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Cardio > Hypertension pathophysiology & treatment > Flashcards

Hypertension pathophysiology & treatment Flashcards

1
Q

Why is treatment of hypertension important?

A

The world’s number 1 cause of preventable morbidity and mortality

The UK’s number 1 preventable cause of premature mortality and morbidity

> 20% of deaths can be linked with hypertension

It is also the most cost effectively treated condition according to NICE

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2
Q

How big does the increase in BP need to be to pose a threat to your health?

A

Very small increase in BP has significant effects on health

2 mmHg rise in BP will:

  • increase risk of dying from IHD by 7%
  • increase risk of dying from a stroke by 10%
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3
Q

Complications of hypertension are described as ‘end-organ’

What organs are at risk?

A 
Brain 
Heart
Eyes 
Vasculature 
Kidneys
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4
Q

What complications can arise in the brain, due to hypertension?

A

Haemorrhage

Stroke

Cognitive decline

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5
Q

What complications can arise in the heart, due to hypertension?

A

Left ventricular hypertrophy

Coronary heart disease

Congestive heart failure

Myocardial infarction

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6
Q

What complications can arise in the vasculature, due to hypertension?

A

Peripheral vascular disease

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7
Q

What complications can arise in the Eyes, due to hypertension?

A

Retinopathy

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8
Q

What complications can arise in the kidneys, due to hypertension?

A

Renal failure

Dialysis

Transplantation

Proteinurea

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9
Q

Describe the variation in BP across a population

A

Normal distribution (bell curve)

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10
Q

The Framingham study investigated the correlation between increased BP & risk of stroke and cardiovascular disease

What did the study show?

A

Increasing blood pressure EXPONENTIALLY increases the risk of stroke & cardiovascular disease

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11
Q

At what blood pressure is a patient hypersensitive?

A

140/90

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12
Q

What is optimum BP?

A

120 / 80

or less

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13
Q

What are the classifications of hypertension according to NICE?

A

Stage 1

Stage 2

Severe

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14
Q

A patient with Clinic blood pressure is 160/100 mmHg or higher is…

A

Stage 2 hypertensive

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15
Q

A patient with ABPM daytime average 135/85 mmHg or higher is…

A

Stage 1 hypertensive

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16
Q

A patient with a clinic systolic blood pressure of 180 mmHg or higher or diastolic blood pressure is 110 mmHg or higher is…

A

Severely hypertensive

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17
Q

A patient with Clinic blood pressure is 140/90 mmHg or higher is…

A

Stage 1 hypertensive

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18
Q

A patient with ABPM daytime average 150/95 mmHg or higher is…

A

Stage 2 hypertensive

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19
Q

What is ABPM and why is it useful?

A

Ambulatory blood pressure monitoring

Takes an average BP over a longer period of time

Avoids problems such as white coat hypertension and gives a more reliable value for BP

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20
Q

What is the cause of most people’s hypertension?

A

No one knows

90% of hypertension is primary and idiopathic

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21
Q

What are the causes of secondary hypertension?

A 
Chronic renal disease 
Drug induced 
Endocrine disease
Vascular disease (CoA) 
Sleep apnoea 
Pre-eclampsia
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22
Q

What factors increase the risks associated with hypertension?

A

Smoking
Age
Male

Diabetes mellitus 
Renal disease 
Hyperlipidaemia 
Previous MI or stroke 
Left ventricular hypertrophy
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23
Q

Why does smoking increase the risk of morbidity with hypertension?

A

Adds 20/10 mmHg to BP

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24
Q

Why does Diabetes increase the risk associated with hypertension?

A

5 - 30 times increase in the risk of MI

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25
Q

How much higher is the risk of morbidity with hypertension in men than in women?

A

Twice as high with men

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26
Q

What effect does left ventricular hypertrophy have on the risk of morbidity from hypertension?

A

Doubles the risk

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27
Q

Therapy for hypertension targets the 3 main contributors to blood pressure

What are these factors?

A

Heart rate & Stroke volume (= cardiac output)

Peripheral vascular resistance

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28
Q

One way to manipulate blood pressure is via sympathetic stimulation

What does sympathetic stimulation produce?

A

Increases blood pressure:

vasoconstriction

reflex tachycardia

increased cardiac output

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29
Q

The Renin-Angiotensin-Aldosterone System is a long term control system for blood pressure

When stimulated, Renin is released and lots of stuff happens (in Big Stephen Davies’s topic) but overall, ANG II is produced

What does ANG II do?

A

vasoconstrictor

anti-natriuretic peptide

stimulator of aldosterone release from the adrenal glands

potent hypertrophic agent which stimulates myocyte and smooth muscle hypertrophy in the arterioles

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30
Q

ANG II stimulates mycoyte & smooth muscle hypertrophy

Why is this clinically relevant to hypertension?

A

Myocyte and smooth muscle hypertrophy:

  • are both poor prognostic indicators in patients with hypertension
  • partially explain why hypertension and the risks of hypertension persist in some patients despite treatment
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31
Q

Primary hypertension is idiopathic, however, what are the likely aetiological causes of primary hypertension?

A

Increased reactivity in arterioles:

  • Overall higher peripheral resistance
  • a result of an hereditary defect of the smooth muscle lining arterioles

Sodium Homeostatic effect:

  • Kidneys don’t excrete enough Na+ at any given BP
  • As a result, sodium & fluid are retained & BP is too high
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32
Q

What is the effect of age on blood pressure?

A

BP tends to rise with age

Possibly because of decreases arterial compliance

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33
Q

What is the approach to treating hypertension in the elderly?

(nothing specific)

A

Aggressively treated

treatment is shown by various studies to significantly reduce the risk of MI & stroke

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34
Q

What is the significance of genetics in hypertension?

A

Hypertension seems to run in families

Closest correlation is between siblings

> 30 genes can be involved hypertension (increase of 0.5 mmHg at most per gene)

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35
Q

What dietary ingredient is linked to hypertension?

A

Salt (sodium)

Strong correlation between salt intake & stroke, hypertension

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36
Q

What is the significance of alcohol with hypertension?

A

High alcohol intake is a common cause of hypertension

Large amounts of alcohol increase BP
However, small amounts of alcohol decrease BP

Relaxing beer vs chinning 10 VKs

Reducing a previously high alcohol intake reduces BP by 5/3 mmHg on average

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37
Q

What is the significance of weight with hypertension?

A

Being obese causes BP to rise

Weight loss for hypertensive obese patients is one of the most important non-pharmacological measures

38
Q

What is the correlation between birth weight and hypertension in later life?

A

low birth weight associated with hypertension in later life

39
Q

Renal disease accounts for 20% of resistant hypertension

What are examples of renal diseases that cause secondary hypertension?

A

chronic pyelonephritis

fibromuscular dysplasia

renal artery stenosis

polycystic kidneys

40
Q

Often, secondary hypertension is drug induced

What drugs can cause hypertension?

A

NSAIDs

Oral contraceptive

Corticosteroids

41
Q

What is the risk to a pregnant woman with hypertension?

A

Pre-eclampsia

42
Q

What endocrine disorders cause hypertension?

A

Conn’s Syndrome

Cushings disease

Phaeochromocytoma

Hypo and hyperthyroidism

Acromegaly

43
Q

What vascular problems cause secondary hypertension?

A

Coarctation of the aorta

44
Q

What sleeping problem causes hypertension?

A

Sleep apnoea

45
Q

Why couldn’t a GP diagnose hypertension in a single clinic?

A

GP would only have normal BP monitoring cuff which doesn’t give true blood pressure reading

To diagnose TRUE hypertension, must use ABPM or HBPM home blood pressure monitoring

46
Q

Summarise the different areas of investigations that must be done for a patient with newly diagnosed hypertension

A

Assess risk

Assess end organ damage

Screen for treatable causes of the hypertension

47
Q

Describe how end organ damage is investigated for

A

ECG & echocardiogram:
- to look for left ventricular hypertrophy

Proteinurea:
- ACR urine test

Renal ultrasound & eGFR (function test)

48
Q

What treatable causes of secondary hypertension are screened for?

A

Renal artery stenosis / FMD

Cushings disease

Conn’s syndrome

Sleep apnoea

49
Q

How is the risk posed to a patient with newly diagnosed hypertension assessed?

What does a risk assessment allow?

A

Assign risk calculator / Q risk - used to determine risk to the patient

Once risk is known - target blood pressure can be set for the patient

Generally, the target risk is < 135/80-85 mmHg

50
Q

What risk ‘score’ is needed for treatment to be needed?

A

Risk of CVD at 20% / 10 years

51
Q

Treating hypertension causes the risk of cerebrovascular disease to drop by _______

A

40-50%

52
Q

Treating hypertension causes the risk of MI to decrease by ______

A

16-30%

53
Q

What pharmacological approach is taken to treating hypertension?

A

Low doses of several drugs

This minimises adverse effects and thus increases compliance

54
Q

If a patient requires new medication for hypertension:

What do you do?
What do you not do?

A

Add new medication to current therapy until target BP achieved

DO NOT continuously change hypertensive medication

55
Q

What classes of drugs are used to treat hypertension?

BHS guidelines

A

A - ACE inhibitor/ARB

C - Calcium channel blocker

D - Diuretic - Thiazide type

(B was for beta blockers)

56
Q

Young (high renin) patients with hypertension should generally be given what type of drug?

A

ACE inhibitors / ARB

57
Q

Elderly (low renin) patients with hypertension should be given what type of drugs?

A

Calcium channel blockers & Thiazide diuretics

58
Q

Summarise the treatment route for Stage 1 hypertension

A

Offer antihypertensive drugs to people under the age of 80 with an ABPM reading above 135/85 if they have ONE OR MORE of the following:

  • Organ damage
  • Cardiovascular disease
  • Renal disease
  • Diabetes
  • CVD Risk of over 20% / 10 years

If under 40 years old:

  • Specialist evaluation for secondary causes
  • Detailed assessment of target organ damage
59
Q

What is the treatment route for people with stage 2 hypertension?

A

Patients with ABPM > 150/95 (stage 2)

Should be offered antihypertensives regardless of age

60
Q

How is the treatment route for people 80, or over, different for stage 1 hypertension?

A

Same drug treatment as people 55-80

Morbidities should be taken into account

Different blood pressure target of < 145/85 instead of 135/80-85 for younger people

61
Q

How is the response to antihypertensive drug treatment monitored?

A

BP can be measured at clinic for most people

However, people identified as having ‘white coat hypertension’ can use ABPM or HBPM instead

62
Q

A 60 year old male patient has been diagnosed with hypertension

What do you prescribe first?

A

Step 1 treatment = Calcium channel blocker

Amlodipine / Felodipine - vasodilators

Diltiazem / Verapamil - rate limiting

CCBs:

  • Aged over 55
  • African/caribbean origin of any age
63
Q

If a calcium channel blocker causes adverse effects on a patient (oedema, intolerance, high risk of heart failure)

(Patient is over 55)

What would you alternatively prescribe?

A

Thiazide-like diuretic

  • Clortalidone
  • Indapamide
64
Q

What is the step 1 treatment for a patient under 55?

A

ACE Inhibitor /ARB

Not afro-caribbean
Not women of child baring age

65
Q

Why must you NEVER prescribe ACE inhibitors to women of child baring age?

A

Teratogenic

66
Q

If step 1 treatment is proving ineffective, what would you prescribe next?

A

Step 2

Thiazide type diuretic:

  • Clortalidone
  • Indapamide

Added on to current prescription (CCB or ACEI/ARB)

67
Q

If a patient is on CCB’s and Thiazide type diuretic treatment but their BP is still not improving as much as desried

What is the next step?

A

Step 3

CCB, ACEI & diuretics together

68
Q

If a patient does not respond to Step 3 treatment, they are said to have _________

A

Resistant hypertension

69
Q

What is the treatment for ‘resistant hypertension’?

A

Add further diuretic treatment to current list (CCB’s, ACEI & diuretic)

If patient has potassium blood level of <4.5 mmol/L:
- Spironolactone 25mg once daily

If patient has potassium blood level > 4.5 mmol/L:
- Higher dosage of thiazide type diuretic

70
Q

Briefly describe the treatment for young people for hypertension

A

ACEI ± ARB

If single agent doesn’t work, then use both together

71
Q

What are ACE inhibitors?

A

Angiotensin converting enzyme inhibitors

eg Ramipril

ACE enzyme is used in RAA system to convert ANG I into ANG II

ANG II causes increase in BP so ACE inhibitors stop it’s production

72
Q

What are ARBs?

A

Angiotensin receptor blockers

Losartan
Valsartan
Candesartan
Irbesartan

(anything with “…sartan”)

Competitive antagonist of ANG II at the AT1 receptor:
- thus blocks effects of ANG II

Advantage over ACE inhibitors = no cough

73
Q

ACEIs and ARBs reduce production of ANG II which plays a central role in organ damage

What organs are damaged by ANG II?

A

Brain
Heart
Vasculature
Kidneys

74
Q

How does ANG II damage the kidneys?

A

Lowers Glomerular filtration rate

Increase prteinurea

Increases aldosterone release

Glomerular sclerosis

75
Q

What are the common adverse drug reactions associated with anti-hypertensives?

A

Cough

First dose hypertension

Taste disturbance

Renal impairment

Angioneurotic oedema

76
Q

When prescribing anti-hypertensive medications:

For what reason is it necessary to check if the patient takes any over the counter medication?

A

NSAIDs (aspirin, ibuprofen, naproxen):

- Precipitate acute renal failure

77
Q

When prescribing anti-hypertensive medications:

Why must you check to see if the patient takes any supplements?

A

Adverse reaction with potassium supplements

= Hyperkalaemia

78
Q

When prescribing anti-hypertensives:

What other prescribed medication has adverse drug-drug interactions with antihypertensives?

A

Potassium sparing diuretics
(spironolactone, amiloride, and triamterene)

= Hyperkalaemia

79
Q

Aside from ACEIs, ARBs, CCBs & TT diuretics :

What other medication can be used to treat hypertension?

A

Beta blockers

‘Atenolol’

80
Q

Describe how Calcium channel blockers work…

A

Work by blocking “L type calcium channels”

They have selectivity between cardiac and vascular L type channels

Their effect:

  • Relax large & small arteries = reduce peripheral resistance
  • Reduce cardiac output
81
Q

When would you prescribe vasodilating CCBs? (amlodipine or Felodipine)

What are it’s advantages?

A

Its the suitable antihypertensive for:
> 55 years
Women of child baring age

  • High compliance
  • Especially beneficial in elderly patients with systolic hypertension
  • Rarely causes postural hypotension (extreme drop in BP when stood up)
82
Q

A patient has recently been prescribed diltiazem, and you are giving them an examination

What signs/symptoms would indicate an adverse drug reaction with Diltiazem?

A

(Diltiazem is a rate limiting CCB)

Inspection:

  • Flushing
  • Ankle oedema

Palpation:
- Bradycardia (specific to rate limiting CCBs)

Symptoms:

  • Headache
  • Constipation
  • Indigestion & reflux oesophagitis (acid reflux)
83
Q

If you’ve got a patient who’s a wee wimp and doesn’t like feeling ill

What type of anti-hypertensive is good to prescribe them?

A

Thiazide type diuretics

Rarely have adverse drug reactions

If they do:

  • Gout
  • Impotence
84
Q

What are the less commonly prescribed agents for hypertension?

A

Alpha-adrenoceptor antagonists:
- Doxazosin

Centrally acting agents:

  • Methyldopa
  • Moxonidine

Vasodilators:

  • Hydralazine
  • Minoxidil
85
Q

How do alpha-adrenocepter antagonists work?

A

DOXAZOSIN

  • Selectively block post synaptic 1-adrenoceptors
  • Oppose vascular smooth muscle contraction in arteries

Has a fuck ton of adverse reactions:

  • First dose hypotension
  • Dizziness
  • Dry mouth
  • Headache
86
Q

What is Methyldopa?

A

Central acting agent

It’s main use is in treating hypertension of pregnancy

It works by doing some spicy stuff:
- Decreases central sympathetic outflow

Adverse reactions:

  • Sedation and drowsiness
  • Dry mouth and nasal congestion
  • Orthostatic hypotension
87
Q

Summarise the common order of prescribed drugs for someone over 55…

(Assuming BP isnt dropping to target)

A

1) CCB
2) Thiazide type diuretic
3) ACE inhibitor
4) Spironolactone or increased dose of TTD
5) Beta blocker
6) Spicy medication

88
Q

Summarise the common order of prescribed drugs for a young male…

A

1) ACEI
2) Thiazide type diuretic
3) CCB
4) Spironolactone or increased TTD dose
5) Beta blocker
6) Spicy drugs

89
Q

Why is being hypertensive and getting pregnant risky business?

A

Approximately 30% of women who have hypertension before pregnancy will develop preeclampsia

2nd most common cause of maternal & foetal death

90
Q

On top of hypertensive medications

What should be administered to a pregnant woman with pre-eclampsia?

A

intravenous hydralazine, esmolol, labetalol

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