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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
What should be offered to those unable to have CCB as stage 1 antihypertensive treatment?
Thiazide like diuretic
26
Who should be offered ACEI/ARB as stage 1 antihypertensive?
-Age<55years
27
Who should not have ACEI/ARB?
- Afro-Caribbean | - Women of child bearing age
28
What is step 2 in hypertension treatment?
-Add thiazide type diuretic such as clortalidone or indapamide to CCB or ACEI/ARB
29
What is step 3 in hypertension treatment?
Add CCB, ACEI, Diuretic together
30
Who receives step 4 treatment?
Resistant hypertension
31
What is step 4 treatment?
- 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
32
Whys should caution be taken with those with reduced GFR and diuretics?
They have increased risk of hyperkalaemia
33
If there is no contraindications what treatment should someone over 55 be started on?
CCB
34
If the is no contraindications what treatment should a young person be started on?
- ACEI or ARB | - If single agent doesn't work then use 2
35
Give 2 examples of ACEI.
- Ramipril | - Perindopril
36
What do ACEI do?
-Competitively inhibit the actions of ACE -ACE converts angiotensin I to active angiotensin II -Angiotensin II is a potent vasoconstrictor and hypertrophic agent
37
What does angiotensin II play a central role in?
Organ damage
38
What are the contraindications for ACEI?
- Renal artery stenosis - Renal failure - Hyperkalaemia
39
What are the adverse drug reactions of ACEI?
- Cough - First dose hypotension - Taste disturbance - Renal impairment - Angioneurotic oedema
40
What drugs do ACEI interact with?
- NSAIDs - Potassium supplements - Potassium sparing diuretics
41
ACEI and NSAIDs
Precipitate acute renal failure
42
ACEI and potassium supplements
Hyperkalaemia
43
ACEI and potassium sparing diuretics
Hyperkalaemia
44
Give 4 examples of ARB?
- Losartann - Valsartan - Candesartan - Irbesartan
45
What is another name for ARB?
-Angiotensin II Antagonists
46
What do ARBs do?
-Angiotensin II antagonists competitively block the actions of angiotensin II at the angiotensin AT1 receptor
47
What is the advantage of ARB over ACEI?
No cough
48
Give 2 examples of vasodilator CCBs.
- Amlodipine | - Felodipine
49
Give 2 examples of rate limiting CCBs
- Verapamil | - Diltiazem
50
How do CCBs work?
- 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
Vasodilating CCBs are the treatment of choice in:
- Age>55 years | - Women of child bearing age
52
What are the advantages of CCBs?
- Compliance is high - Benefit in the elderly patient with systolic hypertension - Rarely cause postural hypotension
53
What are the contraindications for CCBs?
- Acute MI - Heart failure - Bradycardia
54
What are the adverse drug reactions for CCBs?
- Flushing - Ankle oedema - Headache - Indigestion and reflux oesophagitis
55
What can the rate limiting CCBs cause?
- Bradycardia | - Constipation
56
Give 2 examples of thiazide type diuretics.
- Indapamide | - Clortalidone
57
Who are thiazide type diuretics used in as first line treatment?
Mild-moderate hypertension in Afro-Caribbean
58
How can thiazide like diuretics be used in combination therapies?
Can be used in combination with any other agents
59
What is there proven benefit for in for thiazide type diuretics?
Stroke and MI reduction
60
What is the mechanism of action for thiazide type diuretics?
Block reabsorption od sodium and enhance urinary sodium loss
61
What are the adverse drug reactions for thiazide type diuretics?
- Not common - Gout - Impotence
62
What are some less commonly used agents?
- Alpha adrenorecptor antagonists - Centrally acting agents - Vasodilators
63
Give an example of a alpha adrenoreceptor antagonist.
Doxazosin
64
Give 2 examples of centrally acting agents.
- Methyldopa | - Moxonidine
65
Give 2 examples of vasodilators
- Hydralazine | - Minoxidil
66
What do alpha adrenoreceptors do?
- Selectively block post synaptic a1 adrenoreceptors | - Oppose vascular smooth muscle contraction
67
What are the adverse drug reactions for alpha adrenoreceptors?
- First dose hypotension - Dizziness - Dry mouth - Headache
68
What is the main use of methyldopa?
Treatment of hypertension of pregnancy
69
How does methyldopa work?
Converted to a-methylnoradrenaline which acts on CNS a adrenoreceptors which decrease central sympathetic outflow
70
What are the adverse drug reactions for methyldopa?
- Sedation and drowsiness - Dry mouth and nasal congestion - Orthostatic hypotension
71
What is moxonidine?
Centrally acting imidazoline agonist
72
What is the common treatment regime for age>55?
- Start CCB - Add thiazide type diuretic - Add ACEI - Add B blocker - Add less commonly used agent
73
What is the common treatment regime for <55 years?
- 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
What is a common risk factor for pre-eclampsia?
Primary hypertension
75
What happens to BP during normal pregnancy?
Falls
76
Gestational hypertension
HT develops in pregnancy due to BP rise with no proteinuria
77
Pre-eclampsia
HT develops from around 20 week in pregnancy due to severe BP rise with proteinuria
78
What is important to remember when treating HT in pregnancy?
Many medications are teratogenic
79
What drugs are safe to use pre-pregnancy?
- NO ACEI or ARB - Nifedipine MR - Methyldopa - Atenolol - Labetalol
80
What drugs should be used during pregnancy?
Add thiazide diuretic and/or amlodipine
81
How is pre-eclampsia treated?
- Treatment for HT in pregnancy - Plus IV esmolol, labetalol, hydralazine - Deliver the baby
82
Hypertension in children UK
Using UK population data BP greater than or equal to 98th centile represents HT
83
High normal BP children in the UK
Between the 91st and 98th centiles
84
What is the prevalence of pre-hypertension in children?
3-10%
85
What is the prevalence of hypertension in children?
0.1-3% depending on age and ethnicity
86
What can childhood hypertension lead to?
- Adult hypertension | - Target organ damage
87
What end organ damage is childhood hypertension associated with?
- Left ventricular hypertrophy - Decreased vascular responsiveness - Increased carotid artery intimal medical thickness - Reduced GFR - Increased atheroma deposition - Reduced cognitive scores
88
What are the commonest causes of hypertension in new-borns?
- Renal artery stenosis - Renal artery thrombosis - Congenital renal malformations - Coarctation
89
What are the commonest causes of hypertension in infants (6years)?
- Renal parenchymal disease - Coarctation - Renal artery stenosis
90
What are the commonest causes of hypertension in children aged 6-10 years?
- Primary hypertension - Renal artery stenosis - Renal parenchymal disease
91
What are the commonest causes of hypertension in children aged 10-18 years?
- Primary hypertension | - Renal parenchymal disease
92
Why is there an increase in primary hypertension?
- Obesity - 'The Glasgow Salad' - Lack of exercise
93
Accelerated hypertension
- 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
Malignant hypertension
Usually reserved for cases where papilloedema grade IV fundal changes are present
95
Hypertensive urgency
Severe hypertension with no evidences of target organ damage
96
What is accelerated hypertension associated with?
- 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
How should hypertensive urgency be treated?
Should not be considered an emergency but treated by reinstitution or intensification of drug therapy
98
How are hypertensive emergencies treated?
-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
What should not be done in a hypertensive emergency?
- 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
What will excessive correction of BP do?
-Further reduce organ perfusion and produce multi-organ infarction
101
How are patients with hypertensive emergencies best managed?
With continuous infusion of short acting, titrable antihypertensive agent
102
What type of administration should be avoided at all times?
Sublingual and IM
103
What is the immediate goal in the treatment of accelerated hypertension?
Reduce DBP by 15-20% or to about 110mmHg over a 30-60 min period
104
What should be set in the treatment of accelerated hypertension?
A 2h and 6h BP target to achieve
105
What can be done after patients with accelerated hypertension are stabilised?
- Oral therapy can be initiated and the IV agents slowly titrated down - Assess fluid status
106
What agents should be used if there is pulmonary oedema?
- IV GTN - IV furosemide - Amlodipine once stable
107
What agents should be used if there is encephalopathy?
- IV nicardipine, clevidipine - IV labetalol - IV esmolol - Amlodipine once stable
108
What problems with treatment are there?
- Late - Excessive BP reduction - Treatment failure - Adverse events - Multi-organ infarction due to profound hypotension
109
What are the prognostic indicators for accelerated hypertension?
- Plasma creatinine | - Follow up BP

Systems: Cardiovascualar AB (42 decks)

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