Hypertension Therapy Flashcards by Jake Roulstone

How is true hypertension diagnosed?

ABPM - HBPM (home)

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How is risk of hypertension assessed?

Previous MI, stroke, IHD - Smoker - Diabetes - Hypercholesterolaemia - Family history (familial HCRM) - Physical exam

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What would you do to assess the end organ damage of the heart?

ECG - Echocardiogram

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What would you do to assess the end organ damage of the kidneys?

Proteinuria - Renal ultrasound - Renal function (glomerular filtration)

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How would the cause of the hypertension be tested?

Screen for common causes such as endocrine or renal artery stenosis

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What does LVH stand for?

Left ventricular hypertrophy

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What does the ECG show?

Left ventricular hypertrophy can be seen by the inversion of the t wave

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After you have calculated the patients risk what should you next do?

Choose a target BP to reduce to

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At what assign-score risk should treatment for CVD be given?

15-20%

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How do we treat hypertension?

Slow stepped approach
Low doses of multiple drugs

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Why are low doses of multiple hypertensives given?

Reduce side effects

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What class are young people given when deciding hypertension therapy?

A (high renin)

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What drugs are given for people with high renin?

ACE inhibitors

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What class are elderly people put into for hypertension therapy?

C and D (low renin)

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What drugs are used to treat C and D classes?

C - calcium channel blocker

D - thiazide - type diuretic

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When should treatment of stage 1 hypertension of someone under the age of 80 be given?

If they have any of the following

Organ damage
CVD
Renal disease
Diabetes
CVD risk of greater than 20%

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Why is a thiazide-like diuretic sometimes offered in place of a calcium channel blocker?

Intolerence
Evidence or high risk of heart failure

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What is added to the treatment of hypertension if CCB doesn’t reach intended BP?

Thiazide-type diuretic such as clortalidone/indapamide
ACEI

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If desired BP isn’t reached after CCB and additions what is done?

CCB
ACEI
Diuretic

All given at the same time

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If all three drugs together what should be done?

Further diuretic therapy with low dose spironolactone if K levels low
Consider higher dose thiazide-like diuretic

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What are examples of ACE inhibitors?

RAMIPRIL
Perindopril

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What are the contraindictions of ACEI?

Renal artery stenosis
Renal failure
Hyperkalaemia

What are the adverse drug reactions of ACEI?

Cough
First dose hypotension
Taste disturbance
Renal impairment
Angioneurotic oedema (rapid swelling of the dermis)

What are the drug-drug interactions with ACEI?

- NSAIDs - acute renal failure - Potassium supps - hyperkaelemia - Potassium sparing diuretics - hyperkalaemia

What are ARB's?

Angiotensin II antagonists

What is the advantage of ARB's over ACEI?

No cough

What are the two common vasodilator calcium channel blockers?

- Amlodipine - Felodipine

What are the 2 common rate limiting CCB?

- Verapamil - Diltiazem

How do CCB's work?

- Blocking L-type calcium channels - Can be selective between vascular and cardiac L type channels - Relaxes large and small arteris (TPR down) - Reduces CO

What are the CCB's contraindictions?

- Acute MI - Heart failure, bradycardia

What are the adverse drug reactions of CCB's?

- Flushing - Headache - Ankle oedema - Ingestion and reflux oesophagitis

What can rate limiting agents (CCB's) also cause?

- Bradycardia - Constipation

Diagram showing CCB's action

Notice how reducing calcium level will reduce contraction level

What are the 2 common thiazide type diuretics?

- Indapamide - Clortalidone

Where do Thiazides work on in the nephron?

Distal tube

How do thiazide type diuretics work?

- Block reabsorption of sodium - Enhance loss of sodium through urine

What are less commonly used antihypertensives?

- Alpha adrenoreceptor antagonists - Doxazosin - Centrally acting agents - methyldopa, moxonidine - Vasodilators - hyrdalazine, minoxidil

What is the mechanism of action of doxazosin?

- Block post synaptic alpha 1 adrenoreceptors - Stop vascular smooth muscle contraction in arteries

What is the main use of methyldopa to treat hypertension?

In pregnancy

What does methyldopa do?

Acts on alpha receptors in the CNS to decrease sympathetic innervation

Take a patient at 55 years, this is your course of action

If over 55years of age •Start CCB –No or incomplete effect •Add Thiazide-type diuretic –Incomplete effect •Add ACE inhibitor –Still incomplete effect •Add Beta-blocker –Still incomplete effect •Add one of the less commonly used agents

This is the course of action for a young hypertensive

* Start ACEI * If female of child bearing age CCB or Beta Blocker * No or incomplete effect * Add Thiazide type diuretic –Incomplete effect •Add Calcium channel blocker –Still incomplete effect •Add Beta-blocker –Still incomplete effect •Add one of the less commonly used agents

What is the treatment for gestational hypertension?

- NO ACEI OR ARB - Pre pregnancy - use nifedipine, methyldopa, atenolol, labetalol - During pregnancy - add thiazide diuretic

What is the prevelence of childhood pre hypertension?

3-10%

What is typical end organ damage associated with childhood hypertension?

- LVH - Decreased vascular response - Increased carotid artery medial thickness - Low GFR - Increased atheroma deposits - Reduced cognitive scores

What are the common causes of hypertension in newborn infants?

- Renal artery thrombosis - Renal artery stenosis - Congenital renal malformations - Coarctication

What are the common causes of hypertension in infants?

- Renal parenchymal disease - Coarctication - Renal artery stenosis

Why is there an increase in primary childhood hypertension?

- Obesity - Lack of exercise Both very high at the moment

What is accelerated hypertension?

An increase in blood pressure (180/110) resulting in organ damage and retinal changes

What is malignant hypertension?

Cases where papilloedema (stage 4) fundal changes are present (optical disc swelling caused by increased cranial pressure)

What is accelerated hypertension associated with?

- Existing hypertension diagnosis - Poor BP control - POOR REACTION TO MEDICATION

WHAT NOT TO DO WITH HYPERTENSIVE PATIENTS

* Do not reduce BP suddenly and excessively. * Do not use sublingual medication. * Do not use rapidly acting nifedipine or ACEI. * Do not use intermittent as required therapy, oral or IV. * Do not use IV hydralazine –5-20 minute lag before producing an erratic response •Do not use sodium nitroprusside –(coronary steal syndrome and increased intracranial pressure, cyanide toxicity)