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CARD - 1 > Hypertension Therapy > Flashcards

Hypertension Therapy Flashcards

1
Q

How do you identify true hypertension?

A

ABPM (ambulatory BP monitoring)
or
HBPM (home BP monitoring)

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2
Q

What is ABPM?

A

Non-invasive method of obtaining BP readings over a 24-hour period, whilst the patient is in their own environment, representing a true reflection of their blood pressure

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3
Q

Define stage 1 HTN

A

Clinic BP 140/90mmHg or higher

ABPM daytime average 135/85mmHg or higher

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4
Q

Define stage 2 HTN

A

Clinic BP 160/100mmHg or higher

ABPM 150/95mmHg or higher

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5
Q

Define severe HTN

A

Clinic systolic BP 180mmHG or higher or diastolic BP 110mmHg or higher

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6
Q

What is involved in assessing the risk of someone with HTN?

A

Ask about previous stroke, MI, IHD
Find out if they smoke, have DM, hypercholesterlaemia
Check FH
Physical Ex

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7
Q

How can you assess the end organ damage of HTN?

A

ECG/echo (LCH)
Proteinuria (ACR)
Kidney (renal USS)
Renal function (eGFR)

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8
Q

What are some treatable causes of HTN you should screen for?

A

Renal artery stenosis/fibromuscular dysplasia
Cushings disease
Conn’s syndrome
Sleep apnoea

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9
Q

What is the ASSIGN risk score used to calculate?

A

Risk of developing CV disease in the next 10 years

Q risk is an equivalent calculator

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10
Q

How to manage someone with HTN?

A

Assess risk
Set a target BP to be obtained
Address lifestyle
Treat using stepped approach, starting with lowest doses of several drugs

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11
Q

What does the BHS suggest a target BP to be?

A

<135/80-85mmHg

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12
Q

When should treatment of HTN be started?

A

At an overall CVD risk of 20% in 10 years

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13
Q

Why do we treat hypertension?

A

Reduce cerebrovascular disease and MI

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14
Q

What are the BHS guidelines for the treatment of hypertension?

A

In younger patients (who have more renin) use ACEi/ARB

In older patients (who have less renin) better to use CCB or thiazide type diuretic

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15
Q

When do you offer an antihypertensive for stage 1 hypertension?

A

<80y, ABPM >135/80 + one of:

  • Target organ damage
  • Established CV disease
  • DM
  • Renal disease
  • A 10yr CV risk of 20% or greater
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16
Q

When do you offer an antihypertensive for stage 2 HTN?

A

Always

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17
Q

If someone is diagnosed with HTN under 40 what should you do?

A

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

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18
Q

What is different about managing >80 year olds with HTN?

A

Use same drugs BUT target BP is <145/85

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19
Q

What group of patients benefit most from ABPM or HBPM?

A

Those who have white coat effect

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20
Q

What is the first line treatment for HTN?

A

If 55y+/black - CCB
(if not suitable for CCB offer thiazide type diuretic)

If <55y - offer ACEi/ARB

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21
Q

Give reasons for why someone may not be suitable for CCBs

A

It gives them side effects, e.g. oedema

There is evidence of heart failure/high risk of heart failure

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22
Q

What individuals are not suitable for treatment with ACEi/ARBs?

A

Afrocaribbean

Women of child baring age

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23
Q

What is the second line treatment for HTN?

A

Add thiazide type diuretic to CCB/ARB/ACEi

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24
Q

What is third line treatment for HTN?

A

Add CCB, ACEi, diuretic together

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25
Q

What is involved in fourth line treatment of (treatment resistant) HTN?

A

Add on spironolactone (25mg once daily) if blood K is 4.5mmol/L or lower - caution in those with reduced eGFR as they may be at risk of hyperkalaemia

If blood potassium higher than 4.5mmol/l consider higher dose thiazide diuretic

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26
Q

Give examples of thiazide type diuretics

A

Clortalidone

Indapamide

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27
Q

Give examples of ACEi

A

Ramipril, perinodopril

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28
Q

How do ACEis work?

A

Competitively inhibit the actions of angiotensin converting enzyme (ACE coverts angiotensin 1 into angiotensin 2)

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29
Q

What is the action of angiotensin 2?

A

Potent vasoconstrictor and hypertrophogenic agent

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30
Q

What is your systolic BP?

A

Arterial pressure when the heart contracts

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31
Q

What is your diastolic BP?

A

Arterial pressure when the heart is relaxed

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32
Q

What is a normal BP?

A

120/80mmHg

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33
Q

How does HTN affect BVs?

A

Causes wear and tear of the endothelial cells lining the BVs and causes them to crack –> MIs/strokes/aneurysms

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34
Q

What is essential/primary HTN?

A

HTN that has no cause

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35
Q

What are some risk factors for essential HTN?

A

Obesity, sedentary lifestyle, diet high in salt, older age

36
Q

What % of HTN is secondary?

A

10%

37
Q

Give an example of what can cause secondary HTN?

A

Low renal blood flow, e.g. secondary to atherosclerosis, vasculitis or aortic dissection

When low BF to kidneys, they secrete renin which causes more water to be retained and hence increases BP

38
Q

What condition can lead to secondary HTN?

A

Fibromuscular dysplasia

39
Q

What kinds of tumours can lead to secondary HTN?

A

Aldosterone secreting tumours

40
Q

Give the 3 ways that juxtaglomerular cells in the kidneys control BP

A
  1. They are mechanoreceptors: when they collapse from low BP they stimulate renin secretion and vice versa
  2. Mechanoreceptors in the aortic arch and carotid sinus (when they collapse) send sympathetic impulses to the JG cells to stimulate renin release
  3. Macula densa cells (chemoreceptors) sense when Na/Cl is low and send signal to the JG cells to produce renin
41
Q

What does secretion of renin lead to?

A

Stimulation of RAAS
Renin goes into plasma and cleaves peptides off of angiotensinogen leaving angiotensin 1
ACE resides in endothelial cells (esp those in lung) and converts angiotensin 1 into angiotensin 2

42
Q

What is the role of angiotensin 2?

A

Acts on BVs around the body which have the angiotensin 2 receptor and cause them to vasoconstrict –> increasing resistance to BF

43
Q

What are the contraindications of ACEi?

A

Renal artery stenosis
Renal failure
Hyperkalaemia

44
Q

What are the ADRs of ACEis?

A 
Cough 
First dose hypotension 
Taste disturbance
Renal impairment
Angioneurotic oedema
45
Q

What drugs could not be co-prescribed with ACEis?

A

NSAIDs - can precipitate AKI
Potassium supplements - can cause hyperkalaemia
Potassium sparing diuretics - hyperkalaemia

46
Q

Give examples of angiotensin 2 antagonists

A

Losartan, valsartan, candesartan, irbesartan

47
Q

How do ARBs work?

A

Competitively block the actions of angiotensin 2 at the angiotensin AT1 receptor

48
Q

What is the advantage of using ARBs over ACEis?

A

No cough

49
Q

What are the two types of CCBs?

A

Vasodilators

Rate limiters

50
Q

What are the vasodilating CCBs?

A

Amlodipine/felosipine

51
Q

What are the rate limiting CCBs?

A

Verapamil/dilitiazem

52
Q

How do CCBs work?

A

Blocking the L type calcium channels

They relax large and small arteries and reduce peripheral resistance and reduce cardiac output

53
Q

Do CCBs have selectivity between vascular and cardiac L type channels?

A

Yes

54
Q

Who are CCBs the antihypertensive of choice for?

A

Over 55ys

Women of childbearing age

55
Q

Why are CCBs good for elderly patients?

A

They rarely cause postural hypotension

56
Q

What are the contraindications to CCBs?

A

Acute MI

Heart failure, bradycardia (rate limiting CCBs)

57
Q

What are the ADRs of CCBs?

A

Flushing
Headache
Ankle oedema
Indigestion, reflux oesophagitis

Rate limiting CCBs can also cause bradycardia and constipation

58
Q

How do thiazide type diuretics work?

A

Block reabsorption of sodium and enhance urinary sodium loss

59
Q

What is the issue with giving thiazide diuretics?

A

Full antihypertensive effect may take weeks

ADRs not common, but may include gout and impotence

60
Q

What are some less commonly used drugs for treating HTN?

A

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

61
Q

How does doxazosin work?

A

Selectively blocks post-synaptic a1-adrenoreceptors, hence opposing vascular smooth muscle contraction in arteries

62
Q

What are the ADRs of doxazosin?

A

First dose hypotension
Dizziness
Dry mouth
Headache

63
Q

What is the main use of methyldopa?

A

Treatment of HTN in pregnancy

64
Q

How does methyldopa work?

A

Converted into a-methylnoradrenaline which acts on CNS alpha adrenoceptors which decrease central sympathetic outflow

65
Q

What are ADRs of methyldopa?

A

Sedation and drowsiness
Dry mouth and nasal congestion
Orthostatic hypotension

66
Q

What is moxonidine?

A

Centrally acting imidazoline agonist

67
Q

What is the typical treatment regimen for someone over 55 with HTN?

A
  1. CCB
    • TZD
    • ACEi
    • beta-blocker
    • less commonly used agent
68
Q

What is the typical treatment regimen for someone under 55y?

A
  1. ACEi (if woman of child bearing age - CCB/beta-blocker)
    • TZD
    • CCB
    • beta blocker
    • less commonly used agent
69
Q

What is one of the biggest risk factors for pre-eclampsia?

A

Existing primary HTN

70
Q

If a patient’s blood pressure rises during pregnancy but there is no proteinuria, what does the patient have?

A

Gestational HTN

71
Q

If the patients BP rises severely (>140/90) after about 20 weeks and they have proteinuria (>300mg/24h), what do they have?

A

Pre-eclampsia

72
Q

What options do you have for treating HTN during pregnancy?

A 
Pre-pregnancy
Nifedipine
Methyldopa
Atenolol
Labetalol

During pregnancy can add TZD or amlodipine

73
Q

How do you treat pre-eclampsia?

A

Nifedipine, methyldopa, atenolol, labetalol, TZD, amlodipine, IV esmolol, labetalol, hydralazine

74
Q

How is HTN defined in children?

A

BP ≥ 98th centile

75
Q

What does the evidence say about prognosis of childhood HTN?

A

It leads to adult HTN and target organ damage (LVH, decreased vascular responsiveness, increase carotid artery intimal medial thickness, reduced GFR, increased atheroma deposition, reduced cognitive scores)

76
Q

What are the commonest causes of HTN in newborns?

A

Renal artery thrombosis
Renal artery stenosis
Congenital renal malformations
Coarctation

77
Q

What are the commonest causes of HTN in infants-6y?

A

Renal parenchymal disease
Coarctation
Renal artery stenosis

78
Q

What are the commonest causes of HTN in 6-10yos?

A

Renal parenchymal disease
Renal artery stenosis
Primary HTN

79
Q

What are the commonest causes of HTN in 10-18y?

A

Primary HTN

Renal parenchymal disease

80
Q

Define accelerated HTN

A

Increase in BP ≥180mmHg systolic and ≥110mmHg diastolic –> target organ damage, e.g. neurological, CV or renal damage & grade 3 retinal changes

81
Q

Define malignant HTN

A

HTN leading to papilloedema grade 4 fundal changes

82
Q

What is hypertensive urgency?

A

Severe HTN with no evidence of target organ damage

83
Q

What is hypertensive emergency?

A

Severe HTN with evidence of target organ damage

84
Q

What factors are associated with accelerated HTN?

A

Poor BP control prior
Lack of GP contact
Non-adherence to medications
Illicit drug use

85
Q

How do you manage hypertensive emergencies?

A

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

86
Q

How do you manage hypertensive urgencies?

A

Often assoc with discontinuation of Rx/anxiety

Reinstitute or intensify drug therapy and treat anxiety

87
Q

How do you treat accelerated HTN?

A

Reduce DBP by 15-20%/100mmHG over 30-60mins
Assess fluid status and ensure not volume deplete

If pulmonary oedema use GTN, IV furosemide and amlodipine once patient stable

If encephalopathy use IV nicardipine, IV labetalol, IV esmolol and amlodipine once stable

CARD - 1 (28 decks)

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