturbance, seizures
What investigations are required to diagnose hypertension
Clinic BP
ABPM or Home BP monitoring
Assess CV risk: glucose, cholesterol
Assess end organ damage: fundoscopy, urine dipstick, ECG
What are the stages of hypertension
Stage 1: cBP >140/90 And ABPM >135/85
Stage 2: cBP >160/100 and ABPM >150/95
Stage 3: cBP >180 systolic or >110 diastolic
What are treatment goals for hypertension
<140/90
<135/85 for DM
<150/90 for >80yo
What are lifestyle management of hypertension
Low Na diet Stop smoking Low caffeine intake Low alcohol intake Low fat diet Exercise Weight loss
How do you manage clinic BP <140/90
No treatment
Normotensive
How do you manage clinic BP >140/90
ABPM or Home BP monitoring
Assess CV risk
Assess end organ damage
How do you manage clinic BP >180/110
Treat immediately
Referral if: retinal haemorrhage, papilloedema, suspected phaeochromocytoma
How do you manage ABPM <135/85
No treatment
Normotensive
How do you manage ABPM >135/85
Treat if <80yo AND: 10yr CV risk >20% End organ damage Diabetes Reno-vascular disease CV disease
How do you manage ABPM >150/95
Treat
What is first step of management
<55yo: ACE-I or ARB
>55yo or Afro-carribean: CCB or Thiazide-like diuretic
What is second step of management
Ace-I + CCB or
ACE-I + Thiazide
What is third step of management
ACE-I + CCB + Thiazide
What is fourth step of management
Add on a fourth drug: Spironolactone if K <4.5 mmol/L Higher dose thiazide if K >4.5 mmol/L Alpha or beta blocker if diuretic not tolerated Renin inhibitor If non above tolerated
Why are thiazide-like diuretics preferred over traditional thiazide
Lower risk of hyponatraemia and falls
Give examples of ACE inhibitors
Ramipril
Lisinopril
What is mechanism of action of ACE inhibitors
Reduce Angiotensin II synthesis Reduce vasoconstriction Reduce Na and water reabsorption Reduce aldosterone release Enhance bradykinin activity (vasodilator)
What are side effects of ace inhibitors
Dry cough Angio-oedema Renal failure Hyperkalaemia First dose hypotension
What are contra indications of ace inhibitors
High dose diuretics
Severe aortic stenosis (sudden cardiac death)
Renovascular disease
Pregnancy + breastfeeding
What monitoring is required with ace inhibitors
U+Es
Baseline
After increasing dose
Give examples of ARB
Losartan
Candesartan
When is ARB indicated
When ACE-I not tolerated (dry cough)
What is mechanism of action of ARB
Inhibit Angiotensin AT1 receptor
Inhibit AII activity
What are side effects of ARB
Hyperkalaemia
Renal failure
Urticaria
Pruritus
Give examples of CCB
Dihydropyridines: amlodipine
Phenylalkylamines: verapamil
Benzothiazepenes: Diltiazem
What is mechanism of action of CCB
Inhibit L type calcium channels
Inhibit Ca influx
Smooth muscle relaxation of peripheral, coronary and pulmonary arterioles
What are pk properties of amlodipine
Good oral bioavailability
Long T1/2
Few active metabolites - safer in renal disease
What are side effects of amlodipine
Ankle Oedema Flushing sweating tachycardia palpitations
What is mechanism of action of verapamil
Inhibit Ca channels in SAN/AVN, cardiac myocytes, vascular SM
Slow HR
Reduce contractility
Vasodilation
What are side effects of verapamil
Bradycardia
Constipation
Worsen HF
What are contraindications of verapamil
Heart failure
Give examples of thiazide diuretics
Bendroflumethiazide
Thiazide-like diuretic:
Metolazone
Chlortalidone
What are contra indications of thiazide diuretic
Gout
Give examples of alpha blockers
Doxazocin
What is mechanism of action of alpha blockers
Inhibit alpha 1 adrenoceptor of Vascular SM
Inhibit Ca influx
Vascular SM relaxation
Reduce TPR
What are side effects of alpha blockers
Postural hypotension
Ankle oedema
Dizziness
Give examples of beta blockers
Atenolol, bisoprolol
What is mechanism of action of beta blockers
Inhibit beta 2 adrenoceptor of Heart
reduce HR and contractility
Inhibit renin release
What are side effects of beta blockers
Bronchospasm Bradycardia Lethargy Impaired glucose tolerance Impaired exercise tolerance Impotence
What are contraindications of beta blockers
Asthma
Give examples of renin inhibitors
Aliskiren
What is mechanism of action of renin inhibitors
Inhibit conversion of angiotensinogen to Angiotensin I
Reduce AII levels
What are side effects and contra indications of aliskiren
Diarrhoea
Pregnancy
Give examples of direct acting vasodilator
Hydralazine
Miroxidil
When is direct acting vasodilator indicated
Severe hypertension
How do you manage malignant hypertension
Treat immediately
Controlled reduction over days
Oral admin
How do you manage hypertensive encephalopathy
IV sodium nitroprusside
BP reduction to 110 diastolic over 4 hrs
What are cautions of sodium nitroprusside
Metabolised to cyanide
Caution in liver disease
Avoided repeated use
What are side effects of hydralazine
Flushing
Tachycardia
Drug-induced Lupus
What drugs are used in pharmacological management of heart failure
Beta blocker Ace inhibitor Spironolactone Hydralazine combined with nitrate Digoxin Diuretics: loop, thiazide
Which medications improve long term mortality in heart failure
Beta blockers
Ace inhibitors
Spironolactone
Hydralazine with nitrates
What is the role of diuretics in heart failure management
Symptom relief
No improvement in mortality
What is first step of management of heart failure
Beta blocker
Ace inhibitor
What is second step of management of HF
Addition of spironolactone or
ARB or
Hydralazine with nitrates
What is third line of management of HF
Addition of Digoxin
Which diuretics are used in HF management
Loop: furosemide
Add Spironolactone: If hypokalaemic
Add thiazide: if refractory oedema
What are indications of ACE I
All HF patients
What are indications of Beta blockers
What caution is required
All HF patients
Start at low dose, titrate slowly
When is spironolactone indicated
Symptomatic despite optimal therapy
Post-MI with LVSD
When is Digoxin indicated
Symptomatic despite optimal therapy
AF
