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Cardiovascular System > Hypertension Therapy > Flashcards

Hypertension Therapy Flashcards

1
Q

What do you need to identify before starting hypertension treatment?

A

True hypertension (from white coat hypertension) - use ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM)

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2
Q

What should be looked for and included in assessing risk of hypertension?

A 
Previous MI, stroke or IHD 
Smoking 
Diabetes mellitus 
Hypercholesterolaemia 
Family history
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3
Q

What tests should be done to assess for potential end organ damage from hypertension?

A 
ECG for LVH 
Echocardiogram for LVH 
Urine albumin to creatinine ratio for proteinuria 
Renal ultrasound for kidney damage 
eGFR for kidney function
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4
Q

What treatable causes of hypertension should be screened for?

A

Renal artery stenosis
Cushing’s disease
Conn’s syndrome
Sleep apnoea

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5
Q

What tools are available for risk assessment of hypertension?

A

Assign Risk Calculator

Q Risk

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6
Q

What does the BHS suggest as a target BP for hypertension treatment?

A

< 135/85mmHg

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7
Q

When should treatment of hypertension be started?

A

When overall CVD risk is 20%/10 years

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8
Q

What are the main reasons for treating hypertension?

A

Reduce cerebrovascular disease by 40-50%

Reduce MI by 16-30%

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9
Q

What is the treatment approach used for hypertension?

A

Stepped approach - do not continuously change medication, add new medication to current therapy until target BP is achieved
Low doses of several drugs

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10
Q

When should antihypertensive drug treatment be offered to people under 80 years old with ABPM > 135/85?

A 
When they have one or more of;
Target organ damage 
Established cardiovascular disease 
Renal disease 
Diabetes
10 year cardiovascular risk equivalent to 20% or greater
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11
Q

When should people with stage 2 hypertension be offered antihypertensive drug treatment?

A

Antihypertensive drug treatment should be offered to people of any age with stage 2 hypertension

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12
Q

When is specialist evaluation necessary in hypertension?

A

For people aged under 40 years with stage 1 hypertension or greater - evaluation of secondary causes and a more detailed assessment of potential target organ damage is necessary

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13
Q

What should be the approach to antihypertensive drug treatment in people over 80 years old?

A

Offer the same antihypertensive drug treatment as people aged 55-80, but take into account any co-morbidities
Blood pressure target will be different at 145/85mmHg

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14
Q

What should be the approach to treatment of white coat hypertension?

A

Consider ABPM or HBPM as an adjunct to clinical blood pressure measurements to monitor the response to antihypertensive treatment with lifestyle modification or drugs

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15
Q

What is stage 1 treatment of hypertension for people aged over 55 years?

A

Offer calcium channel blocker

If not suitable offer thiazide like diuretic

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16
Q

What is stage 1 treatment of hypertension for black people of African or Caribbean family origin of any age?

A

Offer calcium channel blocker

If not suitable offer thiazide like diuretic

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17
Q

When might a calcium channel blocker not be suitable?

A

Oedema
Intolerance
Evidence of heart failure

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18
Q

What is stage 1 treatment of hypertension for people under 55 years?

A

ACEI or ARB

These should not be offered to people of African or Caribbean family origin or to women of child-bearing age

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19
Q

What is step 2 treatment of hypertension?

A

Add a thiazide like diuretic to the existing CCB, ACEI or ARB

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20
Q

What is step 3 treatment of hypertension?

A

Combine CCB, ACE/ARB and thiazide like diuretic

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21
Q

What is step 4 treatment of hypertension?

A

Treatment of resistant hypertension
Consider further diuretic therapy with low-dose spironolactone if blood potassium level is 4.5mmol/l or lower
Consider high-dose thiazide-like diuretic if blood potassium level is higher than 4.5mmol/l

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22
Q

When might an ACEI and ARB both be used?

A

In young people where one is not sufficient in controlling BP

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23
Q

Give an example of an angiotensin converting enzyme inhibitor

A

Ramipril

Perindopril

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24
Q

How do ACEIs work?

A

Competitively inhibit the actions of angiotensin converting enzyme
Interfere with pathophysiology of coronary ischaemia and renal insufficiency through blockade of the renin-angiotensin system

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25
Q

What is the function of angiotensin converting enzyme?

A

Converts angiotensin I to active angiotensin II

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26
Q

What is the function of angiotensin II?

A

Potent vasoconstrictor and hypertrophic agent - plays a central role in organ damage

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27
Q

What are the contraindications to ACEI use?

A

Renal artery stenosis
Renal failure
Hyperkalaemia

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28
Q

What are the possible adverse drug reactions from ACEI use?

A 
Cough 
First dose hypotension
Taste disturbance 
Renal impairment 
Angioneurotic oedema
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29
Q

What are the potential drug-drug interactions from ACEI use?

A

NSAIDs - precipitate acute renal failure
Potassium supplements - hyperkalaemia
Potassium sparing diuretics - hyperkalaemia

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30
Q

Give an example of an angiotensin II antagonist

A

Losartan
Valsartan
Candesartan
Irbesartan

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31
Q

How do ARBs work?

A

Competitively block the actions of angiotensin II at the angiotensin AT1 receptor

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32
Q

What is the advantage of ARBs over ACEIs in terms of adverse drug reactions?

A

No cough

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33
Q

Give an example of a vasodilating calcium channel blocker

A

Amlodipine

Felodipine

34
Q

Give an example of a rate-limiting calcium channel blocker

A

Verapamil

Diltiazem

35
Q

How do CCBs work?

A

Block L-type calcium channels
Selectivity between vascular and cardiac L-type channels
Relax large and small arteries and reduce peripheral resistance
Reduce cardiac output

36
Q

When are vasodilation CCBs the antihypertensive of choice?

A

In over 55 year olds

Women of child-bearing age

37
Q

What is a rare adverse drug effect of CCBs?

A

Postural hypotension

38
Q

What are the contraindications for CCB use?

A

Acute MI
Heart failure
Bradycardia

39
Q

What are the potential adverse drug reactions of CCBs?

A

Flushing
Headache
Ankle oedema
Indigestion and reflux oesophagitis

Rate-limiting agents also cause;
Bradycardia
Constipation

40
Q

Give an example of a thiazide-like diuretic

A

Indapamide

Clortalidone

41
Q

When are thiazide-like diuretics commonly the first line treatment?

A

In mild-moderate hypertension in Afro-Caribbeans

42
Q

In what conditions do thiazide like diuretics have a proven benefit?

A

Stroke and myocardial infarction reduction

43
Q

What is the mechanism of action of thiazide-like diuretics

A

Block reabsorption of sodium

Enhance urinary sodium loss

44
Q

What are the possible adverse drug reactions of thiazide like diuretics?

A

Gout

Impotence

45
Q

What are some agents which can be used in hypertension treatment but which are less commonly used?

A

Alpha-adrenoceptor antagonists e.g. doxazosin
Centrally acting agents e.g. Methyldopa, moxonidine
Vasodilators e.g. hydralazine, minoxidil

46
Q

How do alpha adrenoceptor antagonists work?

A

Selectively block post-synaptic alpha-1 adrenoceptors

Oppose smooth muscle contraction in arteries

47
Q

What are potential adverse drug reactions of alpha adrenoceptor antagonists?

A

First dose hypotension
Dizziness
Dry mouth
Headache

48
Q

What is the main use of centrally acting agents?

A

Main use in treatment of hypertension of pregnancy

49
Q

How do centrally acting agents work?

A

Converted to alpha-methylnoradrenaline which acts on CNS alpha adrenoceptors which decrease central sympathetic flow

50
Q

What are the potential adverse drug reactions of centrally acting agents?

A

Sedation and drowsiness
Dry mouth and nasal congestion
Orthostatic hypotension

51
Q

What is the common starting regime for hypertension treatment in over 55s?

A

Start CCB
Add thiazide like diuretic if no or incomplete effect
Add ACEI if no or incomplete effect
Add beta-blocker if no or incomplete effect
Add one of less commonly used agents if still incomplete effect

52
Q

What is the common starting regime for hypertension treatment in the young?

A

Start ACEI
Start CCB or beta-blocker if female of child-bearing age
Add ACEI if incomplete effect
Add beta-blocker if incomplete effect
Add one of the less commonly used agents if still incomplete effect

53
Q

Why is it important to treat hypertension during pregnancy?

A

Second most common cause of maternal and foetal death

Common risk factor for pre-eclampsia

54
Q

What is gestational hypertension?

A

BP rises and patient develops hypertension during pregnancy, no proteinuria

55
Q

What is pre-eclampsia?

A

Where BP rises severely from about 20 weeks to a BP or 140-90mmHg combined with proteinuria of > 300mg/24 hours

56
Q

What drugs should not be given to treat hypertension in pregnancy?

A

ACEI

ARB

57
Q

What should treatment of pre-eclampsia involve?

A

Thiazide like diuretic and/or amlodipine

IV esmolol, labetalol or hydralazine

58
Q

How is hypertension defined in children?

A

Statistically

Systolic or diastolic BP ≥ 95th centile for gender, age and height on three or more separate occasions

59
Q

What is stage 1 hypertension in children?

A

BPs from the 95th-99th percentile plus 5mmHg

60
Q

What is stage 2 hypertension in children?

A

BP above the 99th percentile plus 5mmHg

61
Q

Between what centiles should blood pressure be considered high-normal for age?

A

Between 91st and 98th

62
Q

What is the prevalence of pre-hypertension and hypertension in children?

A

Pre-hypertension 3-10%

Hypertension 0.1-3%

63
Q

What is childhood hypertension associated with?

A

LVH
Decreased vascular responsiveness
Increased carotid artery intimal medial thickness
Reduced GFR
Increased atheroma deposition
Reduced cognitive scores in hypertensive children

64
Q

What are the commonest causes of hypertension in newborn infants?

A

Renal artery stenosis
Renal artery thrombosis
Congenital renal malformation
Coarctation of the aorta

65
Q

What are the commonest causes of hypertension in infants/children up to 6 years old?

A

Renal parenchymal disease
Coarctation of the aorta
Renal artery stenosis

66
Q

What are the commonest causes of hypertension in 6-10 year olds?

A

Renal parenchymal disease
Renal artery stenosis
Primary hypertension

67
Q

What are the commonest causes of hypertension in 10-18 year olds?

A

Primary hypertension

Renal parenchymal disease

68
Q

What is accelerated hypertension?

A

Increase in BP to levels ≥ 180mmHg systolic and ≥ 110mmHg diastolic resulting in target organ damage e.g. neurological, cardiovascular or renal damage plus grade III retinal changes

69
Q

What is malignant hypertension?

A

The term malignant hypertension is reserved for cases where papilloedema grade IV Randal changes are present

70
Q

What is hypertensive urgency?

A

Severe hypertension with no evidence of target organ damage

71
Q

What is accelerated hypertension associated with?

A

Existing diagnosis of hypertension and prescribed antihypertensive agents
Poor BP control prior to presentation
Lack of primary care contact and lack of healthcare in general
Non-Adherence to medication
Use of illicit drugs

72
Q

What do NHLBI and ESH/ESC guidelines recommend in hypertensive emergencies?

A

Reducing mean arterial pressure by by ≤ 25% for the first hour and then to 160/100-110mmHg by 2-6 hours, with subsequent gradual normalisation over 24-48 hours

73
Q

How should isolated large BP elevations (often associated with treatment discontinuation or reduction and with anxiety) be treated?

A

Should not be considered as an emergency but should be treated by reinstitution or intensification of drug therapy and treatment of anxiety

74
Q

What should not be done in treatment of a hypertensive emergency?

A

Do not reduce BP suddenly and excessiblef
Do not use sublingual medication
Do not use rapidly acting nifedipine or ACEI
Do not use intermitting as required therapy (oral or IV)
Do not use IV hydralazine
Do not use sodium nitroprusside

75
Q

What will excessive correction of BP result in?

A

Further reduced organ perfection and multi-organ infarction

76
Q

How are patients with a hypertensive emergency best managed?

A

With a continuous infusion of a short acting, titratable antihypertensive agent

77
Q

What is the immediate goal in treatment of a hypertensive emergency?

A

To reduce DBP by 15-20% or to about 100 mmHg over a period of 30-60 minutes

78
Q

How should a hypertensive emergency be managed?

A

Set a 2 hour and 6 hour BP target to be achieved
Stabilise with IV agent(s) then initiate oral therapy and titrate IV agent(s) down slowly
Assess fluid status

79
Q

How should pulmonary oedema in a hypertensive emergency be managed?

A

IV GTN started at low dose the up-titrate
IV furosemide
Initiate oral medication e.g. amlodipine 5mg once patient is stable

80
Q

How should encephalopathy in a hypertensive emergency be treated?

A

IV nicardipine 5mg/hour, elevidipine 1-2mg/hour
IV labetalol 0.5-2mg/min
IV esmolol 0.5-1mg/kg loading dose over 1 min then 50mg/kg/min and up to 300mgkg/min
Initiate oral medication such as amlodipine once stable

Cardiovascular System (40 decks)

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