Hypertension Rx Flashcards
What is the aim of treatment
BP 140 / 90 if <80 or 135/85APBM
Higher in elderly (150/90) or 145 / 85
Lower in DM if complications - 130/80
Lower in DM if type 1 - 135/80
What are non-pharmacological measures (trial period of this unless severe)
Weight reduction Low fat / low salt Exercise Limit alcohol Stop smoking
When do you start pharmacological Rx
What do you do if <40
> 160 / >100 - stage 2 any age
or stage 1 if CVD risk or DM / renal / CVS disease or organ damage or 10% Q risk score
If <40 specialist advice for 2 causes
What is Rx plan for <55 / any DM no matter what
Start on ACEI / ARB - more likely to be due to high renin
Add CCB
Add thiazide diuretic (increase dose if K high)
Add alpha / BB if high K >4.5
Add spironolactone if K <4.5
What do you start with in female <55
CCB
BB
ARB is teratogenic
What is Rx plan for >55 / African (usually low renin)
Start CCB
Add ARB if black (preferred to ACEI)
Add diuretics
Add AB / BB / less common
When would you start with diuretic first
If oedema, HF or CCB not suitable
CCB CI in HF and oedema
What would you do if hypertension is still resistant
CHECK COMPLIANCE Consider further diuretic dose Lose dose spironolactone but risk of hyperkalaemia in reduced GFR Alpha blocker Beta blocker Monitor U+E closely
Why would you not give diuretic and BB together or BB + rate limiting CCB
Aggravate asthma
Conduction block
What are less common hypertension agents
Alpha antagonist
BB
Methylodopa
Vasodilators
What is Rx plan in pregnancy
Labetalol / atenolol
CCB (nifedipine / amlodipine)
Methydopa
Add diuretic during pregnancy
If PET
- Add IV lavetalol / esmolol
- Add hydralazine
- May require termination
What does ACEI do (Ramipril / Perindopirl)
Inhibit angiotensin converting enzyme
Preventions conversion to angiotensin II
Reduce preload and after load
Useful in DM / nephropathy / poor LV function / HF
When are ACEI CI
Renal stenosis / failure Hyperkalaemia - stop ACEI and recheck Pregnancy Breast feeding High dose diuretics Can cause hyperkalaemia is used with NSAID
What are the SE of ACEI
Cough
First dose hypo (common with diuretic)
Renal impairment - check U+E before starting and 2 months after
Interact with NSAID, K supplement and K sparing diuretics = renal + hyperkalamia
Angioedema - stop if develop
What do you suspect if low K and give an ACEI and K doesn’t increase
Conns disease - aldosterone secreted by adrenal
- Hypokalaemia
- Hypernatraemia
- Hypertension
What does ARB do (Larsartan)
Block angiotensin II
No cough and less renal dysfunction
DONT use ARB and ACEI as renal failure
What are benefits of ARB
No cough
Less renal dysfunction
More effective than a BB in preventing CVD / stroke / DM
What shouldn’t you use together and how do you monitor ACEI
ACEI and ARB due to renal
U+E prior to starting and if increase dose
Creatinie and K may rise initially
What is an ARNI
ACEI, ARB and nephrilysen together
What does nephrilysen do
Block ANP / BNP (vasodilators)
What do CCB do
Block L type Ca channels present in myocardial cells and vascular smooth muscles
Relax arteries, reduce resistance and CO
Useful in IHD, angina and hypertension
What are the types of CCB
Vasodilator - Amlodopine - Nifedipine Rate Limiting - reduce HR - Verapamil - Diltazem
When are CCB CI
Acute MI
UAP
HF as -ve inotropic
Bradycardia
What are the SE CCB
Rate Limiting Hypotension Conduction block HF Bradycardia Palpitations
Vasodilators - no affect on heart Peripheral oedema so don't give if swelling Flushing Headache Indigestion
What should you never use
Mifidepine immediate release as precipitate stroke / MI
What do thiazide diuretics do (Indapamide)
Block reabsorption of sodium at DCT
Reduce stroke and MI risk
What are SE of thiazide
Gout due to dehydration Impotence Dehydration Postural hypo Impaired glucose Hyponatraemia Hypercalcaemia - loop causes hypo Hypokalaemia Hypouric - useful in renal stone
What is a potassium sparing diuretic
Spironolactone 50-200mg / Eplenerone
Aldosterone antagonist that acts in DCT
What do alpha blockers do (Doxazosin)
Block A1
Oppose contraction
Vasodilation
Useful in BPH
What are the SE of A blockers
Hypotension HF - dyspnoea Dizzy Dry mouth Headache Cough
When should you use BB
Young intolerance to ACEI
Always add CCB NOT diuretic
What do BB do
Attenuate effects of sympathetic and renin
Don’t protect against heart disease
When are BB CI
Asthma COPD Diuretic - worsen asthma Sick sinus Caution in HF / PVD / DM NEVER with verapamil
What are the SE of BB
HF Bradycardia Bronchospasm COld periphery Lethargy Impotence Sleep disturbance Insulin resistance
What are the central acting agents
Methyldopa
Hydralazine
What does methyldopa do
Decrease sympathetic outflow
Always sustained release
What are the SE of methyldopa
Drowsy Dry mouth Nasal congestion Orthostatic hypo Depression - never give after pregnancy
When are vasodilators used (Hydralazine / Minoxidil)
If resistant to everything in combination with BB
What are SE of vasodilator
Bronchospasm Postural hypo Bradycardia Fatigue Hallucinations
What should be offered as well as Rx
Annual review
Monitor BP
Provide support
Discuss lifestyle, symptoms and medication
What should you do before starting ACEI
Baseline U+E
Why do you start with ACEI in DM
Renoprotective
How do you monitor ACEI
Baseline U+E
U+E if increase dose
U+E annual
Other indications for K sparing diuretic
Ascites
HF
Nephrotic
Conn’s
What do you do if BP >180 / >120
Same day Rx / referral
