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Pharmacology > Hypertension + HF > Flashcards

Hypertension + HF Flashcards

1
Q

What are mechanisms of physiological control of blood pressure

A

RAAS:
vasoconstriction
NA + water reabsorption
Aldosterone release

Autonomic nervous system: HR, TPR

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2
Q

What is definition of hypertension

A

Chronically raised blood pressure:
Clinic BP >140/90
ABPM >135/85

Most important risk factor for CVD (stroke,ihd)

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3
Q

What is white coat hypertension

A

Raised clinic BP but normal ABPM

Do not treat

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4
Q

What is malignant hypertension

A

Rapid increase in BP, leading to severe hypertension and vascular damage
>200/130
Treat immediately

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5
Q

What is primary hypertension

A

Without underlying cause

95%

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6
Q

What is secondary hypertension

A

Underlying cause

5%

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7
Q

What are secondary causes of Hypertension

A

Renal: renal artery stenosis, pyelonephritis, glomerulonephritis, PCKD
Endocrine: Conns Syndrome, Cushing’s syndrome, pheochromocytoma, hyperparathyroidism
Drugs: steroids, oral contraceptives, NSAIDs

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8
Q

What are clinical features of hypertension

A

Asymptomatic
Signs of End organ damage
Malignant: headaches, visual disturbance, seizures

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9
Q

What investigations are required to diagnose hypertension

A

Clinic BP
ABPM or Home BP monitoring
Assess CV risk: glucose, cholesterol
Assess end organ damage: fundoscopy, urine dipstick, ECG

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10
Q

What are the stages of hypertension

A

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

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11
Q

What are treatment goals for hypertension

A

<140/90
<135/85 for DM
<150/90 for >80yo

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12
Q

What are lifestyle management of hypertension

A 
Low Na diet
Stop smoking 
Low caffeine intake
Low alcohol intake
Low fat diet 
Exercise
Weight loss
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13
Q

How do you manage clinic BP <140/90

A

No treatment

Normotensive

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14
Q

How do you manage clinic BP >140/90

A

ABPM or Home BP monitoring
Assess CV risk
Assess end organ damage

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15
Q

How do you manage clinic BP >180/110

A

Treat immediately

Referral if: retinal haemorrhage, papilloedema, suspected phaeochromocytoma

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16
Q

How do you manage ABPM <135/85

A

No treatment

Normotensive

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17
Q

How do you manage ABPM >135/85

A 
Treat if <80yo AND: 
10yr CV risk >20%
End organ damage
Diabetes
Reno-vascular disease 
CV disease
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18
Q

How do you manage ABPM >150/95

A

Treat

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19
Q

What is first step of management

A

<55yo: ACE-I or ARB

>55yo or Afro-carribean: CCB or Thiazide-like diuretic

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20
Q

What is second step of management

A

Ace-I + CCB or

ACE-I + Thiazide

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21
Q

What is third step of management

A

ACE-I + CCB + Thiazide

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22
Q

What is fourth step of management

A 
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
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23
Q

Why are thiazide-like diuretics preferred over traditional thiazide

A

Lower risk of hyponatraemia and falls

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24
Q

Give examples of ACE inhibitors

A

Ramipril

Lisinopril

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25
Q

What is mechanism of action of ACE inhibitors

A 
Reduce Angiotensin II synthesis 
Reduce vasoconstriction
Reduce Na and water reabsorption 
Reduce aldosterone release 
Enhance bradykinin activity (vasodilator)
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26
Q

What are side effects of ace inhibitors

A 
Dry cough 
Angio-oedema
Renal failure 
Hyperkalaemia 
First dose hypotension
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27
Q

What are contra indications of ace inhibitors

A

High dose diuretics
Severe aortic stenosis (sudden cardiac death)
Renovascular disease
Pregnancy + breastfeeding

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28
Q

What monitoring is required with ace inhibitors

A

U+Es
Baseline
After increasing dose

29
Q

Give examples of ARB

A

Losartan

Candesartan

30
Q

When is ARB indicated

A

When ACE-I not tolerated (dry cough)

31
Q

What is mechanism of action of ARB

A

Inhibit Angiotensin AT1 receptor

Inhibit AII activity

32
Q

What are side effects of ARB

A

Hyperkalaemia
Renal failure
Urticaria
Pruritus

33
Q

Give examples of CCB

A

Dihydropyridines: amlodipine
Phenylalkylamines: verapamil
Benzothiazepenes: Diltiazem

34
Q

What is mechanism of action of CCB

A

Inhibit L type calcium channels
Inhibit Ca influx
Smooth muscle relaxation of peripheral, coronary and pulmonary arterioles

35
Q

What are pk properties of amlodipine

A

Good oral bioavailability
Long T1/2
Few active metabolites - safer in renal disease

36
Q

What are side effects of amlodipine

A 
Ankle Oedema
Flushing
sweating 
tachycardia
palpitations
37
Q

What is mechanism of action of verapamil

A

Inhibit Ca channels in SAN/AVN, cardiac myocytes, vascular SM
Slow HR
Reduce contractility
Vasodilation

38
Q

What are side effects of verapamil

A

Bradycardia
Constipation
Worsen HF

39
Q

What are contraindications of verapamil

A

Heart failure

40
Q

Give examples of thiazide diuretics

A

Bendroflumethiazide

Thiazide-like diuretic:
Metolazone
Chlortalidone

41
Q

What are contra indications of thiazide diuretic

A

Gout

42
Q

Give examples of alpha blockers

A

Doxazocin

43
Q

What is mechanism of action of alpha blockers

A

Inhibit alpha 1 adrenoceptor of Vascular SM
Inhibit Ca influx
Vascular SM relaxation
Reduce TPR

44
Q

What are side effects of alpha blockers

A

Postural hypotension
Ankle oedema
Dizziness

45
Q

Give examples of beta blockers

A

Atenolol, bisoprolol

46
Q

What is mechanism of action of beta blockers

A

Inhibit beta 2 adrenoceptor of Heart
reduce HR and contractility
Inhibit renin release

47
Q

What are side effects of beta blockers

A 
Bronchospasm
Bradycardia 
Lethargy 
Impaired glucose tolerance
Impaired exercise tolerance 
Impotence
48
Q

What are contraindications of beta blockers

A

Asthma

49
Q

Give examples of renin inhibitors

A

Aliskiren

50
Q

What is mechanism of action of renin inhibitors

A

Inhibit conversion of angiotensinogen to Angiotensin I

Reduce AII levels

51
Q

What are side effects and contra indications of aliskiren

A

Diarrhoea

Pregnancy

52
Q

Give examples of direct acting vasodilator

A

Hydralazine

Miroxidil

53
Q

When is direct acting vasodilator indicated

A

Severe hypertension

54
Q

How do you manage malignant hypertension

A

Treat immediately
Controlled reduction over days
Oral admin

55
Q

How do you manage hypertensive encephalopathy

A

IV sodium nitroprusside

BP reduction to 110 diastolic over 4 hrs

56
Q

What are cautions of sodium nitroprusside

A

Metabolised to cyanide
Caution in liver disease
Avoided repeated use

57
Q

What are side effects of hydralazine

A

Flushing
Tachycardia
Drug-induced Lupus

58
Q

What drugs are used in pharmacological management of heart failure

A 
Beta blocker
Ace inhibitor 
Spironolactone
Hydralazine combined with nitrate 
Digoxin
Diuretics: loop, thiazide
59
Q

Which medications improve long term mortality in heart failure

A

Beta blockers
Ace inhibitors
Spironolactone
Hydralazine with nitrates

60
Q

What is the role of diuretics in heart failure management

A

Symptom relief

No improvement in mortality

61
Q

What is first step of management of heart failure

A

Beta blocker

Ace inhibitor

62
Q

What is second step of management of HF

A

Addition of spironolactone or
ARB or
Hydralazine with nitrates

63
Q

What is third line of management of HF

A

Addition of Digoxin

64
Q

Which diuretics are used in HF management

A

Loop: furosemide
Add Spironolactone: If hypokalaemic
Add thiazide: if refractory oedema

65
Q

What are indications of ACE I

A

All HF patients

66
Q

What are indications of Beta blockers

What caution is required

A

All HF patients

Start at low dose, titrate slowly

67
Q

When is spironolactone indicated

A

Symptomatic despite optimal therapy

Post-MI with LVSD

68
Q

When is Digoxin indicated

A

Symptomatic despite optimal therapy

AF

Pharmacology (19 decks)

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