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Systems: Cardiovascualar AB > Hypertension Therapy > Flashcards

Hypertension Therapy Flashcards

1
Q

How is the diagnosis of hypertension made?

A
  • ABPM ambulatory blood pressure monitoring

- HBPM home blood pressure monitoring

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2
Q

Stage 1 hypertension

A
  • Clinical blood pressure is 140/90 mmHg or higher

- ABPM daytime average 135/85 mmHg or higher

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3
Q

Stage 2 hypertension

A
  • Clinic blood pressure is 160/100 mmHg or higher

- ABPM daytime average 150/95 mmHg or higher

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4
Q

Severe hypertension

A

Clinic systolic blood pressure is 180 mmHg or higher or diastolic blood pressure is 110mmHg or higher

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5
Q

What factors are considered when assessing risk of hypertension?

A
  • Previous MI, stroke, IHD
  • Smoking
  • Diabetes mellitus
  • Hypercholesterolemia
  • Family History
  • Physical Examination
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6
Q

How is end organ damage assessed?

A
  • ECG: LVH
  • ECHO: LVH
  • Proteinuria: ACR
  • Kidney: renal ultrasound
  • Renal function: eGFR
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7
Q

What treatable causes of hypertension are screened for?

A
  • Renal artery stenosis/ FMD
  • Cushings disease
  • Conn’s syndrome
  • Sleep apnoea
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8
Q

What is used to assess risk correctly?

A

Assign risk calculator/ Q-risk

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9
Q

What should you do once you have assessed a patient’s risk?

A

Set a target blood pressure

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10
Q

What does the BHS suggest the target blood pressure should be?

A

<135/80-85 mmHg

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11
Q

When should treatment be started?

A

When overall CVD risk of 20%/10 yrs

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12
Q

Why do we treat hypertension?

A
  • Reduce cerebrovascular disease by 40-50%

- Reduce MI by 16-30%

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13
Q

What is the general approach in the treatment of hypertension?

A
  • Stepped approach
  • Use low doses of several drugs
  • This approach minimises adverse events and maximises patient compliance
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14
Q

How is a stepped approach achieved?

A
  • Do not continuously change antihypertensive medication

- Add new medication to current therapy until the target BP is achieved

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15
Q

What are the go to drugs for the young?

A

High renin:

-ACE inhibitors/ ARB

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16
Q

What are the go to drugs for the elderly?

A

Low renin:

  • Calcium channel blocker
  • Thiazide type diuretic
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17
Q

Who with stage 1 hypertension should be offered treatment?

A

People aged under 80 yrs old with ABPM >135/85 with 1+ of :

  • Target organ damage
  • Established CVD
  • Renal disease
  • Diabetes
  • A 10 yr CV risk equivalent to 20% or greater
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18
Q

Who with stage 2 hypertension should be offered treatment?

A
  • ABPM >150/95 mmHg

- Any age

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19
Q

What should you do if faced with a patient under 40 and with stage 1 or greater hypertension?

A

Seek specialist evaluation of secondary causes of hypertension and a more detailed assessment of potential target organ damage.

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20
Q

What is the blood pressure target in the over 80s?

A

<145/85mmHg

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21
Q

How does the treatment compare between 80+ and 55-80 yrs old?

A

Offer the same hypertensive treatment, taking into account any co-morbidities

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22
Q

What should you do if people are identified as having ‘white coat effect’?

A

Consider ABPM or HBPM as adjunct to clinic BP measurements to monitor the response to antihypertensive treatment with lifestyle modification or drugs

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23
Q

Who should be offered CCB as step 1 antihypertensive treatment?

A
  • Age >55years

- Black people of African descent or Caribbean family origin

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24
Q

Why may a CCB not be suitable as stage 1 antihypertensive?

A
  • Oedema
  • Intolerance
  • Evidence of heart failure
  • High risk of heart failure
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25
Q

What should be offered to those unable to have CCB as stage 1 antihypertensive treatment?

A

Thiazide like diuretic

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26
Q

Who should be offered ACEI/ARB as stage 1 antihypertensive?

A

-Age<55years

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27
Q

Who should not have ACEI/ARB?

A
  • Afro-Caribbean

- Women of child bearing age

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28
Q

What is step 2 in hypertension treatment?

A

-Add thiazide type diuretic such as clortalidone or indapamide to CCB or ACEI/ARB

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29
Q

What is step 3 in hypertension treatment?

A

Add CCB, ACEI, Diuretic together

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30
Q

Who receives step 4 treatment?

A

Resistant hypertension

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31
Q

What is step 4 treatment?

A
  • Consider further diuretic therapy with low dose spironolactone if blood potassium is 4.5mmol/l or lower
  • Consider higher dose thiazide like diuretic if the blood potassium is more than 4.5mmol/l
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32
Q

Whys should caution be taken with those with reduced GFR and diuretics?

A

They have increased risk of hyperkalaemia

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33
Q

If there is no contraindications what treatment should someone over 55 be started on?

A

CCB

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34
Q

If the is no contraindications what treatment should a young person be started on?

A
  • ACEI or ARB

- If single agent doesn’t work then use 2

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35
Q

Give 2 examples of ACEI.

A
  • Ramipril

- Perindopril

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36
Q

What do ACEI do?

A

-Competitively inhibit the actions of ACE
-ACE converts angiotensin I to active
angiotensin II
-Angiotensin II is a potent vasoconstrictor and hypertrophic agent

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37
Q

What does angiotensin II play a central role in?

A

Organ damage

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38
Q

What are the contraindications for ACEI?

A
  • Renal artery stenosis
  • Renal failure
  • Hyperkalaemia
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39
Q

What are the adverse drug reactions of ACEI?

A
  • Cough
  • First dose hypotension
  • Taste disturbance
  • Renal impairment
  • Angioneurotic oedema
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40
Q

What drugs do ACEI interact with?

A
  • NSAIDs
  • Potassium supplements
  • Potassium sparing diuretics
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41
Q

ACEI and NSAIDs

A

Precipitate acute renal failure

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42
Q

ACEI and potassium supplements

A

Hyperkalaemia

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43
Q

ACEI and potassium sparing diuretics

A

Hyperkalaemia

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44
Q

Give 4 examples of ARB?

A
  • Losartann
  • Valsartan
  • Candesartan
  • Irbesartan
45
Q

What is another name for ARB?

A

-Angiotensin II Antagonists

46
Q

What do ARBs do?

A

-Angiotensin II antagonists competitively block the actions of angiotensin II at the angiotensin AT1 receptor

47
Q

What is the advantage of ARB over ACEI?

A

No cough

48
Q

Give 2 examples of vasodilator CCBs.

A
  • Amlodipine

- Felodipine

49
Q

Give 2 examples of rate limiting CCBs

A
  • Verapamil

- Diltiazem

50
Q

How do CCBs work?

A
  • Block the L type calcium channels
  • Selectivity between vascular and cardiac L type channels
  • Relax large and small arteries and reduce peripheral resistance
  • Reduce CO
51
Q

Vasodilating CCBs are the treatment of choice in:

A
  • Age>55 years

- Women of child bearing age

52
Q

What are the advantages of CCBs?

A
  • Compliance is high
  • Benefit in the elderly patient with systolic hypertension
  • Rarely cause postural hypotension
53
Q

What are the contraindications for CCBs?

A
  • Acute MI
  • Heart failure
  • Bradycardia
54
Q

What are the adverse drug reactions for CCBs?

A
  • Flushing
  • Ankle oedema
  • Headache
  • Indigestion and reflux oesophagitis
55
Q

What can the rate limiting CCBs cause?

A
  • Bradycardia

- Constipation

56
Q

Give 2 examples of thiazide type diuretics.

A
  • Indapamide

- Clortalidone

57
Q

Who are thiazide type diuretics used in as first line treatment?

A

Mild-moderate hypertension in Afro-Caribbean

58
Q

How can thiazide like diuretics be used in combination therapies?

A

Can be used in combination with any other agents

59
Q

What is there proven benefit for in for thiazide type diuretics?

A

Stroke and MI reduction

60
Q

What is the mechanism of action for thiazide type diuretics?

A

Block reabsorption od sodium and enhance urinary sodium loss

61
Q

What are the adverse drug reactions for thiazide type diuretics?

A
  • Not common
  • Gout
  • Impotence
62
Q

What are some less commonly used agents?

A
  • Alpha adrenorecptor antagonists
  • Centrally acting agents
  • Vasodilators
63
Q

Give an example of a alpha adrenoreceptor antagonist.

A

Doxazosin

64
Q

Give 2 examples of centrally acting agents.

A
  • Methyldopa

- Moxonidine

65
Q

Give 2 examples of vasodilators

A
  • Hydralazine

- Minoxidil

66
Q

What do alpha adrenoreceptors do?

A
  • Selectively block post synaptic a1 adrenoreceptors

- Oppose vascular smooth muscle contraction

67
Q

What are the adverse drug reactions for alpha adrenoreceptors?

A
  • First dose hypotension
  • Dizziness
  • Dry mouth
  • Headache
68
Q

What is the main use of methyldopa?

A

Treatment of hypertension of pregnancy

69
Q

How does methyldopa work?

A

Converted to a-methylnoradrenaline which acts on CNS a adrenoreceptors which decrease central sympathetic outflow

70
Q

What are the adverse drug reactions for methyldopa?

A
  • Sedation and drowsiness
  • Dry mouth and nasal congestion
  • Orthostatic hypotension
71
Q

What is moxonidine?

A

Centrally acting imidazoline agonist

72
Q

What is the common treatment regime for age>55?

A
  • Start CCB
  • Add thiazide type diuretic
  • Add ACEI
  • Add B blocker
  • Add less commonly used agent
73
Q

What is the common treatment regime for <55 years?

A
  • Start ACEI (women of child bearing age CCB or B blocker)
  • Add thiazide type diuretic
  • Add CCB
  • Add B blocker
  • Add less commonly used agent
74
Q

What is a common risk factor for pre-eclampsia?

A

Primary hypertension

75
Q

What happens to BP during normal pregnancy?

A

Falls

76
Q

Gestational hypertension

A

HT develops in pregnancy due to BP rise with no proteinuria

77
Q

Pre-eclampsia

A

HT develops from around 20 week in pregnancy due to severe BP rise with proteinuria

78
Q

What is important to remember when treating HT in pregnancy?

A

Many medications are teratogenic

79
Q

What drugs are safe to use pre-pregnancy?

A
  • NO ACEI or ARB
  • Nifedipine MR
  • Methyldopa
  • Atenolol
  • Labetalol
80
Q

What drugs should be used during pregnancy?

A

Add thiazide diuretic and/or amlodipine

81
Q

How is pre-eclampsia treated?

A
  • Treatment for HT in pregnancy
  • Plus IV esmolol, labetalol, hydralazine
  • Deliver the baby
82
Q

Hypertension in children UK

A

Using UK population data BP greater than or equal to 98th centile represents HT

83
Q

High normal BP children in the UK

A

Between the 91st and 98th centiles

84
Q

What is the prevalence of pre-hypertension in children?

A

3-10%

85
Q

What is the prevalence of hypertension in children?

A

0.1-3% depending on age and ethnicity

86
Q

What can childhood hypertension lead to?

A
  • Adult hypertension

- Target organ damage

87
Q

What end organ damage is childhood hypertension associated with?

A
  • Left ventricular hypertrophy
  • Decreased vascular responsiveness
  • Increased carotid artery intimal medical thickness
  • Reduced GFR
  • Increased atheroma deposition
  • Reduced cognitive scores
88
Q

What are the commonest causes of hypertension in new-borns?

A
  • Renal artery stenosis
  • Renal artery thrombosis
  • Congenital renal malformations
  • Coarctation
89
Q

What are the commonest causes of hypertension in infants (6years)?

A
  • Renal parenchymal disease
  • Coarctation
  • Renal artery stenosis
90
Q

What are the commonest causes of hypertension in children aged 6-10 years?

A
  • Primary hypertension
  • Renal artery stenosis
  • Renal parenchymal disease
91
Q

What are the commonest causes of hypertension in children aged 10-18 years?

A
  • Primary hypertension

- Renal parenchymal disease

92
Q

Why is there an increase in primary hypertension?

A
  • Obesity
  • ‘The Glasgow Salad’
  • Lack of exercise
93
Q

Accelerated hypertension

A
  • Increase in BP to levels >180mmHg systolic and >110 diastolic resulting in target organ damage such as neurological, cardiovascular or renal damage plus grade III retinal changes
  • A recent significant increase over baseline BP that is associated with target organ damage
94
Q

Malignant hypertension

A

Usually reserved for cases where papilloedema grade IV fundal changes are present

95
Q

Hypertensive urgency

A

Severe hypertension with no evidences of target organ damage

96
Q

What is accelerated hypertension associated with?

A
  • Non adherence to medication
  • An existing diagnosis of HTN and prescribed antihypertensive agents
  • Poor BP control prior to presentation
  • A lack of primary care contact. Lack of healthcare in general
  • Illicit drug use
97
Q

How should hypertensive urgency be treated?

A

Should not be considered an emergency but treated by reinstitution or intensification of drug therapy

98
Q

How are hypertensive emergencies treated?

A

-Reduction of MAP by less than 25% in 1st hour then to 160/100-1220mmHg by 2-6 hrs with subsequent gradual normalisation over 24-48hrs

99
Q

What should not be done in a hypertensive emergency?

A
  • Reduce BP suddenly and excessively
  • Use sublingual medication
  • Use rapidly acting nifedipine or ACEI
  • Use intermittent as required therapy, oral or IV
  • Use IV Hydralazine
  • Use sodium nitroprusside
100
Q

What will excessive correction of BP do?

A

-Further reduce organ perfusion and produce multi-organ infarction

101
Q

How are patients with hypertensive emergencies best managed?

A

With continuous infusion of short acting, titrable antihypertensive agent

102
Q

What type of administration should be avoided at all times?

A

Sublingual and IM

103
Q

What is the immediate goal in the treatment of accelerated hypertension?

A

Reduce DBP by 15-20% or to about 110mmHg over a 30-60 min period

104
Q

What should be set in the treatment of accelerated hypertension?

A

A 2h and 6h BP target to achieve

105
Q

What can be done after patients with accelerated hypertension are stabilised?

A
  • Oral therapy can be initiated and the IV agents slowly titrated down
  • Assess fluid status
106
Q

What agents should be used if there is pulmonary oedema?

A
  • IV GTN
  • IV furosemide
  • Amlodipine once stable
107
Q

What agents should be used if there is encephalopathy?

A
  • IV nicardipine, clevidipine
  • IV labetalol
  • IV esmolol
  • Amlodipine once stable
108
Q

What problems with treatment are there?

A
  • Late
  • Excessive BP reduction
  • Treatment failure
  • Adverse events
  • Multi-organ infarction due to profound hypotension
109
Q

What are the prognostic indicators for accelerated hypertension?

A
  • Plasma creatinine

- Follow up BP

Systems: Cardiovascualar AB (42 decks)

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